Laparoscopic myomectomy and pregnancy outcome in infertile patients

Surgical treatment of fibroids for subfertility

BACKGROUND

Fibroids are the most common benign tumours of the female genital tract and are associated with numerous clinical problems including a possible negative impact on fertility. In women requesting preservation of fertility, fibroids can be surgically removed (myomectomy) by laparotomy, laparoscopically or hysteroscopically depending on the size, site and type of fibroid. Myomectomy is however a procedure that is not without risk and can result in serious complications. It is therefore essential to determine whether such a procedure can result in an improvement in fertility and, if so, to then determine the ideal surgical approach.

OBJECTIVES

To examine the effect of myomectomy on fertility outcomes and to compare different surgical approaches.

SEARCH METHODS

We searched the Cochrane Gynaecology and Fertility Group (CGFG) Specialised Register, CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL, Epistemonikos database, World Health Organization (WHO) International Clinical Trials Registry Platform search portal, Database of Abstracts of Reviews of Effects (DARE), LILACS, conference abstracts on the ISI Web of Knowledge, OpenSigle for grey literature from Europe, and reference list of relevant papers. The final search was in February 2019.

SELECTION CRITERIA

Randomised controlled trials (RCTs) examining the effect of myomectomy compared to no intervention or where different surgical approaches are compared regarding the effect on fertility outcomes in a group of infertile women suffering from uterine fibroids.

DATA COLLECTION AND ANALYSIS

Data collection and analysis were conducted in accordance with the procedure suggested in the Cochrane Handbook for Systematic Reviews of Interventions.

MAIN RESULTS

This review included four RCTs with 442 participants. The evidence was very low-quality with the main limitations being due to serious imprecision, inconsistency and indirectness. Myomectomy versus no intervention One study examined the effect of myomectomy compared to no intervention on reproductive outcomes. We are uncertain whether myomectomy improves clinical pregnancy rate for intramural (odds ratio (OR) 1.88, 95% confidence interval (CI) 0.57 to 6.14; 45 participants; one study; very low-quality evidence), submucous (OR 2.04, 95% CI 0.62 to 6.66; 52 participants; one study; very low-quality evidence), intramural/subserous (OR 2.00, 95% CI 0.40 to 10.09; 31 participants; one study; very low-quality evidence) or intramural/submucous fibroids (OR 3.24, 95% CI 0.72 to 14.57; 42 participants; one study; very low-quality evidence). Similarly, we are uncertain whether myomectomy reduces miscarriage rate for intramural fibroids (OR 1.33, 95% CI 0.26 to 6.78; 45 participants; one study; very low-quality evidence), submucous fibroids (OR 1.27, 95% CI 0.27 to 5.97; 52 participants; one study; very low-quality evidence), intramural/subserous fibroids (OR 0.80, 95% CI 0.10 to 6.54; 31 participants; one study; very low-quality evidence) or intramural/submucous fibroids (OR 2.00, 95% CI 0.32 to 12.33; 42 participants; one study; very low-quality evidence). This study did not report on live birth, preterm delivery, ongoing pregnancy or caesarean section rate. Laparoscopic myomectomy versus myomectomy by laparotomy or mini-laparotomy Two studies compared laparoscopic myomectomy to myomectomy at laparotomy or mini-laparotomy. We are uncertain whether laparoscopic myomectomy compared to laparotomy or mini-laparotomy improves live birth rate (OR 0.80, 95% CI 0.42 to 1.50; 177 participants; two studies; I² = 0%; very low-quality evidence), preterm delivery rate (OR 0.70, 95% CI 0.11 to 4.29; participants = 177; two studies; I² = 0%, very low-quality evidence), clinical pregnancy rate (OR 0.96, 95% CI 0.52 to 1.78; 177 participants; two studies; I² = 0%, very low-quality evidence), ongoing pregnancy rate (OR 1.61, 95% CI 0.26 to 10.04; 115 participants; one study; very low-quality evidence), miscarriage rate (OR 1.25, 95% CI 0.40 to 3.89; participants = 177; two studies; I² = 0%, very low-quality evidence), or caesarean section rate (OR 0.69, 95% CI 0.34 to 1.39; participants = 177; two studies; I² = 21%, very low-quality evidence). Monopolar resectoscope versus bipolar resectoscope One study evaluated the use of two electrosurgical systems during hysteroscopic myomectomy. We are uncertain whether bipolar resectoscope use compared to monopolar resectoscope use improves live birth/ongoing pregnancy rate (OR 0.86, 95% CI 0.30 to 2.50; 68 participants; one study, very low-quality evidence), clinical pregnancy rate (OR 0.88, 95% CI 0.33 to 2.36; 68 participants; one study; very low-quality evidence), or miscarriage rate (OR 1.00, 95% CI 0.19 to 5.34; participants = 68; one study; very low-quality evidence). This study did not report on preterm delivery or caesarean section rate.

AUTHORS' CONCLUSIONS

There is limited evidence to determine the role of myomectomy for infertility in women with fibroids as only one trial compared myomectomy with no myomectomy. If the decision is made to have a myomectomy, the current evidence does not indicate a superior method (laparoscopy, laparotomy or different electrosurgical systems) to improve rates of live birth, preterm delivery, clinical pregnancy, ongoing pregnancy, miscarriage, or caesarean section. Furthermore, the existing evidence needs to be viewed with caution due to the small number of events, minimal number of studies and very low-quality evidence.

Morbidity, fertility and pregnancy outcomes after myoma enucleation by laparoscopy versus laparotomy

OBJECTIVES

Myomas are defined as benign tumours that arise from smooth muscle cells of the uterus. Clinically, they are found in 5-77% of women of reproductive age. The prevalence rate varies considerably in the literature and a large number of fibroids do not cause symptoms. The lifetime risk of acquiring myomas is 70% for Caucasian women and ≥ 80% for African American women.

MATERIALS/METHODS

The data of 265 patients undergoing surgery for symptomatic myomas by laparoscopy or laparotomy, performed in the gynaecological department of Hannover Medical School, Hannover, Germany, between 2009 and 2013, were retrospectively analysed in this retrospective design study.

RESULTS

High pregnancy rates (up to 70%) and birth rates (up to 86%) after myomectomy, regardless of the surgical approach adopted, were found in the current study. The trend was that ≥ 3 myomas and those that were ≥ 6 cm in size were almost always removed by laparotomy in our clinic. It was possible to remove up to 42 myomas without having to perform a hysterectomy. A statistically significant negative correlation was observed in relation to the association between the size of the largest myoma extracted and the pregnancy rate (p = 0.02). A statistically significant correlation between the number of removed myomas and the pregnancy rate was observed for patients who wished to bear children (p = 0.010). Elevated complication rates (of up to 50%) were reported for more than three extracted myomas with a statistically significance (p = 0.0471).

CONCLUSIONS

It is necessary to ensure sound preoperative selection of the surgical approach in order to achieve the most optimal results, especially for those patients who wished to bear children.

Pushing the boundaries of laparoscopic myomectomy: a comparative analysis of peri-operative outcomes in 323 women undergoing laparoscopic myomectomy in a tertiary referral centre

Background

The aim of this study was to analyse the demographic data and peri-operative outcomes of women undergoing a laparoscopic myomectomy and assess what factors, if any, precluded using the laparoscopic approach.

Methods

A single surgeon observational study of 323 patients undergoing a laparoscopic myomectomy was undertaken. Data was collected prospectively over a 12-year period and analysed using SPSS. Surgical outcomes included operating time, estimated blood loss, conversion to laparotomy, intraoperative and postoperative complications and duration of inpatient stay.

Results

A total of 323 patients underwent a laparoscopic myomectomy over the 12-year period. The majority of fibroids removed were intramural (49%) and subserosal (33%). The mean size of fibroids removed was 7.66 ± 2.83 (7.34–7.99) cm, and the mean number was 4 ± 3.62 (3.6–4.39), with the greatest being 22 removed from a single patient. Average blood loss was 279.14 ± 221.10 (254.59–303.69) ml with mean duration of surgery and inpatient stay recorded as 112.92 ± 43.21 (107.94–117.91) min and 1.88 ± 0.95 (1.77–1.99) days, respectively. No major intraoperative complications were noted, and the conversion to laparotomy rate was 0.62%. All histology following morcellation was benign. Over the 12-year period despite increasingly large and more numerous fibroids being tackled, increasing experience resulted in a simultaneous reduction in overall blood loss, operating time and duration of inpatient stay.

Conclusions

Laparoscopic myomectomy is a safe and efficacious procedure that should be considered the gold standard surgical treatment option for fibroids. With experience, the procedure can be undertaken with minimal complications, a low risk of conversion to laparotomy and early discharge from hospital, even in cases of large and multiple fibroids that historically would have required the open approach. This allows even the most complex of cases to now benefit for the advantages of the minimal access approach.

The conservative and interventional treatment of fibroids

BACKGROUND

Fibroids are the most common benign tumors in women. One-third of all women of reproductive age undergo treatment for symptomatic fibroids. In recent years, the spectrum of available treatments has been widened by the introduction of new drugs and interventional procedures.

METHODS

Selective literature review on the treatment of uterine fibroids, including consideration of several Cochrane Reviews.

RESULTS

Fibroids can be treated with drugs, interventional procedures (uterine artery embolization [UAE] and focused ultrasound treatment [FUS]), and surgery. The evidence regarding the various available treatments is mixed. All methods improve symptoms, but only a few comparative studies have been performed. A meta-analysis revealed that recovery within 15 days is more common after laparoscopic enucleation than after open surgery (odds ratio [OR], 3.2). A minimally invasive hysterectomy, or one performed by the vaginal route, is associated with a shorter hospital stay and a more rapid recovery than open transabdominal hysterectomy. UAE is an alternative to hysterectomy for selected patients. The re-intervention rates after fibroid enucleation, hysterectomy, and UAE are 8.9-9%, 1.8-10.7%, and 7-34.6%, respectively. The main drugs used to treat fibroids are gonadotropin-releasing hormone analogs and selective progesterone receptor modulators.

CONCLUSION

Multiple treatment options are available and enable individualized therapy for symptomatic fibroids. The most important considerations in the choice of treatment are the question of family planning and, in some cases, the technical limitations of the treatments themselves.

Surgical treatment of fibroids for subfertility

BACKGROUND

Fibroids are the most common benign tumours of the female genital tract and are associated with numerous clinical problems including a possible negative impact on fertility. In women requesting preservation of fertility, fibroids can be surgically removed (myomectomy) by laparotomy, laparoscopically or hysteroscopically depending on the size, site and type of fibroid. Myomectomy is however a procedure that is not without risk and can result in serious complications. It is therefore essential to determine whether such a procedure can result in an improvement in fertility and, if so, to then determine the ideal surgical approach.

OBJECTIVES

To examine the effect of myomectomy on fertility outcomes and to compare different surgical approaches.

SEARCH METHODS

We searched the Cochrane Menstrual Disorders and Subfertility Group (MDSG) Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PsycINFO, CINAHL, Database of Abstracts of Reviews of Effects (DARE), LILACS, conference abstracts on the ISI Web of Knowledge, OpenSigle for grey literature from Europe, and ongoing clinical trials registered online. The final search was in June 2012.

SELECTION CRITERIA

Randomised controlled trials examining the effect of myomectomy compared to no intervention or where different surgical approaches are compared regarding the effect on fertility outcomes in a group of infertile women suffering from uterine fibroids.

DATA COLLECTION AND ANALYSIS

Data collection and analysis were conducted in accordance with the procedure suggested in the Cochrane Handbook for Systematic Reviews of Interventions.

MAIN RESULTS

One study examined the effect of myomectomy on reproductive outcomes and showed no evidence for a significant effect on the clinical pregnancy rate for intramural (OR 1.88, 95% CI 0.57 to 6.14), submucous (OR 2.04, 95% CI 0.62 to 6.66), combined intramural and subserous (OR 2.00, 95% CI 0.40 to 10.09) and combined intramural submucous fibroids (OR 3.24, 95% CI 0.72 to 14.57). Similarly, there was no evidence for a significant effect of myomectomy for any of the described types of fibroids on the miscarriage rate (intramural fibroids OR 0.89 (95% CI 0.14 to 5.48), submucous fibroids OR 0.63 (95% CI 0.09 to 4.40), combined intramural and subserous fibroids OR 0.25 (95% CI 0.01 to 4.73) and combined intramural submucous fibroids OR 0.50 (95% CI 0.03 to 7.99).Two studies compared open versus laparoscopic myomectomy and found no evidence for a significant effect on the live birth rate (OR 0.80, 95% CI 0.42 to 1.50), clinical pregnancy rate (OR 0.96, 95% CI 0.52 to 1.78), ongoing pregnancy rate (OR 1.61, 95% CI 0.26 to 10.04), miscarriage rate (OR 1.31, 95% CI 0.40 to 4.27), preterm labour rate (OR 0.68, 95% CI 0.11 to 4.43) and caesarean section rate (OR 0.59, 95% CI 0.13 to 2.72).

AUTHORS' CONCLUSIONS

There is currently insufficient evidence from randomised controlled trials to evaluate the role of myomectomy to improve fertility. Regarding the surgical approach to myomectomy, current evidence from two randomised controlled trials suggests there is no significant difference between the laparoscopic and open approach regarding fertility performance. This evidence needs to be viewed with caution due to the small number of studies. Finally, there is currently no evidence from randomised controlled trials regarding the effect of hysteroscopic myomectomy on fertility outcomes.

Pregnancy outcomes following robot-assisted myomectomy

STUDY QUESTION

What are the characteristics of the pregnancy outcomes in women undergoing robot-assisted laparoscopic myomectomy (RALM) for symptomatic leiomyomata uteri?

SUMMARY ANSWER

Despite a high prevalence of women with advanced maternal age, obesity and multiple pregnancy in our cohort, the outcomes are comparable with those reported in the literature for laparoscopic myomectomy.

WHAT IS KNOWN ALREADY

Reproductive outcomes after traditional laparoscopic myomectomy are well documented. However, reproductive outcomes following robotic myomectomy are not well studied. This paper describes the pregnancy outcomes for a large cohort of women after robotic myomectomy.

STUDY DESIGN, SIZE, DURATION

This is a retrospective cohort of women who became pregnant after robot-assisted myomectomy at three centers. Of the 872 women who underwent robotic myomectomy during the period October 2005-November 2010, 107 subsequently conceived resulting in 127 pregnancies and 92 deliveries through 2011.

PARTICIPANTS/MATERIAL, SETTING, METHODS

Women of reproductive age with fibroids who wanted a minimally invasive treatment option and desired uterine preservation were recruited. We conducted a multicentre study with three centers, two in a private practice and one in an academic setting. Pregnancy outcomes and their relationship to myoma characteristics were analyzed.

MAIN RESULTS AND ROLE OF CHANCE

Mean ± SD age at myomectomy was 34.8 ± 4.5 years and 57.4% [95% confidence interval (CI) 48.0, 66.3] of women were overweight or obese. The mean number of myomas removed was 3.9 ± 3.2 with a mean size of 7.5 ± 3.0 cm and mean weight of 191.7 ± 144.8 g. Entry of the myoma into the endometrial cavity occurred in 20.6% (95% CI 15.0, 27.7) of patients. The mean time to conception was 12.9 ± 11.5 months. Assisted reproduction techniques were employed in 39.4% (95% CI 32.6, 46.7) of these women. Seven twin pregnancies and two triplet pregnancies occurred, for a multiple pregnancy birth rate of 9.8% (95% CI 5.0, 17.8). Spontaneous abortions occurred in 18.9% (95% CI 13.0, 26.6). Preterm delivery prior to 35 weeks of gestational age occurred in 17.4% (95% CI 10.9, 26.5). One uterine rupture (1.1%; 95% CI 0.3, 4.7) was documented. Pelvic adhesions were discovered in 11.4% (95% CI 7.0, 18.0) of patients delivered by Cesarean section. Higher preterm delivery rates were significantly associated with a greater number of myomas removed and anterior location of the largest incision (compared with all other sites) in logistic regression analyses (P = 0.01). None of the myoma characteristics were related to spontaneous abortion.

BIAS, CONFOUNDING AND OTHER REASONS FOR CAUTION

Given the retrospective nature of the data collection, some pregnancies may not have been captured. In addition, owing to the high prevalence of infertility patients in this cohort, the data cannot be used to counsel women who are undergoing RALM about fertility rates after surgery.

GENERALIZABILITY TO OTHER POPULATIONS

Prospective studies are needed to determine if the results shown in our cohort are generalizable to all women seeking a minimally invasive option for the conservative treatment of symptomatic fibroids with pregnancy as a desired outcome.

STUDY FUNDING/COMPETING INTEREST(S)

There was no funding source for this study.

Evaluation of loop ligation of larger myoma pseudocapsule combined with vasopressin on laparoscopic myomectomy

OBJECTIVE

To study the effects of reducing hemorrhage by loop ligation of larger myoma pseudocapsules combined with vasopressin on laparoscopic myomectomy (LM).

DESIGN

Prospective controlled clinical trial.

SETTING

Sheng Jing Hospital, China Medical University.

PATIENT(S)

A total of 105 women with symptomatic single or multiple larger myomas (diameter 6-18 cm) in need of surgical intervention, who wished to retain their uteri, were randomly divided into three groups in our hospital from January 2006 to January 2008: A) loop ligation combined with vasopressin; B) vasopressin alone; and C) neither loop ligation nor vasopressin. All patients were treated by LM. Each group included 35 cases.

INTERVENTION(S)

Loop ligation of larger myoma (6-18 cm) pseudocapsule combined with vasopressin before thoroughly enucleating the myoma.

MAIN OUTCOME MEASURE(S)

Operating time, blood loss, blood transfusion, postoperative stay in hospital, symptom improvement.

RESULT(S)

Average blood loss, postoperative stay in hospital, number of conversions to laparotomy, and need for transfusion because of bleeding during operation in group A were significantly lower than in groups B and C. All patients in group A underwent technically successful laparoscopic operations.

CONCLUSION(S)

Loop ligation of larger myoma pseudocapsules combined with vasopressin is a safe, effective, and promising new method to reduce bleeding during laparoscopic myomectomy and makes the laparoscopic operations with larger myomas easier.

La myomectomie par cœlioscopie en 2007: état des lieux

With fifteen years of development, laparoscopy for myomectomy has proven its advantages. However, this technique remains controversial concerning its feasibility and the quality of uterine scar obtained. Laparoscopic myomectomy (LM) is usually indicated when number of myomas is less than 3 to 4 with a 8 to 9 cm maximal size. Surgical technique is standardized and intervention time becomes acceptable. Risk of conversion ranges between 1 to 3% when technique is realized by trained surgeon. Bleeding is less important compared with laparotomy and immediate postoperative complications are exceptional. Results concerning fertility are positive with more than 50% of infertile patient conceiving after surgery, this rate rising up to 61 to 76% for myomas isolated cause for infertility; these values can be compared with myomectomy realized by laparotomy. Postoperative adhesions seem to be less important after laparoscopy when compared with laparotomy but this point needs to be confirmed. Risk of uterine rupture is estimated between 0 to 1%, but this point needs for larger series evaluation and needs to be compared with pregnancies after laparotomy. Laparoscopic myomectomy is a feasible technique, safe for patients waiting for conception and has proven its interest in case of infertility.

Isobaric gasless laparoscopy versus minilaparotomy in uterine myomectomy: a randomized trial

BACKGROUND

Isobaric gasless laparoscopy and minilaparotomy have been used as more recent minimally invasive approaches to myomectomy. This randomized trial aimed to compare the surgical and immediate postoperative outcomes for myomectomy performed by isobaric gasless laparoscopy with those for minilaparotomy.

METHODS

A total of 100 patients with symptomatic uterine myomas requiring myomectomy were randomly allocated to the gasless laparoscopy group or the minilaparotomy group. The randomization procedure was based on a computer-generated list. The primary outcome was a comparison of the discharge times between the two procedures. A power calculation verified that more than 26 patients for each group was necessary to detect a difference of more than 24 h in discharge time with an alpha error level of 5% and a beta error of 80%. Continuous outcome variables were analyzed using the Student's t-test. Discrete variables were analyzed with the chi-square test or Fisher's exact test. A p value less than 0.05 was considered statistically significant.

RESULTS

The mean discharge time was longer for minilaparotomy than for gasless laparoscopy (98.4 +/- 1.4 vs 52.8 +/- 1.6 h; p < 0.001). Gasless laparoscopy resulted in shorter times for canalization (21.6 +/- 1.1 vs 32 +/- 1.3 h; p < 0.05) and surgery (79.5 +/- 25.1 vs 103.5 +/- 24.9 min; p < 0.001). The intraoperative blood loss was less with gasless laparoscopy (154.2 +/- 1.2 vs 188.6 +/- 1.3 ml; p < 0.001). No intraoperative complications occurred, and no case was returned to the theater in either group. No conversion to standard laparotomy was necessary.

CONCLUSIONS

Isobaric gasless laparoscopy and minilaparotomy can be suitable options for uterine myomectomy. Several surgical and immediate postoperative outcomes were significantly better in the gasless laparoscopy group than in the minilaparotomy group. However, further controlled prospective studies are required to confirm the results.

Isobaric (gasless) laparoscopic uterine myomectomy

The aim of this review has been to assess the usefulness and effectiveness of isobaric (gasless) laparoscopic myomectomy using a subcutaneous abdominal wall lifting system, and to evaluate the advantages and disadvantages of this technique in comparison with the conventional laparoscopic myomectomy using pneumoperitoneum. Laparoscopy using CO2 is more frequently employed for small or medium-sized myomas. Furthermore, multiple myomectomies (>or=3 myomas per patient) are performed rarely. Gasless laparoscopy permits the removal of large intramural myomas overcoming the difficulties associated with laparoscopic myomectomy using pneumoperitoneum. It appears to offer several advantages over conventional laparoscopy, such as elimination of the adverse effects and potential risks associated with CO2 insufflation; use of conventional laparotomy instruments that facilitate several steps of the procedure; reduced operative times and costs. Indeed, this procedure associates the advantages of laparoscopy and minimal access surgery with those of using the laparotomic instruments that are more reliable for uterine closure. The only advantage of the laparoscopy with pneumoperitoneum is the tamponade effect generated by the gas on the small vessels, thus reducing intraoperative bleeding. Laparoscopic myomectomy using CO2 remains the preferred minimally invasive approach for small and medium-sized myomas and when the total number of myomas removed does not exceed 2 or 3. Gasless laparoscopic myomectomy could be mainly indicated for removal of large intramural myomas (>or=8 cm) and/or for multiple myomectomies (>or=3 myomas per patient). Anyhow, further controlled studies are needed to evaluate entirely their respective indications.

Surgical treatment of fibroids for subfertility

BACKGROUND

Fibroids are benign tumours of the uterus occurring in up to 77% of women. Fibroids have been noted to occur more frequently in women with infertility. Retrospective studies have suggested the benefit of surgically removing fibroids to increase the fertility efficacy of both natural conception and assisted conception. There are a variety of methods to surgically remove fibroids including laparotomy, laparoscopy and hysteroscopy. The relative advantages and disadvantages of these modalities in terms of fertility efficacy and side effects are unknown.

OBJECTIVES

To determine the efficacy and safety of the removal of uterine fibroids in subfertile women by laparotomy, laparoscopy or hysteroscopy when compared with expectant management or each other. The review will include also new surgical approaches as and when they are trialed.

SEARCH STRATEGY

We searched the Cochrane Menstrual Disorders and Subfertility Review Group Specialised register of controlled trials, MEDLINE (PUBMED) 1985 to 2004, EMBASE (1985 to 2004), CINAHL (1985 to 2004) and National Research Register.

SELECTION CRITERIA

Randomised controlled trials (RCTs) in which fibroids were removed via surgery for the treatment of infertility

DATA COLLECTION AND ANALYSIS

Three authors independently assessed trial quality and extracted data.

MAIN RESULTS

Only one randomized controlled study was included (131 women) and this was probably underpowered. There was no evidence of a difference in outcome in terms of clinical pregnancy rate and live birth rate when fibroids were removed via laparotomy or laparoscopy for infertility. There were some non fertility benefits of removal via laparoscopy including shorter hospital stay, less febrile illness and a smaller drop in pre-operative haemoglobin concentration when compared to laparotomy. There were no randomised controlled studies comparing hysteroscopic removal or no intervention with other surgical modalities.

AUTHORS' CONCLUSIONS

There is limited evidence to suggest that there is no difference in fertility efficacy outcome if fibroids are removed via laparotomy when compared to laparoscopy. There is no good randomised controlled evidence to support hysteroscopic removal of fibroids compared to other surgical modalities for fertility efficacy.

Isobaric gasless laparoscopic myomectomy for removal of large uterine leiomyomas

BACKGROUND

This study aimed to evaluate the feasibility and safety of isobaric laparoscopic removal of large myomas (> or = 8 cm) using the Laparotenser, a subcutaneous abdominal wall-lifting system.

METHODS

A series of 63 consecutive patients with at least one large symptomatic subserosal or intramural uterine myoma (> or = 8 cm) underwent an isobaric gasless laparoscopic myomectomy. Conventional laparotomy instruments were used.

RESULTS

The procedure was successfully completed for all 63 consecutive patients. The average size of the dominant myoma was 11 cm. The mean number of myomas removed from each patient was 3.6. The mean blood loss was 143 ml, and the mean operating time was 72 min. No intraoperative complication occurred.

CONCLUSIONS

Gasless laparoscopic myomectomy for the removal of large myomas using the Laparotenser is feasible and safe. It offers several advantages over laparoscopy with pneumoperitoneum.

Obstetric and delivery outcome of pregnancies achieved after laparoscopic myomectomy

OBJECTIVE

To assess the risks and outcome of pregnancies and deliveries after laparoscopic myomectomy (LM).

DESIGN

Retrospective study.

SETTING

Center of Reconstructive Pelvic Endosurgery, Reproductive Medicine Unit, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy.

PATIENT(S)

A total of 514 patients of fertile age that underwent LM at the Center were selected.

INTERVENTION(S)

All the surgical procedures were performed using the same technique employing a vertical uterine incision and avoiding the use of electrosurgery.

MAIN OUTCOME MEASURE(S)

Number and outcome of pregnancies achieved after surgery, abortion rate, preterm delivery, gestational age, malpresentation, spontaneous or cesarean delivery, and postpartum hemorrhage. We also paid particular attention to the occurrence of uterine rupture.

RESULT(S)

A total of 158 pregnancies were achieved. There were 43 (27.2%) spontaneous abortions, 4 (2.6%) ectopic pregnancies, and 1 (0.6%) therapeutic abortion. Only 27 patients (25.5%) had vaginal deliveries, whereas 79 (74.5%) underwent cesarean section. No instances of uterine rupture were recorded.

CONCLUSION(S)

Our preliminary results confirmed that LM, performed by an expert surgeon, can restore reproductive capacity, allowing patients to have a successful pregnancy.

Differential infiltration of macrophages and prostaglandin production by different uterine leiomyomas

BACKGROUND

The association between uterine myoma and infertility is still controversial. The anatomical defect of endometrium by uterine fibroids could be a factor for reducing pregnancy rates and increasing miscarriage rates. However, pregnancy and implantation rates were found to be significantly lower in women with intramural myomas (IMMs), when there was no deformity of uterine cavity. This could be due to other biological factors such as increased accumulation of inflammatory cells within fibroid tissue and corresponding endometrium that might impair fertility. Therefore, we tried to investigate the pattern of macrophage (Mvarphi) accumulation in different uterine fibroids and the production of chemokine and prostaglandin (PG) by these tissues.

METHODS

The selection criteria of uterine fibroids were based on the classification of European Society of Hysteroscopy. Biopsy specimens were collected from respective nodules and autologous endometrium of 20 women with submucosal myoma (SMM), 29 women with IMM and 18 women with subserosal myoma (SSM). CD68 immunoreactive Mvarphis were identified in these tissues by immunohistochemistry. A fraction of corresponding tissues were homogenized, and levels of monocyte chemotactic protein-1 (MCP-1) and PGF(2alpha) were measured by enzyme-linked immunosorbent assay (ELISA).

RESULTS

Mvarphi infiltration in the myoma nodule and corresponding endometrium of women with SMM and IMM was significantly higher than that of women with SSM or control women (P<0.01 and P<0.05, respectively). This tissue accumulation of inflammatory cells was independent of the sizes of the myoma nodules and phases of menstrual cycle. The tissue concentration of MCP-1 corresponded to increased Mvarphi infiltration and was significantly higher in women with SMM and IMM than that in women with SSM (P<0.05 for each). A positive correlation was observed between MCP-1 concentration and accumulated Mvarphi numbers in the endometrium of women with SMM and IMM but not in women with SSM. The tissue levels of PGF2alpha were also significantly higher in the nodule and corresponding endometrium of women with SMM and IMM than that in SSM or control women (P<0.05 for each).

CONCLUSIONS

Higher production of MCP-1 could be responsible for the increased accumulation of Mvarphi in women with SMM and IMM. The augmented inflammatory reaction in endometrium and increased PGF2alpha levels might be detrimental to reproductive outcome in women with SMM or IMM.

Laparoscopic Versus Open Myomectomy: A Double-Blind Study to Evaluate Postoperative Pain

The advantages of laparoscopic over open surgery have been documented in nonblinded settings. Our prospective, double-blind setting evaluated pain scores 72 h after surgery by comparing patients who underwent laparoscopic myomectomy or with laparotomy. Forty women referred for conservative myomectomy were included in the study. After stratification (myoma size, number of myomas, and surgeon), patients were randomized to either laparoscopy (n = 19) or laparotomy (n = 21) and received a standardized anesthesia and patient-controlled analgesia for 24 h after surgery. Identical wound dressings were applied to blind the patient and the observer to the surgical approach. The postoperative pain scores were documented on a visual analog scale (VAS; 0 = no and 10 = unbearable pain) at 24, 48, and 72 h after surgery. As the primary outcome variable, we calculated the mean overall VAS-score at these time points. P < 0.05 (t-test and analysis of covariance) was considered statistically significant. There were no differences in patient characteristics among the groups. The mean overall VAS score at 24, 48, and 72 h was statistically significantly lower in the laparoscopic group compared with the laparotomy group (2.28 +/- 1.38 versus 4.03 +/- 1.63; P < 0.01). Our data demonstrate, for the first time in a double-blind setting, that laparoscopic myomectomy reduces postoperative pain for 72 h after surgery compared with laparotomy.

Effects of fibrin sealant on single-layer uterine incision closure in the New Zealand white rabbit

OBJECTIVE

To determine if the addition of fibrin sealant to incision closure in a rabbit uterine horn myomectomy model affects adhesion formation or strength of incision closure.

DESIGN

Prospective randomized controlled trial.

SETTING

Academic research center.

ANIMAL(S)

New Zealand white female rabbits.

INTERVENTION(S)

A pilot study revealed that the time interval for maximal uterine incision healing was eight weeks. Thirty New Zealand white rabbits underwent a 1-cm standardized myotomy incision on both uterine horns. A single interrupted stitch of 3-0 polygalactin suture was placed to reapproximate each incision. Fibrin sealant was then applied to one of each rabbit's horns (randomized). After eight weeks, the rabbits were killed, and the strength of myotomy closure was determined by measurement of maximal burst pressure for each uterine horn. Adhesion presence was recorded.

MAIN OUTCOME MEASURE(S)

Uterine burst pressure, adhesion presence.

RESULT(S)

The mean burst pressure was 267.8 (+/-75.8) mm Hg in the suture only group and 247.8 (+/-92.3) mm Hg in the suture and fibrin sealant group. There was no statistical difference in the presence of adhesions.

CONCLUSION(S)

Fibrin sealant did not strengthen myotomy repair nor did it reduce postoperative adhesion formation. There is no apparent advantage to fibrin sealant in this myomectomy model.

Myomas and Assisted Reproductive Technologies: When and How to Act?

The effect of myomas on reproductive outcome has been the subject of many studies; however, a definitive answer is still missing. Therefore, the authors have tried to outline some guidelines for the management of women who have uterine myomas and desire to conceive. The location and size of the myomas are the two parameters that influence the success of a future pregnancy. Subserosal myomas seem to have little, if any,effect on reproductive outcome, especially if they are up to 5 to 7 cm in diameter. Intramural myomas that do not encroach upon the endometrium also can be considered to be relatively harmless to reproduction, if they are smaller than 4 to 5 cm in diameter. This is the ambiguous gray zone of the subject, and where research should be focused before a consensus can be established. Myomas that compress the uterine cavity with an intramural portion (submucous myoma type II) and submucous myomas significantly reduce pregnancy rates, and should be removed before assisted reproductive techniques are used. Hysteroscopic myomectomy is the gold standard for the treatment of submucous myomas. For other myomas, abdominal myomectomy, or laparoscopic myomectomy--when the experience of the surgeon and the facilities are sufficient--are the best alternatives. In most of the literature, the pregnancy rates were increased and the miscarriage rates were decreased after surgery with these two techniques. Other alternative treatment modalities, such as CUV, laparoscopic myolysis, or MRI-guided focused ultrasound, are to be monitored and evaluated thoroughly before they are applied as routine procedures.

Effects of the position of fibroids on fertility

This prospective, controlled study was performed in order to evaluate whether the location of uterine fibroids may influence reproductive function in women and whether removal of the fibroid prior to conception may improve pregnancy rate and pregnancy maintenance. We examined 181 women affected by uterine fibroids who had been trying to conceive for at least 1 year without success. The main outcome measures were the pregnancy rate and the miscarriage rate. Among the patients who underwent myomectomy, the pregnancy rates obtained were 43.3% in cases of submucosal, 56.5% in cases of intramural, 40.0% in cases of submucosal-intramural and 35.5% in cases of intramural-subserosal uterine fibroids, respectively. Among the patients who did not undergo surgical treatment, the pregnancy rates obtained were 27.2% in women with submucosal, 41.0% in women with intramural, 15.0% in women with submucosal-intramural and 21.43% in women with intramural-subserosal uterine fibroids, respectively. Although the results were not statistically significant in the group of women with intramural and intramural-subserosal fibroids, this study confirms the important role of the position of the uterine fibroid in infertility as well as the importance of fibroids removal before the achievement of a pregnancy, to improve both the chances of fertilization and pregnancy maintenance.

Pregnancy and delivery after laparoscopic myomectomy

STUDY OBJECTIVE

To assess the factors influencing pregnancy outcome and evaluate vaginal birth after laparoscopic myomectomy (VBALM).

DESIGN

Retrospective study (Canadian Task Force classification II-2).

SETTING

University hospital.

PATIENTS

One hundred eight patients who wanted a child after laparoscopic myomectomy (LM) and a follow-up of at least 6 months.

INTERVENTION

Laparoscopic myomectomy.

MEASUREMENTS AND MAIN RESULTS

Forty-seven pregnancies occurred in 40 patients. As for the factors considered to contribute to pregnancy after LM, COX regression analysis showed that pregnancy after LM correlated positively with the diameter of the largest myoma (OR 1.06, 95% CI 1.02-1.10, p = .004) and negatively with the age of the patient at the time of LM (OR 0.88, 95% CI 0.80-0.98, p = .02) and the number of enucleated myomas (OR l.17, 95% CI 1.01-1.37, p=0.04). Vaginal birth after LM was managed in accordance with the standard management of vaginal birth after cesarean section (VBAC) in our hospital. Delivery after LM was accomplished in 32 pregnancies. Vaginal birth after laparoscopic myomectomy was attempted in 23 pregnancies (71.9%) and vaginal birth successful in 19 (82.6%) of these 23 pregnancies. Vaginal birth after LM was unsuccessful in four patients, as labor did not occur during more than 2 weeks after the expected date of delivery in two patients, and cesarean section was performed to prevent fetal asphyxia during the course of delivery in two patients. In the 18 patients (19 pregnancies) with successful VBALM, the diameter of the largest myoma at LM was 68.7 +/- 18.4 mm, the number of enucleated myomas was 2.9 +/- 2.1, and the number of hysterotomies was 2.5 +/- 1.8. As for the depth of the largest myoma, this was intramural in 12 patients, submucosal in 2 patients and subserosal in 4 patients. None of the patients, regardless of whether they had a successful VBALM or not, suffered uterine rupture during or after delivery.

CONCLUSION

Since nearly complete suturing is possible in LM as in laparotomy, vaginal delivery can be accomplished safely without uterine rupture even after LM, provided that delivery is managed as in VBAC.

Miomas e infertilidade: bases fisiopatológicas e implicações terapêuticas

OBJETIVOS: analisar evidências da literatura médica que avaliam a relação entre miomas uterinos e infertilidade, assim como as vantagens e desvantagens dos diferentes tipos de tratamentos disponíveis. MÉTODOS: foi realizada uma revisão da literatura utilizando os termos (MeSh terms) "miomas", "infertilidade", "tratamento", "miomectomia", "gestação", na base de dados "Pubmed" e na "The Cochrane Library 2003". O período analisado foi de 1989 a 2003. RESULTADOS: apesar de alguns resultados contraditórios, a maioria dos autores relata uma possível relação de causa-conseqüência entre determinados tipos de miomas e distúrbios reprodutivos. Em relação à terapêutica, observa-se claramente que a miomectomia representa a técnica cirúrgica com melhores resultados, não havendo diferença significativa entre as vias de acesso utilizadas, com exceção da miomatose submucosa, situação em que a via histeroscópica é preferida. As opções não-cirúrgicas de tratamento existentes não parecem ter indicação em pacientes inférteis. CONCLUSÕES: a possível associação entre miomas e distúrbios reprodutivos necessita de melhores investigações. O incremento nas taxas de gestação após ressecção cirúrgica de miomas submucosos leva-nos a acreditar que esses tumores tenham papel na etiologia da infertilidade. Em miomas de outras localizações, entretanto, a relação com infertilidade não é tão clara. A miomectomia é o procedimento de escolha para as pacientes que ainda desejam engravidar.

Laparoscopic myomectomy for symptomatic uterine myomas

OBJECTIVE

To evaluate the safety, efficacy, and techniques of laparoscopic myomectomy as treatment for symptomatic uterine myomas.

DESIGN

Medline literature review and cross-reference of published data.

RESULTS

Results from randomized trials and clinical series have shown that laparoscopic myomectomy provides the advantages of shorter hospitalization, faster recovery, fewer adhesions, and less blood loss than abdominal myomectomy when performed by skilled surgeons. Improvements in surgical instruments and techniques allows for safe removal and multilayer myometrial repair of multiple large intramural myomas. Randomized trials support the use of absorbable adhesion barriers to reduce adhesions, but there is no apparent benefit of presurgical use of GnRH agonists. Pregnancy outcomes have been good, and the risk of uterine rupture is very low when the myometrium is repaired appropriately.

CONCLUSION(S)

Advances in surgical instruments and techniques are expanding the role of laparoscopic myomectomy in well-selected individuals. Meticulous repair of the myometrium is essential for women considering pregnancy after laparoscopic myomectomy to minimize the risk of uterine rupture. Laparoscopic myomectomy is an appropriate alternative to abdominal myomectomy, hysterectomy, and uterine artery embolization for some women.

Use of the LAP DISK (abdominal wall sealing device) in laparoscopically assisted myomectomy

OBJECTIVE

To evaluate the efficacy of an abdominal wall sealing device (the LAP DISK) used during laparoscopically assisted myomectomy (LAM).

DESIGN

Retrospective study.

SETTING

Tottori University Hospital, Yonago, Japan.

PATIENT(S)

All 43 patients who underwent LAM using the LAP DISK.

INTERVENTION(S)

Ultrasonography and magnetic resonance imaging.

MAIN OUTCOME MEASURE(S)

Treatment strategy, operative outcome, and postoperative pregnancy rate.

RESULT(S)

Weight and size of the myomas removed ranged from 40-700 g (mean: 208.0 g) and 2-10 cm (mean: 5.4 cm). Mean blood loss was 42.3 mL. Half of the 18 patients who had been diagnosed with primary infertility for >2 years became pregnant without postoperative assisted reproductive techniques.

CONCLUSION(S)

The LAP DISK, a useful device for LAM, allows surgeons to remove myomas safely and repair uterine defects effectively while minimizing blood loss and trauma.

Reproductive outcome before and after laparoscopic or abdominal myomectomy for subserous or intramural myomas

OBJECTIVES

To analyze the reproductive outcome before and after myomectomy in patients with subserous or intramural myomas, and to assess the factors influencing pregnancy rate after myomectomy.

STUDY DESIGN

Out of 128 patients submitted to myomectomy, we considered eligible for this study only the 41 patients wishing to conceive after surgery and who did not present any plausible infertility factor, apart from the removed myomas. We have evaluated the pregnancy outcome prior to and following myomectomy, and analyzed the correlation between conception rate after surgery and patient's age at the time of the surgery, type of surgery, number and size of the myomas, location of the largest fibroid and previous pregnancies.

RESULTS

Nineteen patients had been submitted to abdominal (group A) and 22 to laparoscopic myomectomy (group B). Prior to surgery, 28 pregnancies had occurred in 14 of the 41 patients, with a miscarriage rate of 57.1%. Following surgery 29 pregnancies occurred in 25 patients (60.9%), pregnancy rate being similar in both groups. The postoperative delivery rate was 86.2% whereas the miscarriage rate was reduced to 13.8% (P<0.001). Overall, 60% of deliveries were vaginal. No cases of ectopic pregnancy or uterine rupture occurred. Those patients who conceived after surgery were significantly younger (32.36+/-4.06 years versus 35.88+/-3.57 years; P=0.0073), and their removed myomas were significantly larger (5.80+/-2.69 cm versus 4.28+/-1.54 cm; P=0.0274). Furthermore, a multivariate analysis shows that, apart from age and diameter, the probability of conceiving after myomectomy is higher in case of intramural myomas (intramural versus subserosal: OR 12.382, 95% CI: 1.61-95.22) or laparoscopic surgery (laparoscopy versus laparotomy: OR 14.062, 95% CI: 1.40-141.15).

CONCLUSIONS

Our results suggest that myomectomy significantly improves pregnancy outcome in patients with subserous or intramural fibroids, probably removing a plausible cause of altered uterine contractility or blood supply. The main determinants of pregnancy rate after surgery are patient age, diameter and intramural localization of the myomas and type of surgery.

Pregnancy outcomes and deliveries after laparoscopic myomectomy

STUDY OBJECTIVE

To assess pregnancy outcomes and deliveries after laparoscopic myomectomy.

DESIGN

Retrospective study (Canadian Task Force classification II-2).

SETTING

General hospital.

PATIENTS

Three hundred fifty-nine women.

INTERVENTIONS

Laparoscopic myomectomy and laparoscopic and/or hysteroscopic treatment of associated pathologies.

MEASUREMENTS AND MAIN RESULTS

Five patients (1.39%) were lost to follow-up. Seventy-two women were pregnant at least once after laparoscopic myomectomy, for a total of 76 pregnancies. Four women conceived twice and four are pregnant as of this writing. One multiple pregnancy occurred. Twelve pregnancies resulted in first-trimester miscarriage, one in an ectopic pregnancy, one in a blighted ovum, and one in a hydatiform mole. One patient underwent elective first-trimester termination of pregnancy. Thirty-one women had vaginal delivery at term and 26 were delivered by cesarean section. No case of uterine rupture or dehiscence occurred.

CONCLUSION

Our technique of laparoscopic myomectomy appears to allow safe vaginal delivery.

Minimally invasive management of uterine fibroids

PURPOSE OF REVIEW

Many minimally invasive techniques have recently been introduced for the management of uterine fibroids. The purpose of this review is to analyse recent data for techniques that are used to manage uterine fibroids.

RECENT FINDINGS

Laparoscopic myomectomy has provided a minimally invasive alternative to laparotomy for intramural and subserous myomata. However, this technique is still the subject of debate. With good surgical experience, the risk of perioperative complications is comparable with conventional surgery. Laparoscopic myomectomy is associated with faster postoperative recovery, and could potentially reduce the risk of postoperative adhesions compared with laparotomy. Spontaneous uterine rupture, although uncommon after laparoscopic myomectomy, is still a concern. The risk of recurrence seems to be higher after laparoscopic myomectomy than after myomectomy performed by laparotomy. Uterine artery embolization is another new and attractive treatment for patients with symptomatic fibroids. Uterine artery embolization provides excellent relief for abnormal bleeding, pelvic pain, and bulk-related symptoms. Early reports show that uterine artery embolization is associated with normal reproductive and obstetric functions. This technique is associated with a shorter hospital stay and a rapid recovery time.

SUMMARY

Laparoscopic myomectomy and uterine artery embolization are being performed more than ever. Current evidence proves the safety, reliability and reproducibility of both procedures. However, prospective randomized controlled trials comparing both procedures with conventional myomectomy are needed.

What are the implications of myomas on fertility? A need for a debate?

In order to evaluate the relationship between leiomyomas and infertility, which remains a subject of debate, we have tried to evaluate the impact of myomas on fertility and pregnancy outcome in different conditions where myomas are implicated. Medline research was conducted of publications appearing between January 1988 and August 2001 on the subjects of myomas and myomectomy and their impact on fertility and pregnancy outcome in infertile women. A total of 106 manuscripts were consulted. The incidence of myomas in infertile women without any obvious cause of infertility is estimated to be 1-2.4%. The relationship between leiomyomas and infertility remains a subject of debate. The question is: do myomas influence fertility? We are obliged to conclude that the question remains. The absence of an answer to this crucial question is probably due to the fact that we have not yet conducted the appropriate prospective studies required to obtain any clear results.

Determinants of pregnancy rate and obstetric outcome after laparoscopic myomectomy for infertility

OBJECTIVE

To determine the effect of myomectomy on infertility and to assess the factors influencing reproductive outcome.

DESIGN

Retrospective study.

SETTING

Tertiary care center.

PATIENT(S)

One hundred and three infertile women with uterine leiomyoma who had had infertility >2 years and a follow-up time >12 months were enrolled. Follow-up was complete for 88 patients, including 28 (31.8%) with primary infertility and 44 (50%) with unexplained infertility. The mean (+/-SD) age of the patients was 36.1 +/- 2.1 years.

INTERVENTION(S)

Laparoscopic myomectomy.

MAIN OUTCOME MEASURE(S)

Pregnancy rate according to patient and fibroid characteristics.

RESULT(S)

Forty-two patients became pregnant (40.7%). The mean (+/-SD) delay in conception was 7.5 +/- 2.6 months. Nearly 80% of the women conceived spontaneously. Of 44 pregnancies in 42 women, 36 live newborns were delivered. No dehiscence of uterine scar occurred. The pregnancy rate was significantly higher in women <35 years of age or <3 years of infertility. Women with unexplained infertility had higher pregnancy rate than did women with multifactorial infertility (P<.001). No difference was noted in pregnancy rates according to fibroid characteristics.

CONCLUSION(S)

Fertility and pregnancy after laparoscopic myomectomy depend primarily on patient age, duration of infertility before myomectomy, and existence of associated infertility factors.