Ultrasound evaluation of uterine wound healing following laparoscopic myomectomy: preliminary results

Mechanical Effects of a Maylard Scar During a Vaginal Birth After a Previous Caesarean

Caesarean section is one of the most common surgeries worldwide, even though there is no evidence supporting maternal and perinatal long-term benefits. Furthermore, the mechanical behavior of a caesarean scar during a vaginal birth after caesarean (VBAC) is not well understood since there are several questions regarding the uterine wound healing process. The aim of this study is to investigate the biomechanical Maylard fiber reorientation and stiffness influence during a VBAC through computational methods. A biomechanical model comprising a fetus and a uterus was developed, and a chemical-mechanical constitutive model that triggers uterine contractions was used, where some of the parameters were adjusted to account for the matrix and fiber stiffness increase in the caesarean scar. Several mechanical simulations were performed to analyze different scar fibers arrangements, considering different values for the respective matrix and fibers stiffness. The results revealed that a random fiber arrangement in the Maylard scar has a much higher impact on its mechanical behavior during a VBAC than the common fibers arrangement present in the uninjured uterine tissue. An increase of the matrix scar stiffness exhibits a lower impact, while an increase of the fiber's stiffness has no significant influence.

Single layer suturing in intracapsular myomectomy of intramural myomas is sufficient for a normal wound healing

STUDY OBJECTIVE

To evaluate surgical outcomes of intracapsular single-layer myomectomy in terms of efficacy and safety as well as examine potential alterations based on kind of surgical approach.

METHODS

A prospective observational study was performed between January 2010 and December 2018. Women in reproductive age, affected by intramural or subserous myomas (FIGO type 3-6) of 4-14 cm diameter were enrolled. Primary outcomes included initial and final uterine incision length, time to wound healing and uterine rupture in subsequent pregnancies. Furthermore, a sub-analysis was also performed regarding surgical approach, namely laparoscopical or laparoscopically-assisted myomectomy, in order to confirm whether overall observations are similar for both potential surgical approaches.

RESULTS

There were finally 273 patients included in the present study. Overall mean uterine incision was initially 3.1 cm and was shortened to 2.2 cm at the end of operation, indicating a reduction of 29.1 %. Mean estimated blood loss was 154.2 mL and mean operative time was 82.1 min. No severe intraoperative and postoperative complications were presented. 121 of the studied women had pregnancy 3-36 months after myomectomy, without reporting any uterine rupture. When comparing LIM vs. LAIM, all outcomes were also favorable in the total of patients.

CONCLUSION

Intracapsular myomectomy either by LIM or LAIM is a safe and attractive alternative to abdominal myomectomy in setting of premenopausal patients with myomas up to 14 cm. A single-layer continuous suturing in intracapsular myomectomies is enough for a successful wound healing.

Comparison of uterine scarring between robot-assisted laparoscopic myomectomy and conventional laparoscopic myomectomy

This study compared uterine wound healing after robot-assisted laparoscopic myomectomy (RM) and laparoscopic myomectomy (LM). Ultrasound was used to evaluate the scar repair of uterine wounds at 1, 3, and 6 months postoperatively. Ninety-three RM and 110 LM patients were enrolled. More myomas excised using RM were type 1∼type 3(51.1%) and more myomas excised using LM were type 4∼type 6(54.2%), p < .001. Both groups had myomas of similar size (RM vs. LM, 9.0 vs. 8.4 cm, p = .115) and weight (RM vs. LM, 322 vs. 274 g, p = .102). The mean myoma number was significantly larger in RM patients than LM patients (RM vs. LM, 3.3 vs. 1.8, p < .001). Significantly more patients were found to have haematomas in the LM than the RM group (RM vs. LM, 0 vs. 6, p = .032); two in type 3, two in type 4 and two in type 8 myomas. Four small haematomas spontaneously resolved at the 3rd month, and a large one resolved at the 9th month postoperatively. One haematoma caused pelvic infection and a 7-cm peritoneal inclusion cyst during sonographic follow up. RM resulted in fewer postoperative haematomas and may result in superior uterine repair relative to LM after excision of symptomatic type 3, type 4 and type 8 myomas. RM is suggested for these patients, especially those considering future pregnancy.IMPACT STATEMENTWhat is already known on this subject? Reconstructive suturing and uterine wound healing are the main challenges when performing laparoscopic myomectomy (LM), and spontaneous uterine rupture during pregnancy following LM has been reported because of its limitations in multilayer closure of the myoma bed. Robot-assisted laparoscopic myomectomy (RM) has improved visualisation and EndoWrist movements resulted in adequate multilayered suturing, which may overcome the technical limitations of reconstructive suturing in conventional LM.What do the results of this study add? We evaluated postoperative uterine scarring after RM and LM using ultrasound and found RM resulted in fewer postoperative haematomas, which result in superior uterine wound repair, relative to LM after excision of symptomatic type 3, type 4 and type 8 myomas.What are the implications of these findings for clinical practice and/or further research? RM is suggested for symptomatic type 3, type 4 and type 8 myomas because of superior uterine wound repair, especially those considering future pregnancy.

Optimal waiting period for subsequent fertility treatment after various hysteroscopic surgeries

OBJECTIVE

To investigate the endometrial wound healing duration after a hysteroscopic surgery.

DESIGN

Prospective study.

SETTING

Tertiary university hospital.

PATIENT(S)

One hundred sixty-three women who underwent hysteroscopic surgeries for endometrial polyp (n = 37), submucous myoma (n = 65), uterine septum (n = 16), and intrauterine adhesion (IUA; n = 45).

INTERVENTION(S)

Postoperative office hysteroscopy was consecutively done until complete endometrial wound healing. If there was newly formed IUA occurring at the endometrial wounds, adhesiolysis was immediately done with the tip of the office hysteroscope.

MAIN OUTCOME MEASURE(S)

Office hysteroscopic inspection of endometrial wound healing and the presence of newly formed IUA.

RESULT(S)

Thirty-two of 37 women (86%) achieved a fully healed endometrium 1 month after polypectomy, a higher rate than those after myomectomy (18%), septal incision (19%), and adhesiolysis (67%). Postoperative office hysteroscopy revealed that 88% and 76% of the women had new IUA formation after septal incision and adhesiolysis, respectively, more than those after myomectomy (40%) and polypectomy (0%). Women with postoperative new IUA formation were less likely to achieve endometrial wound healing within 1 month compared with those who had no new IUA formation (31% vs. 61%).

CONCLUSION(S)

The duration of endometrial wound healing is different after various hysteroscopic surgeries. Postoperative new IUA formation is an important factor influencing endometrial wound healing.

Surgical management of neurovascular bundle in uterine fibroid pseudocapsule

The uterine fibroid pseudocapsule is a fibro-neurovascular structure surrounding a leiomyoma, separating it from normal peripheral myometrium. The fibroid pseudocapsule is composed of a neurovascular network rich in neurofibers similar to the neurovascular bundle surrounding a prostate. The nerve-sparing radical prostatectomy has several intriguing parallels to myomectomy. It may serve either as a useful model in modern fibroid surgical removal, or it may accelerate our understanding of the role of the fibrovascular bundle and neurotransmitters in the healing and restoration of reproductive potential after intracapsular myomectomy. Surgical innovations, such as laparoscopic or robotic myomectomy applied to the intracapsular technique with magnification of the fibroid pseudocapsule surrounding a leiomyoma, originated from the radical prostatectomy method that highlighted a careful dissection of the neurovascular bundle to preserve sexual functioning after prostatectomy. Gentle uterine leiomyoma detachment from the pseudocapsule neurovascular bundle has allowed a reduction in uterine bleeding and uterine musculature trauma with sparing of the pseudocapsule neuropeptide fibers. This technique has had a favorable impact on functionality in reproduction and has improved fertility outcomes. Further research should determine the role of the myoma pseudocapsule neurovascular bundle in the formation, growth, and pathophysiological consequences of fibroids, including pain, infertility, and reproductive outcomes.

Color Doppler evaluation of changes in uterine perfusion induced by the use of an absorbable cervical tourniquet during open myomectomy

PURPOSE

To evaluate the hemodynamic changes in uterine perfusion following the vascular occlusion of the uterine arteries with an absorbable cervical tourniquet applied during open myomectomy.

METHODS

Twenty-eight patients with symptomatic fibroids and a clinical uterine size equivalent to 14 or more weeks' gestation underwent open myomectomy. Patients were randomized to either the tourniquet or the control group. In the tourniquet group, a number 1 polyglactin suture was tied around the cervix to occlude the uterine arteries and left in situ. Doppler flow measurements were obtained at 5 days, 6 weeks, 3 months, and 6 months postoperatively and compared with preoperative values.

RESULTS

Fourteen women were randomized to each group. Data were obtained from 12 patients in the tourniquet group and 11 in the control group. There were no statistically significant differences between the two groups for uterine artery at 5 days, 6 weeks, 3 months, or 6 months postoperatively. However, the peak systolic velocity was significantly reduced in the tourniquet group compared with the control group at 5 days (p < 0.05); thereafter, there were no significant differences between the two groups.

CONCLUSIONS

A polyglactin cervical tourniquet causes only a temporary effect on uterine perfusion, which is consistent with its absorption profile.

Evaluation of postmyomectomy uterine scar

PURPOSE

To determine preoperative and intraoperative factors that affect the healing pattern of a myomectomy uterine incision and to estimate the incidence and outcome of postmyomectomy hematoma demonstrated with sonography.

METHODS

This observational longitudinal prospective study followed the course of patients diagnosed with at least 1 leiomyomata. Each patent was scheduled for abdominal myomectomy. Preoperative assessments included sonographic measurement of the uterine volume as well as identification of the numbers and sites of the leiomyomata. Detailed operative notes were reported for every patient. Transvaginal sonography was performed for all cases on day 2, day 7, and at 1 month and 3 months postoperatively. The main outcome measure was the occurrence of postoperative hematoma versus preoperative and postoperative factors that possibly affect uterine healing.

RESULTS

We found a statistically significant reduction of the uterine volume on follow-up (P < 0.001) of the 169 women enrolled. Hematoma in the myomectomy bed was observed postoperatively in 40 (24%) 28 (17%) and 12 (7%) patients on day 2, day 7, and 1 month, respectively. A preoperative myoma size greater than 110 cm(3), the use of a tourniquet, and the experience of the surgeon were significantly correlated with formation of uterine scar hematomas.

CONCLUSIONS

The postoperative sonographic diagnosis of wound hematoma may be used as an indicator of wound healing that is usually complete within 3 months. Use of a tourniquet is frequently associated with hematoma formation. Myomectomy should usually be performed by an experienced surgeon without a tourniquet, using microsurgical principles, especially when the sizes of the leiomyomata exceed 110 cm(3).

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.

Pregnancy outcomes and deliveries after laparoscopic myomectomy

STUDY OBJECTIVE

To assess pregnancy outcomes and deliveries after laparoscopic myomectomy.

DESIGN

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

SETTING

General hospital.

PATIENTS

Three hundred fifty-nine women.

INTERVENTIONS

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

MEASUREMENTS AND MAIN RESULTS

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

CONCLUSION

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

Laparoscopic myomectomy: technique, complications, and ultrasound scan evaluations

STUDY OBJECTIVE

To evaluate the feasibility, limits, and complications of laparoscopic myomectomy, assess time to full recovery, and evaluate uterine wound healing by ultrasound in the early postoperative period.

DESIGN

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

SETTING

General hospital.

PATIENTS

Three hundred sixty-eight women undergoing laparoscopic myomectomy.

INTERVENTION

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

MEASUREMENTS AND MAIN RESULTS

In these women 768 myomas were removed laparoscopically. Mean operating time was 100.78 +/- 43.83 minutes, mean decreases in hemoglobin and hematocrit were 1.38 +/- 0.93 g/100 ml and 4.8 +/- 2.9 g/100 ml, respectively, and mean length of hospital stay was 2.89 +/- 1.3 days. Intraoperative complications occurred in 12 patients (3.34%) and intraoperative transfusion of autologous blood was required in 10. Main postoperative complications were continuing hemorrhage requiring blood transfusion in three women and second laparoscopy in two. Pyrexia occurred in 12 patients. Average time to full recovery was 10.58 +/- 6.68 days. At 1-month follow-up 12 of 282 women developed further complications: abdominal pain 5, vaginitis 4, metrorrhagia 2, and dysuria 1. Sonographic evaluation of the uterine scar showed a highly echogenic area with ill-defined margins. In 81 women who had sonographic evaluation 30 days postoperatively, the uterine scar was reduced by an average of 44.1% (p <0.001). Of 176 patients screened at day 30, 6 (3.4%) had anechoic areas adjacent to the uterine scar, possibly due to hematoma. A previously unknown myoma, two ovarian cysts, and two pelvic hematoma were also discovered.

CONCLUSION

. Laparoscopic myomectomy is effective and relatively safe. In skilled hands it has a low risk of complications and appears to be a valid alternative to the open procedure. Sonographic assessment allows detection of alterations in muscular echotexture, but its effectiveness in identifying women at risk of uterine rupture or dehiscence has to be proved.

Laparoscopic myomectomy and subsequent pregnancy: results in 54 patients

The laparoscopic approach to myomectomy has raised questions about the risk of uterine rupture in patients who become pregnant following surgery. It has been suggested that the rupture outside labour in pregnancies following laparoscopic myomectomy can be due to the difficulty of suturing or to the presence of a haematoma or to the wide use of radio frequencies. In this paper we describe the pregnancy outcome of 54 patients submitted to laparoscopic myomectomy at our Institution and prospectively followed during subsequent pregnancies. A total of 202 patients underwent laparoscopic myomectomy. A total of 65 pregnancies occurred in 54 patients who became pregnant following surgery. Data were collected about complications of pregnancy, mode of delivery, gestational age at delivery and birthweight of the neonates. No cases of uterine rupture occurred. Twenty-one pregnancies followed an IVF procedure. Nine patients conceived twice and one three times. Four multiple pregnancies occurred. Eight pregnancies resulted in a first trimester miscarriage and another in an interstitial pregnancy requiring laparotomic removal of the cornual gestational sac. Of the remaining 56 pregnancies, 51 (91%) were uneventful. In two cases a cerclage was performed at 16 weeks. In two cases pregnancy-induced hypertension developed. Two pregnancies ended with a preterm labour (26-36 weeks). A Caesarean section was performed in 45 cases (54/57, 80%). In terms of the safety of laparoscopic myomectomy in patients who become pregnant following surgery, our results were encouraging. However, further studies are needed to provide reliable data on the risk factors and the true incidence of uterine rupture.