Laparoscopic myomectomy focusing on the myoma pseudocapsule: technical and outcome reports

Comparison of uterine myometrial thickness at the site of myomectomy scar after surgery using laparoscopic and laparotomy methods

Fibroids are the most common benign tumours of the uterus, often requiring surgery when symptomatic. This study aims to investigate the impact of surgery using two methods, laparoscopy and laparotomy, on the thickness and vascularity of the uterine myometrium at the site of myomectomy scar (comparing sonographic features at the surgical scar site, including thickness, vascularity, and the extent of fibrotic tissue, in both open and laparoscopic surgical approaches). In this clinical trial, 100 women with type 2-5 fibroids and clinical symptoms, seeking surgery et al. Zahra Hospital, were enrolled in two groups: laparoscopy and laparotomy. Inclusion criteria were a maximum fibroid size of 8 cm and, in the case of multiple fibroids, a maximum of three, with the largest being 8 cm. 6 months post-surgery, sonographic assessments of the myomectomy scar site were compared between both groups. Participants showed no significant differences in demographic and obstetric factors. The most common clinical symptom (87%) in both groups was abnormal uterine bleeding (AUB). The mean hospital stay duration was statistically significantly lower in the laparoscopy group at 1.64 (SD 0.56) compared to 1.89 (SD 0.58) in the laparotomy group (p = 0.028). Additionally, the decrease in haemoglobin levels was 0.89 (SD 0.92) and 1.87 (SD 2.24) units, respectively, which showed a statistically significant difference (p = 0.003). The duration of surgery was significantly shorter in the laparotomy group (p = 0.001). Abdominal pressure was not observed in the laparoscopy group, while 12% of the laparotomy group reported complaints (p = 0.013). Based on the results obtained in this study, it can be concluded that there was no difference between these two methods in terms of improving uterine thickness and associated complications. However, the decrease in haemoglobin levels and the length of hospital stay were lower in patients undergoing laparoscopy.

Evaluating the Effects of Water Balloons on High-Intensity Focused Ultrasound for Treating Uterine Fibroids

OBJECTIVE

In the treatment of uterine fibroids with ultrasound-guided high-intensity focused ultrasound (HIFU), water balloons are considered to be a valuable aid for improving safety and efficiency. However, the water balloons worsen the pathway for acoustic transmission, causing degraded performance both in ultrasound therapy and in ultrasound imaging. This study was aimed at establishing a protocol to evaluate the effects of the water balloon.

METHODS

Simulations and experiments were carefully conducted to quantitatively investigate the effects of water ballons on the efficiency of HIFU energy delivery and on the quality of ultrasound guiding images. More specifically, HIFU-induced temperature increases in the focal region, together with spatial resolution, contrast and signal-to-noise ratio in the ultrasound guiding images, were compared under the conditions with and without the water balloon.

RESULTS

Experiment results revealed that the use of water balloons led to decreases in temperature up to 10ºC within the focal region in some specific situations, but the quality of the guiding images was relatively less affected.

CONCLUSION

The study provided knowledge on what influence the water balloon could have in ultrasound-guided HIFU treatment; it also established a practical and standardized evaluation scheme for further optimizing the water balloon, for example, its material and internal liquid compositions. This study can potentially help improve the efficiency and safety of treating uterine fibroids with ultrasound-guided HIFU systems.

Surgical impact of bilateral transient occlusion of uterine and utero-ovarian arteries during laparoscopic myomectomy

The objective of this article is to compare the amount of intraoperative blood loss during laparoscopic myomectomy when performing bilateral transient clamping of the uterine and utero-ovarian arteries versus no intervention. It´s a randomized controlled prospective study carried out in the Department of Obstetrics and Gynecology Ramón y Cajal University Hospital and HM Montepríncipe-Sanchinarro University Hospital, Madrid, Spain, in women with fibroid uterus undergoing laparoscopic myomectomy. Eighty women diagnosed with symptomatic fibroid uterus were randomly assigned to undergo laparoscopic myomectomy without additional intervention (Group A) or temporary clamping of bilateral uterine and utero-ovarian arteries prior to laparoscopic myomectomy (Group B). Estimated blood loss, operating time, length of hospital stay, and postoperative hemoglobin values were compared in both groups. The number of fibroids removed was similar in both groups (p = 0.77). Estimated blood loss was lower in the group of patients with prior occlusion of uterine arteries (p = 0.025) without increasing operating time (p = 0.17) nor length of stay (p = 0.17). No patient had either intra or postoperative complications. Only two patients (2.5%) required blood transfusion after surgery. We conclude that temporary clamping of bilateral uterine arteries prior to laparoscopic myomectomy is a safe intervention that reduces blood loss without increasing operative time.

HIFU as an alternative modality for patients with uterine fibroids who require fertility-sparing treatment

OBJECTIVES

To compare pregnancy outcomes after high-intensity focused ultrasound ablation (HIFU), myomectomy and uterine artery embolization (UAE) for fertility-sparing patients with uterine fibroids and to investigate the possible mechanism of improving pregnancy by HIFU.

MATERIALS AND METHODS

A meta-analysis of 54 studies containing 12,367 patients was conducted to compare the pregnancy outcomes of three fertility-sparing therapies. And a retrospective self-control study of 26 patients with uterine fibroids from May 2019 to December 2020 was performed to assess the blood flow impedance of bilateral uterine arteries before and after HIFU.

RESULTS

In the analysis by treatment option, the pregnancy rate after myomectomy was 0.43 (95% CI 0.36-0.49), which was higher than 0.18 (95% CI 0.10-0.26) after HIFU, the latter was significantly higher than that after UAE (ratio 0.08, 95% CI 0.06-0.10). The miscarriage rate after HIFU was 0.08 (95% CI 0.04-0.12), which was similar to 0.15 (95% CI 0.09-0.21) after myomectomy and also similar to 0.16 after UAE (95% CI 0.01-0.30). In the subgroup analysis, women who received ultrasound guided HIFU (USgHIFU) were more likely to have ideal pregnancy outcomes than that after magnetic resonance imaging-guided HIFU. The pulsatility index and resistance index on the right side were significantly higher 3 months after HIFU than before (1.637 ± 0.435 vs. 1.845 ± 0.469; p = 0.033; 0.729 ± 0.141 vs. 0.784 ± 0.081, p = 0.039).

CONCLUSIONS

HIFU, especially USgHIFU, may be an alternative fertility-sparing modality for patients with uterine fibroids over 40 years old. HIFU may contribute to improving pregnancy rates by elevating uterine blood flow impedance.

Comparison of surgical and obstetric outcomes in women with uterine leiomyomas after laparoscopic vs. abdominal myomectomy: A single-center cohort study

Our aim was to study the advantages, complications and obstetrical outcomes of laparoscopic myomectomy (LM) compared with abdominal myomectomy (AM). We conducted a retrospective cohort study at La Paz University Hospital that included LMs and AMs performed between 2012 and 2018, analyzing 254 myomectomies (142 AMs [55.7%] and 112 LMs [43.9%]). The mean number of fibroids was 1.8 ± 1.5 and 3 ± 2.9 for the LM and AM groups, respectively (p < 0.006). The mean size of the largest myoma was 7.6 cm ± 2.7 cm and 10.2 cm ± 5.4 cm for the LM and AM groups, respectively (p < 0.001). LMs were associated with longer surgical times (p < 0.001) and shorter hospitalizations (p = 0.001). There were no significant differences in the intraoperative and postoperative complication rates (p = 0.075 and p = 0.285 for LM and AM, respectively). The subsequent pregnancy rate was higher for the LM group (30.8% vs. 16.8%, p = 0.009), with a vaginal delivery rate of 69% and no cases of uterine rupture.

A combination of two novel ligation techniques for complicated laparoscopic intraligamental myomectomy

OBJECTIVE

To perform laparoscopic myomectomy by combining two novel ligation techniques for a large lateral intraligamental myoma.

DESIGN

A step-by-step explanation of the surgical procedure using a video with narration.

SETTING

University hospital.

PATIENT(S)

A 39-year-old woman (gravida 1, para 0) presented with an asymptomatic pelvic mass. Sonographic imaging revealed a 10-cm subserous myoma from the right lateral uterine isthmus wall. Laparoscopic exploration revealed a large myoma growing from the right lateral cervical isthmus wall toward the broad ligament. It was protruding into the pararectal space with duplicated ureters.

INTERVENTION(S)

For such a large lateral intraligamental myoma, any conventional approach has the potential to cause massive bleeding and accidental injuries. We devised and implemented a preventative strategy for intraoperative bleeding by combining two novel ligation techniques used in laparoscopic myomectomy. We made an incision at the posterior leaf of the broad ligament and exposed the myometrium enveloping the fibroid and the base of the fibroid. Then we performed an incision 2 cm away from the right lower edge of the fibroid base, opening the myometrium and pseudocapsule. We applied two novel ligation techniques that ligate the pedicle on the left of the fibroid and the pseudocapsule on the right of the fibroid. Enucleation and loop tightening were implemented simultaneously. The entire pseudocapsule and most of the myometrium enveloping the fibroid were ligated in the loop knot. Only a small portion of the myometrium on the right side was outside the loop knot, which required electrocoagulation. Loop ligation was performed twice more for reinforcement in the same location. The peritoneum was then closed.

MAIN OUTCOME MEASURE(S)

Laparoscopic myomectomy was completed successfully for a large lateral intraligamental myoma using our novel technique.

RESULT(S)

The surgery lasted 110 min, and the volume of intraoperative blood loss was 150 mL. The patient had a normal postoperative course.

CONCLUSION(S)

Combining two novel ligation techniques in laparoscopic myomectomy is a safe and efficient surgical choice. This technique has obvious advantages in large, broad ligament myomas, reducing bleeding and avoiding unintentional injuries, even in duplicated ureters. Furthermore, this technique is not limited by the device and does not increase the cost of surgery.

Comparison of Clinical and Reproductive Outcomes between Adenomyomectomy and Myomectomy

STUDY OBJECTIVE

Women with adenomyosis may show a lower pregnancy rate and a higher miscarriage rate than healthy women. There is also a general agreement that leiomyomas, either submucosal or intramural, negatively affect fertility, when compared with women without myomas. Some of these women may benefit from adenomyomectomy, however this cytoreductive procedure is considered invasive and technically challenging especially in severe diffuse cases. The study aimed to compare the clinical and reproductive outcomes of patients who underwent adenomyomectomy with those of patients who underwent intramural myomectomy.

DESIGN

A retrospective study.

SETTING

Department of Obstetrics & Gynecology, Center of Gynecological Endoscopy and Minimally Invasive surgery, First Faculty of Medicine, General University Hospital in Prague.

PATIENTS

A total of 55 women who underwent surgical resection of uterine adenomyosis and 55 patients who underwent myomectomy for intramural uterine myomas were included in this study. All study participants wished to retain and possibly improve their reproductive potential.

INTERVENTIONS

Between 2004 and 2019, 110 women underwent laparoscopic or open uterus-sparing surgery for clinically significant uterine adenomyosis (group A) or myomas (group B), respectively.

MEASUREMENTS AND MAIN RESULTS

Two groups of women who underwent different fertility-saving procedures were compared. Although all women entering the study had declared their wish to conceive, only 28 patients in group A (group A1) and 24 women in group B (group B1) finally aimed toward pregnancy. The mean age and follow-up period was 35.0 years and 76.81 months, respectively, in group A and 34.8 years and 72.5 months, respectively, in group B. The pregnancy and delivery rates were 75.0% and 46.4%, respectively, in group A1 vs 96.0% and 70.8%, respectively, in group B1, with no significant differences between the 2 groups. The open surgical approach was significantly more frequently employed in group A (47.3% vs 16.4%; p <.01).

CONCLUSION

In this study, women who underwent surgery involving the uterine muscularity, including myomectomy or adenomyomectomy, had comparable reproductive outcomes, with no significant differences.

Intracervical intracapsular myomectomy using loop ligation: a proposed technique

Performing laparoscopic myomectomy for an intracervical myoma, especially a single giant myoma, is challenging. Only skilled surgeons attempt this operation. Surgeons frequently encounter cases of massive intraoperative bleeding, difficulty suturing the cervical incision, risk of injuring the neighbouring tissues, haematoma formation and conversion to laparotomy or hysterectomy. We previously developed a the technique of loop ligation of the pseudocapsule and have been using it to treat sizeable intracervical myomas laparoscopically. Its advantages include less blood loss, lower risk of injuries to the neighbouring tissues, maintenance of the cervical canal and sparing of the pseudocapsule. This technique is safe and feasible, and facilitates fertility.

A comparison of the pregnancy outcomes between ultrasound-guided high-intensity focused ultrasound ablation and laparoscopic myomectomy for uterine fibroids: a comparative study

Objective: To compare the pregnancy outcomes between ultrasound-guided high-intensity focused ultrasound (USgHIFU) ablation and laparoscopic myomectomy (LM).Materials and methods: This study included 676 women with symptomatic uterine fibroids who wished to become pregnant underwent USgHIFU or LM at three hospitals in China from 1 May 2009 to 31 May 2018. The related information of pregnancy and delivery were followed up and analyzed using the chi-square test and two-sided Student t-test.Results: The median follow-up duration was 5 (1-8) years; 20 patients (2.9%) were lost to follow-up. 320 patients were treated with UsgHIFU, and 336 were treated with LM. Two hundred nineteen (68.4%) women became pregnant after USgHIFU ablation, and 224 (66.7%) became pregnant after LM. Four hundred forty-three patients had 501 pregnancies (natural pregnancies, 405; in vitro fertilisation-embryo transfer pregnancies, 38). Average times to pregnancy were 13.6 ± 9.5 months after USgHIFU and 18.9 ± 7.3 months after LM (p < 0.05). The rate of cesarean delivery was lower in the USgHIFU group (41.6%) than in the LM group (54.9%) (p < 0.05). Incidences of placenta increta, placenta previa, and postpartum hemorrhage were low after USgHIFU compared with after LM. Incidences of preterm birth, fetal distress, fetal growth restriction, and puerperal infection were higher after USgHIFU than after LM. There was a risk of uterine rupture after both procedures.Conclusions: Compared with LM, USgHIFU ablation can significantly shorten the time to pregnancy, although pregnancy rates of the two procedures are similar. Some risks in pregnancy and delivery after HIFU should be evaluated and monitored.

Laparoscopic Intracapsular Myomectomy in Women 40 Years Old and Over with Symptomatic Uterine Fibroids. A Pilot Study

Authors evaluated the impact of laparoscopic intracapsular myomectomy (LIM) in women 40 years of age and over with desire of future fertility compared with medical management of symptomatic fibroids, by a prospective cohort study in University affiliated Hospitals. This study includes a cohort of women 40 years of age and older with symptomatic intramural fibroids with desire of future fertility. Women with symptomatic fibroid uterus were offered to undergo LIM or medical management. They were encouraged to attempt conception either spontaneously or by assisted reproductive technology (ART) according to their individual preference. All women were followed for 2 years. Fibroid characteristics, pre- and post-surgical variables, including surgical complications, days of hospitalization, pregnancy rate, and obstetrical outcomes were collected. A total of 100 patient were included in the analysis. Fifty patients were assigned to the LIM group and 50 to the medical treatment group (MT). Groups were similar regarding age (43.5 ± 2.4 and 43.5 ± 2.4, p  = 0.99), body mass index (23.8 ± 3.1 and 24.2 ± 3.1, p  = 0.54), parity (0.46 ± 0.09 and 0.58 ± 0.09, p  = 0.37), fibroid number (1.38 ± 0.6 and 1.46 ± 0.6, p  = 0.53), and fibroid size (5.92 ± 1.62 cm vs. 5.94 ± 1.49 cm, p  = 0.949). Of the patients who underwent LIM, 62% conceived within the study period compared with 56% in the control group ( p  = 0.54). Pregnancy was achieved by ART in 44% of the patients of the LIM group and 30% in control group. There was no significant difference in pregnancy rates among the two groups regarding spontaneous pregnancy rate ( p  = 0.332), nor in pregnancies obtained by ART with own eggs ( p  = 0.146) and oocyte or embryo donation ( p  = 0.821). The take home baby rate was 65% (20/31) in the LIM group and 61% (17/28) in the control group ( p  = 0.7851). Both groups had similar rate of miscarriage ( p  = 0.748). Patients 40 years old and over with symptomatic fibroid uterus who undergo LIM have similar subsequent fertility and obstetrical outcomes than women treated with medical management. LIM has no detrimental impact on future fertility in women 40 years old and over.

The Arachidonic Acid Metabolism Mechanism Based on UPLC-MS/MS Metabolomics in Recurrent Spontaneous Abortion Rats

Recurrent spontaneous abortion (RSA) remains a critical and challenging problem in reproduction. To discover novel biomarkers for RSA, ultra performance liquid chromatography/tandem mass spectrometry (UPLC-MS/MS) metabolomics approach was applied to detect RSA serum metabolic profiles and explore its possible pathogenesis and mechanism. The abortion rat model was established, and a metabolomics analysis was performed to evaluate the differentially expressed metabolites between the control and model groups. Immunohistochemistry (IHC), qRT-PCR, and Western blot further examined the expression of Arachidonic acid metabolism-related genes in uterus tissues. To identify arachidonic acid metabolism-related changes in RSA, ELISA's potential mechanisms were further confirmed in serum. Ninety-one metabolites were significantly different between the two groups, as indicated by a VIP ≥1, fold change ≥1. The metabolic pathways involving arachidonic acid metabolism pathway (P = 0.00044) are related to RSA. Verification by experimental showed that compared with the control rats, the expression of the COX-1, COX-2, PTGFR, and TBXA2R genes associated with the arachidonic acid metabolism pathway has significantly increased the uterus and serum of RSA rats (P < 0.05). Regulation of the arachidonic acid metabolism pathway might serve as a promising therapeutic strategy for relieving RSA women's symptoms.

Blood loss from transverse versus longitudinal uterine incision in abdominal myomectomy: a randomized controlled trial

BACKGROUND

It is unclear whether transverse uterine incision is non-inferior to longitudinal incision during myomectomy with regard to bleeding. Our aim was to compare between transverse and longitudinal uterine incisions in myomectomy.

METHODS

A parallel randomized controlled single-blinded study in a university affiliated hospital, in the period between January 2017 and April 2018, in which 52 women candidates for abdominal myomectomy were randomized into transverse uterine incision or longitudinal uterine incision groups (26 in each group). Intraoperative blood loss (estimated directly by blood volume in suction bottle and linen towels and indirectly by difference between preoperative and postoperative hematocrit), operative time and postoperative fever were analyzed.

RESULTS

No statistically significant difference was found between transverse and longitudinal incisions regarding intraoperative blood loss (389.7 ± 98.56 ml vs 485.04 ± 230.6 ml respectively, p value = 0.07), operative time (59.96 ± 16.78 min vs 66.58 ± 17.33 min respectively, p value = 0.18), and postoperative fever (4% vs 8.33%, p value = 0.6).

CONCLUSION

Transverse uterine incision does not cause more blood loss than longitudinal incision and is a reasonable option during abdominal myomectomy.

TRIAL REGISTRATION

NCT03009812 at clinicaltrials.gov, registered January 2017.

The Biological Impact of Ulipristal Acetate on Cellular Networks Regulating Uterine Leiomyoma Growth

Uterine Fibroids (UFs), or leiomyomas, represent the most frequent pelvic tumor in reproductive-aged women. Although of benign origin, UFs decrease fertility and cause significant reproductive dysfunctions. Compared to normal myometrium, UFs are characterized by a clinical and molecular heterogeneity as demonstrated by the presence of multiple genetic alterations and altered signaling pathways. Recently, selective progesteronereceptor modulators (SPRM), as ulipristal acetate (UPA), have demonstrated their clinical benefits by reducing tumor growth and extracellular matrix deposition. For these reasons, UPA is used in the clinical practice as an intermittent treatment for women symptomatic for UFs or, sometimes, before a myomectomy. However, drug effects on signaling pathways frequently upregulated in UFs remain largely unknown. In fact, the mechanisms of action of the UPA on UFs and on the surrounding areas are not yet understood. To learn more about UPA molecular mechanisms, UF samples were treated ex vivo with UPA and profiled for drug effects on selected markers. During this preliminary ex vivo UPA administration, significant changes were observed in the expression levels of proteins related to cell cycle regulation, cytoskeleton remodeling, and drug resistance. The UPA administration reduced cofilin, Erk and Src phosphorylation, p27 and ezrin protein levels, but not Akt phosphorylation and cyclin D1 and β-catenin levels. This preliminary ex vivo biological analysis provided new insights into the mechanism of action of UPA in the treatment of UFs, which could better explain the biological functioning of the drug on UFs.

Myomectomy during pregnancy: A systematic review

OBJECTIVE

Uterine fibroids affect 2-10 % of pregnant women. Although usually asymptomatic, they may be associated with pregnancy complications. Myomectomy is preferably avoided antenatally, however, it has been reported in symptomatic cases that did not respond to conservative management. The aim of this study was to summarize the published literature and present the reported outcomes and associated risks of this procedure.

STUDY DESIGN

A systematic research of the literature was conducted in PubMed/MEDLINE, Scopus and the Cochrane Library, including case reports and case series. An effort was made to numerically analyse all parameters included in the case reports.

RESULTS

Overall, 54 relevant articles were identified, including 97 patients. The median gestational age at diagnosis was 13 (range 6-26) weeks, while the median age at myomectomy was 16 (range 6-26) weeks. Abdominal pain, not responding to medical treatment was the most common indication for surgery. The median number of fibroids removed per patient was one (range 1-5). Most of them were subserous pedunculated or subserous and fundal. Laparotomy (78.4 %) was the principal surgical approach, however, laparoscopic and vaginal operations were also reported. The median duration of surgery was 53 (range 20-150) min. The histopathology revealed necrosis and degeneration as the main findings of removed fibroids. The pregnancy outcome was favourable in most of the cases, with few complications reported.

CONCLUSION

Based on the limited published data, myomectomy during pregnancy appears as a safe procedure in cases of symptomatic uterine fibroids not responding to conservative management and therefore it may be considered, following appropriate counselling regarding the associated risks.

90 YEARS OF PROGESTERONE: Selective progesterone receptor modulators in gynaecological therapies

Abnormal uterine bleeding (AUB) is a chronic, debilitating and common condition affecting one in four women of reproductive age. Current treatments (conservative, medical and surgical) may be unsuitable, poorly tolerated or may result in loss of fertility. Selective progesterone receptor modulators (SPRMs) influence progesterone-regulated pathways, a hormone critical to female reproductive health and disease; therefore, SPRMs hold great potential in fulfilling an unmet need in managing gynaecological disorders. SPRMs in current clinical use include RU486 (mifepristone), which is licensed for pregnancy interruption, and CDB-2914 (ulipristal acetate), licensed for managing AUB in women with leiomyomas and in a higher dose as an emergency contraceptive. In this article, we explore the clinical journey of SPRMs and the need for further interrogation of this class of drugs with the ultimate goal of improving women's quality of life.

Novel high-coverage targeted metabolomics method (SWATHtoMRM) for exploring follicular fluid metabolome alterations in women with recurrent spontaneous abortion undergoing in vitro fertilization

The complexity of follicular fluid metabolome presents a significant challenge for qualitative and quantitative metabolite profiling, and for discovering the comprehensive biomarkers. In order to address this challenge, a novel SWATHtoMRM metabolomics method was used for providing broad coverage and excellent quantitative capability to discover the human follicular fluid metabolites related to recurrent spontaneous abortion (RSA) after in vitro fertilization and embryo transfer, and to evaluate their relationship with pregnancy outcome. The follicular fluid samples from the spontaneous abortion group (n = 22) and the control group (n = 22) were analyzed using ultra-performance liquid chromatography high-resolution mass spectrometry. A novel, high-coverage, targeted metabolomics method (SWATH to MRM) and a targeted metabolomics method were used to find and validate the differential metabolites between the two groups. A total of 18 follicular fluid metabolites, including amino acids, cholesterol, vitamins, fatty acids, cholic acid, lysophosphatidylcholine and other metabolites, were identified. In the RSA group, 8 metabolites, namely dehydroepiandrosterone, lysoPC(16:0), lysoPC(18:2), lysoPC(18:1), lysoPC(18:0), lysoPC(20:5), lysoPC(20:4), and lysoPC(20:3), were up-regulated, and 10 metabolites, namely phenylalanine, linoleate, oleic acid, docosahexaenoic acid, lithocholic acid, 25-hydroxyvitamin D3, hydroxycholesterol, 13-hydroxy-alpha-tocopherol, leucine, and tryptophan, were down-regulated. These differential metabolites related to RSA may provide a possible diagnostic basis and therapeutic target for RSA, as well as a scientific basis for elucidating the mechanism of RSA.

The Use of Ulipristal Acetate (Esmya) Prior to Laparoscopic Myomectomy: Help or Hindrance?

Introduction:

The aim of this study was to assess the operative effects, both positive and negative, of pretreatment with ulipristal acetate (UPA) on laparoscopic myomectomy.

Materials and Methods:

We conducted a retrospective analysis of prospectively collected data from patients who underwent a laparoscopic myomectomy over a 2-year period.

Results:

A total of 62 patients were included, of which 10 received a 3-month preoperative course of UPA, and 52 patients received no pretreatment. There was no statistically significant difference between the two groups (no pretreatment vs. UPA pretreatment) with regard to blood loss (214.4 [±214.96] vs. 160 [±51.64], P = 0.432), operating time (111.64 [±41.8] vs. 117.5 [±50.4], P = 0.694), and duration of inpatient stay (1.27 [±0.56] vs. 1.11 [±0.33], P = 0.419). There were no complications in either group. In 100% of cases with UPA pretreatment, a distortion of the fibroid capsule with a more technically challenging dissection was noted, compared to 0% in the no pretreatment group. This anatomical distortion may result in more cases of incomplete resection and a potentially higher risk of recurrence.

Conclusion:

We conclude that UPA confers no operative benefits and should be used with caution in the presurgical treatment of fibroids. The use of UPA may indeed result in a more technically difficult myomectomy with distorted cleavage planes and carry a potential risk of incomplete resection.

Robotic myomectomy for large uterine myomas

OBJECTIVE

To evaluate surgical outcomes and feasibility of robotic myomectomy in large uterine myomas.

MATERIALS AND METHODS

This is a retrospective study for robotic myomectomies performed from October 2012 to August 2017 by a single surgeon in a tertiary care referral hospital. Demographics, diagnosis, perioperative variables, operative outcomes and complications were recorded. Large uterine myoma was defined as the estimated diameter of dominant myoma equal to or larger than 10 cm by sonography.

RESULTS

Seventy-four patients were included and 32 (43.2%) patients had large uterine myoma. Patients with myoma larger than 10 cm showed significantly heavier myoma weight (446.5 ± 206.2 mg vs. 288.1 ± 147.5, p < 0.001), similar blood loss (309.4 ± 190.3 mL vs. 200.9 ± 285.9 mL, p = 0.06), and longer operative time (263.4 ± 83.7 min vs. 219.1 ± 75.7 min, p = 0.02) compared with patients with myoma <10 cm. The largest myoma removed was 20 cm in diameter. Perioperative complications were rare.

CONCLUSION

Robotic myomectomy is feasible for managing large uterine myomas. It is a safe procedure with acceptable longer operative time.

Moving Toward Individualized Medicine for Uterine Leiomyomas

Uterine leiomyomas are common and life-altering for many women. Despite a wide range of symptoms, varying characteristics of the uterus and the leiomyomas themselves, and many alternatives, hysterectomy accounts for almost three fourths of all surgical therapy, yet there is increasing evidence for a variety of procedural therapies for symptomatic leiomyomas and a new generation of medical therapies under development. With increasing evidence of long-term risk from hysterectomy and new data regarding leiomyoma biology, individualized medical approaches to leiomyomas are likely in the near future. Key biological attributes that influence this disease process are common driver mutations and the new appreciation of the interaction of smooth muscle cells and fibroblasts. Additionally, the interaction between cell types and steroid hormone responsiveness likely plays a role in pathogenesis that can be leveraged in individualized therapy. However, given the independent clonal nature of leiomyomas within the same uterus, moving in the direction of biopsies for individual leiomyomas to understand the biology is unlikely to be fruitful. Use of advanced imaging will likely continue to evolve not only to accurately predict malignant disease, including sarcomas, but to predict leiomyoma subtypes, response to therapy, or both. We predict the continued evolution of therapy from excisional or interventional therapies to medical therapies and ultimately prediction of at-risk individuals. Ideally, individualized therapies will offer primary prevention for women at high risk of leiomyomas and secondary prevention after initial treatment.

Submucous Fibroids, Fertility, and Possible Correlation to Pseudocapsule Thickness in Reproductive Surgery

Background and Objectives

Fibroids are related to infertility. Fibroid pseudocapsule is a neurovascular bundle surrounding leiomyomas rich of neurofibers involved in myometrial biology. Authors evaluated, by a case-control study, the fibroid pseudocapsule (FP) thickness by ultrasound (US) and the histological measurements, according to uterine location of fibroids.

Methods

137 consecutive patients undergoing hysterectomy for uterine myomas were enrolled and 200 myomas were evaluated. Before surgery, patients underwent an ultrasound (US) investigation to evaluate the number, the size, and the location of fibroids. After surgery, myoma-pseudocapsule-myometrium specimens were measured and evaluated by a single expert pathologist. Both US and histological data were collected and statistically analyzed.

Results

Our results confirm the relevant difference of FP thickness, particularly represented under the endometrium for submucous LMs. FPs near the endometrial cavity were considerably thicker than those of both intramural fibroids and subserous fibroids measured by US (P=0.0001) and histology (P=0.0001). A clear cut-off measurement at 2 mm (P=0.0001) was found between endometrial FPs and all other FPs for either US or histology measurements.

Conclusion

The thickness of FP is considerably higher near the endometrial cavity when compared to those of both intramural and subserous LMs, suggesting a potential role either in fertility or in myometrial healing.

Ultrasound-Guided Percutaneous Microwave Ablation for Subserosal Uterine Myomas

STUDY OBJECTIVE

To prospectively evaluate the clinical effectiveness and safety of ultrasound-guided percutaneous microwave ablation for symptomatic subserosal uterine myomas.

DESIGN

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

SETTING

A teaching hospital (Department of Interventional Ultrasound, General Hospital of Chinese PLA, Beijing, China).

PATIENTS

Sixty-nine patients with symptomatic subserosal uterine myomas treated with ultrasound-guided percutaneous microwave ablation.

INTERVENTIONS

All 69 patients underwent ultrasound-guided percutaneous microwave ablation. The number of patients lost to follow-up at was 21 at 3 months, 34 at 6 months, and 35 at 12 months.

MEASUREMENTS AND MAIN RESULTS

The efficacy of treatment was evaluated based the mean myoma volume shrinkage rate and changes in Uterine Fibroid Symptom and Quality of Life Questionnaire scores at 3, 6, and 12 months after therapy. Treatment safety was evaluated based on the Society of Interventional Radiology practice guidelines. The mean patient age was 40.3 ± 4.9 years (range, 26-49 years). The mean myoma volume was 221.74 ± 153.18 cm³ before ablation, decreasing to 87.24 ± 45.93 cm³ at 3 months after ablation (p < .001), 46.68 ± 24.7 cm³ at 6 months after ablation (p < .001), and 38.05 ± 24.93 cm³ at 12 months after ablation (p <.001), respectively. Between pretreatment and 3-month follow-up, the mean symptom severity score decreased from 34.53 ± 3.83 to 12.74 ± 3.07 (p < .001), and the mean health-related quality of life score increased from 45.25 ± 10.97 to 78.48 ± 11.39 (p < .001). Both scores remained stable at the 6- and 12-month follow-up time points. No permanent injury or fatal complications were seen in this series.

CONCLUSION

Ultrasound-guided percutaneous microwave ablation of subserosal uterine myomas is a promising treatment method. Further studies with larger sample sizes and a control group are needed.

Characteristics of uterine rupture after laparoscopic surgery of the uterus: clinical analysis of 10 cases and literature review

Objective

An increasing trend of uterine rupture (UR) after laparoscopic surgery of the uterus (LSU) has been observed. Although the overall incidence is extremely low, UR may have catastrophic outcomes. Therefore, investigation of its potential risk factors is important.

Methods

We retrospectively reviewed the medical data of 10 women who developed UR after LSU performed at our hospital from October 2003 to October 2016 and conducted a literature review.

Results

All cases of UR occurred during the third trimester of pregnancy. The surgeries contributing to UR were laparoscopic myomectomy, adhesion decomposition, and salpingectomy, resulting in unfavorable outcomes especially for the fetus. Diathermy was routinely used for hemostasis, and multilayer suturing was not adequately performed in many cases. The posterior wall was the most common site of UR in most cases. Silent rupture with unremarkable symptoms was not rare. Similar risk factors were identified in the literature review.

Conclusions

Excessive use of energy equipment and the lack of multilayer suturing were the most common characteristics of UR after LSU. A history of LSU should always be considered a risk factor for UR.

Laparoscopic uterine surgery as a risk factor for uterine rupture during pregnancy

The incidence of uterine rupture through a previous cesarean scar (CS) is declining as a result of a lower parity and fewer options for vaginal birth after cesarean. However, uterine ruptures attributable to other causes that traumatize the myometrium are on the rise. To determine whether changes in the causes of uterine rupture had occurred in recent years, we retrospective retrieved the clinical records of all singletons with uterine rupture observed in the delivery room of a Taiwanese tertiary obstetric center over a 15-year period. The overall uterine rupture rate was 3.8 per 10,000 deliveries. A total of 22 cases in 20 women (with two of them experiencing two episodes). Seven uterine ruptures occurred through a previous cesarean scar (CS ruptures, 32%), 13 through a non-cesarean scar (non-CS ruptures, 59%), whereas the remaining two (9%) were in women who did not previously undergo any surgery. All of the 13 non-CS ruptures were identified in women with a history of laparoscopic procedures to the uterus. Specifically, 10 (76%) occurred after a previous laparoscopic myomectomy, one (8%) following a hysteroscopic myomectomy, and two (16%) after a laparoscopic wedge resection of cornual ectopic pregnancy. Severe bleeding (blood loss >1500 mL) requiring transfusions was more frequent in women who experienced non-CS compared with CS ruptures (10 versus 1 case, respectively, P = 0.024). Patients with a history of endoscopic uterine surgery should be aware of uterine rupture during pregnancy.

Symptomatic Fibroid Management: Systematic Review of the Literature

Background and Objectives:

Symptomatic uterine fibroids are a societal and healthcare burden with no clear consensus among medical professionals as to which procedural treatment is most appropriate for each symptomatic patient. Our purpose was to determine whether recommendations can be made regarding best practice based on review and analysis of the literature since 2006.

Database:

A systematic search of journal articles relevant to the treatment of symptomatic uterine fibroids was performed within PubMed, clinical society websites, and medical device manufacturers' websites. All clinical trials published in English, representing original research, and reporting clinical outcomes associated with interventions for the management of symptomatic uterine fibroids were considered. Each article was screened and selected based on study type, content, relevance, American College of Obstetricians and Gynecologists score, and internal/external validity. Outcomes of interest were patient baseline characteristics, fibroid characteristics, procedural details, complications, and long-term follow-up. Random-effects meta-analyses were used to test the quantitative data. Assessment of 143 full-length articles through January 2016 produced 45 articles for the quantitative analysis. The weighted combined results from hysterectomy trials were compared with those from uterine-preserving fibroid studies (myomectomy, uterine artery embolization, laparoscopic radiofrequency ablation, and magnetic resonance-guided focused ultrasound).

Conclusion:

We explored trends that might guide clinicians when counseling patients who need treatment of symptomatic fibroids. We found that fibroid therapy is trending toward uterine-conserving treatments and outcomes are comparable across those treatments. Since minimally invasive options are increasing, it is important for the clinician to provide the patient with evidence-based therapeutic strategies.

Improved Fertility Following Enucleation of Intramural Myomas in Infertile Women

Background:

The relationship between intramural myomas and fertility remains unclear. The main debate rests on whether cavity-distorting intramural myomas (CDMs) adversely affect fertility more than non-CDMs. We aimed to compare the effects of enucleating non-CDMs and CDMs on fertility improvement in females with unexplained infertility.

Methods:

We prospectively recruited 83 women undergoing myomectomy for unexplained infertility with intramural myomas between June 2008 and November 2012 and classified them into non-CDMs group (n = 45) and CDMs group (n = 38). We then compared postoperative infertility rates, spontaneous pregnancy rates, pregnancy outcomes, live birth rates, and obstetric complications. For continuous variables, we calculated the mean ± standard deviation, median and interquartile range, and analyzed the data using Student's t-test and the Mann-Whitney U-test. For categorical variables, the Pearson's Chi-square test, the continuity correction test, and Fisher's exact test were used.

Results:

Patients’ demographics and myoma characteristics were comparable between the two groups. The overall spontaneous pregnancy rate increased from 0% to 68.42% following myomectomy. The postoperative infertility rate was significantly higher in the non-CDMs group than that in the CDMs group (50.00% vs. 23.53%, t = 5.579, P = 0.018), whereas the postoperative spontaneous pregnancy rate was significantly lower in the non-CDMs group than that in the CDMs group (47.62% vs. 70.59%, t = 4.067, P = 0.044). Compared with the enucleation of non-CDM, the enucleation of CDM patients was a protective factor for the fertility restoration (risk ratio [RR] = 3.717, 95% confidence interval [CI]: 1.284–10.753, P = 0.015), although postoperative fertility restoration declined with age (RR = 1.141, 95% CI: 1.005–1.295, P = 0.041).

Conclusions:

Intramural myomas are associated with impaired fertility. Women experiencing unexplained infertility, and possessing intramural myomas, have a better chance of conception following myomectomy, and these benefits are more obvious for younger patients and patients with CDM.

The Changes of Surgical Treatment for Symptomatic Uterine Myomas in the Past 15 Years

Study Objective:

The aim of this study is to elaborate the changes of the surgical approach of treatment for uterine myomas in Yangpu Hospital in the past 15 years.

Design:

This was retrospective cohort study.

Setting:

Yangpu Hospital, Tongji University School of Medicine, Shanghai, China.

Materials and Methods:

A total of 4113 patients with symptomatic uterine myomas underwent surgical treatments. Interventions: Eight kinds of different surgeries were involved in the study, including abdominal or laparoscopic surgery, hysterectomy, or uterus-sparing myomectomy.

Measurements:

The study collected patients' clinical data and reviewed surgical access and approach, complications, and the results of following up.

Results:

A total of 1559 cases (37.9%) underwent uterus-sparing myomectomy, 3005 cases (73.1%) performed laparoscopic surgeries. The percentage of laparoscopic surgery was significantly higher than homochronous data of laparotomy after 2003 (P < 0.001). The per year total of uterus-reserved surgery was proved to be negatively correlated with patient's age (R² = 0.930; P < 0.001). The rate of myomas recurrence was significantly lower in the combined myomectomy and uterine artery occlusion group (4%, 34/910) than in the single myomectomy group (10.5%, 44/420) (P < 0.001).

Conclusions:

Retaining uterus and minimally invasive surgery were the important trends of surgical treatment for symptomatic uterine myomas. Laparoscopic uterus-sparing myomectomy may be an alternative to hysterectomy to manage to appropriate patients with uterine myomas.

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

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

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

Background

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

Methods

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

Results

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

Conclusions

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

Predictors of postoperative hemoglobin drop after laparoscopic myomectomy

Introduction

Laparoscopic myomectomy (LM) can be associated with significant bleeding.

Aim

To identify factors influencing the postoperative hemoglobin (Hb) drop after LM.

Material and methods

This is a retrospective, single-center study. We evaluated data of 150 consecutive patients undergoing LM due to intramural myomas between 2010 and 2015.

Results

The median age of the patients was 37 (23–53) years. The mean diameter of the largest myoma was 5.7 ±2.3 (1.5–12) cm. The mean surgical time was 83 ±38 (35–299) min. The median number of sutures was 3 (1–11). The mean postoperative Hb drop was 1.6 ±1.2 (0–6) g/dl, and the mean estimated blood loss was 261 ±159 (50–1700) ml. In the univariate analysis, the postoperative Hb drop correlated with the duration of surgery (p < 0.001), diameter of the largest myoma (p < 0.001), cumulative myoma weight (p < 0.001), and number of sutures (p < 0.001), but not with patients’ age or number of intramural myomas. In the multivariable analysis, the surgical time (β = 0.395, p < 0.001), diameter of the largest myoma (β = 0.292, p = 0.03) and preoperative Hb concentration (β = 0.299, p < 0.001) predicted the postoperative Hb change.

Conclusions

Surgical time and dominant myoma diameter are independent predictors of the postoperative Hb drop after LM.

Laparoscopic Myomectomy Using "Cold" Surgical Instruments for Uterine Corpus Leiomyoma: A Preliminary Report

To assess the feasibility and safety of laparoscopic myomectomy without coagulation for uterine corpus leiomyoma between 4 and 9 cm in diameter with types 2-5. A total of 109 patients with uterine corpus myoma, single or multiple, between 4 and 9 cm in diameter with types from 2 to 5 were included who underwent laparoscopic myomectomy without using any unipolar or bipolar coagulation. Surgery time, intraoperative blood loss, hemoglobin decline on the first day after surgery and average days of post-operative hospitalization were recorded. The mean operative time was 70 ± 25 min (range 35-140 min). Mean blood loss during operation was 138 ml (range 20-400 ml), mean hemoglobin decline on the first day after surgery was 1.5 ± 0.75 g/dl (range 0-3.2 g/dl), and mean hospitalization time was 3.2 days (range 2-6 days). No patient required a blood transfusion. There were no major post-operative complications. Laparoscopic myomectomy without coagulation is feasible and safe for uterine corpus leiomyoma between 4 and 9 cm in diameter with types 2-5.

The indication and curative effect of hysteroscopic and laparoscopic myomectomy for type II submucous myomas

Background

The aim of this study was to assess curative effect of hysteroscopic and laparoscopic myomectomy for type II submucous myomas between 3 and 5 cm in diameter and explore the optimal surgical indications.

Methods

A retrospective analysis was performed of those who underwent hysteroscopic or laparoscopic myomectomy from January 2008 to January 2013. The patients were divided into three subgroups according to the myomas diameter (namely, 30 mm ≤ myomas diameter <40 mm; 40 mm ≤ myomas diameter <50 mm; and myomas diameter ≥ 50 mm). Clinical data such as operation time, amount of bleeding, postoperative anal exsufflation time, hospital stay, and complications were collected.

Results

There was no significant difference regarding operation time and amount of bleeding in two groups. We found significant difference in hysteroscopic group (within-subgroup) difference regarding operation time and amount of bleeding, whereas no significant difference in the laparoscopic group, while significant differences between-subgroup differences regarding operation time. Complete removal of myoma was seen in all patients.

Conclusions

Both techniques are feasible for type II submucous myomas. Laparoscopic operation has higher advantages in type II submucous myomas of greater than 4 cm in diameter whereas hysteroscopic operation has higher advantages in type II submucous myomas of lower than 4 cm in diameter.

Epidemiology of Uterine Myomas: A Review

Myomas are the most common benign tumors of the genital organs in women of childbearing age, causing significant morbidity and impairing their quality of life. In our investigation, we have reviewed the epidemiological data related to the development of myomas in order to homogenize the current data. Therefore, a MEDLINE and PubMed search, for the years 1990-2013, was conducted using a combination of keywords, such as "myoma," "leiomyoma," "fibroids," "myomectomy," "lifestyle," "cigarette," "alcohol," "vitamins," "diet," and "hysterectomy". Randomized controlled studies were selected based upon the authors’ estimation. Peer-reviewed articles examining myomas were sorted by their relevance and included in this research. Additional articles were also identified from the references of the retrieved papers and included according to authors’ estimation.

Many epidemiologic factors are linked to the development of myomas; however, many are not yet fully understood. These factors include age, race, heritage, reproductive factors, sex hormones, obesity, lifestyle (diet, caffeine and alcohol consumption, smoking, physical activity and stress), environmental and other influences, such as hypertension and infection. Some of the epidemiological data is conflicting. Thus, more research is needed to understand all the risk factors that contribute to myoma formation and how they exactly influence their onset and growth.

The prevalence of occult leiomyosarcoma at surgery for presumed uterine fibroids: a meta-analysis

There is a concern regarding the risk of occult leiomyosarcomas found at surgery for presumed benign fibroids. We sought to produce a comprehensive review of published data addressing this issue and provide high-quality prevalence estimates for clinical practice and future research. A comprehensive literature search using the PubMed/MEDLINE database and the Cochrane Library was performed. Inclusion criteria were human studies, peer-reviewed, with original data, involving cases for surgery in which fibroid-related indications were the primary reason for surgery, and histopathology was provided. Candidate studies (4864) were found; 3844 were excluded after review of the abstract. The remaining 1020 manuscripts were reviewed in their entirety, and 133 were included in the Bayesian binomial random effect meta-analysis. The estimated rate of leiomyosarcoma was 0.51 per 1000 procedures (95 % credible interval (CrI) 0.16–0.98) or approximately 1 in 2000. Restricting the meta-analysis to the 64 prospective studies resulted in a substantially lower estimate of 0.12 leiomyosarcomas per 1000 procedures (95 % CrI <0.01–0.75) or approximately 1 leiomyosarcoma per 8300 surgeries. Results suggest that the prevalence of occult leiomyosarcomas at surgery for presumed uterine fibroids is much less frequent than previously estimated. This rate should be incorporated into both clinical practice and future research.

Is Cold Loop Hysteroscopic Myomectomy a Safe and Effective Technique for the Treatment of Submucous Myomas With Intramural Development? A Series of 1434 Surgical Procedures

STUDY OBJECTIVE

To assess the safety and efficacy of cold loop hysteroscopic myomectomy in a large series of cases.

DESIGN

Retrospective study (Canadian Task Force Classification III).

SETTING

Arbor Vitae Center for Endoscopic Gynecology, Rome, Italy.

PATIENTS

A total of 1215 patients with 1 or more G1-G2 submucous myomas.

INTERVENTION

Cold loop hysteroscopic myomectomy.

MEASUREMENT AND MAIN RESULTS

A total of 1690 myomas were removed. A minimum of 1 to a maximum of 5 fibroids for each surgical procedure were totally removed. Out of 1215 patients, 1017 (83.7%) were treated with a single surgical procedure. Twelve intraoperative complications occurred (0.84%). No cases of uterine perforation with the thermal loop or clinical intravasation syndrome were reported.

CONCLUSION

Cold loop hysteroscopic myomectomy seems to represent a safe and effective procedure for the removal of submucous myomas with intramural development, while at the same time respecting the anatomic and functional integrity of the myometrium. The use of a cold loop in resectoscopic myomectomy is associated with a low rate of minor intraoperative complications and an absence of major complications. This could be of primary relevance with a view to fertility and future pregnancies.