Pregnancy outcomes and deliveries after laparoscopic myomectomy

Patency of uterine wall in pregnancies following assisted and spontaneous conception with antecedent laparoscopic and abdominal myomectomies - a difficult case and systematic review

A case of uterine rupture at 24 weeks in a pregnancy succeeding myomectomy and triple embryo transfer is described and literature is reviewed systematically to evaluate the importance of uterine rupture in pregnancies after myomectomy in general and some important sub-populations. Systematic search identified 179 papers and following a strategical selection process 45 studies were analyzed in detail, including 6 cohort and 19 observational studies, 3 case series and 17 case reports. Comparison of risk of uterine rupture after abdominal and laparoscopic myomectomy is made. In pregnancies after IVF number of embryos transferred are determined. Optimal contraceptive intervals and surgical techniques are discussed. The consequences of these observations are analyzed and conclusions are made which can assist individualizing treatment options and improve patient selection.

Proceedings from the Third National Institutes of Health International Congress on Advances in Uterine Leiomyoma Research: comprehensive review, conference summary and future recommendations

BACKGROUND Uterine fibroids are the most common gynecologic tumors in women of reproductive age yet the etiology and pathogenesis of these lesions remain poorly understood. Age, African ancestry, nulliparity and obesity have been identified as predisposing factors for uterine fibroids. Symptomatic tumors can cause excessive uterine bleeding, bladder dysfunction and pelvic pain, as well as associated reproductive disorders such as infertility, miscarriage and other adverse pregnancy outcomes. Currently, there are limited noninvasive therapies for fibroids and no early intervention or prevention strategies are readily available. This review summarizes the advances in basic, applied and translational uterine fibroid research, in addition to current and proposed approaches to clinical management as presented at the 'Advances in Uterine Leiomyoma Research: 3rd NIH International Congress'. Congress recommendations and a review of the fibroid literature are also reported. METHODS This review is a report of meeting proceedings, the resulting recommendations and a literature review of the subject. RESULTS The research data presented highlights the complexity of uterine fibroids and the convergence of ethnicity, race, genetics, epigenetics and environmental factors, including lifestyle and possible socioeconomic parameters on disease manifestation. The data presented suggest it is likely that the majority of women with uterine fibroids will have normal pregnancy outcomes; however, additional research is warranted. As an alternative to surgery, an effective long-term medical treatment for uterine fibroids should reduce heavy uterine bleeding and fibroid/uterine volume without excessive side effects. This goal has not been achieved and current treatments reduce symptoms only temporarily; however, a multi-disciplined approach to understanding the molecular origins and pathogenesis of uterine fibroids, as presented in this report, makes our quest for identifying novel targets for noninvasive, possibly nonsystemic and effective long-term treatment very promising. CONCLUSIONS The Congress facilitated the exchange of scientific information among members of the uterine leiomyoma research and health-care communities. While advances in research have deepened our knowledge of the pathobiology of fibroids, their etiology still remains incompletely understood. Further needs exist for determination of risk factors and initiation of preventive measures for fibroids, in addition to continued development of new medical and minimally invasive options for treatment.

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.

Fibroids, infertility and laparoscopic myomectomy

Objective:

To review the literature and summarize the available evidence about the relationship of fibroids with infertility and to review the role of laparoscopic myomectomy in infertility.

Materials and Methods:

Medline, PubMed, and Cochrane Databases were searched for articles published between 1980 and 2010.

Results:

Fertility outcomes are decreased in women with submucosal fibroids, and myomectomy is of value. Subserosal fibroids do not affect fertility outcomes, and removal may not confer benefit. Intramural fibroids appear to decrease fertility, but the results of therapy are unclear. Although pregnancy rates for women with leiomyomata, managed endoscopically, are similar to those after laparotomy, there is a risk of uterine rupture. The risk is essentially unknown. Finally, the risk of recurrence seems higher after laparoscopic myomectomy compared to laparotomy.

Conclusions:

Laparoscopic myomectomy, when performed by an experienced surgeon, can be considered a safe technique, with an extremely low failure rate and good results in terms of the outcome of pregnancy.

Complications of Uterine Fibroids and Their Management, Surgical Management of Fibroids, Laparoscopy and Hysteroscopy versus Hysterectomy, Haemorrhage, Adhesions, and Complications

A critical analysis of the surgical treatment of fibroids compares all available techniques of myomectomy. Different statistical analyses reveal the advantages of the laparoscopic and hysteroscopic approach. Complications can arise from the location of the fibroids. They range from intermittent bleedings to continuous bleedings over several weeks, from single pain episodes to severe pain, from dysuria and constipation to chronic bladder and bowel spasms. Very seldom does peritonitis occur. Infertility may result from continuous metro and menorrhagia. The difficulty of the laparoscopic and hysteroscopic myomectomy lies in achieving satisfactory haemostasis using the appropriate sutures. The hysteroscopic myomectomy requires an operative hysteroscope and a well-experienced gynaecologic surgeon.

Optimal timing and mode of delivery after cesarean with previous classical incision or myomectomy: a review of the data

Uterine rupture is an obstetrical emergency that can be catastrophic for the mother and fetus. Previous uterine surgery, including previous cesarean delivery or myomectomy, is an established risk factor, although the exact magnitude of the associated risk remains uncertain. We reviewed the literature related to uterine rupture after previous cesarean delivery with classical incision or myomectomy in an attempt to quantify outcomes associated with various management strategies. Although cesarean delivery with a classical incision is relatively uncommon (representing 0.3%-0.4% of deliveries), it presents a significant risk of rupture in subsequent pregnancies (1%-12% on the basis of published reports). Available data suggest that scheduled cesarean at 36-37 weeks optimizes both maternal and fetal outcomes in these cases. Patients with previous myomectomy are more frequently encountered in the obstetrical population. The risk of uterine rupture in subsequent pregnancies in these women is substantially lower than those with a history of previous classical incision (0.5%-0.7% on the basis of published reports). Although less common, given the potentially devastating consequences of uterine rupture, scheduled delivery at 38 weeks is suggested in those women requiring cesarean delivery. Despite the lack of well-controlled studies, preferred management strategies can be gleaned from previously published data to optimize maternal and fetal outcomes in women with these risk factors.

Laparoscopic myomectomy: do size, number, and location of the myomas form limiting factors for laparoscopic myomectomy?

STUDY OBJECTIVE

To assess whether it is possible for an experienced laparoscopic surgeon to perform efficient laparoscopic myomectomy regardless of the size, number, and location of the myomas.

DESIGN

Prospective observational study (Canadian Task Force classification II-1).

SETTING

Tertiary endoscopy center.

PATIENTS

A total of 505 healthy nonpregnant women with symptomatic myomas underwent laparoscopic myomectomy at our center. No exclusion criteria were based on the size, number, or location of myomas.

INTERVENTIONS

Laparoscopic myomectomy and modifications of the technique: enucleation of the myoma by morcellation while it is still attached to the uterus with and without earlier devascularization.

MEASUREMENTS AND MAIN RESULTS

In all, 912 myomas were removed in these 505 patients laparoscopically. The mean number of myomas removed was 1.85 +/- 5.706 (95% CI 1.72-1.98). In all, 184 (36.4%) patients had multiple myomectomy. The mean size of the myomas removed was 5.86 +/- 3.300 cm in largest diameter (95% CI 5.56-6.16 cm). The mean weight of the myomas removed was 227.74 +/- 325.801 g (95% CI 198.03-257.45 g) and median was 100 g. The median operating time was 60 minutes (range 30-270 minutes). The median blood loss was 90 mL (range 40-2000 mL). Three comparisons were performed on the basis of size of the myomas (<10 cm and >or=10 cm in largest diameter), number of myomas removed (<or=4 and >or=5 myomas), and the technique (enucleation of the myomas by morcellation while the myoma is still attached to the uterus and the conventional technique). In all these comparisons, although the mean blood loss, duration of surgery, and hospital stay were greater in the groups in which larger myomas or more myomas were removed or the modified technique was performed as compared with their corresponding study group, the weight and size of removed myomas were also proportionately larger in these groups. Two patients were given the diagnosis of leiomyosarcoma in their histopathology and 1 patient developed a diaphragmatic parasitic myoma followed by a leiomyoma of the sigmoid colon. Six patients underwent laparoscopic hysterectomy 4 to 6 years after the surgery for recurrent myomas. One conversion to laparotomy occurred and 1 patient underwent open subtotal hysterectomy for dilutional coagulopathy.

CONCLUSION

Laparoscopic myomectomy can be performed by experienced surgeons regardless of the size, number, or location of the myomas.

Prospective evaluation for the feasibility and safety of vaginal birth after laparoscopic myomectomy

STUDY OBJECTIVE

To estimate the feasibility and safety of vaginal birth after laparoscopic myomectomy (LM).

DESIGN

Prospective clinical study (Canadian Task Force classification II-2).

SETTING

University hospital.

PATIENTS

The study was performed on 1334 patients who underwent LM at our hospital from January 2000 through December 2005.

INTERVENTIONS

Laparoscopic myomectomy.

MEASUREMENTS AND MAIN RESULTS

The potential of a safe vaginal birth after LM was discussed with all 1334 patients before and after their LM. A strict protocol for a vaginal birth after LM was prepared using the criteria for a vaginal birth after cesarean section (CS). Of the 221 women who became pregnant after LM by December 2006, 111 were scheduled to deliver at our hospital. The findings at LM in these patients were as follows: mean diameter of the largest myoma (mean +/- SD, 95% CI), 66.1 +/- 18.8 (62.6-69.6) mm; and mean number of enucleated myomas, 3.5 +/- 3.6 (2.8-4.2). The endometrium was opened in 13 patients. Of the 111 patients, 82 patients opted for a vaginal delivery and 29 patients requested a CS. Of the 82 patients, 8 underwent an elective CS because of complications of pregnancy. Vaginal delivery was completed in 59 (79.7%) of the remaining 74 patients. The 15 patients who failed vaginal delivery underwent a CS: eleven because of failure to progress in labor or absence of spontaneous labor by 42 weeks of gestation; and 4 because of a nonreassuring fetal status during labor. No significant differences in delivery outcomes existed between the successful and failed group. None of the patients had a uterine rupture.

CONCLUSION

Uterine rupture during pregnancy after LM is rare, and vaginal birth after LM appears to be safe in selected patients who meet our criteria.

The uterus and fertility

OBJECTIVE

To review the current understanding of the role the uterus plays in embryo implantation and to outline congenital anomalies and acquired diseases that impact normal uterine function.

DESIGN

The publications related to the embryo implantation, Mullerian anomalies, uterine polyps, uterine synechiae, and myomas were identified through Medline and reviewed.

CONCLUSION(S)

Congenital anomalies and acquired diseases of the uterus may negatively impact on the complex processes of embryo implantation. Hysteroscopic surgery to correct uterine septa, intrauterine synechiae, and myomas that distort the uterine cavity may benefit women with infertility or recurrent pregnancy loss. The effect of endometrial polyps on fertility is uncertain, but their removal, once identified, is justifiable. Complex congenital anomalies such as unicornuate uterus and uterus didelphys may negatively affect fertility and pregnancy outcome, and surgical treatment may benefit select patients.

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.

Pregnancy outcomes following treatment for fibroids: uterine fibroid embolization versus laparoscopic myomectomy

PURPOSE OF REVIEW

The management of uterine fibroids in patients requiring treatment who desire future fertility remains controversial. Myomectomy has been the most common operative procedure to improve pregnancy rates and outcomes. Uterine fibroid embolization is an increasingly popular, minimally invasive treatment for fibroids. This review aims to provide critical analysis of available data on pregnancy following myomectomy and uterine artery embolization.

RECENT FINDINGS

Patients with distorted uterine cavities due to submucosal fibroids of more than 2 cm have higher pregnancy rates following hysteroscopic resection. Pregnancy rates following myomectomy, both via laparoscopy and laparotomy, are in the 50-60% range, with most having good outcomes. Pregnancy rates following uterine artery embolization have not been established. Pregnancies following uterine artery embolization had higher rates of preterm delivery (odds ratio 6.2, 95% confidence interval 1.4-27.7) and malpresentation (odds ratio 4.3, 95% confidence interval 1.0-20.5) than pregnancies following laparoscopic myomectomy.

SUMMARY

Both myomectomy and uterine artery embolization are safe and effective fibroid treatments, which should be discussed with appropriate candidates. Pregnancy complications, most importantly preterm delivery, spontaneous abortion, abnormal placentation and postpartum hemorrhage, are increased following uterine artery embolization compared to myomectomy. Although most pregnancies following uterine artery embolization have good outcomes, myomectomy should be recommended as the treatment of choice over uterine artery embolization in most patients desiring future fertility.

Pregnancy outcomes following laparoscopic myomectomy and single-layer myometrial closure

BACKGROUND

To evaluate pregnancy outcomes following laparoscopic myomectomy and single-layer myometrial closure.

METHODS

This study conducted at a private advanced endoscopy and assisted reproductive technology centre retrospectively evaluated outcomes of 115 women who had pregnancies subsequent to laparoscopic myomectomy.

RESULTS

Of the 217 women followed up, 115 had pregnancies subsequent to a laparoscopic myomectomy. Of 141 pregnancies, there were 87 Caesarean sections, 19 vaginal deliveries, 29 abortions and 6 ectopic pregnancies. There were no incidents of uterine scar rupture in any of these pregnancies.

CONCLUSIONS

Uterine rupture during pregnancies following laparoscopic myomectomy is rare following single-layer myometrial closure.

Fibroids in Pregnancy???Common but Poorly Understood

Uterine fibroids are the most common benign tumors in women, occurring in approximately 20% to 30% of women of reproductive age. They are therefore common in pregnancy. The true incidence of fibroids during pregnancy is, however, unknown, but reported rates vary from as low as 0.1% of all pregnancies to higher rates of 12.5%. It seems that pregnancy has little or no effect on the overall size of fibroids despite the occurrence of red degeneration in early pregnancy. Fibroids, however, affect pregnancy and delivery in several ways, with abdominal pain, miscarriage, malpresentation, and difficult delivery being the most frequent complications. The size, location, and number of fibroids and their relation to the placenta are critical factors. Ultrasound scanning plays a central role in diagnosing and monitoring fibroids during pregnancy and in determining the relative position of the fibroids to the placenta. It is equally useful for detecting heterogeneous echo patterns associated with the appearance of pain in pregnancy. Color flow Doppler scanning differentiates fibroids from myometrial thickening, which may be mistaken for fibroids. Few treatment options are available during pregnancy, but in carefully selected patients, myomectomy has been performed successfully without jeopardizing pregnancy outcome. A successful pregnancy and delivery is common with appropriate surveillance and supportive management.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians

LEARNING OBJECTIVES

After completion of this article, the reader should be able to summarize the influence of pregnancy on fibroids, to explain the influence of fibroids on pregnancy, and to outline the management of fibroids during pregnancy.

Les limites de la myomectomie cœlioscopique

Feasibility of laparoscopic myomectomy has been already shown with numerous clinical studies. Short-term benefits of this procedure are nowadays established. Its limits are related to the surgical technique, the myoma process, and the clinical context of the patient. By using preoperative exclusion criteria, particularly the size and the number of myomas, laparoscopic treatment is possible with little laparoconversion and complications rates. One could be in doubt about the risk of uterine rupture during a pregnancy occurring after laparoscopic myomectomy. In infertile patients, this procedure is as effective as laparotomy, even though its benefits in terms of postoperative adhesions should be demonstrated. Less invasive surgery should be preferred.

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.

Intraoperative ultrasound during a laparoscopic myomectomy

OBJECTIVE

To report a gynecologic use of a laparoscopic ultrasound transducer to isolate a myoma for surgical removal.

DESIGN

Case report.

SETTING

University-based infertility practice.

PATIENT(S)

A 44-year-old woman gravida 1 para 1 with history of a first trimester miscarriage who desired pregnancy as a participant in the donor egg program.

INTERVENTION(S)

Before she entered the assisted reproduction program, a patient was found to have a myoma that was greater than 2 cm with both intramural and submucosal components. During the laparoscopic evaluation, a laparoscopic ultrasound transducer helped identify and properly locate the myoma in what otherwise appeared to be a normal uterus. Appropriate laparoscopic hysterotomy incision was then made, thereby minimizing uterine trauma.

MAIN OUTCOME MEASURE(S)

Appropriately placed hysterotomy incision and successful reconstruction of uterus.

RESULT(S)

After the successful laparoscopic myomectomy, the patient achieved a pregnancy in our donor oocyte program.

CONCLUSION(S)

Laparoscopic intraoperative ultrasound can help gynecologic surgeons complete a laparoscopic myomectomy.