Comparing the effect of FUAS and myomectomy on the elasticity of myometrium around targeted uterine fibroid

BACKGROUND

Focused ultrasound ablation surgery (FUAS) has been widely employed to treat patients with uterine fibroid (UF). This study aimed to estimate myometrial stiffness changes in patients who received FUAS for UFs or myomectomy (ME) and compare the recovery of surrounding myometrium between FUAS and ME groups. Our results may provide more evidence for guiding the proper conception timing in patients with UF.

METHODS

This study enrolled 173 patients from May 2022 to August 2023. Shear wave elastography (SWE) was used to dynamically monitor myometrial elasticity changes in patients before and after surgery. Moreover, our study monitored and analyzed the stiffness changes in the targeted fibroid after FUAS, as well as in the myometrium around after FUAS or ME.

RESULTS

The stiffness of the myometrium around the resected fibroid was significantly higher than at the preoperative level until 6 months. Conversely, the stiffness of the surrounding myometrium was only temporarily increased 1 day after FUAS. The comparison between FUAS and ME groups regarding the stiffness of the surrounding myometrium showed that nonsignificant differences were detected between the two groups before the treatment. The stiffness of the surrounding myometrium in the ME group was statistically significantly higher than that of the FUAS group 1 day as well as 1, 3, and 6 months after the treatment, respectively.

CONCLUSION

The FUAS had less impact on the surrounding myometrium than the ME, which may be more conducive to the recovery of myometrial elasticity in patients with UF.

The challenge of FIGO type 3 leiomyomas and infertility: Exploring therapeutic alternatives amidst limited scientific certainties

Uterine leiomyomas (ULs) are non-cancerous tumors composed of smooth muscle cells that develop within the myometrium and represent the most prevalent pathological condition affecting the female genital tract. Despite the volume of available research, many aspects of ULs remain unresolved, making it a "paradoxical disease" where the increase in available scientific literature has not been matched by an increase in solid evidence for clinical management. Fertility stands at the top of the list of clinical issues where the role of ULs is still unclear. The leiomyoma subclassification system, released by the International Federaion of Gynecology and Obstetrics (FIGO) in 2008, introduced a new and more effective way of categorizing uterine fibroids. The aim was to go beyond the traditional classification "subserosal, intramural and submucosal", facilitating a detailed examination of individual ULs impact on the female reproductive system. The "type 3 UL" is a special type of myoma, characterized by its complete myometrial development while encroaching the endometrium. It is a unique "hybrid" between a submucous and an intramural UL, that may exert a detrimental "double hit" mechanism, which is of particular interest in patients wishing pregnancy. To date, no robust evidence is available regarding the management of type 3 ULs. The aim of this narrative review is to provide a comprehensive overview of the physiopathological mechanisms that type 3 UL may exert on fertility, and to present new perspectives that may help us to better understand both the need for and the methods of treating this unique type of fibroid.

Management guidelines for incidental uterine surgery in early pregnancy: a case report of a robotic myomectomy at 4 weeks gestation after a false-negative pregnancy test

Objective

To share our case and offer guidance to practitioners on the management of incidental uterine surgery in early pregnancy. Although elective uterine surgery should be avoided during pregnancy, there is always a chance of undetected pregnancy at the time of surgery, even after all precautions have been taken. There is currently minimal literature on the management and outcomes of uterine surgery during pregnancy.

Design

Case report.

Setting

University Hospital.

Patient

A 42-year-old G1P1 female with symptomatic fibroids desiring fertility-sparing surgery was retroactively found to be 4 weeks pregnant at the time of surgery, even after a negative pregnancy test and low suspicion for pregnancy under Centers for Disease Control and Prevention guidelines.

Intervention

Robotic-assisted laparoscopic myomectomy performed with a false-negative urine pregnancy test at the time of surgery.

Main Outcome Measures

Guidance for surveillance and management options during continued pregnancy after robotic uterine surgery and cavity disruption by a uterine manipulator performed at 4 weeks gestation that went undetected at the time of surgery.

Results

The patient was able to undergo an uncomplicated delivery by cesarean section at 38 weeks and delivered a healthy infant.

Conclusion

Using a multidisciplinary approach, we describe guidelines for antepartum surveillance uterine surgery during an undetected pregnancy, which resulted in the delivery of a term healthy infant.

Associations between the time interval from myomectomy to subsequent pregnancy and the obstetric outcomes: A population-based cohort study

OBJECTIVE

To investigate the associations between time interval from myomectomy to pregnancy (TIMP) and subsequent pregnancy and obstetric complications, and to explore whether these associations vary according to maternal age at birth.

METHODS

A retrospective population-based cohort study was conducted from 2008 to 2017. Data were extracted from the National Health Insurance Research Database and the Taiwan Maternal and Child Health Database, comprising 2024 379 births from 1 391 856 pregnancies. Eligible cases were identified using diagnostic and procedure codes; 4006 first singleton births in 4006 women after their first laparotomic myomectomy were identified. We estimated the risks of pregnancy and obstetric outcomes according to TIMP (<6, 6-11, and ≥12 months). Subgroup analysis was performed by further dividing according to maternal age at birth (18-34 vs ≥35 years old).

RESULTS

We observed higher risks of gestational hypertensive disorders (adjusted odds ratio [aOR] 1.97, 95% confidence interval [CI] 1.22-3.18, P = 0.005) and neonatal death (aOR 4.59, 95% CI 1.49-14.18, P = 0.008) for TIMP of <6 months versus TIMP of 6-11 months. Likewise, a TIMP ≥12 months was associated with increased risks of gestational hypertensive disorders (aOR 1.72, 95% CI 1.14-2.58, P = 0.010), and neonatal death (aOR 3.27, 95% CI 1.16-9.24, P = 0.025) versus a TIMP of 6-11 months. In subgroup analysis, women over 35 years old still had higher risks of gestational hypertensive disorders when TIMP was <6 months (aOR 2.26, 95% CI 1.17-4.37, P = 0.015) or ≥12 months (aOR 2.04, 95% CI 1.17-3.54, P = 0.012), and a higher risk of neonatal death when TIMP was <6 months (aOR 4.05, 95% CI 1.06-15.53, P = 0.041); whereas women aged 18-34 years old did not.

CONCLUSIONS

This study suggests that a TIMP between 6 and 11 months is associated with lower risks of gestational hypertensive disorders and neonatal death compared with a TIMP <6 months or ≥12 months, especially for women over 35 years old.

Currently Available Treatment Modalities for Uterine Fibroids

Uterine fibroids (leiomyomas and myomas) are the most common benign gynecological condition in patients presenting with abnormal uterine bleeding, pelvic masses causing pressure or pain, infertility and obstetric complications. Almost a third of women with fibroids need treatment due to symptoms.

OBJECTIVES

In this review we present all currently available treatment modalities for uterine fibroids.

METHODS

An extensive search for the available data regarding surgical, medical and other treatment options for uterine fibroids was conducted.

REVIEW

Nowadays, treatment for fibroids is intended to control symptoms while preserving future fertility. The choice of treatment depends on the patient's age and fertility and the number, size and location of the fibroids. Current management strategies mainly involve surgical interventions (hysterectomy and myomectomy hysteroscopy, laparoscopy or laparotomy). Other surgical and non-surgical minimally invasive techniques include interventions performed under radiologic or ultrasound guidance (uterine artery embolization and occlusion, myolysis, magnetic resonance-guided focused ultrasound surgery, radiofrequency ablation of fibroids and endometrial ablation). Medical treatment options for fibroids are still restricted and available medications (progestogens, combined oral contraceptives andgonadotropin-releasing hormone agonists and antagonists) are generally used for short-term treatment of fibroid-induced bleeding. Recently, it was shown that SPRMs could be administered intermittently long-term with good results on bleeding and fibroid size reduction. Novel medical treatments are still under investigation but with promising results.

CONCLUSIONS

Treatment of fibroids must be individualized based on the presence and severity of symptoms and the patient's desire for definitive treatment or fertility preservation.

Cystic Adenomyoma in Pregnancy: A Case Report

Cystic adenomyomas (CA) are rare. They primarily affect adolescents and young women in their fertile years. Therefore, fertility and pregnancy outcome are of pivotal relevance in this patient collective. Apart from the guidelines of the European Society of Human Reproduction and Embryology (ESHRE) on the management of endometriosis in general, there are no specific treatment recommendations for CA and, as far as our research shows, no data illustrating the behavior of a CA over the course of pregnancy. Thus, we report the case of a 32-year-old 1-gravida, 1-para, preconceptionally diagnosed with a CA by ultrasound. After thoroughly discussing further treatment options, the decision was made to opt for a more conservative approach and not perform surgery before attempting a next pregnancy. The patient conceived spontaneously and sonographic monitoring of the CA throughout pregnancy showed complete regression of the cystic component during the second trimester. A healthy baby was delivered at term by an uncomplicated elective cesarean section. Following a review of the literature and taking into account the course of our case, we propose the feasibility of a conservative, non-surgical approach in women with a CA and the desire to conceive.

Trial of labor after cesarean, vaginal birth after cesarean, and the risk of uterine rupture: an expert review

The decision to pursue a trial of labor after cesarean delivery is complex and depends on patient preference, the likelihood of successful vaginal birth after cesarean delivery, assessment of the risks vs benefits of trial of labor after cesarean delivery, and available resources to support safe trial of labor after cesarean delivery at the planned birthing center. The most feared complication of trial of labor after cesarean delivery is uterine rupture, which can have catastrophic consequences, including substantial maternal and perinatal morbidity and mortality. Although the absolute risk of uterine rupture is low, several clinical, historical, obstetrical, and intrapartum factors have been associated with increased risk. It is therefore critical for clinicians managing patients during trial of labor after cesarean delivery to be aware of these risk factors to appropriately select candidates for trial of labor after cesarean delivery and maximize the safety and benefits while minimizing the risks. Caution is advised when considering labor augmentation and induction in patients with a previous cesarean delivery. With established hospital safety protocols that dictate close maternal and fetal monitoring, avoidance of prostaglandins, and careful titration of oxytocin infusion when induction agents are needed, spontaneous and induced trial of labor after cesarean delivery are safe and should be offered to most patients with 1 previous low transverse, low vertical, or unknown uterine incision after appropriate evaluation, counseling, planning, and shared decision-making. Future research should focus on clarifying true risk factors and identifying the optimal approach to intrapartum and induction management, tools for antenatal prediction, and strategies for prevention of uterine rupture during trial of labor after cesarean delivery. A better understanding will facilitate patient counseling, support efforts to improve trial of labor after cesarean delivery and vaginal birth after cesarean delivery rates, and reduce the morbidity and mortality associated with uterine rupture during trial of labor after cesarean delivery.

Status and treatment of patients with uterine fibroids in hospitals in central China: a retrospective study from 2018 to 2021

OBJECTIVE

To evaluate the hospitalised patients with uterine fibroids (UFs) and describe treatment patterns in hospital-treated patients in central China from 2018 to 2021.

DESIGN

A retrospective analysis.

SETTING

The gynaecology departments of class A and class B secondary and tertiary hospitals in Hubei Province, China.

PARTICIPANTS

101 008 patients diagnosed with UFs from 1 January 2018 to 31 December 2021.

RESULTS

The hospitalised patients with UFs increased with age, reaching a peak at ages 45-49 years and then gradually decreasing. Among these patients, 19.05% had anaemia symptoms. Women aged 25-29 years were more likely to be treated with laparoscopic myomectomy (62.22%), while women aged 20-24 years tend to choose open myomectomy (34.58%). Women over age 45 years who had entered perimenopause tended to be treated with laparoscopic hysterectomy (64.85% for those aged 65-69 years). Patients with fibroid with moderate-to-severe anaemia mostly chose hysterectomy. As a whole, the proportion of patients who chose laparoscopic hysterectomy was similar to that of patients who chose laparoscopic myomectomy (31.38% vs 31.14%). Only 2.08% of UFs were treated with high-frequency MRI-guided focused ultrasound surgery (MRgFUS). The number of patients who choose laparoscopic surgery or MRgFUS treatment was increasing year by year. After stratifying by hospital grade, we found that women treated at class A tertiary hospitals were more likely to have laparoscopic than open surgery (66.12% vs 31.26%). At class B secondary hospitals, 61.9% of the patients underwent myomectomy. By contrast, hysterectomy was used to treat the majority of patients at class A secondary hospitals and class B tertiary hospitals (57.79% and 57.57%, respectively). Use of MRgFUS was mainly concentrated within class A tertiary hospitals.

CONCLUSION

UFs affect mainly women in childbearing period. Most patients chose to receive treatment at class A tertiary hospitals, among which laparoscopic myomectomy was the mainstream surgical method for patients in Hubei Province.

TRIAL REGISTRATION NUMBER

NCT05840042.

Women's experiences of birth and birth options counselling after laparoscopic or open myomectomy

There is emerging evidence that vaginal birth after open and laparoscopic myomectomy may be safe in many pregnancies, however, there are no studies examining the perspectives of women who have given birth post myomectomy and their preferences regarding mode of birth. We performed a retrospective questionnaire survey of women who had an open or laparoscopic myomectomy followed by a pregnancy within 3 maternity units in a single NHS trust in the UK over a 5-year period. Our results revealed only 53% felt actively involved in the decision making for their birth plan and 90% had not been offered a specific birth options counselling clinic. Of those who had either a successful trial of labour after myomectomy (TOLAM) or elective caesarean section (ELCS) in the index pregnancy, 95% indicated satisfaction with their mode of birth however, 80% would prefer vaginal birth in a future pregnancy. Whilst long term prospective data is required to fully establish the safety of vaginal birth after laparoscopic and open myomectomy, this study is the first to explore the subjective experiences of women who had given birth post laparoscopic or open myomectomy and has highlighted the inadequate involvement of these women in the decision-making process.IMPACT STATEMENTWhat is already known on this subject? Fibroids are the commonest female solid tumours in women of childbearing age with surgical management including open and laparoscopic excision techniques. However, the management of a subsequent pregnancy and birth remains controversial with no robust guidance on which women may be suitable for vaginal birth.What do the results of this study add? We present the first study to our knowledge which explores women's experiences of birth and birth options counselling after open and laparoscopic myomectomy.What are the implications of these findings for clinical practice and/or further research? We provide a rationale for using birth options clinics to facilitate an informed decision-making process and highlight the current inadequate guidance for clinicians on how to advise women having a pregnancy following a myomectomy. Whilst long term prospective data is required to fully establish the safety of vaginal birth after laparoscopic and open myomectomy, this needs to be carried out in a way which promotes the preferences of the women affected by this research.

Incidence and outcomes of uterine rupture in women with unscarred, preterm or prelabour uteri: data from the international network of obstetric survey systems

OBJECTIVE

Analysis of atypical cases of uterine rupture, namely, uterine rupture occurring in unscarred, preterm or prelabour uteri.

DESIGN

Descriptive multi-country population-based study.

SETTING

Ten high-income countries within the International Network of Obstetric Survey Systems.

POPULATION

Women with unscarred, preterm or prelabour ruptured uteri.

METHODS

We merged prospectively collected individual patient data in ten population-based studies of women with complete uterine rupture. In this analysis, we focused on women with uterine rupture of unscarred, preterm or prelabour ruptured uteri.

MAIN OUTCOME MEASURES

Incidence, women's characteristics, presentation and maternal and perinatal outcome.

RESULTS

We identified 357 atypical uterine ruptures in 3 064 923 women giving birth. Estimated incidence was 0.2 per 10 000 women (95% CI 0.2-0.3) in the unscarred uteri, 0.5 (95% CI 0.5-0.6) in the preterm uteri, 0.7 (95% CI 0.6-0.8) in the prelabour uteri, and 0.5 (95% CI 0.4-0.5) in the group with no previous caesarean. Atypical uterine rupture resulted in peripartum hysterectomy in 66 women (18.5%, 95% CI 14.3-23.5%), three maternal deaths (0.84%, 95% CI 0.17-2.5%) and perinatal death in 62 infants (19.7%, 95% CI 15.1-25.3%).

CONCLUSIONS

Uterine rupture in preterm, prelabour or unscarred uteri are extremely uncommon but were associated with severe maternal and perinatal outcome. We found a mix of risk factors in unscarred uteri, most preterm uterine ruptures occurred in caesarean-scarred uteri and most prelabour uterine ruptures in 'otherwise' scarred uteri. This study may increase awareness among clinicians and raise suspicion of the possibility of uterine rupture under these less expected conditions.

Uterine rupture and factors associated with adverse outcomes

PURPOSE

To review cases of uterine rupture and identify risk factors associated with adverse outcomes.

METHODS

This study is a retrospective cohort of complete uterine ruptures diagnosed in a large hospital system in Massachusetts between 2004 and 2018. Baseline demographics, labor characteristics and outcomes of uterine rupture were collected from medical records.

RESULTS

A total of 173 cases of uterine rupture were identified. There were 30 (17.3%) women with an unscarred uterus, while 142 (82.1%) had a scarred uterus. Adverse outcomes (n = 89, 51.4% of cases) included 26 (15.0%) hysterectomies, 55 (31.8%) blood transfusions, 18 (10.4%) bladder/ureteral injuries, 5 (2.9%) reoperations, 25 (14.5%) Apgar scores lower than 5 at 5 min and 9 (5.2%) perinatal deaths. Uterine rupture of a scarred uterus was associated with decreased risk of hemorrhage (OR 0.40, 95% CI 0.17-0.93), blood transfusion (OR 0.27, 95% CI 0.11-0.69), hysterectomy (OR 0.23, 95% CI 0.08-0.69) and any adverse outcome (OR 0.34, 95% CI 0.13-0.91) compared with unscarred rupture. Uterine rupture during vaginal delivery was associated with increased risk of transfusion (OR 6.55, 95% CI 1.53-28.05) and hysterectomy (OR 8.95, 95% CI 2.12-37.72) compared with emergent C-section.

CONCLUSIONS

Although rare, uterine rupture is associated with adverse outcomes in over half of cases. Unscarred rupture and vaginal delivery demonstrate increased risk of adverse outcomes, highlighting the need for early diagnosis and operative intervention.

Accessory and cavitated uterine masses: a case series and review of the literature

Objectives

The purpose of this study is to report nine patients of young women who underwent a surgical treatment of an accessory and cavitated uterine mass (ACUM) in our hospital between 2014 and 2022 and review all cases described in the literature.

Material and methods

The principal outcomes measured are the imaging techniques used to determine the diagnosis, the type of surgery used and the post-operative evolution of symptoms. We also report and analyse the 79 patients found in the literature since 1996 in addition to our 9 patients.

Results

Surgical excision is the only long-lasting treatment. Small invasive surgery with laparoscopic access is the gold standard and most widely used (83.0%). Some new therapeutic procedures have been recently described of which ethanol sclerotherapy seems very promising. Post-operatively, 54.5% of patients have a complete relief of symptoms. MRI is the best imaging technique to identify ACUM. Finally, we refine the description of this pathology and give a more precise definition of it.

Conclusion

Through our literature review and the analysis of our cases, we want to underline an important diagnostic criterion of this pathology: the fallopian tube on the homolateral side of the ACUM never communicates with the latter. It is a capital element for differential diagnosis.

Towards a clinical consensus on the management of pregnancy and birth after laparoscopic and open myomectomy: A survey of obstetricians and gynaecologists

OBJECTIVES

The primary aim was to assess if a clinical consensus regarding the management of pregnancy post myomectomy existed amongst consultant obstetricians and gynaecologists. Secondary objectives were to evaluate factors which influence the clinician's decision making in this group of women.

STUDY DESIGN

Electronic survey sent to all consultants working in the North Central and East London deanery, Kent Surrey and Sussex deanery and Imperial NHS Trust to assess opinions on mode of birth post myomectomy, intervals advised to pregnancy post myomectomy, factors influencing the management of delivery in the scarred uterus post myomectomy, opinions on induction of labour and questions relating to operative notes.

RESULTS

209 consultant responses received between 07/03/2022-07/05/2022 (44% response rate); 77% (161/209) practicing obstetricians and gynaecologists, 10% (21/109) pure gynaecologists and 13% (27/209) pure obstetricians. The majority would support a vaginal birth after open myomectomy (75%) and laparoscopic myomectomy (79%). No consensus was found as to the optimal time interval between myomectomy and pregnancy. Higher frequency of performing myomectomy and a greater level of experience were significantly associated with a shorter interval to pregnancy advised. The most important operative factors influencing decision to support trial of labour post myomectomy were breach of uterine cavity; location of fibroids removed and number of incisions on the uterus. 77% believe women should be given a choice regarding mode of delivery post myomectomy in a similar way to previous LSCS. 82.8% would support enrolment of patients into a prospective trial to investigate delivery post myomectomy.

CONCLUSIONS

We present a comprehensive survey of clinician opinions on pregnancy post myomectomy demonstrating that the majority of consultant obstetricians and gynaecologists sampled would support vaginal birth post myomectomy; counselling patients in a similar way to VBAC; a standardised myomectomy operation note and enrolment of patients in a future prospective trial. Wide variation in opinion regarding interval to pregnancy post myomectomy has been highlighted. We believe this information will facilitate counselling discussions and empower women with subsequent pregnancies after myomectomy to make an informed decision on mode of birth post myomectomy.

A Rare Secondary Dysmenorrhea Resulted from Separation of Corpus Uteri from Cervix: A Case Report and Literature Review

Secondary dysmenorrhea is a pain associated with disease such as endometriosis, pelvic inflammatory disease, leiomyomas, and interstitial cystitis. Treatment of secondary dysmenorrhea always focuses on the causative pelvic pathology or medical condition. Here, we found a rare case with secondary dysmenorrhea that resulted from traumatic separation of the uterine corpus from the cervix. In this case, the patient experienced a childhood blunt trauma of the pelvic crush and was successfully diagnosed by magnetic resonance imaging and 3-dimensional ultrasonography. Moreover, laparoscopic anastomosis could be a minimally invasive way to resolve this problem.

High-intensity focused ultrasound for the treatment of fibroids: A single-center experience in Singapore

Objectives

Uterine fibroids and adenomyosis are common gynecological conditions that often require surgical treatment. Minimally invasive interventions such as ultrasound-guided high-intensity focused ultrasound (USgHIFU) are gaining popularity as they avoid surgical morbidity and conserve the uterus. We present a single-center experience on the use of USgHIFU for the treatment of fibroids and adenomyosis.

Materials and Methods

This was a retrospective study of 167 patients who underwent USgHIFU for uterine fibroids and adenomyosis between July 2018 and December 2020. Relevant demographic data and pre- and post-intervention fibroid volume, symptom severity scores (SSS), and health-related quality of life (QOL) scores were collected and compared. The paired t-test or Wilcoxon signed-rank test was used to compare the difference before and after treatment. P < 0.001 was considered statistically significant.

Results

One hundred and sixty-seven patients with fibroids or adenomyosis were included in this study. The mean age of the cohort was 42-year-old. USgHIFU treatment led to a reduction in mean fibroid volume, improvement in SSS, and health-related QOL scores. The average reduction in mean fibroid volume was 68% and 75% at 6 and 12 months, respectively. There was a significant reduction in SSS (46.9 [pre] vs. 15.6 [post], P < 0.001) and improvement in health-related QOL scores at 6 months (58 [pre] vs. 86 [post], P < 0.001). The re-intervention rate following USgHIFU was 7.7% and successful pregnancy post USgHIFU was reported in 6 patients.

Conclusion

USgHIFU is safe and effective. In women who desire fertility or are not suitable for surgery, it is a good alternative option. It should be included in the armamentarium for the treatment of uterine fibroids and adenomyosis.

How to boost an obstetrician's confidence in vaginal delivery after high-intensity focused ultrasound: a comparison study on delivery outcomes

OBJECTIVE

To assess the feasibility of vaginal delivery after HIFU.

METHODS

A total of 37 women who met the trial of labor after HIFU (TOLAH) inclusion criteria and 368 women who met the trial of labor after cesarean delivery (TOLAC) inclusion criteria gave birth at Shanghai First Maternity and Infant Hospital between 14^th June 2018 and 24^th September 2021. The delivery outcomes of the two groups were compared. Multivariable logistic regression analysis was used to estimate the adjusted risk of postpartum hemorrhage (PPH).

RESULTS

In the Qualified Candidates for TOLAH group, vaginal delivery is substantially less common (p = 0.000). The prevalence of PPH in the Qualified Candidates for TOLAH group is lower than in the Candidates for TOLAC group (8.82% vs 10.51%, p = 0.534; 0% vs 2.51%, p = 0.418). Hemoglobin drop in the Qualified Candidates for TOLAH group is also lower (7.03 ± 7.39vs 12.11 ± 12.62, p = 0.001). The rate of using more than two types of uterotonic medications to promote contraction is significantly lower in the Qualified Candidates for TOLAH group (54.05% vs 69.84%, p = 0.04), and the percentage of abnormal uterine contraction is lower in the Qualified Candidates for TOLAH group (35.14% vs 49.18%, p = 0.072). PPH is strongly predicted by abnormal uterine contraction (aOR: 17.177, 95% CI:5.046 ∼ 58.472, p = 0.000), but not by HIFU (aOR:1.105; 95% CI:0.240 ∼ 5.087, p = 0.898). No uterine rupture occurred in the cases after HIFU.

CONCLUSIONS

No uterine rupture occurred in our study group after HIFU. HIFU is not a risk for PPH. It is promising for those after HIFU to choose vaginal delivery.

Robotic vaginal natural orifice transluminal endoscopic myomectomy

OBJECTIVE

To describe a novel, minimally invasive technique for performing myomectomy, a fertility-sparing procedure.

DESIGN

This technique was developed based on similar techniques for other surgeries that showed a benefit. Liu et al. (1) described vaginal natural orifice transluminal endoscopic surgery (vNOTES) for myomectomy, in which a 6-cm myoma was resected transvaginally. An anterior colpotomy was made, and single-site surgical skills were used to perform the entire myomectomy without an abdominal incision and with minimal blood loss (1). Another study showed that this technique was also feasible in 8 patients with type 3-7 myomas, and the patients were discharged within a day (2). Robotic vNOTES surgery has been performed for various gynecologic procedures, including hysterectomy, sacrocolpopexy, and the resection of endometriosis (3-6). One study showed that robotic vNOTES was a viable alternative to traditional vNOTES for hysterectomy, with no differences in operative time, the length of hospital stay, postoperative pain levels, or conversions (3). This study in fact proposed that robotic vNOTES was beneficial because of the opportunity to use wristed instruments to increase an otherwise limited range of motion. Another study showed that if surgeons already have significant experience with laparoscopic single-site and abdominal robotic surgeries, only 10 cases of robotic vNOTES and 10-20 port placements with robotic docking are needed to become proficient in robotic vNOTES (7). Another study showed that robotic vNOTES was a safe and feasible approach for the treatment of endometriosis with hysterectomy and the resection of endometriosis, which may be technically challenging because of distorted anatomy or scar tissue due to endometriosis (4). This video demonstrates a robotic vNOTES for myomectomy, a novel, minimally invasive technique for performing myomectomy. Vaginal surgery is the preferred route for hysterectomy compared with other techniques, and this parallel can also be made for other gynecologic procedures, including myomectomy (8). The vaginal approach is preferred for hysterectomy because it is associated with shorter hospital stays and operative time as well as faster recovery. Given these factors, the vaginal approach is preferred over the more traditional umbilical or abdominal laparoscopy. However, visualization and fine movement can be difficult in vaginal surgery, given the lack of space. Robotic techniques in place of traditional or vaginal laparoscopy do not require the surgeon to have a large amount of space to make fine movements because the camera and small robotic instruments are docked close to the tissue. This allows for precision while suturing and performing more layers in the myometrium after myomectomy. This is more difficult to achieve with traditional umbilical laparoscopy and may potentially reduce the risk of uterine rupture in future pregnancies. Given the advantages of the robotic and vaginal approaches, the robotic vNOTES route was pursued for this procedure because it combines the benefits of robotic and vaginal surgeries and can be considered as a feasible alternative to open, vaginal, or laparoscopic techniques.

SETTING

Academic-center hospital.

PATIENT(S)

A 28-year-old presented with heavy periods and pelvic pain. Imaging showed a large, 8-cm posterior fibroid, and the patient strongly desired a fertility-sparing approach.

INTERVENTION(S)

Robotic vNOTES for myomectomy for the 8-cm posterior uterine fibroid.

MAIN OUTCOME MEASURE(S)

Feasibility and safety of using this technique for myomectomy.

RESULT(S)

Robotic vNOTES is a feasible option for performing minimally invasive myomectomy. In this technique, a posterior horizontal colpotomy was made and a gel port was placed through the incision. The DaVinci Robot was docked, and myomectomy was performed using single-incision surgical techniques. The uterine serosa was closed with the V-Loc suture, and an interceed adhesion barrier was placed over the incision. The surgeon should take care to notice that the entire surgery is essentially performed "upside down" compared with the traditional abdominal laparoscopic approach. With this change in perspective, the surgeon should have a very good understanding of the vaginal anatomy and the expected location of the uterine artery, ureter, and rectum to avoid any damage to surrounding structures (the uterus) or increased blood loss. The fibroid was morcellated out of the vagina using The Extracorporeal C-Incision Tissue Extraction technique, and the posterior colpotomy was closed (9). The patient was discharged for home on the same day, with minimal blood loss. A prelabor cesarean section was recommended for all future pregnancies to reduce the risk of uterine rupture. The rate of uterine rupture after myomectomy is approximately 0.6% (10). However, the rate of uterine rupture after classical cesarean section is approximately 1%-12% (11). Given that the incision made was similar to the classical incision, except on the posterior uterus, prelabor cesarean section was recommended, although the uterine cavity was not entered.

CONCLUSION(S)

In this video, we demonstrate a myomectomy performed using the robotic vNOTES technique. The traditional vNOTES technique for myomectomy has been previously described (1); however, this technique can be very burdensome for suturing and does not allow for precision, and performing multiple layers is challenging. However, the robotic vNOTES approach solves this issue and can allow the surgeon to perform very precise suturing. While choosing the ideal patient for this procedure, the preoperative considerations include the desire for future fertility, the size and location of the fibroid, ideally 1 large posterior fibroid, and adequate space for vaginal port placement. This technique combines the advantages of both vaginal and robotic surgeries while maintaining low blood loss, and patients may be discharged for home on the same day.

The trend in cesarean myomectomies and the risk of obstetrical complications in Korea

BACKGROUND

To evaluate pregnancy outcomes and the risk of adverse obstetrical outcomes of cesarean myomectomy (CM) compared with cesarean section (CS) only, and to investigate the trend of surgeons in choosing CM.

METHODS

A retrospective cohort study was performed on all patients who underwent CS complicated by leiomyoma at two university hospitals between January 2010 and May 2020. All patients were categorized into the CM (341 women) or CS-only (438 women) group. We analyzed the demographic factors, obstetric factors, surgical outcomes, and possible risk factors for adverse outcomes between the two groups.

RESULTS

Women who underwent CS only were significantly more likely to have a previous myomectomy and multiple leiomyoma history than women who underwent CM. The gestational age at delivery and pregnancy complications were significantly higher in the CS-only group. The mean size of the leiomyomas was larger in the CM group than in the CS-only group (5.8 ± 3.2 cm vs. 5.2 ± 3.1 cm, P = 0.005). The operation time and history of previous CS and preterm labor were higher in the CM group. The leiomyoma types differed between the two groups. The subserosal type was the most common in the CM group (48.7%), and the intramural type was the most common in the CS-only group. Patients in the CM group had fewer than three leiomyomas than those in the CS-only group. Preterm labor and abnormal presentation were relatively higher in the CM group than in the CS-only group, concerning leiomyoma presence. There were no significant differences in the preoperative and postoperative hemoglobin levels. The size of the leiomyoma (odds ratio [OR] = 1.162; 95% confidence interval [CI]: 1.07-1.25; P < 0.001) and operation time > 60 min (OR = 2.461; 95% CI: 1.45-4.15) were significant independent predictors of adverse outcomes after CM.

CONCLUSIONS

CM should be considered a reliable and safe approach to prevent the need for another surgery for remnant leiomyoma. Herein, surgeons performed CM when uterine leiomyomas were large, of the subserosal type, or few. Standardized treatment guidelines for myomectomy during CSs in pregnant women with uterine fibroids should be established.

Management of women with uterine fibroids in reproductive center: retrospective analysis of clinical and reproductive outcomes

BACKGROUND

Uterine fibroids are the most common benign tumor in women. According to literature, submucosal myomas have a negative effect on reproductive outcomes in women undergoing assisted reproductive techniques (ART) but there are fewer data concerning intramural fibroids. During last years, ulipristal acetate (UPA) 5 mg was widely used as medical option of fibroid's treatment, but from 2020, the Pharmacovigilance Risk Assessment Committee (PRAC) has revoked the marketing authorization after some cases of liver toxicity.

METHODS

In this observational, retrospective study we collected data from a sample of 23 women affected by symptomatic uterine fibroids (from type 1 to type 7 according FIGO classification) followed in our center for assisted reproduction from 2016-2019. All patients received 5 mg/day UPA for three months, followed by two months of wash-out therapy. A group of 13 women treated with UPA, with intramural fibroid not distorting the uterine cavity, after wash-out therapy, affected by tubal or idiopathic factors of infertility too, underwent ART. We also evaluated a control group of women, not affected by fibroids, randomly selected from a general group of our ART patients, similar by age, BMI, and cause of infertility only idiopathic or tubal factors. We evaluated the impact of UPA on reduction of fibroid volume, symptomatology and distortion of the cavity in all the women treated, and the IVF (in-vitro fertilization) outcome between the fibroid group of women affected by intramural fibroids who underwent ART, and the control group.

RESULTS

In all the women treated with UPA the overall median fibroid volume pretreatment was 45.168±35.360 mm3, that decreased to a mean value of 22.592±22.116 mm3 post one cycle of UPA, with an overall mean decrease of -22.586 mm3 (of 49%) statistically significant (P=0.00001). After treatment, the distortion of the uterine cavity reduced in high percentage of cases: 85,71% (type 1-2), χ2 difference in respect to the value pretreatment of 0.3941, and 86.96% of patients subjectively referred an improvement in the symptomatology. In the group of 13 women that undergone ART, after one IVF cycle for each patient, we obtained 61% of positivity of dosage of beta human chorionic gonadotropin (hCG) after UPA treatment, and we obtained a similar value in the control group.

CONCLUSIONS

In our little sample we have observed that UPA represented a valid non-invasive medical treatment strategy for fibroids in women candidate for (IVF, not only in women affected by sub-mucosal, but also by intramural fibroids not distorting uterine cavity. After a single, three months course of treatment, we obtained good results in terms of reduction of fibroid's volume and improvement of symptomatology, without side effects, preparing a more favorable environment for ART.

Induction of labour in patients with prior caesarean births or uterine surgery

The current evidence favours trial of labour after one caesarean in the absence of any other contraindications, recognizing that risks with both trial of labour after caesarean (TOLAC) and elective repeat caesarean section (ERCS) birth are relatively uncommon. When the need for induction of labour (IOL) following a previous caesarean arises, shared decision-making should be based on the current available evidence. This approach, however, needs to be tailored, taking into account the individual's history, initial examination and response to the ongoing process of induction to optimize the maternal and foetal outcomes. This paper aims to review the evidence and provide guidance on decision making surrounding labour induction in a pregnancy following a prior caesarean or uterine surgery.

Complete Rupture of the Pregnant Uterus: A 10-year Retrospective Descriptive Study

OBJECTIVE

The goal of this work is to analyze the incidence, etiology, clinical characteristics, maternal and neonatal outcomes of complete uterine rupture during pregnancy.

METHODS

The information of complete uterine rupture between June 2010 and May 2020 was investigated retrospectively at a tertiary center, and included demographic data, delivery characteristics, intraoperative findings, and maternal and neonatal outcomes. The prevalence rate of uterine rupture in the early group (hospitalized from June 2010 to May 2015) and late group (June 2015 to May 2020) was compared and analyzed.

RESULTS

There were 37 (0.056%) cases of complete uterine rupture in 66 092 births, including 27 (0.041%) of scar uterus and 10 (0.015%) of non-scarred uterus. High-risk factors for scarred uterine rupture included: previous cesarean section (13, 48.1%), myomectomy (8, 29.6%), corneal pregnancy resection (6, 22.2%), history of uterine rupture (1, 3.7%), and uterus perforation during abortion (1, 3.7%). Compared to the early group, the number of uterine ruptures caused by previous cesarean section was significantly reduced in the late group. Of the 10 patients with non-scarred uterine rupture, 3 (30%) occurred during delivery and 7 (70%) were spontaneous. Among the 37 complete rupture patients, 3 (8.1%) died of uterine scar rupture, 19 (51.3%) cases were reported with fetal/newborn deaths, 5 (13.5%) cases underwent hysterectomy and the rest were treated with uterine repair.

CONCLUSION

Complete uterine rupture often has catastrophic effect on pregnancy outcomes. Obstetrics doctors should be vigilant to identify the risk factors and clinical presentations of uterine rupture during pregnancy. Strict prenatal management is beneficial to improve pregnancy outcomes.

Pregnancy outcomes after ultrasound-guided high-intensity focused ultrasound (USgHIFU) for conservative treatment of uterine fibroids: experience of a single institution

OBJECTIVE

To assess the impact of ultrasound-guided high-intensity focused ultrasound (USgHIFU) ablation for uterine fibroids on fertility.

MATERIAL AND METHODS

A retrospective observational study was conducted of 560 reproductive-age women with symptomatic uterine fibroids who underwent USgHIFU therapy at Mútua Terrassa University Hospital, Spain, between February 2008 and February 2018. We analyzed pregnancy outcomes including time to conception, pregnancy approach, gestational age, delivery mode, neonatal outcomes and complications during pregnancy and delivery.

RESULTS

After USgHIFU treatment, 71 pregnancies were obtained in 55 patients. Of these, 58 (82%) cases were natural pregnancies and 13 (18%) were in vitro fertilization (IVF) pregnancies. The median time to conception was 12 (range 1-72) months. There were 43 (61%) successful deliveries, including a twin gestation, 22 (31%) spontaneous abortions and 6 (8%) therapeutic abortions. The rate of full-term deliveries was 91% (39/43) and the remaining 9% (4/43) were preterm deliveries. Of the 44 live births, 25 (57%) were born vaginally and 19 (43%) by cesarean section. The complications reported included 3 women with retained placenta (7%), 2 with placenta previa (5%) and 1 with severe preeclampsia (2%). The mean birth weight was 3.1 (range: 1.4-4.3) kg, and except for a baby born with a tetralogy of Fallot, all newborns developed well without complications during postpartum and breastfeeding.

CONCLUSION

Patients undergoing USgHIFU treatment of uterine fibroids can achieve full-term pregnancies with few intrapartum or postpartum complications. More studies are required to compare fertility and perinatal outcomes between patients who underwent or not USgHIFU.

Subsequent pregnancy outcomes after abdominal vs. laparoscopic myomectomy

OBJECTIVE

To determine whether abdominal (open) vs. laparoscopic myomectomy affects the obstetrical outcomes of subsequent pregnancies.

METHODS

A retrospective cohort study was conducted at a tertiary university medical center. The study population included women who had a documented birth following a myomectomy at our institution between the years 1997 and 2018. The obstetrical characteristics and immediate perinatal outcomes of the subsequent pregnancy following open vs. laparoscopic myomectomy were collected and compared. Data were retrieved from patients' medical records via the institutional computerized database. Cases that lacked detailed surgery and delivery reports were excluded. Data were analyzed using a chi-square test for categorical variables and one-way ANOVA for continuous variables. A p-value <.05 was considered statistically significant.

RESULTS

During the study period, 57 women met the inclusion criteria, of whom 66.6% (38/57) had an open and 33.3% (19/57) had a laparoscopic myomectomy. Women who underwent an open myomectomy had a higher rate of cesarean birth than those in the laparoscopic group (89.5 vs. 42.1%, p < .001). No cases of severe maternal or perinatal complications, uterine ruptures, or placental abruptions were identified in either study group. No other significant differences were noted between the two types of myomectomy.

CONCLUSION

Open myomectomy is associated with a higher rate of cesarean delivery than laparoscopic. No severe adverse maternal or neonatal outcomes were detected in either study group.

D-chiro-inositol, Vitamin D, and Epigallocatechin Gallate Avoid Surgery in Females with Uterine Fibroids: Two Case Reports

Uterine fibroids (UF) represent the most common benign tumours in females of reproductive age, and can negatively affect fertility. Patients with UFs need to reduce the tumour size with pharmacological treatments or surgically remove the fibroid before using assisted reproductive technology (ART). On the other hand, surgery implies long waiting times before ART to avoid the risk of rupture of the uterus. Long waiting periods are often unacceptable for older individuals who want to undergo ART procedures. Unfortunately, no specific and safe treatment for UFs is currently available. Here the author reports two cases of patients with UFs and associated heavy menstrual bleeding who seek pregnancy through ART. Both underwent a daily treatment with epigallocatechin gallate, vitamin D, vitamin B6, and D-chiro-inositol for 3 months. The patients showed a volume reduction of 73.8% and 68.4%, respectively. This was associated with decreased blood loss (42.1% and 48.7%, respectively). After 3 months from the end of the treatment, both patients underwent ART procedure without the need for surgical intervention.

Long-term Clinical Outcomes of US-Guided High-Intensity Focused Ultrasound Ablation for Symptomatic Submucosal Fibroids: A Retrospective Comparison with Uterus-Sparing Surgery

RATIONALE AND OBJECTIVES

Uterus-sparing surgery and ultrasound (US)-guided high-intensity focused ultrasound (HIFU) ablation are both treatment options for symptomatic submucosal fibroids. No study had compared the long-term clinical outcomes between the two techniques. Therefore, the aim of this study was to compare the long-term clinical outcomes between US-guided HIFU ablation and uterus-sparing surgery for the treatment of symptomatic submucosal fibroids.

MATERIALS AND METHODS

A retrospective study was conducted on 245 women who were treated by US-guided HIFU ablation and 129 women who underwent uterus-sparing surgery for type I or type II symptomatic submucosal fibroids in a single institution from January 2007 to January 2015. The mean diameter of the fibroids was about 6 cm in both groups. They were followed up until December 2018. The symptom relief rate, symptom recurrence rate and incidence of major complications were compared between the two groups.

RESULTS

The symptom relief rate was 95.9% for US-guided HIFU ablation and 89.1% for uterus-sparing surgery. The cumulative symptom recurrence rate at 1-, 3-, 5-, and 8 years was 1.7%, 6.8%, 9.4%, and 11.9% for US-guided HIFU ablation and 6.1%, 12.2%, 22.6%, and 27.8% for uterus-sparing surgery. Compared to uterus-sparing surgery group, US-guided HIFU ablation had a statistically higher symptom relief rate and a lower symptom recurrence rate (p < 0.05). The major complication rate was 3.1% in the uterus-sparing surgery group. No major complications occurred in the US-guided HIFU ablation group.

CONCLUSION

This study showed that the long-term clinical outcomes of US-guided HIFU ablation may be better that of uterus-sparing surgery for the treatment of symptomatic submucosal fibroids. US-guided HIFU ablation may also be safer than uterus-sparing surgery. Further larger randomized trials are needed to confirm these findings.

Uterine rupture during pregnancy: The URIDA (uterine rupture international data acquisition) study

OBJECTIVE

To describe the characteristics and peripartum outcomes of patients diagnosed with uterine rupture (UR) by an observational cohort retrospective study on 270 patients.

METHODS

Demographic information, surgical history, symptoms, and postoperative outcome of women and neonates after UR were collected in a large database. The statistical analysis searched for correlation between UR, previous uterine interventions, fibroids, and the successive perinatal outcomes in women with previous UR.

RESULTS

Uterine rupture was significantly associated with previous uterine surgery, occurring, on average, at 36 weeks of pregnancy in women also without previous uterine surgery. UR did not rise exponentially with an increasing number of uterine operations. Fibroids were related to UR. The earliest UR occurred at 159 days after hysteroscopic myomectomy, followed by laparoscopic myomectomy (251 days) and laparotomic myomectomy (253 days). Fertility preservation was feasible in several women. Gestational age and birth weight seemed not to be affected in the subsequent pregnancy.

CONCLUSION

Data analysis showed that previous laparoscopic and abdominal myomectomies were associated with UR in pregnancy, and hysteroscopic myomectomy was associated at earlier gestational ages. UR did not increase exponentially with an increasing number of previous scars. UR should not be considered a contraindication to future pregnancies.

Time to conceive after myomectomy: should we advise a minimum time interval? A systematic review

The optimal time interval between myomectomy and pregnancy is unclear and no specific guidelines exist. The aim of this review was to study the time interval from myomectomy to pregnancy and the occurrence of uterine rupture after myomectomy. Randomized controlled trials, cohort studies and retrospective studies were used to assess the primary objective, and case reports, cases series or letters to the editor for the secondary objective. Only articles reporting myomectomy performed via the vaginal route, laparotomy, laparoscopy or robot-assisted surgery were selected for inclusion. Among 3852 women who wanted to become pregnant after the surgery, 2889 became pregnant, accounting for 3000 pregnancies (77.9%) and 2097 live births (54.4%). Mean time between myomectomy and pregnancy was estimated at 17.6 months (SD 9.2) for 2451 pregnant women. Among 1016 women, a third were advised to delay attempting to conceive for between 3 and 6 months and another third for between 6 and 12 months. A total of 70 spontaneous uterine ruptures with a mean gestational age of 31 weeks at occurrence were identified. No linear relationship was found between gestational age at the event and time interval from myomectomy to conception (P = 0.706). There are insufficient data to advise a minimal time interval between myomectomy and conception.

The first ethanol sclerotherapy of an accessory cavitated uterine mass

Accessory cavitated uterine mass (ACUM) is a very rare, underdiagnosed pathology. It is treated with radical surgery, which results in uterine scarring. Here, we describe the first case of ethanol sclerotherapy of an ACUM, modeled on the treatment of recurring endometrioma. Ethanol sclerotherapy avoids uterine scarring and the secondary risk of uterine rupture and enables the rapid achievement of pregnancy.

Nanoparticles in pregnancy: the next frontier in reproductive therapeutics

BACKGROUND

Nanotechnology involves the engineering of structures on a molecular level. Nanomedicine and nano-delivery systems have been designed to deliver therapeutic agents to a target site or organ in a controlled manner, maximizing efficacy while minimizing off-target effects of the therapeutic agent administered. In both reproductive medicine and obstetrics, developing innovative therapeutics is often tempered by fears of damage to the gamete, embryo or developing foetus or of negatively impacting a woman's reproductive potential. Thus, nanomedicine delivery systems may provide alternative targeted intervention strategies, treating the source of the disease and minimizing long-term consequences for the mother and/or her foetus.

OBJECTIVE AND RATIONALE

This review summarizes the current state of nanomedicine technology in reproductive medicine and obstetrics, including safety, potential applications, future directions and the hurdles for translation.

SEARCH METHODS

A comprehensive electronic literature search of PubMed and Web of Science databases was performed to identify studies published in English up until February 2020. Relevant keywords were used to obtain information regarding use of nanoparticle technology in fertility and gene therapy, early pregnancy complications (ectopic pregnancy and gestational trophoblastic disease) and obstetric complications (preeclampsia, foetal growth restriction, preterm birth and gestational diabetes) and for selective treatment of the mother or foetus. Safety of specific nanoparticles to the gamete, embryo and foetus was also investigated.

OUTCOMES

Pre-clinical research in the development of nanoparticle therapeutic delivery is being undertaken in many fields of reproductive medicine. Non-hormonal-targeted nanoparticle therapy for fibroids and endometriosis may provide fertility-sparing medical management. Delivery of interventions via nanotechnology provides opportunities for gene manipulation and delivery in mammalian gametes. Targeting cytotoxic treatments to early pregnancy tissue provides an alternative approach to manage ectopic pregnancies and gestational trophoblastic disease. In pregnancy, nanotherapeutic delivery offers options to stably deliver silencing RNA and microRNA inhibitors to the placenta to regulate gene expression, opening doors to novel genetic treatments for preeclampsia and foetal growth restriction. Restricting delivery of teratogenic drugs to the maternal compartment (such as warfarin) may reduce risks to the foetus. Alternatively, targeted delivery of drugs to the foetus (such as those to treat foetal arrythmias) may minimize side effects for the mother.

WIDER IMPLICATIONS

We expect that further development of targeted therapies using nanoparticles in a reproductive setting has promise to eventually allow safe and directed treatments for conditions impacting the health and reproductive capacity of women and for the management of pregnancy and serious pregnancy complications.

Nationwide population-based cohort study of adverse obstetric outcomes in pregnancies with myoma or following myomectomy: retrospective cohort study

BACKGROUND

Our objective was to evaluate risks of adverse obstetric outcomes in pregnancies with myoma(s) or in pregnancies following myomectomy.

METHODS

We analyzed the national health insurance database, which covers almost the entire Korean population, between 2004 and 2015. The risks of adverse pregnancy outcomes in pregnancies with myoma(s) or in pregnancies following myomectomy, compared to those in women without a diagnosed myoma, were analyzed in multivariate logistic regression analysis.

RESULTS

During the study period, 38,402 women with diagnosed myoma(s), 9890 women with a history of myomectomy, and 740,675 women without a diagnosed myoma gave birth. Women with a history of diagnosed myoma(s) and women with a history of myomectomy had significantly higher risks of cesarean section (aOR 1.13, 95% CI 1.1-1.16 and aOR 7.46, 95% CI 6.97-7.98, respectively) and placenta previa (aOR 1.41, 95% CI 1.29-1.54 and aOR 1.58, 95% CI 1.35-1.83, respectively), compared to women without a diagnosed myoma. And the risk of uterine rupture was significantly higher in women with previous myomectomy (aOR 12.78, 95% CI 6.5-25.13), compared to women without a diagnosed myoma, which was much increased (aOR 41.35, 95% CI 16.18-105.69) in nulliparous women. The incidence of uterine rupture was the highest at delivery within one year after myomectomy and decreased over time after myomectomy.

CONCLUSIONS

Women with a history of myomectomy had significantly higher risks of cesarean section and placenta previa compared to women without a diagnosed myoma.

Is Uterine Myomectomy a Real Contraindication to Vaginal Delivery? Results from a Prospective Study

OBJECTIVES

The main goal of our research was to explore correlations between a history of uterine myomectomy and maternal-fetal outcomes, throughout a comparison between vaginal deliveries in patients with or without a history of uterine myoma excision.

MATERIALS AND METHODS

A prospective study was carried out at two tertiary care hospitals between January 2019 and January 2020. Women were assigned into two groups according to the history of laparoscopic or laparotomic myomectomy (Group 1) or without myomectomy (Group 2).

RESULTS

80 women successfully delivered after myomectomy. Pregnancies with previous laparoscopic or laparotomic myomectomy were associated with a minor rate of spontaneous labor onset (RR 1.17; 95% CI 1.04 - 1.31) and with an increased rate of emergency cesarean section (RR 1.22; 95% CI 1.09 - 1.36). Moreover, myomectomy group had a significant number of indications to emergency cesarean section correlated to suspected uterine rupture (RR 1.19; 95% CI 1.02-1.39). There were no uterine ruptures or neonatal deaths recorded. First stage of labor was longer in the myomectomy group (316 vs 204 mins, p = 0.01). No differences in the rates of the prolonged first and second stage of labor, postpartum hemorrhage and vaginal laceration, and no neonatal adverse outcomes were found between groups.

CONCLUSIONS

Pregnancies after myomectomy might be associated with an elevated rate of emergency cesarean section only due to a higher percentage of suspected uterine rupture, without a real hazard of adverse obstetric or neonatal outcomes.

Non-hysteroscopic Myomectomy and Fertility Outcomes: A Systematic Review

OBJECTIVE

To perform a systematic review of the literature to identify best practices for nonhysteroscopic myomectomy for women with myomas who desire future fertility. The focus areas included factors associated with conception and pregnancy outcomes after myomectomy, impact of surgical route (laparotomic, laparoscopic, and the incorporation of robot assistance), and preoperative findings and surgical techniques that have an impact on reproduction.

DATA SOURCES

Librarian-led electronic searches of the Ovid MEDLINE, Ovid Embase, and Cochrane CENTRAL databases were performed from inception to February 2020. A targeted reference review was performed to update the original searches.

METHODS OF STUDY SELECTION

The participants were women of reproductive age with myomas who underwent myoma removal surgery through laparotomic or laparoscopic approaches. The fertility outcomes included markers for ovarian reserve, clinical pregnancy rates, and pregnancy outcomes. We performed quality assessment using National Institutes of Health Study Quality Assessment Tools and developed clinical recommendations graded according to the strength of the evidence.

TABULATION, INTEGRATION, AND RESULTS

The initial search identified 2163 studies, of which 51 met the inclusion criteria. These consisted of 11 studies that focused on the factors associated with conception or pregnancy outcomes after myomectomy, 10 studies that examined the route of nonhysteroscopic myomectomy, and 30 that were related to intraoperative techniques and findings. Overall, younger age, lower myoma number, and distortion of the endometrial cavity were associated with improved reproductive outcomes after myomectomy. The route of nonhysteroscopic myomectomy and intraoperative uterine artery occlusion did not significantly affect pregnancy rates or outcomes. Adhesion barriers present a possible target for further research.

CONCLUSION

This study provides insights into patient selection and intraoperative techniques for nonhysteroscopic myomectomy. Further research with well-designed clinical trials is needed to highlight the relationships between myoma characteristics (International Federation of Gynecology and Obstetrics type, location, and size) and reproductive outcomes.

Reproductive Outcomes following Use of Barbed Suture during Laparoscopic Myomectomy

STUDY OBJECTIVE

To review pregnancy outcomes after laparoscopic myomectomy with the use of barbed suture.

DESIGN

Retrospective cohort study and follow-up survey.

SETTING

Single, large academic medical center.

PATIENTS

Patients who underwent laparoscopic myomectomy with the use of barbed suture for myometrial closure between 2008 and 2016.

INTERVENTION

Laparoscopic myomectomy and a follow-up survey regarding pregnancy outcome.

MEASUREMENTS AND MAIN RESULTS

A total of 486 patients met inclusion criteria and underwent a laparoscopic myomectomy between 2008 and 2016. Of the 428 with viable contact information, 240 agreed to participate (56%). Of those who responded to the survey, 101 (42%) attempted to get pregnant, and there were 4 unplanned pregnancies. There were 110 pregnancies among 76 survey respondents. In total, of the women attempting a postoperative pregnancy, 71% had at least 1 pregnancy. Comparing the women who did and did not conceive postoperatively, the group who got pregnant was on average younger, 33.8 ± 4.5 years vs 37.5 ± 6.5 years (p = .001); had fewer myomas removed, median = 2 (range 1-9) vs median = 2 (range 1-16) myomas (p = .038); and had a longer follow-up period, 30 months ( vs 30 (11-93 months) ± 20 (p <.001). The mean time to first postoperative pregnancy was 18.0 months (range 2-72 months). Of the 110 reported postoperative pregnancies, there were 60 live births (55%), 90% by means of cesarean section. The mean gestational age at birth was 37.8 weeks. In the cohort, there were 8 preterm births, 3 cases of abnormal placentation, 2 cases of fetal growth restriction, 3 cases of hypertensive disorders of pregnancy, and 2 cases of myoma degeneration requiring hospitalization for pain control. There were no uterine ruptures reported.

CONCLUSION

According to our findings, pregnancy outcomes after laparoscopic myomectomy with barbed suture are comparable with available literature on pregnancy outcomes with conventional smooth suture.

What does non-eligibility for myoma surgery mean in the context of sequential prescription of ulipristal acetate?

Ulipristal Acetate (UPA) is the only selective progesterone receptor modulator currently approved for medical management of myomas. Following several cases of liver toxicity during UPA treatment, new recommendations of PRAC (Pharmacovigilance Risk Assessment Committee) and EMA (European Medicines Agency) have been proposed, including a pre-therapeutic assessment of liver function and a close monitoring during treatment. Repeated courses of UPA have also been restricted to women who are defined as "non-eligible" for surgery. This article raises important questions and tries to provide clarification about the concept of 'non-eligibility' for myoma surgery.

Augmented Reality with Diffusion Tensor Imaging and Tractography during Laparoscopic Myomectomies

Augmented reality is a technology that allows a surgeon to see key hidden subsurface structures in an endoscopic video in real-time. This works by overlaying information obtained from preoperative imaging and fusing it in real-time with the endoscopic image. Magnetic resonance diffusion tensor imaging (DTI) and fiber tractography are known to provide additional information to that obtained from standard structural magnetic resonance imaging (MRI). Here, we report the first 2 cases of the use of real-time augmented reality during laparoscopic myomectomies with visualization of uterine muscle fibers after DTI tractography-MRI to help the surgeon decide the starting point incision. In the first case, a 31-year-old patient was undergoing laparoscopic surgery for a 6-cm FIGO type V myoma. In the second case, a 38-year-old patient was undergoing a laparoscopic myomectomy for a unique 6-cm FIGO type VI myoma. Signed consent forms were obtained from both patients, which included clauses of no modification of the surgery. Before surgery, MRI was performed. The external surface of the uterus, the uterine cavity, and the surface of the myomas were delimited on the basis of the findings of preoperative MRI. A fiber tracking algorithm was used to extrapolate the uterine muscle fibers' architecture. The aligned models were blended with each video frame to give the impression that the uterus is almost transparent, enabling the surgeon to localize the myomas and uterine cavity exactly. The uterine muscle fibers were also displayed, and their visualization helped us decide the starting incision point for the myomectomies. Then, myomectomies were performed using a classic laparoscopic technique. These case reports show that augmented reality and DTI fiber tracking in a uterus with myomas are possible, providing fiber direction and helping the surgeon visualize and decide the starting incision point for laparoscopic myomectomy. Respecting the fibers' orientation could improve the quality of the scar and decrease the architectural disorganization of the uterus.

Laparoscopic Myomectomy: An Alternative Approach to Tackling Submucous Myomas?

STUDY OBJECTIVE

To evaluate the differences in perioperative outcomes and immediate complication rates between laparoscopic myomectomy for submucous myomas and laparoscopic myomectomy for myomas in other locations.

DESIGN

Retrospective cohort study.

SETTING

University-affiliated hospital in London.

PATIENTS

A total of 350 patients with symptomatic uterine myomas underwent laparoscopic myomectomy. Thirty-three of these were performed for submucous myomas (group 1), and 317 were for myomas in other uterine locations (group 2).

INTERVENTIONS

Analysis of prospectively collected data on patient demographics, myoma characteristics, perioperative outcomes, and immediate complications.

MEASUREMENTS AND MAIN RESULTS

Patient demographics, including age, body mass index, and parity, were similar in the 2 groups. No significant differences in myoma characteristics were seen between groups 1 and 2, including the mean dimension of largest myoma (7.1 vs 7.8 cm, respectively; p = .35), mean number of myomas removed (3.8 vs 4.1; p = .665), and mean mass of myomas removed (142.0 g vs 227.3 g; p = .186). There were also no significant between-group differences in any perioperative outcomes, including mean blood loss (226.8 mL vs 266.4 mL; p = .373), duration of surgery (103 minutes vs 113 minutes; p = .264), and duration of hospital stay (1.4 days vs 1.7 days; p = .057). No complications arose from laparoscopic resection of submucous myomas.

CONCLUSION

Laparoscopic myomectomy for submucous myomas has similar perioperative outcomes and immediate complications as laparoscopic myomectomy for other myomas and can be considered for large or type 2 submucous myomas.

Perinatal outcomes of women undergoing cesarean delivery after prior myomectomy

Background: The American College of Obstetricians and Gynecologists recommends that women who have had a prior myomectomy that entered the endometrial cavity undergo cesarean delivery in order to avoid the possible complication of uterine rupture. Women with prior myomectomies may also have intraabdominal adhesions, complicating future surgery and if myomas remain after myomectomy, they may have more bleeding complications during their subsequent pregnancies.Objectives: The purpose of this study was to evaluate maternal and neonatal outcomes after prior myomectomy in women undergoing planned cesarean delivery.Study design: We conducted a retrospective cohort study using the Maternal Fetal Medicine Units Cesarean Registry database comparing women undergoing a cesarean delivery with a history of prior myomectomy to women undergoing a cesarean delivery without a history of a prior myomectomy. Inclusion criteria were singleton gestations at term undergoing planned cesarean delivery. Exclusion criteria were stillbirth, cesarean delivery indication for nonreassuring fetal heart rate, macrosomia, abruption, previa or women undergoing planned trial of labor after cesarean. Primary outcome was incidence of blood transfusion. Maternal and neonatal outcomes were compared secondarily. Logistic regression was used to adjust for confounders.Results: The entire study population included 73,257 deliveries; 34,002 women met inclusion criteria, of which 367 had a prior myomectomy and 33,635 were controls. The demographics, which varied by maternal age, race and number of prior cesareans were adjusted for when calculating maternal outcomes. The rate of intraoperative transfusion in the prior myomectomy group was 1.4% (5/367) compared to 0.4% (131/33,635) in the control group (aOR 2.8; 95% CI 1.15-6.79). The prior myomectomy group had a higher incidence of postpartum transfusion rate (2.5%, 9/367) compared to the control group (1.2%, 416/33,635) (aOR 2.03; 1.06-3.92), uterotonic usage (5.4%, 20/367) compared to the control group (3.5%, 1165/33,635; aOR 1.57; 95% CI 1.01-2.45), bowel injury (0.5%, 2/367) compared to the control group (0.0%, 14/33,635; aOR 8.13; 95% CI 2.05-32.28) and cesarean hysterectomy (1.4%, 5/367) compared to the control group (77/33,635; aOR 3.43; 95% CI 1.32-8.91). Neonatal outcomes were not different between groups.Conclusion: Prior myomectomy in women with term, singleton gestations undergoing planned cesarean delivery was associated with an 180% increased risk of intraoperative transfusion compared to the control group. We also found that women in the myomectomy group are 57% more likely to use uterotonics, 713% more likely to experience a bowel injury, 243% more likely to undergo a cesarean hysterectomy, and 227% more likely to need a classical uterine incision during delivery. Neonatal morbidity was not statistically different between the groups.

Vaginal birth after prior myomectomy

OBJECTIVE

The aim of this retrospective cohort study was to evaluate the obstetrical and perinatal outcomes of vaginal birth in case of pregnancies achieved after prior myomectomy. We also analyzed how operative characteristics at the time of surgery might influence the choice of obstetricians about mode of delivery.

STUDY DESIGN

We analyzed retrospectively all women who underwent laparoscopic (LPS) or laparotomic (LPT) myomectomy between January 2002 and December 2014, in a network of three Institutions belonging to the University of Milano Bicocca, Italy. Women were contacted by phone interview and only cases with available follow-up data and who had a subsequent pregnancy were included. Operative characteristics and subsequent obstetrical outcomes were recorded and analyzed.

RESULTS

469 women who underwent myomectomy were contacted by phone interview, and 152 pregnancies were achieved after surgery, 96 after LPS and 56 after LPT. A total of 110 pregnancies ended in deliveries at ≥24 weeks. Seventy-three (66.4%) women had trial of labor after myomectomy (TOLAM), while 24 (21.8%) had a planned cesarean delivery (CD). Sixty-six (90.4%) of the TOLAM cases successfully accomplished vaginal delivery. No cases of uterine rupture (UR) were reported, and all deliveries ended in live births. The incidence of Neonatal Intensive Care Unit admission was 14.5% (16/110), with no cases of perinatal death. Comparing the surgical details at the time of myomectomy, the incidence of uterine cavity entered was significantly higher in planned CD group compared to TOLAM cases (p < 0.001). No other significant difference between the two groups was reported.

CONCLUSIONS

A successful vaginal delivery was accomplished by 90.4% of women who had TOLAM, without any case of UR or severe maternal and perinatal complications. TOLAM may be considered and offered as feasible and relatively safe option. Obstetricians' attitude toward mode of delivery after prior myomectomy seems to be influenced by the reported entry into the uterine cavity at the time of surgery.

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.

A case of scarred uterine rupture at 11 weeks of gestation having a uterine scar places induced by in vitro fertilization-embryo transfer

Having a uterine scar places a woman at increased risk of complications, such as Cesarean scar pregnancy (CSP), uterine rupture, placenta previa, and placenta accreta, in subsequent pregnancies. We report a case of uterine rupture at 11 weeks of gestation in a woman with a previous Cesarean section. A 43-year-old woman with a history of abdominal myomectomy and Cesarean section had her pregnancy induced by in vitro fertilization with donor eggs. The exact location of the gestational sac was identified on her first day of hospitalization, and her pregnancy was suspected to be a CSP. The following day, the patient complained of sudden lower abdominal pain. A uterine scar rupture was diagnosed, and an emergency surgery was required. It may be that first-trimester screening could allow the early recognition of patients at risk for these perinatal complications.

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.

Laparoscopy or laparotomy as the way of entrance in myoma enucleation

PURPOSE

Uterine myomas are the main cause of benign uterine diseases in premenopausal women. Objective of the present paper is to investigate the current best treatment modalities of myomas, depending on age of the patient and her desire to preserve fertility, as well as on clinical presentation of this pathology, such as size, number, and location of fibroids and, furthermore, on surgical experience of the gynecologist.

METHODS

The design of our work is a systematic literature review of existing studies, reviews, and meta-analysis conducted in PubMed and Cochrane Library to identify relevant literature. Commonly, the myomectomy is to be recommended in women desiring to preserve fertility when myomas are associated with symptoms such as excessive bleeding, pelvic discomfort, or palpable abdominally fibroids. The decision of surgical approach for myomectomy should be individualized, depending on size and location, as well as on surgeon's experience. The different modalities of myomectomy, laparoscopic, hysteroscopic, robotic-assisted, or laparotomic are in detail presented in the paper, according to Society of Obstetricians and Gynecologists of Canada (SOGC) clinical practice guidelines and taking into consideration possible concerns of myomectomy such as uterine rupture, development of adhesions, and myomas' recurrence.