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Sparić R, Andrić L, Guler O, Malvasi A, Babović I, Hatirnaz S, Dellino M, Tinelli A. Cesarean Myomectomy: Reflections on Clinical and Surgical Controversies between a New Trans-Decidual Technique vs. Traditional Method. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:609. [PMID: 38674255 PMCID: PMC11052397 DOI: 10.3390/medicina60040609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Revised: 04/04/2024] [Accepted: 04/06/2024] [Indexed: 04/28/2024]
Abstract
Up to 70-80% of women of reproductive age may be affected with the most common uterine tumors, known as fibroids or myomas. These benign tumors are the second most prevalent cause of surgery among premenopausal women. Predictions show that the occurrence of myomas in pregnancy will increase, and that the risk of having myomas during pregnancy increases with advanced maternal age. Although most women with fibroids do not experience any symptoms during pregnancy, up to 30% of women experience problems during pregnancy, childbirth, and the puerperium. The viability of myoma excision during cesarean surgery (CS) is a contentious issue raised by the rising incidence of myomas in pregnancy and CS rates. A new surgical procedure for removing fibroids using a trans-endometrial approach, which involves making an incision through the decidua itself, has put into doubt the long-standing practice of cesarean myomectomy (CM) with a trans-serosal approach. Some authors have recently advocated for this last approach, highlighting its advantages and potential uses in real-world situations. The purpose of this paper is to critique the present approach to cesarean myomectomy by analyzing the clinical and surgical distinctions between the two approaches and providing illustrations of the CM methods.
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Affiliation(s)
- Radmila Sparić
- Faculty of Medicine, University of Belgrade, Dr Subotića 8, 11000 Belgrade, Serbia;
- Clinic for Gynecology and Obstetrics, University Clinical Centre of Serbia, Dr Koste Todorovića 26, 11000 Belgrade, Serbia;
| | - Luka Andrić
- Clinic for Gynecology and Obstetrics, University Clinical Centre of Serbia, Dr Koste Todorovića 26, 11000 Belgrade, Serbia;
| | - Oguz Guler
- Department of Obstetrics and Gynecology, Private Asya Hospital, Yenimahalle mh. 537, St. No.5 Gaziosmanpasa, 34250 Istanbul, Turkey;
| | - Antonio Malvasi
- Department of Interdisciplinary Medicine (DIM), University of Bari, Aldo Moro, 70100 Bari, Italy; (A.M.); (M.D.)
| | - Ivana Babović
- Faculty of Medicine, University of Belgrade, Dr Subotića 8, 11000 Belgrade, Serbia;
- Clinic for Gynecology and Obstetrics, University Clinical Centre of Serbia, Dr Koste Todorovića 26, 11000 Belgrade, Serbia;
| | - Safak Hatirnaz
- Mediliv Medical Center, Kale, Mevlevihane Cd. No.11, 55100 Samsun, Turkey;
| | - Miriam Dellino
- Department of Interdisciplinary Medicine (DIM), University of Bari, Aldo Moro, 70100 Bari, Italy; (A.M.); (M.D.)
| | - Andrea Tinelli
- Department of Obstetrics and Gynecology, CERICSAL (CEntro di RIcerca Clinico SALentino), “Veris delli Ponti Hospital”, Via Giuseppina Delli Ponti, 73020 Scorrano, Italy;
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Tabakova N, Sparić R, Tinelli A. Reflections on Postpartum Hysterectomy as a Possible Complication of Cesarean Myomectomy: A Long Debate. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:594. [PMID: 38674240 PMCID: PMC11052403 DOI: 10.3390/medicina60040594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/10/2024] [Revised: 03/28/2024] [Accepted: 04/01/2024] [Indexed: 04/28/2024]
Abstract
Uterine fibroids are common benign tumors found in fertile women. Numerous obstetrical issues, such as dystocia during labor, fetal hypotrophy, a ruptured amniotic sac, early labor, low-birth-weight newborns, etc., are associated with fibrous pregnant uteri. Cesarean myomectomy is not a common procedure because of the possibility of postpartum hysterectomy or a potentially lethal hemorrhage. For the chosen topic, we present two instances of emergency postpartum hysterectomies following cesarean myomectomy. After a cesarean myomectomy, two women experienced a perioperative hemorrhage that required a postpartum hysterectomy without a salpingo-oophorectomy. A postpartum hysterectomy was required in every instance due to the failure of additional hemostatic techniques to control the bleeding after the cesarean myomectomy. In every case, the location and number of fibroids-rather than their size-were the primary factors leading to the postpartum hysterectomy. In order to ensure that the patient is safe and that the advantages outweigh the dangers, the current trends in cesarean myomectomy include aiming to conduct the procedure either electively or when it offers an opportunity. The treatment is still up for debate because it is unknown how dangerous a second hysterectomy is for people who have had a cesarean myomectomy.
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Affiliation(s)
- Nikoleta Tabakova
- Department of Obstetrics and Gynecology, Medical University Varna, Marin Drinov Street No. 55, 9002 Varna, Bulgaria
- Obstetrics and Gynecology Hospital SBAGAL Varna, 9000 Varna, Bulgaria
| | - Radmila Sparić
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia;
- Clinic for Gynecology and Obstetrics, University Clinical Centre of Serbia, 11000 Belgrade, Serbia
| | - Andrea Tinelli
- Department of Obstetrics and Gynecology, 73100 Scorrano, Lecce, Italy;
- CERICSAL (CEntro di RIcerca Clinico SALentino), “Veris delli Ponti Hospital”, 73100 Scorrano, Lecce, Italy
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Laganà AS, Romano A, Vanhie A, Bafort C, Götte M, Aaltonen LA, Mas A, De Bruyn C, Van den Bosch T, Coosemans A, Guerriero S, Haimovich S, Tanos V, Bongers M, Barra F, Al-Hendy A, Chiantera V, Leone Roberti Maggiore U. Management of Uterine Fibroids and Sarcomas: The Palermo Position Paper. Gynecol Obstet Invest 2024; 89:73-86. [PMID: 38382486 DOI: 10.1159/000537730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 01/19/2024] [Indexed: 02/23/2024]
Abstract
BACKGROUND Uterine fibroids are benign monoclonal tumors originating from the smooth muscle cells of the myometrium, constituting the most prevalent pathology within the female genital tract. Uterine sarcomas, although rare, still represent a diagnostic challenge and should be managed in centers with adequate expertise in gynecological oncology. OBJECTIVES This article is aimed to summarize and discuss cutting-edge elements about the diagnosis and management of uterine fibroids and sarcomas. METHODS This paper is a report of the lectures presented in an expert meeting about uterine fibroids and sarcomas held in Palermo in February 2023. OUTCOME Overall, the combination of novel molecular pathways may help combine biomarkers and expert ultrasound for the differential diagnosis of uterine fibroids and sarcomas. On the one hand, molecular and cellular maps of uterine fibroids and matched myometrium may enhance our understanding of tumor development compared to histologic analysis and whole tissue transcriptomics, and support the development of minimally invasive treatment strategies; on the other hand, ultrasound imaging allows in most of the cases a proper mapping the fibroids and to differentiate between benign and malignant lesions, which need appropriate management. CONCLUSIONS AND OUTLOOK The choice of uterine fibroid management, including pharmacological approaches, surgical treatment, or other strategies, such as high-intensity focused ultrasound (HIFU), should be carefully considered, taking into account the characteristics of the patient and reproductive prognosis.
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Affiliation(s)
- Antonio Simone Laganà
- Unit of Obstetrics and Gynecology, "Paolo Giaccone" Hospital, Palermo, Italy
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Palermo, Italy
| | - Andrea Romano
- Department of Obstetrics and Gynecology, GROW-School for Oncology and Reproduction, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Arne Vanhie
- Department of Obstetrics and Gynaecology, Leuven University Fertility Center, University Hospitals Leuven, Leuven, Belgium
- Department of Development and Regeneration - Woman and Child, KU Leuven, Leuven, Belgium
| | - Celine Bafort
- Department of Obstetrics and Gynaecology, Leuven University Fertility Center, University Hospitals Leuven, Leuven, Belgium
- Department of Development and Regeneration - Woman and Child, KU Leuven, Leuven, Belgium
| | - Martin Götte
- Department of Gynecology and Obstetrics, Münster University Hospital, Munster, Germany
| | - Lauri A Aaltonen
- Department of Medical and Clinical Genetics, University of Helsinki, Helsinki, Finland
- Applied Tumor Genomics Research Program, Research Programs Unit, University of Helsinki, Helsinki, Finland
- iCAN Digital Precision Cancer Medicine Flagship, University of Helsinki, Helsinki, Finland
| | - Aymara Mas
- Carlos Simon Foundation - INCLIVA Health Research Institute, Valencia, Spain
| | - Christine De Bruyn
- Department of Development and Regeneration - Woman and Child, KU Leuven, Leuven, Belgium
- Department Obstetrics and Gynaecology, University Hospital Antwerp, Edegem, Belgium
| | - Thierry Van den Bosch
- Department of Development and Regeneration - Woman and Child, KU Leuven, Leuven, Belgium
- Department of Obstetrics and Gynecology, University Hospital Leuven, Leuven, Belgium
| | - An Coosemans
- Department of Oncology, Laboratory of Tumor Immunology and Immunotherapy, Leuven Cancer Institute, KU Leuven, Leuven, Belgium
| | - Stefano Guerriero
- Centro Integrato di Procreazione Medicalmente Assistita (PMA) e Diagnostica Ostetrico-Ginecologica, Azienda Ospedaliero Universitaria-Policlinico Duilio Casula, Monserrato, Italy
- Department of Surgical Sciences, University of Cagliari, Cagliari, Italy
| | - Sergio Haimovich
- Department of Obstetrics and Gynecology, Laniado University Hospital, Netanya, Israel
- Adelson School of Medicine, Ariel University, Ariel, Israel
| | - Vasilios Tanos
- Department of Obstetrics and Gynecology, Aretaeio Hospital, Nicosia, Cyprus
- Department of Basic and Clinical Sciences, University of Nicosia Medical School, Nicosia, Cyprus
| | - Marlies Bongers
- Department of Obstetrics and Gynecology, GROW-School for Oncology and Reproduction, Maastricht University Medical Centre, Maastricht, The Netherlands
- Department of Obstetrics and Gynecology, Máxima Medical Centre, Veldhoven, The Netherlands
| | - Fabio Barra
- Unit of Obstetrics and Gynecology, P.O. "Ospedale del Tigullio" - ASL4, Metropolitan Area of Genoa, Genoa, Italy
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
| | - Ayman Al-Hendy
- Department of Obstetrics and Gynecology, University of Chicago, Chicago, USA
- Department of Surgery, University of Illinois at Chicago, Chicago, USA
| | - Vito Chiantera
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Palermo, Italy
- Unit of Gynecologic Oncology, National Cancer Institute - IRCCS - Fondazione "G. Pascale", Naples, Italy
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Zhu-Ge L, Bei Q, Pan W, Ni X. Spontaneous regression of a giant uterine leiomyoma after delivery: a case report and literature review. BMC Pregnancy Childbirth 2024; 24:123. [PMID: 38341545 PMCID: PMC10858580 DOI: 10.1186/s12884-024-06324-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 02/06/2024] [Indexed: 02/12/2024] Open
Abstract
BACKGROUND Uterine leiomyomas are hormone-dependent benign tumors and often begin to shrink after menopause due to the reduction in ovarian steroids. The influence of pregnancy on uterine leiomyomas size remains unclear. Here, we present a case of spontaneous regression of a giant uterine leiomyoma after delivery. CASE PRESENTATION A 40-year-old woman presented with multiple uterine leiomyomas, one of which is a giant uterine leiomyomas (approximately 8 cm in diameter) that gradually shrinked after delivery. At over two months postpartum, the large myometrial leiomyoma had transformed into a submucosal leiomyoma, and over 3 years postpartum, both the submucosal leiomyoma and multiple intramural leiomyomas completely regressed. CONCLUSION Spontaneous regression of a giant uterine leiomyom is rare after delivery. Considering uterine leiomyoma regression until over 3 year postpartum,we need to observe the regression of uterine fibroid for a longer time postpartum in the absence of fibroid related complications. In addition, it will provide new insights for treatment options of uterine leiomyomas in the future.
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Affiliation(s)
- Lifang Zhu-Ge
- Department of Gynaecology, Beilun District People's Hospotal, 1288 Lusan East Road, Ningbo, Zhejiang Province, 315800, China
| | - Qiaoli Bei
- Department of Gynaecology, Beilun District People's Hospotal, 1288 Lusan East Road, Ningbo, Zhejiang Province, 315800, China
| | - Weiping Pan
- Department of Gynaecology, Beilun District People's Hospotal, 1288 Lusan East Road, Ningbo, Zhejiang Province, 315800, China.
| | - Xiaojun Ni
- Department of Gynaecology and Obstetric, The Second Affiliated Hospital of Zhejiang University School of Medicine, Lanxi Hospital, Jinhua, China
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Wang Q, Lin J, Dai Y. Outcomes of cesarean myomectomy via trans-endometrial approach in women with single intramural fibroid in the posterior uterine wall. J Matern Fetal Neonatal Med 2023; 36:2232655. [PMID: 37433647 DOI: 10.1080/14767058.2023.2232655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 06/12/2023] [Accepted: 06/29/2023] [Indexed: 07/13/2023]
Abstract
OBJECTIVE To evaluate the feasibility and effectiveness of cesarean myomectomy (CM) via trans-endometrial approach in pregnant women with single intramural fibroid in the posterior uterine wall. METHODS Ninety-eight patients with single intramural fibroids in the posterior uterine wall who underwent CM were divided into two groups depending on surgical style. The study group consisted of 50 patients who underwent trans-endometrial myomectomy (EM), whereas the control group included 48 patients who had trans-serosal myomectomy (SM). Patients' demographic data, intraoperative and postoperative outcomes were analyzed retrospectively. RESULTS No significant differences were found in the baseline characteristics of the two groups, including demographic data, size, location of fibroids, comorbidities, and indications for cesarean section. During the perioperative period, we did not observe significant differences between the two groups in terms of intraoperative hemorrhage, blood transfusion rate, postoperative fever incidence and postoperative hospitalization (all p > .05). It's worth noting that the time of operation and postoperative ventilation in the EM group was shorter than that in the SM group (p < .05). More importantly, estimated blood loss and postoperative hemoglobin decline were less in the EM group than in the SM group (p < .05). CONCLUSION EM seems to be a viable approach to CM for the treatment of single intramural fibroids in the posterior wall, with the potential advantages of short operative time, low intraoperative bleeding, and low risk of pelvic adhesions.
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Affiliation(s)
- Qi Wang
- Fujian Key Laboratory of Women and Children's Critical Diseases Research, Department of Obstetrics and Gynecology, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, P.R. China
| | - Jinxiao Lin
- Fujian Key Laboratory of Women and Children's Critical Diseases Research, Department of Obstetrics and Gynecology, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, P.R. China
| | - Yan Dai
- Fujian Key Laboratory of Women and Children's Critical Diseases Research, Department of Obstetrics and Gynecology, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, P.R. China
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Shi C, Chen J, Chen A. Clinical outcome analysis of intramural myoma greater than 8 cm in diameter removed during caesarean section: a retrospective study. BMC Womens Health 2023; 23:60. [PMID: 36774454 PMCID: PMC9921307 DOI: 10.1186/s12905-023-02210-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Accepted: 02/03/2023] [Indexed: 02/13/2023] Open
Abstract
OBJECTIVE To explore the safety and efficiency of endometrial myomectomy (EM) and Serosal myomectomy (SM) for the removal of intramural myoma greater than 8 cm in diameter during cesarean section. METHODS Retrospective analysis and follow-up were used, and 190 cases of pregnancy complicated with uterine myoma from Jan. 2017 to May 2022 in Ningbo Women's and Children's Hospital were collected, 130 cases of caesarean myomectomy as study group, 64 cases of EM as study group A, 66 cases of SM as study group B, 33 cases with uterine fibroids removed before suturing the uterine incision as study group B1, 33 cases with uterine incision sutured followed by removal of fibroids as study group B2, 60 cases of Caesarean section alone as control group. To compare perioperative conditions between and within groups. RESULTS ① Operation time, postoperative exhaust time, pre- and post-operative haemoglobin drop, intraoperative blood loss were all more than those of the control group in the study group (68.65 ± 11.87 vs 56.17 ± 9.18 min, 21.04 ± 4.98 vs 17.03 ± 1.3 h, 1.27 ± 0.59 vs 1.09 ± 0.43 g/dl, 613 ± 221 vs 532 ± 156 ml, P < 0.001, P < 0.001, P = 0.025, P = 0.011). ② For type III and V fibroids, the time of myoma removal, postoperative exhaust and pre- and post-operative haemoglobin drop and intraoperative blood loss in study group A were less than those in study group B (18.02 ± 3.89 vs 20.19 ± 5.32 min, 18.83 ± 2.57 vs 23.93 ± 6.84 h, 600 ± 194 vs 730 ± 277 ml, 1.20 ± 0.57 vs 1.59 ± 0.70 g/dl, P = 0.036, P < 0.001, P = 0.014, P = 0.008); For type IV uterine fibroids, only postoperative exhaust time was less in Study Group A than in Study Group B (19.27 ± 2.2 vs 21.35 ± 3.23 h, P = 0.016). ③ Time of myoma removed was less in study group B1 than in study group B2 (18.24 ± 4.53 vs 20.7 ± 4.59 min, P = 0.033). CONCLUSION It is safe and feasible to remove interstitial myomas larger than 8 cm in diameter during caesarean section. EM has the advantage of shorter operation time and less intraoperative bleeding, SM, in a way that the myoma is removed before suturing the uterine incision, can shorten the myomectomy time. It can benefit the patients more.
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Affiliation(s)
- Chunbo Shi
- Department of Obstetrics and Gynecology, Ningbo Women and Children’s Hospital, Ningbo, 315012 Zhejiang China
| | - Jinliang Chen
- Radiology Department, Ningbo Women and Children’s Hospital, Ningbo, 315012 Zhejiang China
| | - Aner Chen
- Department of Obstetrics and Gynecology, Ningbo Women and Children's Hospital, Ningbo, 315012, Zhejiang, China.
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Almusalam MM, Badawi A, Bushaqer N. Are Deliveries by Inverted T-Incision on the Rise Due to Fibroids?: A Case Report. Cureus 2022; 14:e24781. [PMID: 35677011 PMCID: PMC9167637 DOI: 10.7759/cureus.24781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/03/2022] [Indexed: 11/08/2022] Open
Abstract
Fibroids are a common finding among women in their reproductive years. In pregnancy, many are incidentally diagnosed and if they are large, they often require careful monitoring concerning their size, number, and location. This case presents a 27-year-old pregnant female with a 15 cm fibroid occupying the lower segment, who had delivered by a cesarean section. This was a complicated delivery conducted at the Bahrain Defence Force Royal Medical Services, requiring a high transverse incision, followed by an extended inverted T-incision. The baby was successfully delivered as breech after prior presenting in a transverse lie. In conclusion, in pregnant cases where large fibroids are obstructing the lower segment, performing a lower segment cesarean section (LSCS) followed by an inverted T-incision is the safest option. Deliveries by inverted T-incisions have increased throughout the years, and this could be explained by the recent favoring of performing cesarean myomectomies, in large obstructing fibroids. Nowadays, with advanced preparations, myomectomies during cesarean section are safely and frequently performed when the benefits outweigh the risks.
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Affiliation(s)
- Maryam M Almusalam
- Obstetrics and Gynaecology, Royal College of Surgeons in Ireland - Bahrain, Busaiteen, BHR
| | - Anga Badawi
- Obstetrics and Gynaecology, Bahrain Defense Force - Royal Medical Services, Riffa, BHR
| | - Nayla Bushaqer
- Obstetrics and Gynaecology, Royal College of Surgeons in Ireland - Bahrain, Busaiteen, BHR
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