Traditional surgical approaches to uterine fibroids: abdominal myomectomy and hysterectomy

Robot-assisted laparoscopic myomectomy: Technique & brief literature review

The worldwide growth of robot-assisted laparoscopic surgery has been exponential since its FDA approval for use in gynecologic surgery in the spring of 2005. This growth has spanned the entire gamut of gynecologic procedures and pathology. One area that has leveraged the unique aspects of robotics has been its application to the conservative surgical management of uterine fibroids. This manuscript will review the surgical technique and highlight the current situation regarding the scientific literature with an evidence-based focus on the role of robot-assisted laparoscopic myomectomy (RALM) with the daVinci Surgical System (Intuitive Surgical, Sunnyvale, CA).

Large Submucosal Uterine Leiomyoma Prolapse Into the Vagina After Complicating a Pregnancy: A Case Report

Uterine leiomyomas are the most common pelvic neoplasm in females. They are non-cancerous monoclonal tumors that develop from the fibroblasts and smooth muscle cells of the myometrium. They can develop in females of reproductive age and post-menopausal as well. When symptomatic, they frequently manifest as abnormal uterine bleeding and/or pelvic pain or pressure. Reproductive effects are also possible in fibroids such as infertility and poor pregnancy outcomes. In this report, we present a case of a 39-year-old woman, G9P4A4, GA 16 weeks who came to the ER with an incomplete abortion at home after which she had large multiple uterine submucosal fibroids prolapsing into the vagina. On ultrasound, the placenta was still inside, and a large submucosal anterior uterine fibroid and a posterior uterine fibroid were found with sizes 10x10 cm and 2x3, respectively. Evacuation and curettage (E&C) could not be completed because fibroids were obstructing and limiting the access. The patient was managed medically and then discharged, after which she came back with prolapsing uterine fibroids and part of the placenta. In the end, she was managed by hysteroscopic myomectomy.

Intrauterine Fetal Demise Associated with Vascular Malperfusion and Multiple Uterine Leiomyomata: A Report of Two Cases

BACKGROUND

Uterine leiomyomata have been loosely associated with intrauterine fetal demise (IUFD), largely attributed to fetal growth restriction from cavitary distortion. We present two cases of IUFD in patients with non-distorting leiomyomata and pathologic placental findings of maternal vascular malperfusion (MVM) and fetal vascular malperfusion (FVM).

CASE REPORT

Case 1 details a 28w3d IUFD associated with large leiomyomata (largest 11.9 × 7.6 × 9.7 cm), post-partum deep vein thrombosis, and severe pre-eclampsia histologic features. Case 2 details a 25w2d IUFD associated with smaller leiomyomata (largest 3.1 × 3.0 × 3.3 cm). Both placentas demonstrated MVM, including parenchymal thrombi and accelerated villous maturity, and FVM, including avascular stem villi.

DISCUSSION

As the placentas in both cases demonstrated findings consistent with altered placental perfusion, we posit that leiomyomata in these cases may have been associated with both maternal and fetal vascular malperfusion, ultimately contributing to fetal demise.

A Systematic Review of Minimally Invasive Treatments for Uterine Fibroid-Related Bleeding

Newer minimally invasive techniques provide treatment options for symptomatic uterine fibroids while allowing uterus preservation. The objective of this review was to analyze the efficacy of uterine-preserving, minimally invasive treatment modalities in reducing fibroid-related bleeding. A comprehensive search was conducted of PubMed, Embase, PsycINFO, ClinicalTrials.gov, Scopus, and Cochrane Library databases from inception to July 2020. English-language publications that evaluated premenopausal women with fibroid-related bleeding symptoms before and after treatment were considered. Randomized controlled trials were assessed for bias with the established Cochrane Risk of Bias Tool 2.0 and observational studies were assessed for quality under the New Castle-Ottawa Scale guidelines. Eighty-four studies were included in the review, including 10 randomized controlled trials and 74 observational studies. Six studies on myomectomy demonstrated overall bleeding symptom improvement in up to 95.9% of patients, though there was no significant difference between mode of myomectomy. Forty-one studies on uterine artery embolization reported significant reduction of fibroid-related bleeding, with symptomatic improvement in 79 to 98.5% of patients. Three studies suggested that embolization may be superior to myomectomy in reducing fibroid-related bleeding. Six studies reported that laparoscopic uterine artery occlusion combined with myomectomy led to greater reduction of bleeding than myomectomy alone. Fifteen studies demonstrated significantly reduced bleeding severity after radiofrequency ablation (RFA). Additional research is needed to establish the superiority of these modalities over one another. Long-term evidence is limited in current literature for magnetic resonance-guided focused ultrasound surgery, cryomyolysis, microwave ablation, and laser ablation.

Relugolix for the treatment of uterine fibroids

INTRODUCTION

Uterine fibroids (UF) are benign tumors common in premenopausal women, with strong impact on the health-care systems. For many years, surgery represented the only therapy for symptomatic fibroids. However, clinicians are observing a switch from surgery to noninvasive methods; in particular, medical treatment has been shown to be efficacious in obtaining a bleeding reduction and in ameliorating patient conditions.

AREAS COVERED

The authors review the current options available for the treatment of women with UF, with a special focus on the newest one, relugolix. It is an orally active non-peptide Gonadotropin-releasing hormone (GnRH)-receptor antagonist recently licensed for women with symptomatic fibroids. Relugolix is a well-tolerated safe drug; it is effective in inducing a dose-dependent decrease in menstrual blood loss, with faster reduction of heavy menstrual bleeding (HMB) and a greater shrinkage in fibroid volume compared to the current standard of GnRH agonist treatment.

EXPERT OPINION

Relugolix is a promising drug for the non-surgical treatment of women with UF. To date, the only published data come from a well-selected Japanese female population study while results from worldwide ongoing studies are ongoing in order to confirm the efficacy of this GnRH agonist receptor.

Robotic Surgery in Gynecology

The robotic-assisted laparoscopic surgical approach has improved complex gynecologic surgeries. It has the advantages of excellent visualization through the high-resolution 3-dimensional view, a wrist-like motion of the robotic arms and improved ergonomics. Similar to conventional laparoscopic surgeries, it is associated with a decrease in long-term surgical morbidity, early recovery and return to work, and improved esthetics. We discuss preoperative planning, surgical techniques, and some of the latest clinical results of robotic-assisted laparoscopic gynecologic surgery.

Unplanned hysterectomy following myomectomy at a tertiary institution: A case series and review of the literature

Introduction:

Myomectomy is the gold standard uterine-sparing treatment for fibroids. However, the procedure is often complicated by blood loss. In rare cases, haemorrhage may be so severe that a conversion to hysterectomy is warranted. The aim of our study was to investigate the rates of and the clinical reasoning behind unplanned hysterectomies following attempted myomectomies at our institution.

Methods:

All patients who underwent an open or laparoscopic myomectomy at the Royal Women’s Hospital were identified using a gynaecology unit database, maintained from January 2004 to December 2013. Records for patients whose surgeries were unexpectedly converted to a hysterectomy were examined. A review of the literature was also performed, investigating the rates of unplanned hysterectomies following myomectomies.

Results:

Of the 1501 myomectomies performed, six resulted in an unplanned hysterectomy; an incidence rate of 0.4%. Fibroids were either intramural or pedunculated with the median number of tumours per patient being 2.5 (interquartile range: 1–6). The largest tumour for each patient varied significantly from 4.0 × 3.2 cm to 29.0 × 25.0 cm. In all cases, despite being strongly advised to have a planned hysterectomy, patients insisted on having a myomectomy. Two patients underwent conversion to hysterectomy intraoperatively while the remainder required a return to theatre. Difficulty achieving intraoperative haemostasis (n = 2), and the development of postoperative bleeding and coagulopathy (n = 4) were reasons cited for proceeding to hysterectomy.

Conclusion:

The rate of conversion from myomectomy to hysterectomy at our institution was low at 0.4%. In all cases, the reason for conversion was difficulty with haemostasis, despite infrequent use of haemostatic agents, and coagulopathy.

Size matters in planning hysterectomy approach

Hysterectomy is the second most common gynecologic surgery; approximately 600,000 women undergo hysterectomies each year in the United States. Estimated uterine size, either by bimanual examination, ultrasonography, or both, is one of the major factors in evaluating the need for hysterectomy and in selecting the surgical approach. In this article, we review how physician-estimated uterine size can be confidently used in providing optimal hysterectomy care, as data indicate estimation is closely correlated with actual post-surgical pelvic specimen weight.

Uterine Artery Embolization and Surgical Methods for the Treatment of Symptomatic Uterine Leiomyomas: A Systemic Review and Meta-analysis Followed by Indirect Treatment Comparison

PURPOSE

There is significant discussion and uncertainty about the optimal management of symptomatic uterine leiomyomas (SULs). Nonsurgical procedures such as uterine artery embolization (UAE) have been developed. The goal of this study was to conduct a meta-analysis and an indirect treatment comparison to examine the comparative efficacy and safety of the surgical procedures to treat SULs compared with UAE.

METHODS

MEDLINE, EMBASE, Lilacs, and the Cochrane Central Register of Controlled Trials databases were searched from inception to February 2016. Ten randomized controlled trials comparing UAE versus hysterectomy, myomectomy, and laparoscopic occlusion of the uterine arteries in patients with SUL published in a peer-reviewed journal were included. Two reviewers independently selected studies, assessed quality, and extracted data. Discrepancies were resolved through consensus.

FINDINGS

Data from 986 patients submitted to UEA (n = 527) or surgery (n = 459) were analyzed. UAE had a lower risk of major complications (risk ratio [RR], 0.45 [95% CI, 0.22-0.95]; P = 0.04)and a higher risk of minor complications (RR, 1.65 [95% CI, 1.32-2.06]; P < 0.00001); UAE had a higher risk of re-intervention up to 2 years (RR, 3.74 [95% CI, 1.76-7.96]; P = 0.0006) and up to 5 years (RR, 5.01 [95% CI, 1.37-18.39]; P = 0.02); UAE had a similar risk of follicle-stimulating hormone levels >40 IU/L after 6 months (RR, 1.76 [95% CI, 0.24-12.95]; P = 0.58)and of recommending the procedure to another patient up to 5 years after treatment (RR, 1.00 [95% CI, 0.87-1.14]; P = 0.94). The indirect comparison between myomectomy and hysterectomy found that the 2 procedures were similar in the studied outcomes.

IMPLICATIONS

Compared with surgery, UAE had lower rates of major complications with an increased risk of re-intervention up to 2 and 5 years after the first procedure. UAE compared with surgery had a similar risk of ovarian failure and similar recommendation of the procedure to another patient. However, the number of trials was limited, and there was a high risk of bias in at least 2 domains. None of the trials blinded the participants and personnel or the outcome assessment. PROSPERO identifier: CRD42015026319.

Robot-assisted laparoscopic myomectomy: current status

Robotic-assisted surgery has seen a rapid development and integration in the field of gynecology. Since the approval of the use of robot for gynecological surgery and considering its several advantages over conventional laparoscopy, it has been widely incorporated especially in the field of reproductive surgery. Uterine fibroids are the most common benign tumors of the female reproductive tract. Many reproductive-aged women with this condition demand uterine-sparing surgery to preserve their fertility. Myomectomy, the surgical excision of uterine fibroids, remains the only surgical management option for fibroids that entails preservation of fertility. In this review, we focus on the role of robotic-assisted laparoscopic myomectomy and its current status, in comparison with other alternative approaches for myomectomy, including open, hysteroscopic, and traditional laparoscopic techniques. Several different surgical techniques have been demonstrated for robotic myomectomy. This review endeavors to share and describe our surgical experience of using the standard laparoscopic equipment for robotic-assisted myomectomy, together with the da Vinci Robot system. For the ideal surgical candidate, robotic-assisted myomectomy is a safe minimally invasive surgical procedure that can be offered as an alternative to open surgery. The advantages of using the robot system compared to open myomectomy include a shorter length of hospital stay, less postoperative pain and analgesic use, faster return to normal activities, more rapid return of the bowel function, and enhanced cosmetic results due to smaller skin incision sizes. Some of the disadvantages of this technique include high costs of the robotic surgical system and equipment, the steep learning curve of this novel system, and prolonged operative and anesthesia times. Robotic technology is a novel and innovative minimally invasive approach with demonstrated feasibility in gynecological and reproductive surgery. This technology is expected to take the lead in gynecological surgery in the upcoming decade.

Uterine Artery Embolization for Symptomatic Myomata

Fibroid disease is common and causes significant health problems in women of childbearing age. Over the past several years, uterine artery embolization (UAE) has emerged as a minimally invasive treatment for symptomatic uterine myomata. Embolotherapy is effective in relieving myoma-related symptoms in 80% to 90% of patients. It requires shorter hospitalizations than traditional surgical therapies for myoma disease and is associated with faster recovery and lower complication risks than surgery. Patient selection, the UAE procedure, and post-UAE management are reviewed.

Overview of latest evidence on uterine fibroids

Uterine fibroids are the most common type of benign gynecologic mass, and are present in up to 80 percent of women. Research exploring risk factors for fibroids presents conflicting or inconclusive findings. Symptoms for up to 50 percent of women experiencing fibroids include heavy menstrual bleeding, pelvic pressure or pain and gastrointestinal and genitourinary changes. Diagnosis is made by history and symptoms, physical examination and imaging. Several treatment options are available, and are based on symptoms, preferences and reproductive plans. Given the high prevalence of fibroids and the potential for women's health implications, it is essential that clinicians are aware of the latest evidence regarding fibroids to provide the highest quality of care for women whose health is affected by this condition.

Effects of a single rectal dose of Misoprostol prior to abdominal hysterectomy in women with symptomatic leiomyoma: a randomized double blind clinical trial

Background

Fibroma, the most common benign pelvic tumor in women, affects 25 to 30% of women of reproductive age. Primary treatment for patients with symptomatic or large fibroma is surgery.

Objective

The purpose of this study was to investigate the effect of a single rectal dose of Misoprostol on bleeding during abdominal hysterectomy.

Methods

This double blind randomized clinical trial was conducted with 80 candidates for abdominal hysterectomy, due to uterine myoma, in the Shahid Sadoughi hospital of Yazd in 2012. The aim of this study was to assess the effect of single rectal dose of Misoprostol on peri-operational abdominal hysterectomy bleeding. Following administration of 400 micrograms of Misoprostol in the case group (n=40), predetermined criteria were compared with control group (n=40).

Results

Volume of bleeding during the operation was significantly lower in cases where Misoprostol was used. (268.71 ± 156.85 vs. 350.38 ± 152.61 cc in the case and control groups, respectively). Our findings also showed that Hemoglobin (Hb) levels before, 8, and 30 hours following the operation differed significantly (p=0.001), but these changes were similar in both groups. Pre-operative Hb levels were 11.90 ± 1.7 and 11.90 ± 2.0 in the case and control groups, respectively.

Conclusion

A single rectal dose of Misoprostol has positive effect on reducing peri-operational bleeding in women undergoing abdominal hysterectomy due to symptomatic leiomyoma.

Predisposing factors for fibroids and outcome of laparoscopic myomectomy in infertility

Introduction:

Fibroids are very common tumors affecting women for centuries, however surprising that no significant data is still available as to what could be the cause of fibroid? What could be the predisposing or risk factors? Does it has any impact on fertility? Outcomes of Laparoscopic myomectomy in infertility?

Setting:

Advanced Tertiary Gynecologic endoscopic unit.

Aims and Objectives:

1) What are the predisposing factors to develop fibroids? 2) Do fibroids lead to infertility? 3) What are the indications for removal of fibroids in infertility? 4) Is laparoscopic surgery better than open surgery? 5) Is the risk of rupture uterus more after laparoscopic myomectomy? 6) What is the success in terms of pregnancy rate after myomectomy? 7) What are the chances of abortions with or without myomectomy?

Materials and Methods:

A retrospective research study was carried out on 2540 women at the National Institute of Laser and Endoscopic Surgery and Aakar IVF Centre, Mumbai, a referral centre in India. This study was done over a period of 14 years. Women varied in age from 23 to 51 years and infertility of at least more than three years. The woman had fibroids from one to seventeen in number and two centimeters to eighteen centimeters in size which were either submucous, intramural, serosal, cervical or broad ligament. The women requiring hysteroscopic myoma resection were excluded in this study and Laparoscopic myomectomy done in woman other than infertility are also excluded from the study.

Results:

During the course of our study we found that the diet, weight, hypertension, habits had a bearing on incidence of fibroid. In one of the most promising research fact we found that fibroids itself produce prolactin and due to three times high level of aromatase had higher level of estradiol locally compared to normal myometrium. This was detrimental to fertility. A mild elevation of blood levels of prolactin usually in the range of 40 – 60 ng/ml was noticed in nearly 42% of the cases. Fibroids with infertility as a major complaint along with excessive vaginal bleeding in 33%, pain abdomen and dysmenorhea 10%, pressure symptoms in 3%, accidental finding of a large mass in 5% were the major indications for laparoscopic myomectomy. The pregnancy rate after removal of fibroids with active fertility treatment was 42 % and in donor oocyte IVF was 50%, abortion rate was 5%, 64% LSCS, 31% vaginal deliveries. There was no scar rupture in all pregnancies post laparoscopic myomectomy.

Conclusion:

Presence of fibroids in first degree female relative, predominantly red meat eating women, excess weight and high Blood pressure increased incidence of fibroids. Pregnancies & oral contraceptives decreased chances of fibroids. In infertile patient fibroids of significant size, multiple, had high local prolactin & aromatase level affecting fertility. Laparoscopic removal of fibroids increased pregnancy rate to 37.2% & 50% in donor oocyte IVF.

Mifepristone for uterine fibroids

BACKGROUND

Uterine fibroids are the most common benign uterine tumours present in women of reproductive age. Mifepristone (RU-486) competitively binds and inhibits progesterone receptors. Studies have suggested that fibroid growth depends on the sexual steroids. Mifepristone has been shown to decrease fibroid size. This review summarises the effects of mifepristone treatment on fibroids and the associated adverse effects as described in randomised controlled trials.

OBJECTIVES

To determine the efficacy and safety of mifepristone for the management of uterine fibroids in pre-menopausal women.

SEARCH METHODS

We searched the specialised register of the Cochrane Menstrual Disorders and Subfertility (Cochrane Menstrual Disorders and subfertility Review Group), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 4), MEDLINE, EMBASE, PsycINFO, and CINAHL (to November 2011). We handsearched a number of journals, and searched reference lists, databases of ongoing trials and the Internet. There were no language restrictions.

SELECTION CRITERIA

Only truly randomised controlled trials of mifepristone versus other forms of medical therapy or placebo in pre-menopausal women with confirmed uterine fibroids were included.

DATA COLLECTION AND ANALYSIS

Four authors independently extracted data and assessed trial quality. Data were analysed using the Peto odds ratios (OR) for dichotomous data and the weighted mean differences for continuous data, with 95% confidence intervals (CI). Meta-analyses were performed using the fixed-effect model.

MAIN RESULTS

Three studies involving 112 participants were included. Comparison interventions included different dosages of mifepristone, placebo and vitamin B tablets. There is evidence that treatment with mifepristone relieves heavy menstrual bleeding compared with placebo (Peto OR 17.84; 95% CI 6.72 to 47.38; 2 RCTs, 77 women, I(2) = 0%). Three studies (Bagaria 2009; Engman 2009; Fiscella 2006) were included in the meta-analysis of this comparison. There was no evidence of an effect of mifepristone on the fibroid volume (standardised mean difference (SMD) -0.02; 95% CI -0.38 to 0.41; 99 women). Two studies (Bagaria 2009; Fiscella 2006) were included in the meta-analysis of this comparison. There was no evidence of an effect of mifepristone on uterine volume (mean difference (MD) -77.24; 95% CI -240.62 to 86.14; 72 women). The pooled data suggest an increased adverse event (abnormal endometrial histology) in the mifepristone group compared to placebo (OR 31.65; 95% CI 4.83 to 207.35; 2 RCTs; 54 women; I(2) = 0%). Only one study (Bagaria 2009) reported endometrial hyperplasia at the end of the therapy (12/19 women in the mifepristone group versus 0/16 in the placebo group; OR 55.0; 95% CI 2.86 to 105.67). Engman 2009 found a significantly higher rate of cystic glandular dilatation in women in the mifepristone group (5/8 women biopsied) compared with the placebo group (1/11 women biopsied) (OR 16.67; 95% CI 1.36 to 204.03). One study (Fiscella 2006) suggested significant improvements (P < 0.001) for specific quality of life outcomes.

AUTHORS' CONCLUSIONS

Mifepristone reduced heavy menstrual bleeding and improved fibroid-specific quality of life. However, it was not found to reduce fibroid volume. Further well-designed, adequately powered RCTs are needed before a recommendation can be made on the use of mifepristone for the treatment of uterine fibroids.

Whole exome sequencing in a random sample of North American women with leiomyomas identifies MED12 mutations in majority of uterine leiomyomas

Uterine leiomyomas (uterine fibroids) arise from smooth muscle tissue in the majority of women by age 45. It is common for these clonal tumors to develop from multiple locations within the uterus, leading to a variety of symptoms such as pelvic pain, abnormal uterine bleeding, and infertility. We performed whole exome sequencing on genomic DNA from five pairs of leiomyomas and corresponding normal myometrium to determine genetic variations unique to leiomyomas. Whole exome sequencing revealed that the gene encoding transcription factor MED12 (Mediator complex subunit 12) harbored heterozygous missense mutations caused by single nucleotide variants in highly conserved codon 44 of exon 2 in two of five leiomyomas. Sanger re-sequencing of MED12 among these five leiomyomas confirmed the two single nucleotide variants and detected a 42 base-pair deletion within exon 2 of MED12 in a third leiomyoma. MED12 was sequenced in an additional 143 leiomyomas and 73 normal myometrial tissues. Overall, MED12 was mutated in 100/148 (67%) of the genotyped leiomyomas: 79/148 (53%) leiomyomas exhibited heterozygous missense single nucleotide variants, 17/148 (11%) leiomyomas exhibited heterozygous in-frame deletions/insertion-deletions, 2/148 (1%) leiomyomas exhibited intronic heterozygous single nucleotide variants affecting splicing, and 2/148 (1%) leiomyomas exhibited heterozygous deletions/insertion-deletions spanning the intron 1-exon 2 boundary which affected the splice acceptor site. Mutations were not detected in MED12 in normal myometrial tissue. MED12 mutations were equally distributed among karyotypically normal and abnormal uterine leiomyomas and were identified in leiomyomas from both black and white American women. Our studies show an association between MED12 mutations and leiomyomas in ethnically and racially diverse American women.

Plastic and reconstructive uterus operations by minimally invasive surgery? A review on myomectomy

BACKGROUND

Plastic and reconstructive uterus operations are performed in congenital uterine anomalies or benign uterine conditions. Congenital uterine anomalies are relatively rare diseases with various approaches for surgical treatment. Therefore, to address the question of the usefulness of a minimally invasive approach in plastic uterus operations, the most common uterine condition which requires reconstructive surgery, namely myomectomy, is discussed.

METHOD

Searches were conducted in PubMed and The Cochrane Library to identify relevant literature.

FINDINGS

Compared with myomectomy by laparotomy and minilaparotomy, laparoscopic myomectomy is associated with improved short-term outcomes. Laparoscopy is further associated with less adhesion formation. Pregnancy rates after myomectomy in symptomatic patients might be higher after laparoscopy than after laparotomy. Although uterine ruptures following laparoscopic myomectomy are described in the literature, it seems to be a rare event. Concerning the recurrence, there is evidence that rates are similar after laparoscopy and laparotomy.

CONCLUSION

Myomectomy by laparoscopy has several advantages over abdominal myomectomy (by conventional laparotomy and minilaparotomy) and should be the standard procedure. Despite the advantages of laparoscopy, abdominal myomectomy is still a frequently performed procedure. Lack of training in advanced laparoscopic procedures hampers the wide-spread use of laparoscopic myomectomy. Due to the advantages of laparoscopic surgery, efforts should be made to implement this procedure into daily practice. To provide the best care, physicians should offer patients the opportunity of a laparoscopic treatment of myomas.

Indications and outcome of abdominal myomectomy in University of Maiduguri Teaching Hospital: Review of ten year

BACKGROUND

Abdominal myomectomy is a common modality of treatment for large and symptomatic uterine fibroid in women who wish to retain their fertility. Though frequently performed the procedure may still be associated with complications.

MATERIALS AND METHODS

A retrospective review of all patients who had abdominal myomectomy from January 1999 to December 2008 at the University of Maiduguri Teaching Hospital. Information on the Sociodemographic characteristics, indication for the myomectomy, uterine size, pre and post operative packed cell volume (PCV), intraoperative findings, cadre of surgeon, duration of hospital stay and complications were obtained.

RESULTS

The rate of abdominal myomectomy was 3.34%. Majority of the patients (79.8%) aged 30-49 years, and most (58.9%) were nulliparas. Abdominal mass (63.7%), menorrhagia (57.7%), and subfertility 55.2% were the leading indications for abdominal myomectomy. Complications were seen in 10.9% of the cases, 55.5 % of which were wound infections. Clinical and intra operative factors associated with complications included menorrhagia (P=0.003), estimated blood loss (EBL) ≥500mls (P=0.005) and post operative PCV of <30% (P=0.081).

CONCLUSION

Complication rate after myomectomy was low with menorrhagia and EBL ≥ 500 mls being significantly associated with development of complication.

Current and emerging treatments for uterine myoma - an update

Uterine myomas, the most common benign, solid, pelvic tumors in women, occur in 20%–40% of women in their reproductive years and form the most common indication for hysterectomy. Various factors affect the choice of the best treatment modality for a given patient. Asymptomatic myomas may be managed by reassurance and careful follow up. Medical therapy should be tried as a first line of treatment for symptomatic myomas, while surgical treatment should be reserved only for appropriate indications. Hysterectomy has its place in myoma management in its definitiveness. However, myomectomy, rather than hysterectomy, should be performed when subsequent childbearing is a consideration. Preoperative gonadotropin-releasing hormone analog treatment before myomectomy decreases the size and vascularity of the myoma but may render the capsule more fibrous and difficult to resect. Uterine artery embolization is an effective standard alternative for women with large symptomatic myomas who are poor surgical risks or wish to avoid major surgery. Its effects on future fertility need further evaluation in larger studies. Serial follow-up without surgery for growth and/or development of symptoms is advisable for asymptomatic women, particularly those approaching menopause. The present article is incorporated with multiple clear clinical photographs and simplified elaboration of the available management options for these tumors of uterine smooth muscle to facilitate clear understanding.

Novel 3-aryl indoles as progesterone receptor antagonists for uterine fibroids

We report the synthesis and characterization of novel 3-aryl indoles as potent and efficacious progesterone receptor (PR) antagonists with potential for the treatment of uterine fibroids. These compounds demonstrated excellent selectivity over other steroid nuclear hormone receptors such as the mineralocorticoid receptor (MR). They were prepared from 2-bromo-6-nitro indole in four to six steps using a Suzuki cross-coupling as the key step. Compound 8f was orally active in the complement 3 model of progesterone antagonism in the rat uterus and demonstrated partial antagonism in the McPhail model of progesterone activity.

Transvaginal ultrasound-guided radiofrequency myolysis for uterine myomas

BACKGROUND

Myolysis is one of the procedures that is claimed to provide significant improvement in myoma status without hysterectomy. Myolysis procedures have been generally performed via laparoscopy, and there are limited data on transvaginal radiofrequency (RF) myolysis. This study investigated the feasibility, efficacy and safety of transvaginal ultrasound-guided RF myolysis.

METHODS

Transvaginal ultrasound-guided RF myolysis was performed on 69 premenopausal women with symptomatic uterine myomas as an outpatient procedure. Outcomes were assessed 1, 3, 6 and 12 months after RF myolysis. Myoma volumes were measured by ulrasonography. Menorrhagia was evaluated by the number of soaked normal-sized sanitary products used per menstrual period and overall symptoms were evaluated using the symptom severity subscale of the uterine fibroids symptom questionnaire.

RESULTS

Mean (± SD) age of patients was 39.8 ± 6.5 years. Mean baseline volume of the dominant myomas was 304.6 ± 229.1 cm(3) and its volume at 3 months following RF myolysis decreased compared with the previous examination (P = 0.002). An improvement of menorrhagia occurred 1, 3, 6 and 12 months after operation (all P < 0.001 versus baseline). Overall symptoms at 1, 3, 6 and 12 months after RF myolysis also improved (all P < 0.001 versus baseline). No major complications were observed or reported. After 12 months, three patients had successfully conceived and delivered and there were no complications during labor or delivery.

CONCLUSIONS

Transvaginal ultrasound-guided RF myolysis might be a safe, effective and minimally invasive outpatient procedure for uterine myoma in terms of size reduction, symptom improvement and safety.

Single-port laparoscopic myomectomy using a new single-port transumbilical morcellation system: initial clinical study

STUDY OBJECTIVE

To evaluate the feasibility of single-port laparoscopic myomectomy with transumbilical morcellation and suturing.

DESIGN

Continuing prospective study (Canadian Task Force classification II-3).

SETTING

University hospital.

PATIENTS

Fifteen patients who underwent single-port laparoscopic myomectomy between September 2008 and October 2009 to remove single or multiple uterine myomas, at least 1 in each patient measuring greater than 4 cm in diameter.

INTERVENTIONS

All single-port laparoscopic myomectomy procedures were performed by a single surgeon (Dr. Y.W. Kim). Myomas were extracted transumbilically by cutting the myomas into smaller pieces with a knife or a conventional electromechanical morcellator. After making a single 1.5- to 2.0-cm umbilical incision, the single-port system, created with a wound retractor and a surgical glove, was inserted. All operations were performed using conventional rigid straight laparoscopic instruments. Laparoscopic suturing was performed in intramural myomas and some subserosal myomas.

MEASUREMENTS AND MAIN RESULTS

Patient mean (SD; range) age was 38.3 (5.6; 29-49) years. The number of myomas per patient was 1.6 (1.4; 1-6). The diameter of the largest myomas was 6.1 (1.5; 4.2-9.6) cm. In 4 patients, only a knife was required for transumbilical extraction of myomas, and in 11 patients, transumbilical morcellation with an electromechanical morcellator with or without a knife was used. Transumbilical drainage tubes were inserted into the pelvic cavity in 11 of 15 patients. Operative time was 96.7 (33.8; 35-150) minutes. The decrease in postoperative hemoglobin concentration was 1.8 (1.2; 0.4-3.6) g/dL. During the operations, no patients required blood transfusion. No patients developed postoperative fever. Neither bowel injury nor urinary tract injury occurred in any patient. The postoperative hospital stay was 3.1 (0.8; 2-4) days.

CONCLUSION

Single-port transumbilical morcellation using a conventional electromechanical morcellator with or without a knife is feasible. Single-port laparoscopic myomectomy is an alternative method with cosmetic advantage.

The relationship between urokinase plasminogen activator/plasminogen activator inhibitor type-1 expression in myoma/myometrium and mechanism of uterine artery occlusion by laparoscopy for uterine myoma treatment

The objective of the study was to investigate the pattern of expression of plasminogen activator/plasminogen activator inhibitor (PAI) system between myoma and myometrium and its correlation between outcome and laparoscopic uterine artery occlusion prior to myomectomy in the treatment of myoma. mRNA expression of PAI type-1 (PAI-1) and urokinase plasminogen activator (uPA) was detected with real-time PCR in the myoma and myometrium cells primary cultured in vitro, and uPA and PAI-I protein expression was detected with cellular immunity histochemistry. First, the expression of uPA mRNA was 0.123 +/- 0.189 in myoma, which was significantly lower than 0.331 +/- 0.306 in myometrium (P < 0.05); however, the expression of PAI-I mRNA was 0.091 +/- 0.036 in myoma, which was significantly higher than 0.016 +/- 0.020 in myometrium (P < 0.05). Second, the expression of uPA protein was 8.805 +/- 1.645 in myoma cells, which was lower than 22.173 +/- 4.381 in myometrium (P < 0.05); the expression of PAI-I protein was 44.765 +/- 1.090 in myoma cells, which was significantly higher than 35.928 +/- 5.351 in myometrium (P < 0.05). The distinct expression pattern of uPA/PAI in myoma and myometrium might be correlated to the low recurrence rate after uterine artery occlusion prior to myomectomy in the treatment of myoma.

Uterine artery occlusion for the treatment of symptomatic fibroids: Endoscopic, radiological and vaginal approach

Uterine fibroids are the most common solid pelvic tumors in women. Although many fibroids seem to cause no symptoms, for some women they can have serious adverse effects and impact on quality of life. Common symptoms associated with fibroids include abnormal uterine bleeding, pelvic pressure and reproductive dysfunction. The past decade has witnessed highly sophisticated diagnostic and therapeutic technology for fibroids. The tools currently at our disposal permit greater management flexibility, which must be tailored to the individual clinical situation. Nonsurgical treatments include medical therapy and treatments interfering with the blood supply to the uterus or the fibroid; among the latest introduced are uterine artery embolization performed by the interventional radiologist and laparoscopic uterine occlusion performed by the gynaecologist. Even simpler is the non-incision temporary uterine clamp directed with Doppler and placed in the side fornices in the vagina.

Myomectomy: A review of surgical technique

Fibroids are common amongst women of reproductive age. In women wanting to retain their fertility and/or uterus open myomectomy remains the most widely performed procedure. It is important to carefully counsel the patient about the pros and cons of surgery versus expectant management. Meticulous pre-operative evaluation and preparation will help ensure the procedure goes smoothly. Attention to the operating technique used is paramount in ensuring patient safety and surgical peace of mind. This review addresses the important aspects of open myomectomy including operative technique.

Murine xenograft model for human uterine fibroids: an in vivo imaging approach

Uterine fibroids are the most prevalent benign tumors in women of reproductive age. The current knowledge on the fibroid disease mechanism has derived from studies of the Eker rat model where a unique germ line defect in the tuberous sclerosis 2 (Tsc2) tumor suppressor gene leads to the development of leiomyosarcoma, leiomyoma, and renal cancer. To study fibroids of human origin, we sought to establish fibroid xenografts in immune-compromised mice. We determined that lentiviral-mediated transduction of a green fluorescence protein (GFP)-luciferase (LUC) fusion gene and bioluminescence-based whole animal imaging allowed for the monitoring of transplanted fibroid cells in mice. We used this in vivo imaging approach to test a series of transplantation protocols and found that only freshly dissociated fibroid cells, but not the fibroid-derived smooth muscle cells grown in ex vivo cultures, can generate stable xenografts in subcutaneous Matrigel implants. Formation of the fibroid-xenografts requires the implantation of 17betaestradiol-releasing pellets in the recipient mice. Furthermore, freshly dissociated myometrial cells do not form xenografts under the experimental conditions. The xenograft protocol developed from this study provides an avenue for investigating the pathogenesis and drug responses of human fibroids.

Benign gynecologic conditions

Benign gynecologic conditions constitute the majority of the general gynecologist's practice. Along with health maintenance examinations, contraceptive management, family planning issues, and concerns about incontinence, the gynecologic conditions for which patients commonly present include adnexal masses, leiomyomata, endometriosis, and pelvic inflammatory disease. This article addresses each of these last four entities and incorporates a discussion of their etiologies, clinical presentations, keys to diagnosis, and the various treatment options available.

Laparoscopic uterine artery occlusion combined with myomectomy for uterine myomas

We sought to evaluate the clinical feasibility and mid- to long-term effects of laparoscopic uterine artery occlusion before myomectomy in the treatment of uterine myomas. A total of 566 patients with uterine myoma were treated by laparoscopic uterine artery occlusion before myomectomy from October 2001 through July 2007. Mean blood loss was 88.2 +/- 52.7 mL (95% CI 82.7-93.8). The highest postoperative temperature was 37.8 +/- 0.3 degrees C, and the postoperative morbidity was 5.7% (32/566). Number of days to the return of bowel movement was 1.9 +/- 0.5d and in hospital stay after surgery was 7.7 +/- 2.5d. Complications included 2 instances of subcutaneous emphysema, 1 of vaginal bleeding, and 3 of mild intestinal obstruction. At a median of 26.3 months (range 6-69 months) of follow-up, the rate of myoma recurrence was 3.0% (15/517), uterus volume reduction was 48.9%, and correction of menstruation abnormality was 97.1% (502/517). Laparoscopic uterine artery occlusion before myomectomy can expand myomectomy indications with better results.

Current treatment options for abnormal uterine bleeding: an evidence-based approach

Heavy menstrual bleeding is the predominant complaint in women with abnormal uterine bleeding. Treatment options are drug therapy, and first- and second-generation endometrial resection. Many women will subsequently have a hysterectomy. Uterine fibroids are the most common solid pelvic tumours in women, and although many fibroids seem to cause no symptoms, they can have serious adverse effects and impact on quality of life. As women postpone having children, gynaecologists will have to manage fibroids and polyps in a conservative manner. The past decade has witnessed the development of highly sophisticated diagnostic and therapeutic technology for women suffering from menorrhagia, fibroids and polyps, including minimally invasive uterine therapy. The tools currently at our disposal permit greater management flexibility, which must be tailored to the individual clinical situation. This chapter reviews the evidence-based approach and minimally invasive therapy.

Uterine myomas: management

OBJECTIVE

To review the currently available literature regarding the current management alternatives available to women with uterine myomas.

DESIGN

Literature review of 198 articles pertaining to uterine myomas.

RESULT(S)

Many advances have been made in the management of uterine myomas. Watchful waiting; medical therapy; hysteroscopic myomectomy; endometrial ablation; laparoscopic myomectomy; abdominal myomectomy; abdominal, vaginal, and laparoscopic hysterectomy; uterine artery embolization; uterine artery occlusion; and focused ultrasound are now available.

CONCLUSION(S)

Many options are now available to women with uterine myomas. The presently available literature regarding the treatment of myomas is summarized.

Uterine myomas, dyspareunia, and sexual function

OBJECTIVE

To determine the prevalence of deep dyspareunia (DD) and characteristics of sexual life in women with uterine myomas.

DESIGN

Cross-sectional survey.

SETTING

University hospital.

PATIENT(S)

Three hundred seven sexually active premenopausal women who underwent surgery because of uterine myomas (group M, n = 132), uterine myomas and ovarian cysts (group MC, n = 84), ovarian cysts (group C, n = 67), and tubal sterilization (group S, n = 24). Exclusion criteria were as follows: endometriosis, pelvic inflammatory disease, interstitial cystitis, and preoperative treatment with GnRH analogues.

INTERVENTION(S)

Before surgery, patients underwent transvaginal ultrasound; number and characteristics of myomas were recorded.

MAIN OUTCOME MEASURE(S)

The presence and intensity of DD were determined. Patients completed a sexual-function questionnaire.

RESULT(S)

Patients included in the four groups had similar DD prevalence and DD intensity. No significant difference was observed in DD prevalence and pain intensity according to the number, position, and size of myomas. Deep dyspareunia intensity was higher in women with fundal and anterior myomas than in those with other myoma positions. No significant difference was observed in sexual function among the four study groups.

CONCLUSION(S)

Women with uterine myomas do not have increased prevalence or severity of DD; their sexual function is not impaired.

Patients' satisfaction with laparoscopic myomectomy

BACKGROUND

Laparoscopic myomectomy offers a uterus-conserving alternative to hysterectomy for patients suffering from symptomatic myomas. The following study aimed to examine clinically relevant aspects of perceived satisfaction following laparoscopic myomectomy.

METHOD

191 women completed a 17-item questionnaire on retrospective satisfaction with their choice for the operation and with the surgical outcome (e.g., "all myomas were removed", "termination of discomfort"). A comparison was performed using questionnaire data, patients' demographical data and surgical records (e.g., duration of surgery).

RESULTS

Women who trusted in their decision for the surgical procedure revealed better surgical outcome and greater satisfaction with the treatment process than those who were insecure with their choice. Age did not influence the patients' perceived satisfaction. In anticipation of the surgical outcome, patients placed stronger emphasis on tissue preservation than on their wish for a child or on the termination of discomfort.

CONCLUSIONS

The high overall level of satisfaction and positive outcome in various age groups contradicts current recommendations against laparoscopic myomectomy for women over 40 years of age.

Surgical treatment of fibroids for subfertility

BACKGROUND

Fibroids are benign tumours of the uterus occurring in up to 77% of women. Fibroids have been noted to occur more frequently in women with infertility. Retrospective studies have suggested the benefit of surgically removing fibroids to increase the fertility efficacy of both natural conception and assisted conception. There are a variety of methods to surgically remove fibroids including laparotomy, laparoscopy and hysteroscopy. The relative advantages and disadvantages of these modalities in terms of fertility efficacy and side effects are unknown.

OBJECTIVES

To determine the efficacy and safety of the removal of uterine fibroids in subfertile women by laparotomy, laparoscopy or hysteroscopy when compared with expectant management or each other. The review will include also new surgical approaches as and when they are trialed.

SEARCH STRATEGY

We searched the Cochrane Menstrual Disorders and Subfertility Review Group Specialised register of controlled trials, MEDLINE (PUBMED) 1985 to 2004, EMBASE (1985 to 2004), CINAHL (1985 to 2004) and National Research Register.

SELECTION CRITERIA

Randomised controlled trials (RCTs) in which fibroids were removed via surgery for the treatment of infertility

DATA COLLECTION AND ANALYSIS

Three authors independently assessed trial quality and extracted data.

MAIN RESULTS

Only one randomized controlled study was included (131 women) and this was probably underpowered. There was no evidence of a difference in outcome in terms of clinical pregnancy rate and live birth rate when fibroids were removed via laparotomy or laparoscopy for infertility. There were some non fertility benefits of removal via laparoscopy including shorter hospital stay, less febrile illness and a smaller drop in pre-operative haemoglobin concentration when compared to laparotomy. There were no randomised controlled studies comparing hysteroscopic removal or no intervention with other surgical modalities.

AUTHORS' CONCLUSIONS

There is limited evidence to suggest that there is no difference in fertility efficacy outcome if fibroids are removed via laparotomy when compared to laparoscopy. There is no good randomised controlled evidence to support hysteroscopic removal of fibroids compared to other surgical modalities for fertility efficacy.

Laparoscopic radiofrequency thermal ablation: a new approach to symptomatic uterine myomas

OBJECTIVE

The purpose of this study was to evaluate the feasibility and efficacy of laparoscopic radiofrequency ablation of uterine fibroids.

STUDY DESIGN

Eighteen women with symptomatic intramural uterine myomas underwent radiofrequency ablation under laparoscopic guidance. Postoperative sonographic evaluations of the fibroids size were scheduled at 1, 3, 6 ,9, and 12 months. The impact of myoma-related symptoms on quality of life (QOL) was assessed using a validated questionnaire.

RESULTS

The median number of myomas treated per patient was 1 (1-3). The median baseline volume of the dominant myoma was 67.2 cm 3 (14.8-332.8). No intraoperative or postoperative complications occurred. The median reductions in myomas volume were 41.5%, 59%, and 77% at 1, 3, and 6-months, follow-up evaluation, respectively. No further change in fibroid size was observed at 9 months and 1 year. A significant improvement in the symptoms score and QOL score was observed at 3 and 6 months, follow-up.

CONCLUSION

In this pilot study, laparoscopic radiofrequency ablation successfully reduced fibroid symptoms and fibroid volume in short-term follow-up. Additional studies are needed before its efficacy and safety can be confirmed.