BACKGROUND: Laparoscopic myomectomy (LM) is a preferred alternative to abdominal myomectomy due to shorter hospitalization, faster recovery, and decreased intraoperative adhesions. The criteria, however, which constitute proper selection of patients for LM, are still a matter of debate. Since conversion to either laparoscopic-assisted myomectomy (LAM) or laparotomy (EL) entails longer time and increased costs compared to performing an open procedure from the outset, this research aims to evaluate size, location, and type of myoma as predictors for LM.
METHODOLOGY: Inpatient medical records of all women who underwent LM from January 2014 to August 2016 were retrieved and reviewed. Demographic data, intraoperative records, and postoperative course were obtained. The association of size, type, and location of myomas to the procedure performed was analyzed.
RESULTS: There was no significant association between the size of the myoma or its location to the procedure performed. However, intramural and subserous myomas were associated with successful LM, while submucous myomas were associated with conversion to either LAM or EL (P = 0.010).
CONCLUSION: LM is a difficult procedure that challenges even the most skilled laparoscopic surgeon. Proper patient selection lessens complications and decreases the risk of conversion. In this study, type of myoma may be a good predictor for successful LM; however, this conclusion may be limited by the small sample size. A large-scale multicentric prospective study is necessary to validate the role of the proposed predictors to prevent unplanned conversion to an open procedure and reduce cost and increase safety of LM.
STUDY OBJECTIVE: To determine if the number of myomas removed during myomectomy for symptomatic relief affects long-term fertility outcomes in reproductive-aged women.
DESIGN: Retrospective cohort survey study (Canadian Task Force classification II-2).
SETTING: University hospital.
PATIENTS: One hundred forty-four patients who underwent myomectomy for symptomatic myomas and attempted to conceive afterward.
INTERVENTION: Questionnaire mailed to reproductive-aged women who received robotic, laparoscopic, or abdominal myomectomy.
MEASUREMENTS AND MAIN RESULTS: Patients with >6 myomas removed were less likely to achieve pregnancy after myomectomy than patients with ≤6 myomas removed (22.9% vs 70.8%, respectively; p < .001). To achieve pregnancy, 45% of those with >6 myomas removed (vs 17.6% of those with ≤6 myomas removed) relied on fertility treatment (clomiphene citrate, letrozole, intrauterine insemination, or in vitro fertilization). Of those with >6 myomas removed who became pregnant, 45.5% had a term birth, 45.5% miscarried, and 9.1% had an ectopic pregnancy. Of those with ≤6 myomas removed who became pregnant, 61.8% had a term birth, 23.5% had a preterm birth, and 13.2% miscarried.
CONCLUSION: The number of myomas removed during myomectomy significantly affects fertility. Women with >6 myomas removed were less likely to become pregnant, more likely to require fertility treatment, and less likely to have a term birth when compared with women with ≤6 myomas removed.
Uterine fibroids (UFs) are common benign tumors of the female genital tract, diagnosed in almost one-quarter of women of reproductive age. UFs may cause numerous clinical symptoms, including prolonged or heavy menstrual bleeding, pelvic pressure symptoms, pain, infertility and others. Submucous fibroids arise from the muscular part of the uterus and pen-etrate into the uterine cavity. They are mostly managed with the use of hysteroscopic myomectomy (HM), which provides direct visualization from the transcervical approach. The sheer number of HM standards and techniques is reason enough to review the available literature about HM-related complications. HM is a safe and effective treatment in patients with the normal size of the uterus and with no more than a few UFs. The procedure should not be initiated without adequate preparation and diagnosis, using the best methods available.
Uterine fibroids are the most common tumors of the uterus and the female pelvis and are associated with substantial morbidity for several women. In women with a wish to preserve fertility, a myomectomy is the surgical procedure of choice when medical therapy is inadequate. Despite evidence that minimally invasive surgery is preferable to laparotomy, most myomectomies are still performed by laparotomy. Robotic surgery was introduced to overcome some of the difficulties associated with laparoscopic surgery. A myomectomy is a suture-intensive surgery where the properties of a surgical robot have been suggested to be of particular value. Robotic myomectomy is feasible and safe, with similar outcome to laparoscopic surgery, although a robotic procedure is associated with a higher cost. The introduction of robotic surgery has expanded the indications for minimally invasive myomectomy to more complex cases previously performed by laparotomy. Randomized trials comparing different approaches to myomectomy are yet to be published. More studies are needed to determine the patients in whom a robotic approach is most beneficial, both in terms of patient outcomes and cost efficiency.
STUDY OBJECTIVE: This study aimed to investigate the morbidity of laparoscopic myomectomy (LM) versus open myomectomy (OM), including intraoperative blood loss, duration of surgery, hospital stay, and complications and to evaluate the criteria for selection of cases suitable for LM.
DESIGN: This was a retrospective study.
SETTING: This study was conducted at tertiary hospital.
PARTICIPANTS: The records of 67 women who underwent LM, 22 women who underwent OM, and 14 women who had laparo-conversion from January 2010 to November 2014 were reviewed.
MEASUREMENT AND MAIN RESULTS: Fibroids up to 10 cm were removed by LM, while most fibroids more than 10 cm were managed through OM. The number and weight of myomas are significantly associated with laparo-conversion, with a rate of 17%. Mean blood loss was significantly reduced in LM group than the OM and laparo-conversion groups. Duration of hospital stay was also significantly less in LM (2 ± 1 days) compared to both OM and laparo-conversion groups (3 ± 1 days). Most women underwent LM (88%) had no postoperative complications compared to OM (50%) and laparo-conversion (57.1%). The number of fibroids removed and duration of surgery was positively correlated with blood loss in the women who underwent myomectomy.
CONCLUSION: LM is an ideal surgical approach for removal of fibroids which are up to 10 cm diameter and <5 in number, while OM is useful for cases with multiple (5 or more), larger fibroids (>10 cm), and deeply located fibroids. Preoperative evaluation of the size and number of myomas is necessary to avoid laparo-conversion and to reduce intraoperative and postoperative complications.
OBJECTIVE: To evaluate the feasibility and safety of vaginal delivery after ultrasound-guided high-intensity focused ultrasound (HIFU) ablation treatment for women with uterine fibroids of child-bearing ages.
METHODS: A prospective study was conducted on women who underwent ultrasound-guided HIFU therapy for uterine fibroids at the Chinese PLA General Hospital from January 2008 to December 2014. Patients were interviewed yearly to assess their fertility outcomes, including conception method, delivery mode, neonatal outcomes and complications during pregnancy, labor, and delivery.
RESULTS: A total of 174 patients with plans for future pregnancy were included, and 88 pregnancies in 81 women occurred. The pregnancy rate was 46.6% (81/174), and the median follow-up time was 76 months. The rate of pregnancies that ended in miscarriages was 10% (9/88), the rate of elective pregnancy termination was 6% (5/88), and 84% (74/88) of the pregnancies resulted in deliveries, with 3 of the 71 women having two deliveries. A cesarean section was requested by 50% (37/74) of the women, and 50% (37/74) opted for a vaginal delivery. Eleven of the 37 pregnancies were scheduled for elective cesarean sections, owing to pregnancy complications; the remaining 26 pregnancies were scheduled for vaginal delivery, and 21 (80.8%) were successful. None of the patients with a vaginal delivery experienced any complications during pregnancy and labor.
CONCLUSIONS: Ultrasound-guided HIFU ablation could be considered a promising clinical treatment for women with uterine fibroids and plans for future pregnancy, and vaginal delivery after ultrasound-guided HIFU ablation treatment appear to be feasible and safe.
STUDY OBJECTIVE: The aim of this study is to elaborate the changes of the surgical approach of treatment for uterine myomas in Yangpu Hospital in the past 15 years.
DESIGN: This was retrospective cohort study.
SETTING: Yangpu Hospital, Tongji University School of Medicine, Shanghai, China.
MATERIALS AND METHODS: A total of 4113 patients with symptomatic uterine myomas underwent surgical treatments. Interventions: Eight kinds of different surgeries were involved in the study, including abdominal or laparoscopic surgery, hysterectomy, or uterus-sparing myomectomy.
MEASUREMENTS: The study collected patients' clinical data and reviewed surgical access and approach, complications, and the results of following up.
RESULTS: A total of 1559 cases (37.9%) underwent uterus-sparing myomectomy, 3005 cases (73.1%) performed laparoscopic surgeries. The percentage of laparoscopic surgery was significantly higher than homochronous data of laparotomy after 2003 (P < 0.001). The per year total of uterus-reserved surgery was proved to be negatively correlated with patient's age (R2 = 0.930; P < 0.001). The rate of myomas recurrence was significantly lower in the combined myomectomy and uterine artery occlusion group (4%, 34/910) than in the single myomectomy group (10.5%, 44/420) (P < 0.001).
CONCLUSIONS: Retaining uterus and minimally invasive surgery were the important trends of surgical treatment for symptomatic uterine myomas. Laparoscopic uterus-sparing myomectomy may be an alternative to hysterectomy to manage to appropriate patients with uterine myomas.
WHAT IS KNOWN AND OBJECTIVE: Ulipristal acetate, a progesterone receptor modulator, pharmacologically inhibits endometrial proliferation and thereby prevents pregnancy. It is primarily used as emergency contraception, but also for the treatment of fibroids in women of reproductive age. There have been no published cases of pregnancy, while on therapy with ulipristal acetate.
CASE DESCRIPTION: In this article, we present a case report of spontaneous pregnancy during ulipristal acetate therapy.
WHAT IS NEW AND CONCLUSION: To our knowledge, this is the first patient with spontaneous conception, while on ulipristal acetate treatment. There were no drug-related complications, and the pregnancy resulted in the delivery of a healthy baby.
The incidence of uterine rupture through a previous cesarean scar (CS) is declining as a result of a lower parity and fewer options for vaginal birth after cesarean. However, uterine ruptures attributable to other causes that traumatize the myometrium are on the rise. To determine whether changes in the causes of uterine rupture had occurred in recent years, we retrospective retrieved the clinical records of all singletons with uterine rupture observed in the delivery room of a Taiwanese tertiary obstetric center over a 15-year period. The overall uterine rupture rate was 3.8 per 10,000 deliveries. A total of 22 cases in 20 women (with two of them experiencing two episodes). Seven uterine ruptures occurred through a previous cesarean scar (CS ruptures, 32%), 13 through a non-cesarean scar (non-CS ruptures, 59%), whereas the remaining two (9%) were in women who did not previously undergo any surgery. All of the 13 non-CS ruptures were identified in women with a history of laparoscopic procedures to the uterus. Specifically, 10 (76%) occurred after a previous laparoscopic myomectomy, one (8%) following a hysteroscopic myomectomy, and two (16%) after a laparoscopic wedge resection of cornual ectopic pregnancy. Severe bleeding (blood loss >1500 mL) requiring transfusions was more frequent in women who experienced non-CS compared with CS ruptures (10 versus 1 case, respectively, P = 0.024). Patients with a history of endoscopic uterine surgery should be aware of uterine rupture during pregnancy.
Transcervical radiofrequency ablation of uterine fibroids was performed on a patient in Germany, who subsequently conceived. This is the first report of a normal spontaneous vaginal delivery after fibroid ablation with the Sonata® System.
Laparoscopic myomectomy (LM) is a preferred alternative to abdominal myomectomy due to shorter hospitalization, faster recovery, and decreased intraoperative adhesions. The criteria, however, which constitute proper selection of patients for LM, are still a matter of debate. Since conversion to either laparoscopic-assisted myomectomy (LAM) or laparotomy (EL) entails longer time and increased costs compared to performing an open procedure from the outset, this research aims to evaluate size, location, and type of myoma as predictors for LM.
METHODOLOGY:
Inpatient medical records of all women who underwent LM from January 2014 to August 2016 were retrieved and reviewed. Demographic data, intraoperative records, and postoperative course were obtained. The association of size, type, and location of myomas to the procedure performed was analyzed.
RESULTS:
There was no significant association between the size of the myoma or its location to the procedure performed. However, intramural and subserous myomas were associated with successful LM, while submucous myomas were associated with conversion to either LAM or EL (P = 0.010).
CONCLUSION:
LM is a difficult procedure that challenges even the most skilled laparoscopic surgeon. Proper patient selection lessens complications and decreases the risk of conversion. In this study, type of myoma may be a good predictor for successful LM; however, this conclusion may be limited by the small sample size. A large-scale multicentric prospective study is necessary to validate the role of the proposed predictors to prevent unplanned conversion to an open procedure and reduce cost and increase safety of LM.
