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Acharya N, Singhal S, Agrawal M, Singh N, Verma N. Lantern on Dome of St. Paul's Cathedral - An Apt Metaphor for a Challenging Leiomyoma. J Midlife Health 2021; 11:181-184. [PMID: 33384545 PMCID: PMC7718941 DOI: 10.4103/jmh.jmh_143_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 02/28/2020] [Accepted: 03/03/2020] [Indexed: 11/24/2022] Open
Abstract
Fibroids are ubiquitous in women of the reproductive age group more so in midlife. The cervical fibroids are challenging to operating surgeons because it distorts the surgical anatomy of the pelvis and urogenital system. The metaphor given historically to this condition is apt as the uterus appears like a lantern sitting on the dome of cervical fibroid similar to the dome of the cathedral. Here, we report two cases of cervical fibroid in perimenopausal age group of different sizes managed by following specific steps.
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Affiliation(s)
- Neema Acharya
- Department of Obstetrics and Gynaecology, Datta Meghe Institute of Medical Sciences, Wardha, Maharashtra, India
| | - Sonakshi Singhal
- Department of Obstetrics and Gynaecology, Datta Meghe Institute of Medical Sciences, Wardha, Maharashtra, India
| | - Mohit Agrawal
- Department of Obstetrics and Gynaecology, Datta Meghe Institute of Medical Sciences, Wardha, Maharashtra, India
| | - Nidhi Singh
- Department of Obstetrics and Gynaecology, Datta Meghe Institute of Medical Sciences, Wardha, Maharashtra, India
| | - Neha Verma
- Department of Obstetrics and Gynaecology, Datta Meghe Institute of Medical Sciences, Wardha, Maharashtra, India
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Ziętek-Strobl A, Futyma K, Kuna-Broniowska I, Wojtaś M, Rechberger T. Urogynaecological Symptoms among Oncological Survivors and Impact of Oncological Treatment on Pelvic Floor Disorders and Lower Urinary Tract Symptoms. A Six-Month Follow-Up Study. J Clin Med 2020; 9:E2804. [PMID: 32872660 PMCID: PMC7563446 DOI: 10.3390/jcm9092804] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Revised: 07/29/2020] [Accepted: 08/25/2020] [Indexed: 11/25/2022] Open
Abstract
It has been widely underlined that both gynaecological malignancies and urogynaecological disorders are often associated with high stress and have a negative impact on the quality of life and psychological well-being of women affected. Knowledge of the pelvic anatomy is crucial in recommending and carrying out the least harmful although successful treatment. Subsequent chemoradiation may also induce or exaggerate troublesome symptoms. The aim of the study was to establish the frequency of urogynaecological symptoms (stress urinary incontinence, urgency, pelvic organ prolapse) and to assess the impact of surgical treatment and additional oncological therapy: pelvic radiation, chemoradiation, chemotherapy, on the prevalence of pelvic floor dysfunctions (PFD) and lower urinary tract symptoms (LUTS) in patients suffering from gynecological malignancies. The study group consisted of 160 women, diagnosed with gynaecological malignancy, who underwent surgical treatment and additional adjuvant treatment as necessary. To establish the QoL and prevalence of PFD Urinary Distress Inventory-6 (UDI-6), Incontinence Impact Questionnaire 7 (II-Q7), King's Health Questionnaire (KHQ) and the SF-36 Questionnaire were used. Herein, 69 patients reported urinary incontinence (UI) and 67 reported symptoms of pelvic organ prolapse (POP). After the six months follow-up UI was found in 78 patients, 25 patients showed de novo symptoms, 65 patients reported POP and 10 patients demonstrated de novo POP. Our data show that urogynaecological symptoms are not correlated with the type of malignancy, but with the extensiveness of surgery.
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Affiliation(s)
- Alicja Ziętek-Strobl
- 2nd Department of Gynecology, Medical University of Lublin, Jaczewskiego 8, 20-954 Lublin, Poland; (K.F.); (M.W.); (T.R.)
| | - Konrad Futyma
- 2nd Department of Gynecology, Medical University of Lublin, Jaczewskiego 8, 20-954 Lublin, Poland; (K.F.); (M.W.); (T.R.)
| | - Izabela Kuna-Broniowska
- Department of Applied Mathematics and Computer Science, University of Life Science, Akademicka 13, 20-950 Lublin, Poland;
| | - Małgorzata Wojtaś
- 2nd Department of Gynecology, Medical University of Lublin, Jaczewskiego 8, 20-954 Lublin, Poland; (K.F.); (M.W.); (T.R.)
| | - Tomasz Rechberger
- 2nd Department of Gynecology, Medical University of Lublin, Jaczewskiego 8, 20-954 Lublin, Poland; (K.F.); (M.W.); (T.R.)
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Sirkeci RF, Belli AM, Manyonda IT. Treating symptomatic uterine fibroids with myomectomy: current practice and views of UK consultants. ACTA ACUST UNITED AC 2017; 14:11. [PMID: 28890674 PMCID: PMC5570799 DOI: 10.1186/s10397-017-1014-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2017] [Accepted: 06/12/2017] [Indexed: 12/23/2022]
Abstract
BACKGROUND The demand for uterus-sparing treatments is increasing as more women postpone childbirth to their 30-40s, when fibroids are more symptomatic. With an increasing choice of treatment options and changing care-provider profiles, now is an opportune time to survey current practices and opinions. Using a 25-stem questionnaire, a web-based survey was used to capture the practices and opinions of UK consultant gynecologists on the treatment of symptomatic fibroids, including the types of procedure most frequently used, methods used to reduce blood loss, and awareness and acceptability of treatment options, and to assess the impact of gender and experience of the treating gynecologist. RESULTS The response rate was 22%. Laparascopic myomectomy is used least frequently, with 80% of the respondents using GnRHa preoperatively to minimize blood loss and correct anemia, while vasopressin is most frequently used to reduce intraoperative blood loss. Female consultants operate significantly less frequently than males. Those with more than 10 years consultant experience are more likely to perform an open myomectomy compared to those with less than 10 years experience. CONCLUSIONS Compared to a similar survey performed 10 years ago, surgical methods remain to be the most common treatments, but use of less invasive treatments such as UAE has increased. Consultants' attitudes appear to be responding to the patient demand for less radical treatments. However, it is yet to be seen if the changing consultant demographics will keep up with this demand. The low response rate warrants cautious interpretation of the results, but they provide an interesting snapshot of current views and practices.
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Affiliation(s)
| | - Anna Maria Belli
- Department of Radiology, St George's Healthcare NHS Foundation Trust, St George's, University of London, London, UK
| | - Isaac T Manyonda
- Department of Obstetrics and Gynecology, St George's Healthcare NHS Foundation Trust, St George's, University of London, Blackshaw Road, Tooting, SW17 0QT London, UK
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Sancho JM, Delgado VSDLC, Valero MJN, Soteras MG, Amate VP, Carrascosa AA. Hysteroscopic myomectomy outcomes after 3-month treatment with either Ulipristal Acetate or GnRH analogues: a retrospective comparative study. Eur J Obstet Gynecol Reprod Biol 2016; 198:127-130. [PMID: 26871272 DOI: 10.1016/j.ejogrb.2016.01.014] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2015] [Revised: 12/11/2015] [Accepted: 01/02/2016] [Indexed: 11/18/2022]
Abstract
Ulipristal Acetate (UPA) modifies the endometrium, as well as fibroids, and therefore it might make hysteroscopic surgery more difficult. To confirm that pre-treatment with UPA is as safe and effective an option as pre-treatment with GnRH analogues, considered the gold standard. We present the first series of 26 hysteroscopic myomectomies after 3 months treatment with UPA and we compare the results with a series of 24 cases pretreated with GnRH analogues. This was a retrospective cohort study between July 2013 and May 2015. We analyszed patients with submucous myomas >2.5 in diameter. Hysteroscopic myomectomy was performed after 3 months of treatment with either UPA (5mg daily) or the GnRH agonist (3.75mg/month). Both groups were similar in age, myoma initial size and classification. There were no significant differences between UPA and GnRHa treated groups in terms of percentage of myomas resected (93% vs 98%), duration of surgery (38 vs 37min), fluid deficit (200 vs 350ml) and complications. In the surgeon's subjective opinion, UPA treatment was associated with an easier resection. Based on our experience, previous treatment with UPA does not difficult Hhysteroscopic myomectomy. Endometrial changes have no impact on surgery. Safety and feasibility are comparable to hysteroscopic myomectomies with previous treatment with GnRH analogues. This allows us to take advantage of the reduction in size of fibroids before surgery with less side effects.
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Moroni R, Vieira C, Ferriani R, Candido-Dos-Reis F, Brito L. Pharmacological treatment of uterine fibroids. Ann Med Health Sci Res 2014; 4:S185-92. [PMID: 25364587 PMCID: PMC4212375 DOI: 10.4103/2141-9248.141955] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Uterine fibroids (UF) are common, benign gynecologic tumors, affecting one in three to four women, with estimates of up to 80%, depending on the population studied. Their etiology is not well established, but it is under the influence of several risk factors, such as early menarche, nulliparity and family history. More than 50% of affected women are asymptomatic, but the lesions may be related to bothersome symptoms, such as abnormal uterine bleeding, pelvic pain and bloating or urinary symptoms. The treatment of UF is classically surgical; however, various medical options are available, providing symptom control while minimizing risks and complications. A large number of clinical trials have evaluated commonly used medical treatments and potentially effective new ones. Through a comprehensive literature search using PubMed, EMBASE, CENTRAL, Scopus and Google Scholar databases, through which we included 41 studies out of 7658 results, we thoroughly explored the different pharmacological options available for management of UF, their indications, advantages and disadvantages.
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Affiliation(s)
- Rm Moroni
- Department of Gynecology and Obstetrics, Ribeirão Preto School of Medicine, University of São Paulo, São Paulo, Brazil
| | - Cs Vieira
- Department of Gynecology and Obstetrics, Ribeirão Preto School of Medicine, University of São Paulo, São Paulo, Brazil
| | - Ra Ferriani
- Department of Gynecology and Obstetrics, Ribeirão Preto School of Medicine, University of São Paulo, São Paulo, Brazil
| | - Fj Candido-Dos-Reis
- Department of Gynecology and Obstetrics, Ribeirão Preto School of Medicine, University of São Paulo, São Paulo, Brazil
| | - Lgo Brito
- Department of Gynecology and Obstetrics, Ribeirão Preto School of Medicine, University of São Paulo, São Paulo, Brazil
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Di Tommaso S, Massari S, Malvasi A, Vergara D, Maffia M, Greco M, Tinelli A. Selective genetic analysis of myoma pseudocapsule and potential biological impact on uterine fibroid medical therapy. Expert Opin Ther Targets 2014; 19:7-12. [DOI: 10.1517/14728222.2014.975793] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Abstract
BACKGROUND Benign smooth muscle tumours of the uterus, known as fibroids or myomas, are often symptomless. However, about one-third of women with fibroids will present with symptoms that are severe enough to warrant treatment. The standard treatment of symptomatic fibroids is hysterectomy (that is surgical removal of the uterus) for women who have completed childbearing, and myomectomy for women who desire future childbearing or simply want to preserve their uterus. Myomectomy, the surgical removal of myomas, can be associated with life-threatening bleeding. Excessive bleeding can necessitate emergency blood transfusion. Knowledge of the effectiveness of the interventions to reduce bleeding during myomectomy is essential to enable evidence-based clinical decisions. This is an update of the review published in The Cochrane Library (2011, Issue 11). OBJECTIVES To assess the effectiveness, safety, tolerability and costs of interventions to reduce blood loss during myomectomy. SEARCH METHODS In June 2014, we conducted electronic searches in the Cochrane Menstrual Disorders and Subfertility Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL and PsycINFO, and trial registers for ongoing and registered trials. SELECTION CRITERIA We selected randomised controlled trials (RCTs) that compared potential interventions to reduce blood loss during myomectomy to placebo or no treatment. DATA COLLECTION AND ANALYSIS The two authors independently selected RCTs for inclusion, assessed the risk of bias and extracted data from the included RCTs. The primary review outcomes were blood loss and need for blood transfusion. We expressed study results as mean differences (MD) for continuous data and odds ratios for dichotomous data, with 95% confidence intervals (CI). We assessed the quality of evidence using GRADE methods. MAIN RESULTS Eighteen RCTs with 1250 participants met our inclusion criteria. The studies were conducted in hospital settings in low, middle and high income countries.Blood lossWe found significant reductions in blood loss with the following interventions: vaginal misoprostol (2 RCTs, 89 women: MD -97.88 ml, 95% CI -125.52 to -70.24; I(2) = 43%; moderate-quality evidence); intramyometrial vasopressin (3 RCTs, 128 women: MD -245.87 ml, 95% CI -434.58 to -57.16; I(2) = 98%; moderate-quality evidence); intramyometrial bupivacaine plus epinephrine (1 RCT, 60 women: MD -68.60 ml, 95% CI -93.69 to -43.51; low-quality evidence); intravenous tranexamic acid (1 RCT, 100 women: MD -243 ml, 95% CI -460.02 to -25.98; low-quality evidence); gelatin-thrombin matrix (1 RCT, 50 women: MD -545.00 ml, 95% CI -593.26 to -496.74; low-quality evidence); intravenous ascorbic acid (1 RCT, 102 women: MD -411.46 ml, 95% CI -502.58 to -320.34; low-quality evidence); vaginal dinoprostone (1 RCT, 108 women: MD -131.60 ml, 95% CI -253.42 to -9.78; low-quality evidence); loop ligation of the myoma pseudocapsule (1 RCT, 70 women: MD -305.01 ml, 95% CI -354.83 to -255.19; low-quality evidence); and a fibrin sealant patch (1 RCT, 70 women: MD -26.50 ml, 95% CI -44.47 to -8.53; low-quality evidence). We found evidence of significant reductions in blood loss with a polyglactin suture (1 RCT, 28 women: MD -1870.0 ml, 95% CI -2547.16 to 1192.84) or a Foley catheter (1 RCT, 93 women: MD -240.70 ml, 95% CI -359.61 to -121.79) tied around the cervix. However, pooling data from these peri-cervical tourniquet RCTs revealed significant heterogeneity of the effects (2 RCTs, 121 women: MD (random) -1019.85 ml, 95% CI -2615.02 to 575.32; I(2) = 95%; low-quality evidence). There was no good evidence of an effect on blood loss with oxytocin, morcellation or clipping of the uterine artery.Need for blood transfusion We found significant reductions in the need for blood transfusion with vasopressin (2 RCTs, 90 women: OR 0.15, 95% CI 0.03 to 0.74; I(2) = 0%; moderate-quality evidence); peri-cervical tourniquet (2 RCTs, 121 women: OR 0.09, 95% CI 0.01 to 0.84; I(2) = 69%; low-quality evidence); gelatin-thrombin matrix (1 RCT, 100 women: OR 0.01, 95% CI 0.00 to 0.10; low-quality evidence) and dinoprostone (1 RCT, 108 women: OR 0.17, 95% CI 0.04 to 0.81; low-quality evidence), but no evidence of effect on the need for blood transfusion with misoprostol, oxytocin, tranexamic acid, ascorbic acid, loop ligation of the myoma pseudocapsule and a fibrin sealant patch.There were insufficient data on the adverse effects and costs of the different interventions. AUTHORS' CONCLUSIONS At present there is moderate-quality evidence that misoprostol may reduce bleeding during myomectomy, and low-quality evidence that bupivacaine plus epinephrine, tranexamic acid, gelatin-thrombin matrix, a peri-cervical tourniquet, ascorbic acid, dinoprostone, loop ligation and a fibrin sealant patch may reduce bleeding during myomectomy. There is no evidence that oxytocin, morcellation and temporary clipping of the uterine artery reduce blood loss. Further well designed studies are required to establish the effectiveness, safety and costs of different interventions for reducing blood loss during myomectomy.
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Affiliation(s)
| | - Charles Shey Wiysonge
- Stellenbosch UniversityCentre for Evidence‐based Health CareFrancie van Zijl DriveTygerbergCape TownSouth Africa7505
- South African Medical Research CouncilSouth African Cochrane CentreCape TownSouth Africa
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Use of GnRH analogues pre-operatively for hysteroscopic resection of submucous fibroids: a systematic review and meta-analysis. Eur J Obstet Gynecol Reprod Biol 2014; 177:11-8. [DOI: 10.1016/j.ejogrb.2014.03.009] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2013] [Revised: 02/19/2014] [Accepted: 03/06/2014] [Indexed: 11/18/2022]
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Abstract
BACKGROUND Uterine myomas (fibroids) are benign tumours of the uterus. Myomectomy, the surgical removal of myomas, can be associated with life-threatening bleeding and prolonged postoperative stay. Knowledge of the effectiveness of the interventions to reduce bleeding during myomectomy is essential to enable evidence-based clinical decisions. This is an update of the review published in The Cochrane Library Issue 3, 2009. OBJECTIVES To assess the effectiveness, safety, tolerability, and costs of interventions to reduce blood loss during myomectomy. SEARCH STRATEGY Electronic searches were undertaken in the Cochrane Menstrual Disorders and Subfertility Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 3), MEDLINE (1950 to February 2011), EMBASE (1980 to February 2011), CINAHL (1982 to February 2011), and PsycINFO (1801 to February 2011). SELECTION CRITERIA Only randomised controlled trials (RCTs) that compared the use of interventions to reduce blood loss during myomectomy to placebo or no treatment were included. DATA COLLECTION AND ANALYSIS The two authors independently selected RCTs for inclusion, assessed the methodological quality of trials, and extracted data. We expressed study results as mean differences (MD) for continuous data and odds ratios for dichotomous data, with 95% confidence intervals (CI). MAIN RESULTS Twelve RCTs with 674 participants met our inclusion criteria. The interventions were intramyometrial vasopressin (two RCTs), intravenous oxytocin (two RCTs), peri-cervical tourniquet (two RCTs), and one RCT each for vaginal misoprostol, gelatin thrombin matrix, chemical dissection with sodium-2-mercaptoethane sulfonate (mesna), intramyometrial bupivacaine plus epinephrine, tranexamic acid, and myoma enucleation by morcellation. We found significant reductions in blood loss with misoprostol (MD -149.00 ml, 95% CI -229.24 to -68.76), vasopressin (MD -298.72 ml, 95% CI -593.10 to -4.34; I(2) = 99%), bupivacaine plus epinephrine (MD -68.60 ml, 95% CI -93.69 to - 43.51), tranexamic acid (MD -243 ml, 95% CI -460 to -25.98), peri-cervical tourniquet (MD -289.44, 95% CI -406.55 to -172.32; I(2) = 95%), and gelatin-thrombin matrix (MD -545.00 ml, 95% CI -593.26 to -496.74). There was no evidence of an effect on blood loss with oxytocin or morcellation. None of the interventions significantly increased myomectomy-related complications. The trials did not assess the costs of the different interventions. AUTHORS' CONCLUSIONS There is limited evidence that misoprostol, vasopressin, bupivacaine plus epinephrine, tranexamic acid, gelatin thrombin matrix, peri-cervical tourniquet, and mesna may reduce bleeding during myomectomy. Bupivacaine plus epinephrine has limited clinical importance compared with other interventions as the clinical impact was small. There is no evidence that oxytocin and morcellation reduce blood loss. Further well designed studies are required to establish effectiveness, safety and the costs of different interventions for reducing blood loss during myomectomy.
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Abstract
BACKGROUND Uterine myomas (fibroids) are benign tumours of the uterus. Myomectomy, the surgical removal of myomas, is an important treatment option especially for women who wish to preserve their uteri. The major problem with myomectomy is excessive bleeding, which can be life-threatening and prolong postoperative stay. Knowledge of the effectiveness of the interventions to reduce bleeding during myomectomy is essential to enable evidence-based clinical decisions. OBJECTIVES To assess the effectiveness, safety, tolerability, and costs of interventions to reduce blood loss during myomectomy. SEARCH STRATEGY Electronic searches were undertaken in the Cochrane Menstrual Disorders and Subfertility Group Specialised Register, CENTRAL (The Cochrane Library 2008, Issue 3), MEDLINE (1950 to September 2008), EMBASE (1980 to September 2008), CINAHL (1982 to September 2008), and PsycINFO (up to September 2008). SELECTION CRITERIA Only randomised controlled trials (RCTs) that compared the use of interventions to reduce blood loss during myomectomy to placebo or no treatment were included. DATA COLLECTION AND ANALYSIS The two authors independently selected RCTs for inclusion, assessed the methodological quality of trials, and extracted data. We expressed study results as mean differences (MD) for continuous data and odds ratios for dichotomous data, with 95% confidence intervals (CI). MAIN RESULTS Ten RCTs with 531 participants met our inclusion criteria: intramyometrial vasopressin and analogues (two trials), intravenous oxytocin (two trials), and one RCT for each of the interventions vaginal misoprostol, peri-cervical tourniquet, chemical dissection with sodium-2-mercaptoethane sulfonate (mesna), intramyometrial bupivacaine plus epinephrine, tranexamic acid and the enucleation of myoma by morcellation while it is attached to the uterus. We found significant reductions in blood loss with misoprostol (MD -149.00 ml, 95% CI -229.24 to -68.76), vasopressin and analogues (MD -298.72 ml, 95% CI -593.10 to -4.34), bupivacaine plus epinephrine (MD -68.60 ml, 95% CI -93.69 to - 43.51), tranexamic acid (MD -243 ml, 95% CI -460 to -25.98), and peri-cervical tourniquet (MD -1870.00 ml, 95% CI -2547.16 to -1192.84). There was no evidence of effect on blood loss with myoma enucleation by morcellation or oxytocin. The trials did not assess the tolerability and costs of the different interventions. AUTHORS' CONCLUSIONS Evidence is limited from a few RCTs that misoprostol, vasopressin, bupivacaine plus epinephrine, tranexamic acid, tourniquet, and mesna may reduce bleeding during myomectomy. There is no evidence that oxytocin and morcellation have an effect on intraoperative blood loss. There is a need for adequately powered RCTs to shed more light on the effectiveness, safety, and costs of different interventions in reducing blood loss during myomectomy.
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Affiliation(s)
- Eugene J Kongnyuy
- Child and Reproductive Health Group, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, UK, L3 5QA
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11
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Abstract
Fibroids are common amongst women of reproductive age. In women wanting to retain their fertility and/or uterus open myomectomy remains the most widely performed procedure. It is important to carefully counsel the patient about the pros and cons of surgery versus expectant management. Meticulous pre-operative evaluation and preparation will help ensure the procedure goes smoothly. Attention to the operating technique used is paramount in ensuring patient safety and surgical peace of mind. This review addresses the important aspects of open myomectomy including operative technique.
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Affiliation(s)
- Myvanwy McIlveen
- The Jessop Wing, Assisted Conception Unit, Sheffield S10 3SF, UK.
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Mukhopadhaya N, De Silva C, Manyonda IT. Conventional myomectomy. Best Pract Res Clin Obstet Gynaecol 2008; 22:677-705. [DOI: 10.1016/j.bpobgyn.2008.01.012] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Abstract
The ideal medical therapy for fibroids is, arguably, a tablet that is taken by mouth, once a day or, even better, once a week, with minimal, if any, side-effects, that induces fibroid regression and thus a resolution of symptoms rapidly, but without affecting fertility. Such a magic bullet does not yet exist, and there are no indications that one is on the horizon. Driven by the observation that fibroid growth is hormone dependent, current medical treatments mainly involve hormonal manipulations. Gonadotrophin-releasing hormone analogues (GnRHa) have been the most widely used, and while they do cause fibroid regression, they can only be used in the short term, as temporizing measures in the perimenopausal woman, or pre-operatively to reduce fibroid size, influence the type of surgery, restore haemoglobin levels and apparently reduce blood loss at operation. They are notorious for rebound growth of the fibroids upon cessation of therapy, and have major side-effects. GnRH antagonists avoid the initial flare effect seen with GnRHa therapy, but otherwise do not appear to have any additional advantages over GnRHa. Selective oestrogen receptor modulators, such as raloxifene, have been shown to induce fibroid regression effectively in post-, but not pre-, menopausal women; even in the former group, experience with these drugs is limited, and they are associated with significant side-effects. Aromatase inhibitors only appear to be effective in postmenopausal women, have potentially significant long-term side-effects, and experience with their use is also limited. There are suggestions that the levonorgestrel intra-uterine system can cause dramatic reduction in menstrual flow in women with fibroids, but to date there have been no RCTs of its use in these women, in whom rates of expulsion of the device appear to be high. The progesterone antagonists mifepristone and asoprisnil have shown significant promise and warrant further research, as they appear to show efficacy in inducing fibroid regression without major side-effects. However, they and the other hormonal therapies that alter oestrogen and progesterone production or function significantly (danazol, gestrinone) are not compatible with reproduction. Therefore, the quest for the ideal medical therapy for fibroid disease continues, and increasing understanding of fibroid biology is ushering in non-hormonal therapies, although all are confined to laboratory experimentation at present. In the meantime, surgical and radiological approaches remain the mainstay effective therapies.
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Affiliation(s)
- Srividhya Sankaran
- St George's Hospital NHS Trust, Department of Obstetrics and Gynaecology, Blackshaw Road, London SW17 0QT, UK
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Kongnyuy EJ, van den Broek N, Wiysonge CS. A systematic review of randomized controlled trials to reduce hemorrhage during myomectomy for uterine fibroids. Int J Gynaecol Obstet 2007; 100:4-9. [PMID: 17894936 DOI: 10.1016/j.ijgo.2007.05.050] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2007] [Accepted: 05/13/2007] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To assess the effectiveness and safety of interventions to reduce blood loss during myomectomy. METHODS Electronic searches of the Cochrane Library, MEDLINE, and EMBASE, between 1966 and 2006 for randomized controlled trials (RCTs). RESULTS We found significant reductions in blood loss with vaginal misoprostol (weighted mean difference [WMD] -149.00 mL, 95% confidence interval [CI] -229.24 to -68.76); intramyometrial vasopressin and analogues (WMD -298.72 mL, 95% CI -593.10 to -4.34); intramyometrial bupivacaine plus epinephrine (WMD -68.60 mL, 95% CI -93.69 to -43.51); and pericervical tourniquet (WMD -1870.00 mL, 95% CI -2547.16 to -1192.84). There was no evidence of effect in blood loss with myoma enucleation by morcellation and oxytocin. CONCLUSION There is limited evidence from a few RCTs that some interventions may reduce bleeding during myomectomy. There is need for adequately powered RCTs to shed more light on the effectiveness, safety, and cost of different interventions to reduce blood loss during myomectomy.
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Affiliation(s)
- E J Kongnyuy
- Child and Reproductive Health Group, Liverpool School of Tropical Medicine, Liverpool, UK.
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Hsu WC, Hwang JS, Chang WC, Huang SC, Sheu BC, Torng PL. Prediction of operation time for laparoscopic myomectomy by ultrasound measurements. Surg Endosc 2007; 21:1600-6. [PMID: 17294306 DOI: 10.1007/s00464-006-9189-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2006] [Accepted: 11/20/2006] [Indexed: 11/24/2022]
Abstract
BACKGROUND This study aimed to develop a regression-based prediction equation for operation time for laparoscopic myomectomy (LM) using ultrasound measurement. METHODS Patients who were to undergo laparoscopic myomectomy from March 2003 to December 2005 were enrolled prospectively in a tertiary institution. Ultrasound was performed before operation. The myoma weights were calculated and converted into mass units (g) by an assumed smooth muscle density of 1.04 g/cm3. Myomas were weighed immediately after operation, and the correlation between these two weights was assessed by linear regression and limits of agreement. A multivariate linear regression model was fitted to the ultrasound parameters and clinical variables to predict operation time. RESULTS Of 109 patients, 203 myomas were removed laparoscopically with a mean ultrasound-measured myoma weight of 137.9 (100.7) g, a diameter of the dominant myoma of 6.30 (1.92) cm, and an operation time of 125 (41) min. Strong correlations were observed between the ultrasound-measured and operated myoma weights. A predictive model, in which operation time = 0.14 x ultrasound-measured myoma weight + 1.68 x BMI + 5.21 x operated myoma number + 0.06 x (ultrasound-measured myoma weight x operated myoma number) + 43.97, was developed. CONCLUSIONS Operation time was significantly related to the myoma weight measured by ultrasound. The ultrasound-derived prediction equation is valid and reliable in predicting operation time for LM.
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Affiliation(s)
- Wen-Chiung Hsu
- Department of Obstetrics and Gynecology, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
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16
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Abstract
BACKGROUND Uterine myomas (fibroids) are benign tumours of the uterus. Myomectomy, the surgical removal of the myomas, is an important treatment option especially for women who desire to preserve their uteri. The major problem with myomectomy is excessive bleeding from increased uterine blood supply, and this can be life-threatening and prolong postoperative stay. Knowledge of the effectiveness of the interventions used to reduce blood loss during myomectomy is essential to enable evidence-based clinical decisions. OBJECTIVES To assess the effectiveness and safety of interventions (other than GnRH analogues) to reduce blood loss during myomectomy. SEARCH STRATEGY Electronic searches were undertaken in the Cochrane Menstrual Disorders and Subfertility Group specialised register, CENTRAL (Cochrane Library Issue 1, 2006), MEDLINE (1966 to March 2006), EMBASE (1980 to March 2006), Current Contents (1993 to March 2006), the National Research Register, and the National Library of Medicine's Clinical Trial Register (up to March 2006). SELECTION CRITERIA Only randomised controlled trials (RCTs) that compared interventions to reduce blood loss during myomectomy to placebo or no treatment were included. DATA COLLECTION AND ANALYSIS The two authors independently selected RCTs for inclusion, assessed the methodological quality and extracted data. We expressed study results as weighted mean differences (WMD) for continuous data, and odds ratios for dichotomous data. MAIN RESULTS Eight RCTs met the inclusion criteria: two on intramyometrial vasopressin and analogues, and one each on vaginal misoprostol, IV oxytocin, pericervical tourniquet, chemical dissection with mesna, intramyometrial bupivacaine plus epinephrine and the enucleation of myoma by morcellation while it is attached to the uterus. We found significant reductions in blood loss with misoprostol (WMD -149.00 ml, 95% confidence interval [CI] -229.24 to -68.76), vasopressin and analogues (WMD -298.72 ml, 95% CI -593.10 to -4.34), bupivacaine plus epinephrine (WMD -68.60 ml, 95% CI -93.69 to - 43.51), and pericervical tourniquet (WMD -1870.00 ml, 95% CI -2547.16 to -1192.84). There was no evidence of effect in blood loss with myoma enucleation by morcellation and oxytocin. The trials did not assess the tolerability and costs of different interventions. AUTHORS' CONCLUSIONS There is limited evidence from a few RCTs that misoprostol, vasopressin, bupivacaine plus epinephrine, tourniquet and mesna may reduce bleeding during myomectomy. There is no evidence that oxytocin and morcellation have an effect on intraoperative blood loss. There is need for adequately powered RCTs to shed more light on the effectiveness, safety and costs of different interventions in reducing blood loss during myomectomy.
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Affiliation(s)
- E J Kongnyuy
- University of Yaounde 1,PO Box 1364, Yaounde, Cameroon.
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17
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McIntosh E, Luengo-Fernandez R. Economic evaluation. Part 1: Introduction to the concepts of economic evaluation in health care. ACTA ACUST UNITED AC 2006; 32:107-12. [PMID: 16824302 DOI: 10.1783/147118906776276549] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Emma McIntosh
- Health Economics Research Centre, University of Oxford, Department of Public Health, Oxford, UK.
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18
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McIntosh E, Luengo-Fernandez R. Economic evaluation. Part 2: frameworks for combining costs and benefits in health care. ACTA ACUST UNITED AC 2006; 32:176-80. [PMID: 16857073 DOI: 10.1783/147118906777888242] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Emma McIntosh
- Department of Public Health, Health Economics Research Centre, University of Oxford, Oxford, UK.
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Brown PM, Farquhar CM, Lethaby A, Sadler LC, Johnson NP. Cost-effectiveness analysis of levonorgestrel intrauterine system and thermal balloon ablation for heavy menstrual bleeding. BJOG 2006; 113:797-803. [PMID: 16827763 DOI: 10.1111/j.1471-0528.2006.00944.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To compare the cost-effectiveness of levonorgestrel intrauterine system (LNG-IUS) (Mirena; Schering Co., Turku, Finland) and thermal balloon ablation (Thermachoicetrade mark; Gynecare Inc., Menlo Park, CA, USA) for the treatment of heavy menstrual bleeding. DESIGN An open, pragmatic, prospective randomised trial. SETTING A menstrual disorders clinic at National Women's Hospital, Auckland, New Zealand. POPULATION Seventy-nine women with self-defined heavy menstrual bleeding randomised to the LNG-IUS (40 women) or the thermal balloon ablation (39 women). METHODS Decision tree modelling using primary source data was used to identify the incremental cost-effectiveness of the two treatments. MAIN OUTCOME MEASURES Direct and indirect costs of medical treatment, including treatment costs, subsequent medical procedures, lost income and medical treatment for failed procedures. The change in quality of life as assessed by the Short Form-36 (SF-36) measured between time of treatment and 24 months was the primary outcome measure. Economic modelling examined the expected cost and outcome for a woman entering each treatment. Sensitivity analysis explored the robustness of the results. RESULTS The expected cost of treatment was $NZ1241 ($US869) for the LNG-IUS and $NZ2418 ($US1693) for the thermal balloon ablation. The LNG-IUS was associated with an increase of 15 points on the SF-36 scale, compared with 12 points for the thermal balloon ablation. Sensitivity analysis indicates that the results are robust to a 25% decrease in the price of the primary cost drivers and to variations in the rates of failed treatment between the conditions. CONCLUSION The LNG-IUS would appear to be cost-effective when compared with the thermal balloon ablation for treatment of heavy menstrual bleeding.
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Affiliation(s)
- P M Brown
- School of Population Health, University of Auckland, Auckland, New Zealand.
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20
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Nishiyama S, Saito M, Sato K, Kurishita M, Itasaka T, Shioda K. High recurrence rate of uterine fibroids on transvaginal ultrasound after abdominal myomectomy in Japanese women. Gynecol Obstet Invest 2006; 61:155-9. [PMID: 16391486 DOI: 10.1159/000090628] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2004] [Accepted: 07/20/2005] [Indexed: 11/19/2022]
Abstract
AIM To evaluate the recurrence rate of uterine fibroids (UF) after abdominal myomectomy and the risk factors for recurrences. METHODS In a retrospective study, transvaginal ultrasound examinations were performed in 135 women after abdominal myomectomy. The main outcome measures were cumulative UF recurrence rates after abdominal myomectomy. The Kaplan-Meier survival analysis was used to estimate the cumulative recurrence rate, and log-rank tests were applied to compare survival curves among different categorical groups of potential risk factors for recurrences. RESULTS The cumulative UF recurrence rates at 12 and 24 months after abdominal myomectomy were 12.4 and 46.0%, respectively. Women who had a history of previous myomectomy had a higher hazard of UF recurrence than women without such a history (hazard ratio 4.1, 95% confidence interval 1.20-13.6). The women having four or more UFs had a higher hazard than those who had less than four UFs (hazard ratio 3.7, confidence interval 1.41-9.88). After adjusting these variables to each other, the hazard ratio remained similar. CONCLUSIONS The UF recurrence rate detected by transvaginal ultrasound after abdominal myomectomy was high, but did not require any additional surgery. Physicians need to consider the timing of the myomectomy, taking into account complications of pregnancy and infertility due to UF recurrence.
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Affiliation(s)
- Sachie Nishiyama
- Department of Obstetrics and Gynecology, St. Luke's International Hospital, 9-1 Akashi-cho, Chuo-ku, Tokyo 104-8560, Japan
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21
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Gutmann JN, Corson SL. GnRH agonist therapy before myomectomy or hysterectomy. J Minim Invasive Gynecol 2005; 12:529-37; quiz 528, 538-9. [PMID: 16337584 DOI: 10.1016/j.jmig.2005.09.012] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2005] [Accepted: 08/03/2005] [Indexed: 10/25/2022]
Affiliation(s)
- Jacqueline N Gutmann
- Department of Obstetrics and Gynecology, Thomas Jefferson University Medical Center, Philadelphia, PA 19107, USA.
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23
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Abstract
Health resources are finite, and it is increasingly necessary to practise medicine within defined budgets. Hysterectomy is recognized as one of the most frequently performed of all major surgical operations and is of great economic as well as medical and social importance. A full assessment of the value of an intervention requires consideration of both economic and clinical outcomes. New alternative therapies to uterine excision have been introduced, and new ways of performing hysterectomy have been developed. Cost-effectiveness analysis enables each of these approaches to be meaningfully compared. Using such analytic techniques, hysterectomy can be shown to be an effective and cost-effective intervention across a variety of indications. The vaginal route is the most cost-effective approach. There seems to be no obvious advantage in conserving or retaining the cervix, but there is as yet no evidence about the cost-effectiveness of concomitant oophorectomy.
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Affiliation(s)
- Ray Garry
- King Edward Memorial Hospital, Bagot Road, Subiaco, Perth, WA 6008, Australia.
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Banu NS, Manyonda IT. Alternative medical and surgical options to hysterectomy. Best Pract Res Clin Obstet Gynaecol 2005; 19:431-49. [PMID: 15985257 DOI: 10.1016/j.bpobgyn.2005.01.006] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The range of alternatives to hysterectomy includes 'expanded' oral medical regimens, the levonorgestrel-releasing intrauterine system (LNG-IUS), a wide range of endometrial ablative techniques, and-where fibroids are the primary pathology-myomectomy and uterine artery embolization. Since research has shown that hysterectomy is a highly effective treatment, these alternatives must be assessed against the recognized high satisfaction rates and improved quality of life reported following hysterectomy. Additional issues that would also need to be addressed include complication rates, side-effects, and cost-effectiveness. For women with prolonged abnormal uterine bleeding, recent research suggests that hysterectomy is significantly superior to an expanded medical treatment regimen for health-related quality-of-life measures. Satisfaction with treatment, and health-related quality of life and psychosocial well-being, are reportedly similar between hysterectomy and the LNG-IUS, but the latter has the advantage of reduced cost. Endometrial ablation reduces menstrual blood flow, but its benefits relative to hysterectomy lessen over time. No large-scale studies have adequately compared uterine artery embolization or myomectomy to hysterectomy. Perhaps the most telling finding from recent research with respect to the place of alternative therapies to hysterectomy is that the existence or advent of these alternatives has not reduced hysterectomy rates, but merely increased treatment options and interventions for excessive menstrual loss.
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Affiliation(s)
- Nassera S Banu
- Department of Obstetrics and Gynaecology, St George's Healthcare NHS Trust, Blackshaw Road, Tooting, London SW17 0QT, UK
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Flierman PA, Oberyé JJL, van der Hulst VPM, de Blok S. Rapid reduction of leiomyoma volume during treatment with the GnRH antagonist ganirelix. BJOG 2005; 112:638-42. [PMID: 15842290 DOI: 10.1111/j.1471-0528.2004.00504.x] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To assess maximal volume reduction of leiomyomas and uterus and the duration of treatment required to reach these reductions with daily GnRH antagonist treatment. DESIGN Prospective, open-label study. SETTING Large teaching hospital in The Netherlands. POPULATION Premenopausal women with symptomatic fibroids, who were scheduled for surgery. METHODS Twenty women were treated with daily 2 mg of subcutaneous ganirelix. Prior to the first injection and weekly during treatment, the volume of leiomyomas and the uterus were assessed by ultrasound (USS) and serum hormones were measured. Prior to treatment and when maximal size reduction was observed by USS, the volume of the leiomyomas and the uterus were also assessed by magnetic resonance imaging (MRI). MAIN OUTCOME MEASURES Leiomyoma and uterine size reduction, time to maximal reduction. RESULTS One woman was excluded from the study due to incorrect administration dose of ganirelix. Data on the remaining 19 women (average age 39 years) with subserosal (n= 9), submucosal (n= 7), intramural (n= 10) and transmural (n= 1) leiomyomas were evaluated. Baseline leiomyoma volumes ranged from small (3-4 mL) to large (>1000 mL). The median duration of treatment up to maximal leiomyoma size reduction was 19 days (range 1-65 days). The maximal size reduction in leiomyomas measured by USS was -42.7% (-77.0% to 14.1%) and -29.2% (-62.2% to 35.6%) by MRI. Comparable uterine size reductions of -46.6% (-78.6% to -6.1%) and -25.2% (-63.6% to 28.9%) were observed by USS and MRI. During the first three weeks of treatment, 8 out of 19 women reported adverse events related to the induced hypoestrogenic state. Most of these events resolved within one week after treatment was discontinued. CONCLUSION Daily treatment with 2 mg of ganirelix results in rapid reduction of leiomyoma and uterine volume in premenopausal women with minor side effects. If longer-acting GnRH antagonists become available, pretreatment with GnRH antagonist should be preferred over GnRH agonists prior to surgery.
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Affiliation(s)
- P A Flierman
- Department of Gynaecology, Obstetrics and Reproductive Medicine, OLVG, Amsterdam, The Netherlands
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Hurst BS, Matthews ML, Marshburn PB. Laparoscopic myomectomy for symptomatic uterine myomas. Fertil Steril 2005; 83:1-23. [PMID: 15652881 DOI: 10.1016/j.fertnstert.2004.09.011] [Citation(s) in RCA: 192] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2004] [Revised: 09/03/2004] [Accepted: 09/03/2004] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- Bradley S Hurst
- Division of Reproductive Endocrinology, Department of Obstetrics and Gynecology, Carolinas Medical Center, Charlotte, North Carolina, USA.
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Manyonda I, Sinthamoney E, Belli AM. Controversies and challenges in the modern management of uterine fibroids. BJOG 2004; 111:95-102. [PMID: 14723744 DOI: 10.1046/j.1471-0528.2003.00002.x] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Isaac Manyonda
- Department of Gynaecology, St George's Healthcare NHS Trust, London, UK
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