Pregnancy Rate after Myomectomy and Associated Factors among Reproductive Age Women Who Had Myomectomy at Saint Paul's Hospital Millennium Medical College, Addis Ababa: Retrospective Cross-Sectional Study

Monogram and Heat Map on Magnetic Resonance Imaging to Evaluate the Recommendation for Myomectomy in Patients with Infertility: A Pilot Study

Uterine myomas can cause infertility. Studies are attempting to determine the indications for myomectomy. However, the multiplicity and localization of myomas complicate this issue. We aimed to develop a visualization tool to aid patients with infertility in their decision-making for myomectomy. We included 191 women with uterine myoma attending an outpatient infertility clinic, of whom 124 patients underwent myomectomy. Of these, 65 (52.4%) patients became pregnant within 17.6 months after surgery, and 54 (83.1%) of them had a live birth. A logistic regression model predicting the pregnancy rate (area under the curve, 0.82; 95% confidence interval, 0.74-0.89; validation value, 74.6%) was generated using the leave-one-out cross-validation method. This model incorporated five factors: age, maximum level of infertility intervention following myomectomy, presence of submucosal myoma, maximum diameter of the myoma, and type of myomas (multiple or single). We successfully visualized the degree of involvement of each factor in the pregnancy rate by developing a nomogram based on this model. We expanded the data from the preoperative magnetic resonance images and applied machine learning using a convolutional neural network. The classification accuracy was 71.4% for sensitivity and 77.7% for specificity. Heatmap images, generated using gradient-weighted class activation mapping to show the classification results of this model, could distinguish between myomas that required enucleation and those that did not. Although a larger sample size is needed to further validate our findings, this innovative pilot study demonstrates the potential of machine learning to refine assessment criteria and improve patient decision-making.

The Impact of Laparoscopic Myomectomy on Pregnancy Outcomes: A Systematic Review

STUDY OBJECTIVE

The objective of this systematic review is to investigate the impact of laparoscopic myomectomy techniques on pregnancy outcomes, with a specific focus on the correlation between the type of suture used during the procedure and the incidence of uterine rupture. Additionally, the study aims to examine how the localization and size of myomas, key factors in laparoscopic myomectomy, may influence fertility outcomes.

DATA SOURCES

extensive searches were conducted using MDPI, PubMed, Web of Science, and Cochrane Library databases from 2008 to November 2023.

METHODS OF STUDY SELECTION

The study involved women of reproductive age diagnosed with fibroids who underwent surgical removal of fibroids using either laparotomy or laparoscopy. The evaluation of pregnancy outcomes focused on indicators such as live birth rates, miscarriage rates, stillbirth rates, premature delivery rates, and cases of uterine rupture. Quality assessment was systematically performed by employing the National Institutes of Health Study Quality Assessment Tools, with the subsequent formulation of clinical recommendations that were meticulously graded in accordance with the robustness of the underlying evidence.

RESULTS

The pregnancy outcomes post-myoma treatment, as reflected in one of the presented tables, show a promising number of pregnancies and live births, but also indicate the potential risks of miscarriages and preterm births. The diversity in outcomes observed among various studies underscores the imperative for tailored patient care, as well as the necessity for additional research aimed at optimizing fertility and pregnancy outcomes following myoma treatment.

CONCLUSION

This study offers insights into the criteria for patient selection and intraoperative methodologies specifically related to laparoscopic myomectomy. To enhance our understanding of the associations between fibroid characteristics (location, size) and reproductive outcomes, additional research is warranted, particularly through well-designed clinical trials.

The Hangman's Tourniquet: A Safe and Practical Approach for Reducing Blood Loss During Uterine Myomectomy

STUDY OBJECTIVES

The application of a pericervical uterine artery tourniquet is a useful method of reducing intraoperative haemorrhage during abdominal myomectomy. However, the utilization of a single combined pericervical uterine artery and infundibulopelvic ligament tourniquet is a more effective and influential method of temporarily occluding the uterine vasculature to decrease intraoperative blood loss, reducing the requirement for blood products, the risk of conversion to hysterectomy, and patient morbidity and mortality during fertility-sparing leiomyoma surgery. Our objective of this retrospective review was to assess the effectiveness of the combined uterine artery and infundibulopelvic ligament tourniquet, which we coin as the "Hangman's uterine tourniquet", in reducing intraoperative blood loss during abdominal myomectomy, thereby reducing the need for blood products.

METHODS

This retrospective study included 39 patients diagnosed with symptomatic subserosal, intramural, and/or submucosal uterine leiomyoma (>3 cm) who underwent an abdominal myomectomy between January 2021 and December 2022.

RESULTS

Thirty-nine patients met the eligibility criteria for our study. The average patient age included in our study was 36 years. All myomectomies were completed with a mean intraoperative blood loss of 252.60 ml and the average number of fibroids removed was seven. The largest fibroid removed measured 27 x 20 cm in diameter while the most significant number of fibroids removed was 41. Moreover, the mean duration of the tourniquet application was 45.31 minutes, and the mean duration of operation was 80.44 minutes. Thirty-six patients (92.3%) had an estimated blood loss <500 ml. The number of fibroids removed was a statistically significant risk factor influencing estimated blood loss (p = 0.019). However, there was no statistical significance between estimated blood loss and the size of the largest fibroid removed (p = 0.178) nor estimated blood loss and a history of previous surgery (p = 0.412). The postoperative blood transfusion rate was 2.5% and no patients suffered grade III or higher surgical complications according to the Clavien-Dindo classification.

CONCLUSION

This study showed that the utilization of a temporary intraoperative combined pericervical uterine artery and infundibulopelvic ligament tourniquet is an effective, practical, and economical approach to limiting intraoperative blood loss during abdominal myomectomy.

Incidence and Risk Factors of Postoperative Febrile Morbidity among Patients Undergoing Myomectomy

Background and Objectives: To identify the incidence, causes, and independent predictors of postoperative febrile morbidity among patients undergoing myomectomy. Material and methods: Medical records of patients who had undergone myomectomy at Chiang Mai University Hospital between January 2017 and June 2022 were comprehensively reviewed. The clinical variables, including age, body mass index, previous surgery, leiomyoma size and number, the International Federation of Gynecology and Obstetrics (FIGO) fibroid type, preoperative and postoperative anemia, type of surgery, operative time, estimated blood loss, and intraoperative antiadhesive use, were analyzed as a predictive factor of postoperative febrile morbidity. Results: During the study period, 249 consecutive women were reviewed. The mean age was 35.6 years. The majority of women had FIGO fibroid type 3-5 (58.2%) and type 6-8 (34.2%). Febrile morbidity was noted in 88 women (35.34%). Of them, 17.39% had a urinary tract infection and 4.34% had a surgical site infection, whereas the causes in the majority of cases (78.26%) could not be identified. The significant independent risk factors for febrile morbidity were abdominal myomectomy (adjusted odds ratio: aOR, 6.34; 95% CI, 2.07-19.48), overweight women (aOR, 2.25; 95% CI, 1.18-4.28), operation time of more than 180 min (aOR, 3.37; 95% CI, 1.64-6.92), and postoperative anemia (aOR, 2.71; 95% CI, 1.30-5.63). Conclusions: Approximately one-third of women undergoing myomectomy experienced febrile morbidity. The cause could not be identified in most cases. The independent risk factors included abdominal myomectomy, overweight, prolonged operation time, and postoperative anemia. Of them, abdominal myomectomy was the most significant risk factor.

Uterine fibroids: modern methods of treatment, advantages and complications

The state of the reproductive system by women with uterine fibroids is considered as a part of this literature review. The main clinical manifestations of myomatous nodes were identified by writing the review: abnormal uterine and heavy menstrual bleeding, infertility, miscarriage, chronic pelvic pain, dysfunction of adjacent organs, which are indications for surgical treatment. It is noted that approximately 30 % of women with uterine fibroids suffer from abnormal uterine bleeding, leading to anemia and reduced quality of life. Chronic pelvic pain significantly reduces the quality of life of patients, worsening their functional and mental state and disrupting sexual function. This review focuses on reproductive problems in women with leiomyoma. Taking into consideration the high prevalence of this nosology and the need to preserve the fertility of patients, the review describes modern methods of treating patients with uterine myoma, including drug therapy surgical treatment and alternative methods. Currently, in order to stop the symptoms of uterine fibroids, as well as for preoperative preparation, conservative therapy is used, which allows to reduce pain, restore hemoglobin levels, reduce intraoperative blood loss and reduce surgery time. Reproductive disorders associated with uterine fibroids, such as infertility, recurrent miscarriage, and adverse obstetric outcomes, are a significant reason to improve organ-preserving therapies or develop new ones. Although hysterectomy is a radical treatment for uterine fibroids, it is unacceptable for patients who have not realized their reproductive function. Therefore, the most justified intervention is myomectomy with various surgical approaches, and as an alternative treatment, uterine artery embolization, radiofrequency ablation or high-intensity focused ultrasound treatment of uterine fibroids. These data allow us to conclude that the high prevalence and versatility of symptoms of uterine fibroids among patients of reproductive age determine the relevance of searching for optimal methods of treatment.

Laparoscopic myomectomy - The importance of surgical techniques

Laparoscopy is a routine procedure for benign gynecological tumors. Although the laparoscopic approach for myomas is a common procedure, it can be challenging. To improve outcomes, research regarding port access, suture type, morcellation, and complication management remains ongoing. Myomectomy is the main surgical option for patients seeking uterus-sparing procedures to maintain future fertility. The laparoscopic technique is the most important in these cases, given that possible complications can impact fertility and pregnancy outcomes. Herein, we reviewed and collated the available data regarding different suture techniques, including advantages, difficulties, and possible long-term impacts.