Surgical and radiological management of uterine fibroids - a UK survey of current consultant practice

Reducing blood loss during laparoscopic myomectomy using a tourniquet loop around the lower uterine segment

OBJECTIVE

To present a simple and effective hemostatic technique using a tourniquet loop during laparoscopic myomectomy.

DESIGN

Pericervical tourniquet has been proven to be a safe and effective measure to reduce blood loss during open myomectomy. However, the use of a tourniquet in laparoscopic myomectomy has been rarely reported probably because the application is difficult and troublesome. In our technique, a prefabricated tourniquet loop, adapted from a Foley catheter, is applied around the lower segment of the uterus. It is easy to apply a tourniquet loop around the lower uterine segment during laparoscopic myomectomy. There is no need to make a window in the broad ligament to apply a pericervical tourniquet or triple tourniquets. Meanwhile, complete blockage of blood supply from the uterine artery and utero-ovarian anastomoses may ensure better hemostasis.

SETTING

A tertiary hospital.

PATIENT(S)

The patient was a 34-year-old woman with uterine leiomyoma and a desire for future fertility. She had been suffering from urinary frequency and chronic bladder pressure for the past 6 months. Magnetic resonance imaging confirmed 2 intramural masses measuring 96 mm × 91 mm and 25 mm × 13 mm at the anterior uterine wall.

INTERVENTION(S)

Institutional review board and ethics committee approval was obtained. Laparoscopic myomectomy was performed with the application of a tourniquet loop around the lower segment of the uterus (step-by-step video demonstration): homemade tourniquet loop formation using a 14-Fr latex Foley catheter; trocar placement with 2 umbilical ports (10 mm and 5 mm) and a 5-mm port at the lower-left quadrant of the abdomen; application of a tourniquet loop around the lower uterine segment; tumor enucleation and myometrial closure; removal of the tourniquet loop and a check for bleeding; contained specimen extraction via the merged umbilical incision; and inspection of the abdominal cavity and closure of the merged umbilical incision.

MAIN OUTCOME MEASURE(S)

Feasibility of using a tourniquet loop as an effective hemostatic technique in laparoscopic myomectomy.

RESULT(S)

The surgery lasted for approximately 90 minutes, and the tourniquet time was approximately half an hour. The estimated blood loss was only 20 mL. Her hemoglobin value on day 1 after the surgery was 131 g/L, the same as the preoperative level. Pathology confirmed the diagnosis of leiomyoma. The patient was discharged 2 days after the surgery with no complications. During follow-up, the patient reported that there was no discomfort and that her menses were normal. Her fallopian tubes were patent in the hysterosalpingogram. Her ovarian function, which was assessed by serum follicle-stimulating hormone concentration (5.34 mIU/mL) on day 3 of her menstrual cycle and antimüllerian hormone level (2.01ng/mL), was in the normal range. She was suggested to conceive 1 year after the procedure.

CONCLUSION(S)

Application of a tourniquet loop around the lower uterine segment is a simple and effective hemostatic technique during laparoscopic myomectomy. Randomized prospective studies are needed to determine the hemostatic effect of the laparoscopic use of a tourniquet loop and its impact on fertility and ovarian function.

Treating symptomatic uterine fibroids with myomectomy: current practice and views of UK consultants

BACKGROUND

The demand for uterus-sparing treatments is increasing as more women postpone childbirth to their 30-40s, when fibroids are more symptomatic. With an increasing choice of treatment options and changing care-provider profiles, now is an opportune time to survey current practices and opinions. Using a 25-stem questionnaire, a web-based survey was used to capture the practices and opinions of UK consultant gynecologists on the treatment of symptomatic fibroids, including the types of procedure most frequently used, methods used to reduce blood loss, and awareness and acceptability of treatment options, and to assess the impact of gender and experience of the treating gynecologist.

RESULTS

The response rate was 22%. Laparascopic myomectomy is used least frequently, with 80% of the respondents using GnRHa preoperatively to minimize blood loss and correct anemia, while vasopressin is most frequently used to reduce intraoperative blood loss. Female consultants operate significantly less frequently than males. Those with more than 10 years consultant experience are more likely to perform an open myomectomy compared to those with less than 10 years experience.

CONCLUSIONS

Compared to a similar survey performed 10 years ago, surgical methods remain to be the most common treatments, but use of less invasive treatments such as UAE has increased. Consultants' attitudes appear to be responding to the patient demand for less radical treatments. However, it is yet to be seen if the changing consultant demographics will keep up with this demand. The low response rate warrants cautious interpretation of the results, but they provide an interesting snapshot of current views and practices.

Women seeking second opinion for symptomatic uterine leiomyoma: role of comprehensive fibroid center

OBJECTIVE

The objective of the study was to describe our early experience with a comprehensive uterine fibroid center and report our results in women seeking a second opinion for management of symptomatic uterine leiomyoma.

METHODS

We performed a HIPAA-complaint, IRB-approved retrospective study of women seeking second opinion for management of uterine fibroids at our multidisciplinary fibroid treatment center in a tertiary care facility from July 2008 to August 2011. After a review of patients' history, physical examination, and magnetic resonance imaging (MRI) findings, treatment options were discussed which included conservative management, uterine-preserving options, and hysterectomy. We performed Fisher's exact test for categorical variables between the cohort that did or did not undergo a uterine-preserving treatment. Differences were considered significant at p < 0.05.

RESULTS

The mean age of the 205 patient study cohort was 43.8 years (SD 7.5). One hundred sixty-two (79.0%) patients had no prior therapy. Based on MRI, one or more fibroids were detected in 178/205 (86.8%), adenomyosis in 8/205 (3.9%), and a combination of fibroid and nonfibroid condition (i.e., adenomyosis, endometrial polyp) in 18/205 (8.8%). In those who desired to transition their care to our institution (n = 109), 85 patients underwent 90 interventions: 39 MRgFUS (magnetic resonance-guided high-intensity focused ultrasound surgery), 14 UAE (uterine artery embolization), 25 myomectomies, 8 hysterectomies, 3 polypectomies, and 1 endometrial ablation. Five patients had two procedures. Intramural and subserosal fibroids were most commonly treated with MRgFUS followed by myomectomy and then UAE; in contrast, pedunculated fibroids were frequently managed with myomectomy.

CONCLUSIONS

Multidisciplinary fibroid evaluation may facilitate the increase use of less invasive options over hysterectomy for symptomatic fibroid treatment.

GnRH agonists: do they have a place in the modern management of fibroid disease?

In the management of women with fibroid disease, GnRH agonists (GnRHa) are frequently used to reduce volume and vascularity before myomectomy, apparently to render the operation easier and reduce operative blood loss, and to enable a transverse supra-pubic incision instead of a midline vertical one. They induce amenorrhoea and thus aid in the correction of pre-operative anaemia. Other gynaecologists use GnRHa to shrink sub mucous fibroids greater than 5 cm in diameter to facilitate access and reduce blood loss and operating time at transcervical resection. GnRHa are also occasionally used as a temporizing measure in women with symptomatic fibroids within the climacteric. We argue against the use of GnRHa in the management of fibroid disease because they are not cost effective, render myomectomy more difficult to apply because they destroy tissue planes, the more difficult enucleation in fact increasing rather than reducing peri-operative blood loss and operating time. When used before myomectomy, they increase the risk of 'recurrence' because they obscure smaller fibroids that 'recur' when the effects of the GnRHa wear off, and are associated with side effects in situations where they confer no benefits, or where alternative cheaper drugs with fewer side effects are available.

MR imaging evaluation of fibroid clearance following open myomectomy for massive/multiple symptomatic fibroids

PURPOSE

To evaluate the technical success of total fibroid clearance at open myomectomy for massive and/or multiple symptomatic fibroids using MR imaging (MRI) as the imaging modality.

METHODS

The study group comprised 27 women [mean age 37.4 ± 6.9 years (range 27-53)] who underwent open myomectomy for the treatment of massive/multiple symptomatic fibroids at our institution between January 2009 and April 2010. Myomectomy was performed with the intention of achieving complete fibroid clearance. Pre- and postmyomectomy MRI was performed to assess changes in uterine volume and fibroid burden. Periprocedural data (including blood loss and complications) and relief of clinical symptoms at follow-up were also recorded.

RESULTS

The mean time to MRI and clinical follow-up was 10 months (range 6-15 months). The mean uterine volume premyomectomy was 795 ± 580 cc and postmyomectomy was 123 ± 70 cc (p < 0.001). The mean percentage reduction in uterine volume was 80.3 % (range 43.0-98.1 %). Of the 10/27 (37.0 %) women with residual fibroids at follow-up: 7 patients had fibroids measuring up to 1 cc in volume, 3 patients had fibroids measuring up to 6 cc. Postoperative adnexal seromas were observed in 6/27 (22.2 %) patients. The clinical success rates of myomectomy amongst the 22/27 (81 %) responders were: 73 % for menorrhagia, 64 % for pain, and 36-64 % for mass-related symptoms.

CONCLUSIONS

Using MRI, we have confirmed that open myomectomy can achieve total or near-total fibroid clearance in the majority of patients with massive and/or multiple fibroids.

The use of novel hemostatic sealant (Tisseel) in laparoscopic myomectomy: a case-control study

BACKGROUND

This is the first case-control study on the use of a fibrin sealant (Tisseel) on uterine suture during laparoscopic myomectomy (LM), with the primary endpoint to evaluate the intraoperative bleeding and postoperative blood loss. In addition, we evaluated the time required to achieve hemostasis using Tisseel and how much it can influence operative time.

METHODS

From December 2009 to January 2011, consecutive patients older than 18 years with symptomatic isolate intramural myoma with maximal diameter B6 cm and ≥ 4 cm and with a sonographically diagnosed free myometrium margin ≥ 0.5 cm were included in the study. We selected from our institute's database a group of consecutive patients with homogeneous features of the study group, who underwent laparoscopic myomectomy without Tisseel application.

RESULTS

Fifteen women with symptomatic myoma were enrolled in the study (group A). Regarding the control group (group B), we selected a homogenous group of 15 patients with the same preoperative characteristics of the study group. Mean operative time was 47.7 min and 62.1 min, for groups A and B respectively (p < 0.05). Mean time required to achieve complete haemostasis was 195.5 s in group A and 361.8 in control group B (p < 0.0001). Mean estimated blood loss was 111.3 mL and 230 mL in groups A and B, respectively (p < 0.05). Mean hemoglobin decrease was 1.36 g/dL and 2.04 g/dL in groups A and B, respectively (p < 0.05).

CONCLUSIONS

The use of Tisseel during LM may represent a valid alternative solution for obtaining hemostasis, reducing intra- and postoperative bleeding. Furthermore, it may help the surgeon to obtain a rapid healing of the injured surfaces, probably reducing the use of electrocoagulationand traumatisms.

New tool (Laparotenser) for gasless laparoscopic myomectomy: a multicenter-controlled study

OBJECTIVE

To assess feasibility and safety of a new surgical instrument-Laparotenser-in the procedure of gasless laparoscopic myomectomy.

DESIGN

Multicenter controlled study.

SETTING

Academic departments of obstetrics and gynecology, Italy.

PATIENT(S)

Thirty patients scheduled for gasless laparoscopic myomectomy (experimental group) and another group of 30 patients from our historical records that have undergone traditional laparoscopic myomectomy, matched with the cases for number of fibroids and for size of the main fibroid (control group).

INTERVENTION(S)

Gasless laparoscopic myomectomy using Laparotenser.

MAIN OUTCOME MEASURE(S)

Surgical data.

RESULT(S)

No significant differences in total operative time, postoperative ileus, hospitalization, time to return to full activity/work, and complication rates were observed between groups. Intraoperative blood loss, hemoglobin level, and surgical difficulty were significantly higher in the experimental than in the control group. Postoperative pain and number of analgesic vials used were significantly lower in the experimental group than in the control group.

CONCLUSION(S)

Although performed during the learning curve period, the use of the Laparotenser instrument in gasless laparoscopic myomectomy is a safe procedure.

Reducing blood loss at myomectomy with use of a gelatin-thrombin matrix hemostatic sealant

OBJECTIVE

To evaluate the hemostatic efficacy and handling of gelatin-thrombin matrix in abdominal myomectomy.

DESIGN

Prospective and randomized trial.

SETTING

University teaching hospital.

PATIENT(S)

Women (n = 50) with uterine fibroids with a uterine size equivalent to > or =16 weeks gestation.

INTERVENTION(S)

Gelatin-thrombin matrix (FloSeal Matrix; Baxter Healthcare Corp., Fremont, CA) was delivered to the site of the uterine bleeding during myomectomy.

MAIN OUTCOME MEASURE(S)

Patient age, parity, number of myomas, operative time, blood loss, transfusion, intraoperative and postoperative complications, and length of hospitalization were evaluated.

RESULT(S)

The average blood loss during surgery was 80 +/- 25.5 mL for the FloSeal group and 625 +/- 120.5 mL for the control group. Intraoperative blood transfusion was necessary in five patients from the control group. Postoperative blood loss was 25 +/- 5 mL for the FloSeal group and 250 +/- 75 mL for the control group. Length of the postoperative hospital stay was 2.5 +/- 1.2 days for FloSeal group and 4.5 +/- 1.3 for the control group. No major immediate or delayed complications were observed in either group.

CONCLUSION(S)

Reductions in hemorrhage in FloSeal-treated women undergoing a myomectomy are encouraging, and provide evidence for the ability of gelatin-thrombin matrix to reduce blood loss when applied immediately and directly to bleeding uterine tissue.

Rate, type, and cost of invasive interventions for uterine myomas in Germany, France, and England

STUDY OBJECTIVE

The objective of our study was to quantify the rate, type, and cost of interventions for uterine myomas to payers in Germany, France, and England.

DESIGN

Computations using data from national hospital activity databases.

DESIGN CLASSIFICATION

II-3.

SETTING

Hospital admissions in Germany, France, and England.

PATIENTS

Women admitted for a surgical or radiologic intervention for uterine myomas.

INTERVENTIONS

Surgical or radiologic interventions for uterine myomas.

MEASUREMENTS AND MAIN RESULTS

We identified the number and type of hospital admissions involving surgical or radiologic interventions for uterine myomas, through the analysis of national hospital activity databases from each country. We calculated the costs of these hospitalizations to payers in these countries using the diagnosis-related group reimbursement rates. In 2005, the number (rate) of hospital admissions involving interventions for uterine myomas was 64 299 (1.53/1000 women) in Germany, 37 787 (1.17/1000 women) in France, and 18 274 (0.71/1000 women) in England. The annual costs of these interventions to payers were euro212 313 090 in Germany, euro73 278 270 in France (excluding surgeon and anesthetist fees for interventions in the private sector), and euro52 674 672 in England. The percentage of interventions for uterine myomas that included a hysterectomy was 84.9% in Germany, 59.7% in France, and 64.1% in England.

CONCLUSION

The number of admissions and costs associated with interventions for uterine myomas are substantial in the 3 European countries studied. Hysterectomy is the most frequent surgical intervention used to treat uterine myomas. The results in this article provide useful information for policy makers wishing to evaluate the cost effectiveness and budget impact of new, less invasive interventions.

The uterus and fertility

OBJECTIVE

To review the current understanding of the role the uterus plays in embryo implantation and to outline congenital anomalies and acquired diseases that impact normal uterine function.

DESIGN

The publications related to the embryo implantation, Mullerian anomalies, uterine polyps, uterine synechiae, and myomas were identified through Medline and reviewed.

CONCLUSION(S)

Congenital anomalies and acquired diseases of the uterus may negatively impact on the complex processes of embryo implantation. Hysteroscopic surgery to correct uterine septa, intrauterine synechiae, and myomas that distort the uterine cavity may benefit women with infertility or recurrent pregnancy loss. The effect of endometrial polyps on fertility is uncertain, but their removal, once identified, is justifiable. Complex congenital anomalies such as unicornuate uterus and uterus didelphys may negatively affect fertility and pregnancy outcome, and surgical treatment may benefit select patients.

A multicenter randomized, controlled study comparing laparoscopic versus minilaparotomic myomectomy: short-term outcomes

OBJECTIVE

To compare the laparoscopic and minilaparotomic approaches for symptomatic uterine leiomyomas treatment in terms of safety and feasibility.

DESIGN

Randomized controlled trial.

SETTING

Three university departments of obstetrics and gynecology of Catanzaro, Rome, and Florence, Italy.

PATIENT(S)

One hundred thirty-six women wishing to conceive and candidate for myomectomy due to symptomatic uterine leiomyomas or unexplained infertility.

INTERVENTION(S)

Myomectomy through laparoscopic or minilaparotomic access.

MAIN OUTCOME MEASURE(S)

Surgical outcomes.

RESULT(S)

Leiomyoma enucleation and hysterotomy suturing times were significantly shorter after minilaparotomic myomectomy, whereas the degree of surgical difficulty was significantly higher for the laparoscopic myomectomy. Intraoperative blood loss, variation in hemoglobin levels, quantity of pain control drugs used postoperatively, and hospitalization were significantly lower in the laparoscopic group than in the minilaparotomic one. Our surgical outcomes were significantly influenced by specific investigational centers involved, and by leiomyoma dimensions and localizations. This last variable is the strongest predictor of surgical outcome.

CONCLUSION(S)

Laparoscopic and minilaparotomic approaches to myomectomy are two safe and minimally invasive surgical procedures. A careful evaluation of the dimensions and localizations of fibroids are needed to address to the right choice to the best approach.

Hysterectomy and loss of fertility: implications for women's mental health

OBJECTIVE

The objective of this study was to assess the percentage of women scheduled for hysterectomy who would have liked to have had a child or more children and associated factors.

METHODS

The study sample included 1140 premenopausal women having hysterectomy for benign indications who were interviewed before and after their surgery over the course of a 2-year follow-up period. The main outcome measures for this study were desire for a (or another) child measured preoperatively; concurrent measures of psychological distress, including anxiety, depression, anger, and confusion, and seeking of professional help for emotional problems; and psychological distress measured 12 and 24 months postoperatively.

RESULTS

Of the sample, 10.5% (n=120) answered yes to the question, "Before you were told you needed a hysterectomy, would you have wanted a (or another) child?" As compared with those who did not, those who desired a (another) child were younger; more likely to be nulliparous; waited longer before having surgery; were more likely to have an indication of endometriosis; had higher levels of depression, anxiety, anger, and confusion; and were more than twice as likely to have seen a mental health professional for anxiety or depression in the 3 months before their surgery. These differences in psychological distress persisted over the course of the 2-year follow-up period.

CONCLUSIONS

The issue of loss of fertility should be discussed candidly with women considering hysterectomy, and those who express ambivalence, sadness, or regret at the loss of future childbearing options may benefit from further exploration of fertility-sparing treatments.

Surgical and radiological management of uterine fibroids in the UK

PURPOSE OF REVIEW

Uterine fibroids remain the most common benign gynaecological pathology and a frequent reason for gynaecological referral and treatment. The range of available treatments is currently undergoing a minor revolution with the introduction of nonsurgical therapies, but their role remains to be established.

RECENT FINDINGS

Arguably the most significant change in recent years has been the availability of uterine artery embolization as a form of nonsurgical management. A survey of UK gynaecologists, however, has shown that the option of embolization is only utilized by just over half the respondents. Instead, conventional surgery such as hysterectomy and myomectomy remain the mainstay of nonsymptomatic treatment. In the absence of gross uterine enlargement, vaginal hysterectomy is feasible and safe. Fewer hysterectomies, however, are being done and more women are undergoing myomectomy, with almost 50% of UK consultant gynaecologists carrying out hysteroscopic myomectomy and just over 10% laparoscopic myomectomy.

SUMMARY

Greater utilization of less invasive endoscopic or vaginal procedures for the management of uterine fibroids seems a reasonable target. In the longer term, it is likely that the various nonsurgical techniques which shrink fibroids and thereby reduce symptoms will have an increasingly important role in the treatment of this common condition.

New uterine-preserving therapies raise questions about interdisciplinary management and the role of surgery for symptomatic fibroids

Mounting evidence to support the safety and effectiveness of new uterine-preserving fibroid therapies is raising questions not only about changing indications for surgery but also about gynecologists' role in therapies offered by other specialists. New collaborative relationships are needed to provide the best possible treatment; without them, those lag times of 10-15 years often cited as the time it takes for advances in clinical research to diffuse into clinical practice will be even longer for women with symptomatic fibroids.