Uterine rupture after laparoscopic myomectomy

Perioperative and reproductive outcomes' comparison of mini-laparotomy and laparoscopic myomectomy in the management of uterine leiomyomas: a systematic review

OBJECTIVE

To evaluate and compare mini-laparotomy (MLPT) with laparoscopic (LPS) myomectomy perioperative and reproductive outcomes.

METHODS

We systematically searched for related articles in the MEDLINE, Embase, Web of Science and the Cochrane library databases. Nine studies (4 randomized, 3 retrospective, 1 prospective and 1 case-control study) which involved 1723 patients met the inclusion criteria and were considered eligible for inclusion.

RESULTS

Demographic characteristics were similar between the two groups. LPS was associated with shorter hospital stay (p = 0.04), lower blood loss (p < 0.00001), shorter duration of median ileus (p < 0.00001) and fewer episodes of postoperative fever (p = 0.04). None of the reproductive factors examined (pregnancy rate, preterm delivery, vaginal delivery and delivery with caesarean section) in women diagnosed with unexplained infertility and/or symptomatic leiomyomas reached statistical significance although the results represent a small size effect.

CONCLUSION

Our analysis demonstrated that LPS seems to be an alternative, safe and reliable surgical procedure for uterine leiomyoma treatment and in everyday practice seems to offer improved outcomes-regarding at least the perioperative period-over MLPT.

Removal of uterine fibroids by mini-laparotomy technique in women who wish to preserve their uterus and fertility

INTRODUCTION

The minilaparotomy is considered to be a safe and effective alternative to laparoscopy and abdominal laparotomy in myomectomy cases.

AIM

To perform a retrospective analysis of pre-surgical assessment, surgical course and post-operational parameters in women wishing to preserve their uterus and fertility who underwent myomectomy by minilaparotomy in the Department of Gynecology and Gynecological Oncology at the Polish Mother's Memorial Hospital - Research Institute in Lodz in the years 2008-2014.

MATERIAL AND METHODS

A total of 76 patients were qualified for minilaparotomy due to a benign gynecological pathology. Only 21 patients with uterine fibroids who wanted to preserve their uterus and fertility were appropriate for this study. Patients' records were analyzed in terms of: epidemiological history, surgical course, postoperative stay and pathological data. All studied patients were asked in 2014 about conception and pregnancy after minilaparotomy.

RESULTS

The median age was 35.7 years. The median patient body mass index (BMI) was 24 kg/m(2). The average decrease of hemoglobin was 1.5 g/dl. The size of the myoma was between 1.5 and 15 cm. There were no serious post-surgical complications. The size of the myoma did not correlate significantly with operation time, BMI or blood loss. There was no statistically significant dependence between operation time and average hematocrit and hemoglobin decrease. In our group 7 patients who had undergone myomectomy tried to achieve conception. Four of them succeeded in pregnancy and gave birth to healthy infants.

CONCLUSIONS

Myomectomy performed via minilaparotomy is a safe procedure for patients willing to preserve their uterus and fertility, and it combines some advantages of both laparotomy and laparoscopy.

Pregnancy Outcomes and Risk Factors for Uterine Rupture After Laparoscopic Myomectomy: A Single-Center Experience and Literature Review

STUDY OBJECTIVE

To evaluate pregnancy outcomes after laparoscopic myomectomy (LSM), focusing on the risk of uterine rupture.

DESIGN

Retrospective cohort study (Canadian Task Force classification III).

SETTING

University hospital.

PATIENTS

Of 676 women who visited the obstetrics department for a pregnancy after undergoing LSM performed at the same center between 1994 and 2012, we included the 523 women who had follow-up through the end of pregnancy.

INTERVENTIONS

All patients underwent LSM, and their medical charts were retrospectively reviewed.

MEASUREMENTS AND MAIN RESULTS

Multiple myomas were removed in 35.2% of cases, intramural-type lesions occurred in 46.5% of cases, and the mean myoma diameter was 4.9 cm. Pregnancy outcomes after LSM included 400 (76.5%) full-term deliveries and 100 (19.1%) vaginal deliveries, with other adverse outcomes being no different than the general population. The mean interval between LSM and pregnancy was 14 months, and only 3 (0.6%) cases of uterine rupture occurred during pregnancy. In analysis, by reviewing the published cases of uterine rupture, we found that the mean diameter, myoma number and type, and the rate of uterine suture were similar between the ruptured cases and all of our cases of LSM.

CONCLUSION

LSM can be safely used in women of reproductive age who want to become pregnant. Uterine rupture occurs in rare cases, regardless of myoma features, but further large-scale studies are required to ascertain the detailed effects of various surgical techniques.

Perspectives of obstetricians on labour and delivery after abdominal or laparoscopic myomectomy

OBJECTIVE

Because of concerns about uterine rupture, many obstetricians recommend elective Caesarean section for women with a prior myomectomy. This practice has led to an increased rate of elective CS and subsequently of repeat Caesarean sections. The purpose of this study was to evaluate the perspectives of obstetricians on labour and delivery after abdominal or laparoscopic myomectomy.

METHODS

We conducted a survey of 49 practising obstetricians from July 2012 to January 2013, using a standard questionnaire. This included questions on labour and delivery after myomectomy by laparotomy or laparoscopy.

RESULTS

Overall, the inter-respondent agreement was fair (kappa 0.3; P < 0.001). There was no significant difference in the likelihood that respondents would allow vaginal delivery after myomectomy by laparotomy and by laparoscopy (27% and 14% if the uterine cavity was entered and 76% and 71% if the uterine cavity was not entered, respectively). However, the likelihood that respondents would allow vaginal delivery was significantly reduced if the uterine cavity was entered, regardless of the surgical approach (P < 0.001). Entry into the uterine cavity during myomectomy also significantly increased the likelihood that obstetricians would recommend elective CS rather than induction of labour. There was no significant difference in practice regarding the use of oxytocin with amniotomy, oxytocin infusion, or prostaglandins.

CONCLUSION

Despite a lack of evidence, obstetricians consider entry into the uterine cavity at myomectomy to be an important factor in determining the method of delivery, the use of oxytocin, and delivery by elective Caesarean section. This was independent of the myomectomy approach.

Learning curve of minimally invasive two-port laparoscopic myomectomy

The authors report that the minimally invasive 2-port total laparoscopic myomectomy technique may be mastered after experiencing 7 operative cases.

Background and Objects:

To examine the learning curve of minimally invasive 2-port total laparoscopic myomectomy (TTLM).

Methods:

TTLM was performed by using only umbilicus and left inguinal ports, for 30 patients at our university affiliated hospital between May 2009 and February 2010. The times required for each of the 5 surgical phases of the early and late cases performed by the same surgeon were compared by using a DVD time counter.

Results:

The mean surgical time was 82.5±5.2 minutes, blood loss was 42.1±7.5mL, and weight of specimen was 65.3±13.3g. The eighth case was the first in which the surgical time fell below the overall mean surgical time. Comparison of the mean time of each phase between the 7 early and the subsequent (late) cases revealed significant differences in the times required for suturing.

Conclusions:

Although this was a feasibility study, the results suggest that this technique can be mastered after 7 cases.

Learning curve, Suturing.

Abdominal myomectomy--a safe procedure in an ambulatory setting

OBJECTIVE

To evaluate the efficacy and safety of minilaparotomy myomectomy in an ambulatory setting.

DESIGN

Retrospective, nonrandomized study.

SETTING

Center for Assisted Reproduction, Bedford, Texas.

PATIENT(S)

One hundred eighty-nine women desiring fertility with symptomatic uterine leiomyomata.

INTERVENTION(S)

Minilaparotomy myomectomy in an ambulatory setting.

MAIN OUTCOME MEASURE(S)

Operative time, blood loss, recovery time, postoperative analgesia, and complications.

RESULT(S)

The mean diameter of the largest leiomyoma was 4.4 cm (range, 1-14 cm). The mean number and weight of the leiomyomata was 4.9 (range, 1-35) and 109.8 gm (range, 1-1,165 g), respectively. The mean operative time was 73 minutes, and the mean blood loss was 96 mL. On average, patients required 3.5 hours of recovery time. In the recovery room, patients received a mean of 12 mg of morphine/37 mg of meperidine for pain control postoperatively before discharge home. Only one major complication, pulmonary edema related to extubation, occurred.

CONCLUSION(S)

This study demonstrates that minilaparotomy myomectomy, when performed using a systematic operative technique, can be accomplished in an outpatient setting with minimal blood loss, fast recovery time, and a low complication rate. Postoperatively, patients require minimal analgesia, which permits them to be discharged home the same day. Minilaparotomy myomectomy is a safe, cost-effective treatment of most symptomatic uterine leiomyomata in an ambulatory setting.

Prospective evaluation for the feasibility and safety of vaginal birth after laparoscopic myomectomy

STUDY OBJECTIVE

To estimate the feasibility and safety of vaginal birth after laparoscopic myomectomy (LM).

DESIGN

Prospective clinical study (Canadian Task Force classification II-2).

SETTING

University hospital.

PATIENTS

The study was performed on 1334 patients who underwent LM at our hospital from January 2000 through December 2005.

INTERVENTIONS

Laparoscopic myomectomy.

MEASUREMENTS AND MAIN RESULTS

The potential of a safe vaginal birth after LM was discussed with all 1334 patients before and after their LM. A strict protocol for a vaginal birth after LM was prepared using the criteria for a vaginal birth after cesarean section (CS). Of the 221 women who became pregnant after LM by December 2006, 111 were scheduled to deliver at our hospital. The findings at LM in these patients were as follows: mean diameter of the largest myoma (mean +/- SD, 95% CI), 66.1 +/- 18.8 (62.6-69.6) mm; and mean number of enucleated myomas, 3.5 +/- 3.6 (2.8-4.2). The endometrium was opened in 13 patients. Of the 111 patients, 82 patients opted for a vaginal delivery and 29 patients requested a CS. Of the 82 patients, 8 underwent an elective CS because of complications of pregnancy. Vaginal delivery was completed in 59 (79.7%) of the remaining 74 patients. The 15 patients who failed vaginal delivery underwent a CS: eleven because of failure to progress in labor or absence of spontaneous labor by 42 weeks of gestation; and 4 because of a nonreassuring fetal status during labor. No significant differences in delivery outcomes existed between the successful and failed group. None of the patients had a uterine rupture.

CONCLUSION

Uterine rupture during pregnancy after LM is rare, and vaginal birth after LM appears to be safe in selected patients who meet our criteria.

La myomectomie par cœlioscopie en 2007: état des lieux

With fifteen years of development, laparoscopy for myomectomy has proven its advantages. However, this technique remains controversial concerning its feasibility and the quality of uterine scar obtained. Laparoscopic myomectomy (LM) is usually indicated when number of myomas is less than 3 to 4 with a 8 to 9 cm maximal size. Surgical technique is standardized and intervention time becomes acceptable. Risk of conversion ranges between 1 to 3% when technique is realized by trained surgeon. Bleeding is less important compared with laparotomy and immediate postoperative complications are exceptional. Results concerning fertility are positive with more than 50% of infertile patient conceiving after surgery, this rate rising up to 61 to 76% for myomas isolated cause for infertility; these values can be compared with myomectomy realized by laparotomy. Postoperative adhesions seem to be less important after laparoscopy when compared with laparotomy but this point needs to be confirmed. Risk of uterine rupture is estimated between 0 to 1%, but this point needs for larger series evaluation and needs to be compared with pregnancies after laparotomy. Laparoscopic myomectomy is a feasible technique, safe for patients waiting for conception and has proven its interest in case of infertility.

Obstetric and delivery outcome of pregnancies achieved after laparoscopic myomectomy

OBJECTIVE

To assess the risks and outcome of pregnancies and deliveries after laparoscopic myomectomy (LM).

DESIGN

Retrospective study.

SETTING

Center of Reconstructive Pelvic Endosurgery, Reproductive Medicine Unit, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy.

PATIENT(S)

A total of 514 patients of fertile age that underwent LM at the Center were selected.

INTERVENTION(S)

All the surgical procedures were performed using the same technique employing a vertical uterine incision and avoiding the use of electrosurgery.

MAIN OUTCOME MEASURE(S)

Number and outcome of pregnancies achieved after surgery, abortion rate, preterm delivery, gestational age, malpresentation, spontaneous or cesarean delivery, and postpartum hemorrhage. We also paid particular attention to the occurrence of uterine rupture.

RESULT(S)

A total of 158 pregnancies were achieved. There were 43 (27.2%) spontaneous abortions, 4 (2.6%) ectopic pregnancies, and 1 (0.6%) therapeutic abortion. Only 27 patients (25.5%) had vaginal deliveries, whereas 79 (74.5%) underwent cesarean section. No instances of uterine rupture were recorded.

CONCLUSION(S)

Our preliminary results confirmed that LM, performed by an expert surgeon, can restore reproductive capacity, allowing patients to have a successful pregnancy.

Reproductive outcome after laparoscopic myomectomy for intramural myomas in infertile women with or without associated infertility factors

Aims:   To evaluate reproductive outcome after laparoscopic myomectomy for intramural myomas in infertile women with or without associated infertility factors. Methods:   A retrospective study was carried out in 30 infertile women with intramural myomas measuring ≥50 mm in diameter and treated using laparoscopy. Results:   The overall rate of spontaneous intrauterine pregnancy was 50.0% (15 patients). Of 13 patients with infertility factors associated with the uterine myomas, three (23.1%) became pregnant, whereas 12 of 17 patients (70.6%) with no other associated infertility factor became pregnant. No uterine ruptures were observed. All pregnancies were spontaneous and 13 occurred within 1 year of the operation. In the 10 patients who gave birth by Cesarean section, no adhesions were found on the myomectomy scar. Conclusions:   On the basis of these results, laparoscopic surgery for myomas appears to offer comparable results to laparotomy. In infertile patients with intramural myoma, pregnancy rates are affected by the presence of other infertility factors associated with the uterine myomas. (Reprod Med Biol 2006; 5: 31-35).

Minilaparotomy myomectomy: A minimally invasive alternative for the large fibroid uterus

STUDY OBJECTIVE

To assess the efficacy of performing myomectomies through 3- to 6-cm incisions for the removal of myomas up to 14 cm in diameter.

DESIGN

A retrospective analysis of 139 myomectomies performed at our center from January 1995 through December 2003 (Canadian Task Force classification II-3).

SETTING

A suburban medical center, part of a large prepaid health maintenance organization.

PATIENTS

One hundred thirty-nine women.

INTERVENTIONS

Myomectomies were performed through 3- to 6-cm suprapubic cruciate incisions using atraumatic elastic retractors with or without laparoscopic assist. Myomas were morcellated with a scalpel before being enucleated. The uterus was repaired in a classic three-layered closure in all cases. All procedures were performed in the ambulatory surgery unit of our hospital, which is part of the main operating room.

MEASUREMENTS AND MAIN RESULTS

The median age of the patients in this series was 30.0 years (range 23-56 years). The median weight of the myomas removed was 275.0 g (range of 30-975 g). One hundred thirty-seven (98.5%) of 139 patients were discharged in 23 hours or less, with 24 patients leaving within 4 hours and 61 within 8 hours. The median length of stay was 6.0 hours, with two patients remaining hospitalized for 48 hours. The median operating time was 110 minutes (range 44-260 min). Estimated blood loss ranged from 50 to 2000 mL, with a median of 300 mL. Three hysterectomies were performed: one as an emergency for hemorrhage and two for recurrent myomas. Three patients developed wound seromas, and one developed a wound infection.

CONCLUSIONS

Minilaparotomy myomectomy is a safe, effective minimally invasive alternative to laparoscopic myomectomy. Early discharge and return to normal activities is comparable to laparoscopy and is far more cost effective. It affords the ability to palpate the uterus and close the myometrial defect easily with a standard three-layered closure making it particularly suitable for gynecologists with limited laparoscopic suturing skills.

Repair of uterine dehiscence with continuation of pregnancy

BACKGROUND

Uterine dehiscence in the past has been treated with delivery of the pregnancy and repair of the uterus or cesarean hysterectomy. Uterine repair and continuation of the pregnancy has not been attempted to our knowledge.

CASE

A patient with a history of a laparoscopic myomectomy presented at 28 weeks of gestation with a uterine dehiscence. This was repaired and the pregnancy continued until fetal lung maturity at 34 weeks.

CONCLUSION

Repair of a uterine dehiscence in a hemodynamically stable patient and continuation of the pregnancy should be considered in a very premature pregnancy to improve neonatal outcome.

Les limites de la myomectomie cœlioscopique

Feasibility of laparoscopic myomectomy has been already shown with numerous clinical studies. Short-term benefits of this procedure are nowadays established. Its limits are related to the surgical technique, the myoma process, and the clinical context of the patient. By using preoperative exclusion criteria, particularly the size and the number of myomas, laparoscopic treatment is possible with little laparoconversion and complications rates. One could be in doubt about the risk of uterine rupture during a pregnancy occurring after laparoscopic myomectomy. In infertile patients, this procedure is as effective as laparotomy, even though its benefits in terms of postoperative adhesions should be demonstrated. Less invasive surgery should be preferred.

Laparoscopic myomectomy for symptomatic uterine myomas

OBJECTIVE

To evaluate the safety, efficacy, and techniques of laparoscopic myomectomy as treatment for symptomatic uterine myomas.

DESIGN

Medline literature review and cross-reference of published data.

RESULTS

Results from randomized trials and clinical series have shown that laparoscopic myomectomy provides the advantages of shorter hospitalization, faster recovery, fewer adhesions, and less blood loss than abdominal myomectomy when performed by skilled surgeons. Improvements in surgical instruments and techniques allows for safe removal and multilayer myometrial repair of multiple large intramural myomas. Randomized trials support the use of absorbable adhesion barriers to reduce adhesions, but there is no apparent benefit of presurgical use of GnRH agonists. Pregnancy outcomes have been good, and the risk of uterine rupture is very low when the myometrium is repaired appropriately.

CONCLUSION(S)

Advances in surgical instruments and techniques are expanding the role of laparoscopic myomectomy in well-selected individuals. Meticulous repair of the myometrium is essential for women considering pregnancy after laparoscopic myomectomy to minimize the risk of uterine rupture. Laparoscopic myomectomy is an appropriate alternative to abdominal myomectomy, hysterectomy, and uterine artery embolization for some women.

Use of the LAP DISK (abdominal wall sealing device) in laparoscopically assisted myomectomy

OBJECTIVE

To evaluate the efficacy of an abdominal wall sealing device (the LAP DISK) used during laparoscopically assisted myomectomy (LAM).

DESIGN

Retrospective study.

SETTING

Tottori University Hospital, Yonago, Japan.

PATIENT(S)

All 43 patients who underwent LAM using the LAP DISK.

INTERVENTION(S)

Ultrasonography and magnetic resonance imaging.

MAIN OUTCOME MEASURE(S)

Treatment strategy, operative outcome, and postoperative pregnancy rate.

RESULT(S)

Weight and size of the myomas removed ranged from 40-700 g (mean: 208.0 g) and 2-10 cm (mean: 5.4 cm). Mean blood loss was 42.3 mL. Half of the 18 patients who had been diagnosed with primary infertility for >2 years became pregnant without postoperative assisted reproductive techniques.

CONCLUSION(S)

The LAP DISK, a useful device for LAM, allows surgeons to remove myomas safely and repair uterine defects effectively while minimizing blood loss and trauma.

A Case Report: Change in Fetal Heart Rate Pattern on Spontaneous Uterine Rupture at 35 Weeks Gestation after Laparoscopically Assisted Myomectomy

A 31-year-old nulligravid woman who underwent laparoscopically assisted myomectomy 5 months before becoming pregnant suffered uterine rupture at 35 weeks gestation. A 50 g intramuscular myomatous node had been removed laparoscopically. Early signs of rupture included sudden onset of severe abdominal tenderness and frequent uterine contractions despite reassuring FHR tracing. Variable deceleration was observed as late as 7.5 hours after onset. Emergency cesarean section was performed due to increasing severity of tenderness, revealing complete uterine rupture at the fundus site without extrusion of the fetus or placenta. A male neonate (2,860 g) was delivered without asphyxia and an Apgar score of 8. Total volume of hemorrhage was approximately 50 ml. The ruptured uterine wall was repaired by suturing in 2 layers. The present case indicates that sudden onset of abdominal tenderness in pregnant women with a history of laparoscopic myomectomy may suggest uterine rupture even in the presence of reassuring FHR. This is a rare case, as non-reassuring FHR patterns generally appear in the late stages of uterine rupture.

Pregnancy outcome after laparoscopic and laparoconverted myomectomy

OBJECTIVE

To compare fertility and pregnancy-related complications after laparoscopic and laparoconverted myomectomy.

METHODS

Retrospective analysis of 106 infertile women with uterine leiomyomas, of whom 88 women underwent laparoscopic myomectomy and 18 laparoconversion.

RESULTS

There was no difference in the patients' baseline characteristics or the mean number of fibroids between the laparoscopic and laparoconversion groups. The mean (+/-S.D.) diameter of the largest fibroid in the laparoscopic and laparoconversion groups was 6.2+/-1.8 and 8.1+/-1.4 cm, respectively (P<0.001). There was no difference in operating time between the two groups. The hospital stay was shorter in the laparoscopic group: 3.0+/-1 versus 5.5+/-1 days (P<0.001). The mean follow-up in the laparoscopic and laparoconversion groups was 27.3+/-7.0 and 32.0+/-3.1 months, respectively (NS). No difference in the pregnancy rate was noted between the laparoscopic and laparoconversion groups (48 and 56%, respectively). The mean time before conception in the laparoscopic and laparoconversion groups was 7.5+/-2.6 and 15.1+/-2.4 months, respectively (P<0.001). There was no difference between the two groups as regards the rates of pregnancy-related complications and vaginal delivery. No uterine rupture occurred.

CONCLUSION

Laparoscopic myomectomy is feasible and safe, and should be considered for infertile women with uterine fibroids. Fertility and pregnancy outcomes following laparoscopic myomectomy are comparable with those following myomectomy after laparoconversion.

Pregnancy outcomes and deliveries after laparoscopic myomectomy

STUDY OBJECTIVE

To assess pregnancy outcomes and deliveries after laparoscopic myomectomy.

DESIGN

Retrospective study (Canadian Task Force classification II-2).

SETTING

General hospital.

PATIENTS

Three hundred fifty-nine women.

INTERVENTIONS

Laparoscopic myomectomy and laparoscopic and/or hysteroscopic treatment of associated pathologies.

MEASUREMENTS AND MAIN RESULTS

Five patients (1.39%) were lost to follow-up. Seventy-two women were pregnant at least once after laparoscopic myomectomy, for a total of 76 pregnancies. Four women conceived twice and four are pregnant as of this writing. One multiple pregnancy occurred. Twelve pregnancies resulted in first-trimester miscarriage, one in an ectopic pregnancy, one in a blighted ovum, and one in a hydatiform mole. One patient underwent elective first-trimester termination of pregnancy. Thirty-one women had vaginal delivery at term and 26 were delivered by cesarean section. No case of uterine rupture or dehiscence occurred.

CONCLUSION

Our technique of laparoscopic myomectomy appears to allow safe vaginal delivery.

What are the implications of myomas on fertility? A need for a debate?

In order to evaluate the relationship between leiomyomas and infertility, which remains a subject of debate, we have tried to evaluate the impact of myomas on fertility and pregnancy outcome in different conditions where myomas are implicated. Medline research was conducted of publications appearing between January 1988 and August 2001 on the subjects of myomas and myomectomy and their impact on fertility and pregnancy outcome in infertile women. A total of 106 manuscripts were consulted. The incidence of myomas in infertile women without any obvious cause of infertility is estimated to be 1-2.4%. The relationship between leiomyomas and infertility remains a subject of debate. The question is: do myomas influence fertility? We are obliged to conclude that the question remains. The absence of an answer to this crucial question is probably due to the fact that we have not yet conducted the appropriate prospective studies required to obtain any clear results.

Laparoscopic myomectomy fertility results

The appearance of uterine myomas has been linked to infertility. It has been suggested that surgical management of myomas by laparoscopic myomectomy improves fertility rates in these group of patients. In this paper we initially describe specific aspects of the surgical technique of laparoscopic myomectomy including the set-up, precise technique for hysteroromy, enucleation of the myoma, suturing of the uterus, and extraction of the myoma. We detail recent findings that demonstrate improved fertility rates in women undergoing laparoscopic myomectomy. We recommend that, when criteria for selection of patients is strictly adhered to and patients present with no other associated infertility, laparoscopic myomectomy be used to increase the implantation rate.

Determinants of pregnancy rate and obstetric outcome after laparoscopic myomectomy for infertility

OBJECTIVE

To determine the effect of myomectomy on infertility and to assess the factors influencing reproductive outcome.

DESIGN

Retrospective study.

SETTING

Tertiary care center.

PATIENT(S)

One hundred and three infertile women with uterine leiomyoma who had had infertility >2 years and a follow-up time >12 months were enrolled. Follow-up was complete for 88 patients, including 28 (31.8%) with primary infertility and 44 (50%) with unexplained infertility. The mean (+/-SD) age of the patients was 36.1 +/- 2.1 years.

INTERVENTION(S)

Laparoscopic myomectomy.

MAIN OUTCOME MEASURE(S)

Pregnancy rate according to patient and fibroid characteristics.

RESULT(S)

Forty-two patients became pregnant (40.7%). The mean (+/-SD) delay in conception was 7.5 +/- 2.6 months. Nearly 80% of the women conceived spontaneously. Of 44 pregnancies in 42 women, 36 live newborns were delivered. No dehiscence of uterine scar occurred. The pregnancy rate was significantly higher in women <35 years of age or <3 years of infertility. Women with unexplained infertility had higher pregnancy rate than did women with multifactorial infertility (P<.001). No difference was noted in pregnancy rates according to fibroid characteristics.

CONCLUSION(S)

Fertility and pregnancy after laparoscopic myomectomy depend primarily on patient age, duration of infertility before myomectomy, and existence of associated infertility factors.

Laparoscopic myomectomy: technique, complications, and ultrasound scan evaluations

STUDY OBJECTIVE

To evaluate the feasibility, limits, and complications of laparoscopic myomectomy, assess time to full recovery, and evaluate uterine wound healing by ultrasound in the early postoperative period.

DESIGN

Prospective study (Canadian Task Force classification II-2).

SETTING

General hospital.

PATIENTS

Three hundred sixty-eight women undergoing laparoscopic myomectomy.

INTERVENTION

Laparoscopic myomectomy and laparoscopic and/or hysteroscopic treatment of associated pathologies.

MEASUREMENTS AND MAIN RESULTS

In these women 768 myomas were removed laparoscopically. Mean operating time was 100.78 +/- 43.83 minutes, mean decreases in hemoglobin and hematocrit were 1.38 +/- 0.93 g/100 ml and 4.8 +/- 2.9 g/100 ml, respectively, and mean length of hospital stay was 2.89 +/- 1.3 days. Intraoperative complications occurred in 12 patients (3.34%) and intraoperative transfusion of autologous blood was required in 10. Main postoperative complications were continuing hemorrhage requiring blood transfusion in three women and second laparoscopy in two. Pyrexia occurred in 12 patients. Average time to full recovery was 10.58 +/- 6.68 days. At 1-month follow-up 12 of 282 women developed further complications: abdominal pain 5, vaginitis 4, metrorrhagia 2, and dysuria 1. Sonographic evaluation of the uterine scar showed a highly echogenic area with ill-defined margins. In 81 women who had sonographic evaluation 30 days postoperatively, the uterine scar was reduced by an average of 44.1% (p <0.001). Of 176 patients screened at day 30, 6 (3.4%) had anechoic areas adjacent to the uterine scar, possibly due to hematoma. A previously unknown myoma, two ovarian cysts, and two pelvic hematoma were also discovered.

CONCLUSION

. Laparoscopic myomectomy is effective and relatively safe. In skilled hands it has a low risk of complications and appears to be a valid alternative to the open procedure. Sonographic assessment allows detection of alterations in muscular echotexture, but its effectiveness in identifying women at risk of uterine rupture or dehiscence has to be proved.

Pregnancy outcomes after laparoscopic myomectomy with ultrasonic energy and laparoscopic suturing of the endometrial cavity

STUDY OBJECTIVE

To evaluate pregnancy outcomes in women with laparoscopic removal of myomas that resulted in entry into the endometrial cavity and required laparoscopic repair of the endometrial cavity.

DESIGN

Retrospective chart review (Canadian Task Force classification II-2). SETTING; Private obstetrics-gynecology practice and departments of obstetrics and gynecology at two university-affiliated hospitals.

PATIENTS

Seven women with symptomatic uterine leiomyomata treated by laparoscopic myomectomy, who achieved pregnancy.

INTERVENTION

Laparoscopic dissection of myomas with the ultrasonic scalpel and laparoscopic suturing of the uterus with the Endo Stitch device in three layers.

MEASUREMENTS AND MAIN RESULTS

Indications for laparoscopic myomectomies were excessive bleeding and significant growth of uterine myomas. The size of myomas in all patients ranged from 12 to 2 cm. Average operating time was 232.8 minutes and average blood loss was 117.8 ml. The largest number of myomas removed from a single patient was nine. All procedures were performed on an outpatient basis and no complications occurred. All women easily achieved pregnancy and four were delivered at or near term by cesarean section. One delivered vaginally at 28 weeks secondary to uncontrolled premature labor, without uterine dehiscence. Two had elective terminations at 8 weeks.

CONCLUSION

Laparoscopic suturing of the endometrial cavity in three layers does not prevent future pregnancies, and pregnancies can progress to term and in some cases be delivered vaginally without dehiscence. (J Am Assoc Gynecol Laparosc 8(1):129-136, 2001)

Fertility and obstetric outcome after laparoscopic myomectomy of large myomata: a randomized comparison with abdominal myomectomy

The purpose of this study was to compare, in infertile patients, the efficacy of laparoscopic myomectomy versus abdominal myomectomy, in restoring fertility and to evaluate the obstetric outcomes. Between January 1993 and January 1998, 131 patients of reproductive age, with anamnesis of infertility, underwent myomectomy because of the presence of at least one large myoma (diameter greater than or = 5 cm). Patients were randomly selected for treatment by laparotomy (n = 65) or laparoscopy (n = 66). The two groups were homogeneous for number, size and position of large myomata. Significant differences were found in the post-operative outcome: febrile morbidity (> 38 degrees C) was more frequent in the abdominal than in the laparoscopic group (26.2 versus 12.1%; P < 0.05). Laparotomy caused a more pronounced haemoglobin drop (2.17 +/- 1.57 versus 1.33 +/- 1.23; P < 0.001); three patients received a blood transfusion after laparotomy and none after laparoscopy. The post-operative hospital stay was shorter in the laparoscopic group (142.80 +/- 34.60 versus 75.61 +/- 37.09 h; P < 0.001). No significant differences were found between the two groups as concerns pregnancy rate (55.9% after laparotomy, 53.6% after laparoscopy), abortion rate (12.1 versus 20%), preterm delivery (7.4 versus 5%) and the use of Caesarean section (77.8 versus 65%). No case of uterine rupture during pregnancy or labour was observed.

Uterine artery embolization for symptomatic uterine myomas

OBJECTIVE

To evaluate the role of uterine artery embolization as treatment for symptomatic uterine myomas.

DESIGN

Medline literature review, cross-reference of published data, and review of selected meeting abstracts.

RESULT(S)

Results from clinical series have shown a consistent short-term reduction in uterine size, subjective improvement in uterine bleeding, and reduced pain following treatment. Posttreatment hospitalization and recovery tend to be shorter after uterine artery embolization compared with hysterectomy. Randomized controlled trials have not been conducted, and long-term efficacy has not been studied. A limited number of deliveries have been reported following uterine artery embolization for uterine myomas.

CONCLUSION(S)

Uterine artery embolization is a unique new treatment for symptomatic uterine myomas. Even without controlled studies, demand for this procedure has increased rapidly. Uterine artery embolization may be considered an alternative to hysterectomy, or perhaps myomectomy, in well-selected cases. At the present time, however, uterine artery embolization should not be routinely recommended for women who desire future fertility.

Laparoscopic myomectomy and subsequent pregnancy: results in 54 patients

The laparoscopic approach to myomectomy has raised questions about the risk of uterine rupture in patients who become pregnant following surgery. It has been suggested that the rupture outside labour in pregnancies following laparoscopic myomectomy can be due to the difficulty of suturing or to the presence of a haematoma or to the wide use of radio frequencies. In this paper we describe the pregnancy outcome of 54 patients submitted to laparoscopic myomectomy at our Institution and prospectively followed during subsequent pregnancies. A total of 202 patients underwent laparoscopic myomectomy. A total of 65 pregnancies occurred in 54 patients who became pregnant following surgery. Data were collected about complications of pregnancy, mode of delivery, gestational age at delivery and birthweight of the neonates. No cases of uterine rupture occurred. Twenty-one pregnancies followed an IVF procedure. Nine patients conceived twice and one three times. Four multiple pregnancies occurred. Eight pregnancies resulted in a first trimester miscarriage and another in an interstitial pregnancy requiring laparotomic removal of the cornual gestational sac. Of the remaining 56 pregnancies, 51 (91%) were uneventful. In two cases a cerclage was performed at 16 weeks. In two cases pregnancy-induced hypertension developed. Two pregnancies ended with a preterm labour (26-36 weeks). A Caesarean section was performed in 45 cases (54/57, 80%). In terms of the safety of laparoscopic myomectomy in patients who become pregnant following surgery, our results were encouraging. However, further studies are needed to provide reliable data on the risk factors and the true incidence of uterine rupture.

Case-control study of laparoscopic versus abdominal myomectomy

PURPOSE

To compare laparoscopic with abdominal approaches to myomectomy.

PATIENTS AND METHOD

Frequency matching was used to ensure similar fibroid weights among the laparoscopic and abdominal groups in this case-control study. The study group consisted of prospectively recruited patients undergoing laparoscopic (N = 5) or laparoscopically assisted (N = 20) myomectomy (lap). The control group represented both prospectively (N = 14) and retrospectively (N = 37) identified abdominal myomectomy patients (abd). Analysis of the variables was performed using a t-test, Wilcoxon rank-sum test, chi-square test, or analysis of covariance at the 0.01 significance level.

RESULTS

All results are reported after matching for fibroid weight, with the median (quartiles) aggregate weight measuring 151 g (31.0, 262.0) and 170.0 g (81.0, 285.0) for the lap and abd patients, respectively (P = 0.15). Median (quartiles) length of hospital stay (30.5 hours [25.0, 52.5] v 65.0 hours [45.0, 76.0]; P < 0.001) and duration of postoperative intravenous narcotic use (14.8 hours [3.0, 18.5] v 24.0 hours [18.0, 40.0]; P = 0.001) were significantly shorter for the lap patients. The laparoscopic cases required a longer median operative time (222.5 minutes [192.5, 270.0]) than the abdominal cases (180.0 minutes [160.0, 220.0]; P = 0.001). No difference was detected in estimated blood loss from surgery (P = 0.57).

CONCLUSIONS

A laparoscopic approach to myomectomy may be safely chosen for patients with fibroids and offers the benefits of less postoperative intravenous narcotic use, a shorter hospital stay, and no greater intraoperative blood loss than abdominal myomectomy.

Myomectomy. Comparison of open and laparoscopic techniques

It appears that both laparoscopic and laparotomy approaches to myomectomy are viable surgical procedures. Both surgeries can be performed with minimal risk. Pregnancy rates after either procedure are high. The advantage of laparotomy over laparoscopy is that it is technically easier. On the other hand, laparoscopy enables quicker and easier recovery. Moreover, the risk of adhesion formation is reduced. If the surgeon can rise to the technical challenge, a laparoscopic approach to myomectomy should be the intended surgery.

Ultrasound evaluation of uterine wound healing following laparoscopic myomectomy: preliminary results

The purpose of our work was to study the evolution of the uterine scar following laparoscopic myomectomy, as imaged by ultrasonography and Doppler velocimetry of the uterine arteries. We prospectively studied 30 patients. In the first phase, 15 patients were submitted to two-dimensional (2D) endovaginal ultrasound on day -1, 1, 7, 30 and 60 (surgery = day 0). In the second phase an additional 15 patients were studied by both 2D ultrasound and by Doppler velocimetry. The resistance index (RI) was calculated from the flow velocity waveform of the uterine arteries, at the origin of their ascending branch. Only one ultrasonic pattern was found, which was a dense echogenic area having an ill-defined, heterogeneous texture. In one case a small anechoic area (1 cm) was detected in the scar, possibly due to a haematoma. The evolution of uterine healing showed a progressive reduction in the size of the scar. On day 1 its mean diameter was 37.04% less than the myoma diameter and on day 30 71.7% less. The difference was significant at P < 0.001. A further significant (P < 0.001) reduction was found at day 60 in the 15 patients studied in phase I. On both day 1 and day 30 following surgery, there was no correlation between the sizes of the myoma and the scar. There was a statistically significant increase (P < 0.01) in the RI value of the ipsilateral uterine artery from 0.64 on day -1 to 0.79 on day 1. On day 30, 12/15 (80%) cases had RI values ranging between 0.80 and 0.98, while in three cases there was absence of end diastolic flow. The RI values of the contralateral uterine artery were high (0.90) before surgery and did not change afterwards. There was no correlation between the size of the myoma and the increase in the uterine artery RI value following surgery. Considering the velocimetric findings, 30 days are a reference point for assessing the healing process. Ultrasound imaging and Doppler velocimetry can be used for studying the evolution of the uterine scar following myomectomy.

Dilute ornitin vasopressin and a myoma drill for laparoscopic myomectomy

To improve enucleation of uterine myomas, we designed a reusable 5-mm laparoscopic drill with a distal forked pin and locking system. Because the device is jointed, it can apply traction not only along its own axis, but also along planes, depending on its bending radius. We compared enucleation time for myomas 5 to 8 cm in size before and after introduction of the drill. The last 23 procedures performed with this instrument were easier, with a reduction in operating time of about 28.5% for the enucleation part of the procedure (p <0.001). (J Am Assoc Gynecol Laparosc 6(2):189-193, 1999)

Laparoscopic myomectomy and pregnancy outcome in infertile patients

OBJECTIVE

To assess outcomes and pregnancy-related complications after laparoscopic myomectomy in infertile patients.

DESIGN

Retrospective analysis.

SETTING

Tertiary care advanced laparoscopic center.

PATIENT(S)

Twenty-eight infertile patients with at least one uterine leiomyoma of >5 cm in diameter.

INTERVENTION(S)

Laparoscopic myomectomy.

MAIN OUTCOME MEASURE(S)

Occurrence of pregnancy, delivery rate, and pregnancy-related complications.

RESULT(S)

The average size of the myomas removed was 6 cm (range, 4-13.3 cm). None of the procedures were converted to laparotomy. The postoperative rate of intrauterine pregnancy was 64.3% (n = 18), including 1 of 2 patients who underwent concomitant hysteroscopic myomectomy. Four patients had spontaneous abortions and 14 delivered viable term neonates. Six women had a vaginal delivery without complications and 8 had a cesarean section. No antepartum or intrapartum complications were reported.

CONCLUSION(S)

Laparoscopic myomectomy can be offered to patients who want to have children and who refuse to undergo an abdominal myomectomy. Patient selection as well as meticulous surgical technique are the key factors in achieving a successful outcome.

Pregnancy outcome after laparoscopic electromyolysis

Laparoscopic myolysis, a procedure designed to shrink uterine myomas by coagulating their blood supply, is an alternative to myomectomy or hysterectomy in women who do not contemplate childbearing. Three patients conceived within 3 months after myolysis against the surgeon's advice. In two of these women the uterus ruptured at 32 and 39 weeks' gestation, respectively, associated with death of the 32-week fetus. The third patient had an uneventful elective cesarean section at 39 weeks' gestation. Until the risk of uterine rupture after myolysis has been accurately compared with that after myomectomy, women should not undergo myolysis if they wish to conceive. Should pregnancy occur after myolysis, caution and intensive surveillance of mother and fetus must be applied, and cesarean section should be performed at earliest signs and symptoms of uterine rupture and at term before onset of labor.

Hysterectomy and myomectomy by laparotomy

Hysterectomy provides definitive treatment for uterine fibroids. Surgery should be offered to women whose fibroids are symptomatic; it is not indicated on the basis of uterine size alone. Myomectomy is an option for those wishing to preserve uterine function. The prospects for successful pregnancy following myomectomy are encouraging, although there is a significant risk of the later recurrence of fibroids. Laparotomy remains the most appropriate surgical approach for large fibroids, although vaginal, rather than abdominal, hysterectomy may be suitable for some women whose uteri do not exceed a 12-14 week gestation size. There is some evidence that the morbidity of abdominal procedures increases with very large uteri. Uterine shrinkage with GnRH analogues may facilitate vaginal hysterectomy and be useful prior to abdominal hysterectomy or myomectomy for very large fibroids, although cost-effectiveness for its use with abdominal procedures has not been demonstrated.