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.

Gasless Laparoscopic Myomectomy Using A J-shaped Retractor and Suture Technique

OBJECTIVE

This study aimed to compare gasless single-port access (SPA) laparoscopic myomectomy using a J-shaped retractor and conventional SPA laparoscopic myomectomy.

STUDY DESIGN

The medical records of 60 patients who underwent laparoscopic myomectomy between January 2016 and August 2019 were reviewed. Thirty patients underwent gasless SPA laparoscopic myomectomy using a J-shaped retractor, and 30 patients underwent conventional SPA laparoscopic myomectomy. The 2 groups were compared in terms of surgical outcomes. In gasless laparoscopic myomectomy, closure of the uterine defect after myomectomy was performed using an extracorporeal suture technique with a Kelly clamp and knot pusher.

RESULTS

On comparing gasless SPA and conventional SPA laparoscopic myomectomy, no significant differences were observed in age, body mass index, parity, previous abdominal surgery, and size of the dominant uterine myoma. The median retraction setup time from skin incision was 8 minutes (range, 5 to 15 min) with gasless SPA laparoscopic myomectomy. The median total operation times were 105 minutes (range, 62 to 210 min) with gasless SPA myomectomy and 110 minutes (range, 60 to 270 min) with conventional SPA myomectomy, and there was no significant difference (P=0.251). There was no difference between the groups in terms of estimated blood loss. None of the patients experienced laparotomy conversion in both groups. No major complications, such as urologic, bowel, and vessel injuries, were found in both groups.

CONCLUSION

Gasless SPA laparoscopic myomectomy using a J-shaped retractor is a safe and feasible approach, which allows for easy and convenient suturing of a uterine defect after myomectomy.

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.

Obstetric outcomes after uterine myomectomy: Laparoscopic versus laparotomic approach

OBJECTIVE

To compare the pregnancy-related complications after laparoscopic and laparotomic uterine myomectomy.

METHODS

A retrospective study of 415 women who received laparoscopic (n = 340) or laparotomic (n = 75) resection of uterine leiomyomas in one center. The mean follow-up period was 26.5 months in laparoscopic group and 23.9 months in laparotomic group.

RESULTS

Fifty-four and 12 pregnancies occurred in laparoscopic and laparotomic myomectomy group, respectively. The major obstetric outcomes were similar between two groups. There was no ectopic pregnancy or preterm birth. There were two cases of obstetric complication in laparoscopic group only; one experienced neonatal death and postpartum hemorrhage due to placental abruption and the other underwent subtotal hysterectomy due to uterine dehiscence identified during Cesarean section.

CONCLUSION

Uterine rupture or dehiscence after laparoscopic myomectomy occurred in 3.7% (2/54) which lead to unfavorable outcome. Appropriate selection of patients and secure suture techniques appears to be important for laparotomic myomectomy in reproductive-aged women.

Uterine rupture in a nulliparous woman with septate uterus of the second trimester pregnancy and review in literature

INTRODUCTION

Uterine rupture (UR) in early pregnancy in nulliparous women is a rare and unpredictable occurrence with high maternal morbidity and fatal fetal outcomes. Intrauterine anomalies could be the primum movens of this dangerous condition and underestimated in the literature.

PRESENTATION OF CASE

An uncommon case of uterine rupture at the 23rd week of gestation in a nulliparous woman, who became pregnant before the resection of an uterine septum. To provide more insight into the possible risk factors, a literature review was performed.

DISCUSSION

Loss of pregnancy is common, despite prompt uterine repair. In all cases reviewed abdominal pain characterized by indistinct vague symptoms constitutes the initial symptom of this obstetrical life threatening condition.

CONCLUSION

The current case highlights the association of curettage and septate uterus as a risk factor for UR in the second trimester of pregnancy. It's reasonable that obstetricians must take into account that common gastrointestinal tract problems might be an indicator of the initial weakness of uterine wall leading to the rupture, which is unpredictable all of cases reviewed.