STUDY OBJECTIVE: To compare surgical experience of laparoscopic/robotic myomectomy in premenopausal patients pretreated with ulipristal acetate (UPA) with women not hormonally pretreated.
DESIGN: A retrospective, multicenter cohort study of laparoscopic/robotic myomectomy procedure videos (Canadian Task Force Classification III).
SETTING: Multiple university-affiliated tertiary care hospitals.
PATIENTS: Fifty-five premenopausal women who underwent laparoscopic/robotic myomectomy for intramural myomas and were either pretreated with 3 months of UPA or had no hormonal pretreatment.
INTERVENTIONS: Laparoscopic/robotic myomectomy surgical videos were independently reviewed by 2 gynecologists blinded to whether or not patients received pretreatment with UPA. Each procedure was scored using a novel 22-point surgical global rating tool containing 6 subscales: depth of myometrial incision, ease of myoma-myometrium cleavage plane identification, ease of myoma detachment, blood loss during myoma detachment, myometrial blood loss after myoma detachment, and myoma consistency.
MEASUREMENTS AND MAIN RESULTS: Participating surgeons submitted 55 videos of laparoscopic/robotic myomectomy procedures recorded over a 3-year period (2012-2015). Fifty met the inclusion criteria (25 UPA-treated patients and 25 patients without hormonal pretreatment). Patients treated with UPA were more likely to be older than patients with no medical pretreatment (mean age = 33.5 vs 38.3 years, p = .002). There were no statistically significant differences regarding other baseline characteristics such as the largest diameter of myoma removed, the number of myomas removed, or the estimated blood loss. There was no difference in the physician assessors' mean global rating score for patients with UPA pretreatment versus no pretreatment (12.4 vs 13.4, p = .23). Within the 6 subscales, no differences were observed between the 2 groups. Each video was graded independently by 2 assessors, and there was high inter-rater agreement for the total score and each subscale.
CONCLUSION: There was no difference in surgical experience for myomectomies of patients pretreated with UPA versus those without medical pretreatment.
Gonadotropin-releasing hormone (GnRH) agonist therapy is used before myomectomy to decrease the size of the fibroids, but its association with fibroid recurrence postoperatively remains unsettled. We undertook a retrospective study of robotic-assisted myomectomy (RM) patients at our academic medical center to determine symptomatic recurrence and reoperation rates in those who did versus did not receive preoperative GnRH therapy. Only patients, who had their index myomectomy at least 2 years prior to the chart review, were included in this study. Of 118 RM patients identified between January 2005 and December 2009, 17 patients (14.4 %) had symptomatic recurrence as early as 5 months to as late as 30 months postoperatively. The symptomatic recurrence group had significantly higher preoperative GnRH use (35 vs 9 % non-recurrence; p = 0.009). A total of 7.6 % of all patients underwent reoperation. GnRH agonist use was significantly higher in the reoperation group (56 vs 9 % no reoperation; p = 0.002). Cavity entry during the initial surgery was also more frequent in the reoperation group (56 vs 20 %; p = 0.030), whereas the presence of multiple fibroids, size of the largest leiomyoma, and uterine volume were not statistically different between groups. Our study is among the earliest to report RM reoperation rates in patients receiving preoperative GnRH therapy, showing that the role of GnRH agonist therapy to shrink myomas may not be beneficial when measured against risk of disease recurrence.
OBJECTIVE: To assess the usefulness of 3-month treatment with ulipristal acetate (UPA) before laparoscopic myomectomy of large uterine myomas.
STUDY DESIGN: This retrospective analysis of a prospectively collected database included women of reproductive age requiring laparoscopic myomectomy with the following characteristics: FIGO type 3, 4 or 5 myomas; largest diameter of the main myoma ≥10cm; number of myomas ≤3; largest diameters of the other myomas ≤5cm (second myoma) and ≤3cm (third myoma). Patients either underwent direct surgery (group S) or were treated before surgery with UPA for 3 months (group UPA).
RESULTS: The mean (±SD) intraoperative blood loss was lower in group UPA (507.1±214.9ml) than in group S (684.2±316.8; p=0.012). The total operative time was lower in group UPA (137.6±26.8min) than in group S (159.7±26.8min; p<0.001); there was no significant difference in the suturing time between the two study groups (p=0.076). Hemoglobin drop was lower in group UPA (1.1±0.5g/dl) than in group S (1.3±0.7g/dl; p=0.034). Six patients in group S and no patient in group UPA required postoperative blood transfusions (p=0.031). Complications were not different between the two groups (p=0.726). Moreover, preoperative treatment with UPA caused a significant increase in hemoglobin levels (11.9±1.6g/dl) compared with baseline (9.1±1.1g/dl; p<0.001).
CONCLUSION: A 3-month treatment with UPA before laparoscopy for large uterine myomas decreases intraoperative blood loss, hemoglobin drop, postoperative blood transfusion and length of surgery.
STUDY OBJECTIVE: To evaluate the efficacy of gonadotropin-releasing hormone analogue (GnRHa) use before laparoscopic myomectomy (LM) in large myomas.
DESIGN: Prospective study (Canadian Task Force classification II-1).
SETTING: University-affiliated hospital.
PATIENTS: Ninety-one women with large myomas (≥10 cm) or more than 2 myomas ≥ 5 cm underwent LM between July 2011 and March 2014.
INTERVENTIONS: Forty patients underwent LM after GnRHa use (group A) and 51 underwent LM only (group B). GnRHa was used for 3 doses every 4 weeks before LM in group A.
MEASUREMENTS AND MAIN RESULTS: Group A had a significantly smaller maximum diameter of the largest myoma than group B (8.5 ± 2.1 vs 10.7 ± 2.4, p < .001) and fewer patients with myomas larger than 10 cm after GnRHa administration (33% vs 67%, p = .001). In group A, there was a decrease in 2 or more myomas ≥ 5 cm (20% vs 50%) after GnRHa use. Group A also had significantly smaller mean myoma weight (448 vs 567 g, p = .045) and significantly shorter mean operative time (129 ± 30 vs 152 ± 34 minutes, p = .001). Most patients in group A (40%) had an operative time < 119 minutes, whereas most patients in group B (37%) had an operative time between 150 and 179 minutes. Group A also had less intraoperative blood loss (84 ± 53 vs 137 ± 166 mL, p < .001), drop in hemoglobin (1.5 ± 0.8 vs 3.0 ± 1.7 g/dl, p < .001), excessive bleeding (5% vs 33%, p = .001), postoperative hematoma (2.5% vs 9.8%, p = .168), and blood transfusion (7.5% vs 35%, p = .001).
CONCLUSION: GnRHa before LM in large myomas may be an effective adjuvant treatment for women with large and multiple myomas. This method is beneficial in decreasing operative time, intraoperative bleeding, postoperative hemorrhage, and need of blood transfusion.
The aim of this randomised prospective study was to investigate the impact of preoperative gonadotrophin-releasing hormone agonist (GnRHa) compared with a control group with myomectomy. A total of 36 women (n = 36, group 1) with fibroids were randomised to receive either two monthly doses (n = 18/36, group 1a) or three monthly doses of goserelin (n = 18/36, group 1b) prior to myomectomy. The 32 women who received no treatment (group 2) comprised the controls. All patients had similar demographic features. There were no significant differences among the three groups with respect to: (1) mean intraoperative blood loss; (2) preoperative and postoperative blood transfusion or (3) length of hospital stay. The only advantage of administering GnRHa prior to myomectomy for symptomatic fibroids in our population was a higher haemoglobin level prior to surgery among the women who received three doses of the drug.
OBJECTIVE: To evaluate the role of three-monthly pre-treatment with gonadothropin releasing hormone (GnRH) analogues prior to myomectomy for women in comparison with control group of patients with no application. Analysis is focused on peroperative and postoperative results of surgery treatment for women with clinically symptomatic uterine fibroids in reproductive age with interest in getting pregnant.
DESIGN: Prospective clinical study.
SETTING: Gynecological and Obstetric Clinic of Medical Faculty of Masaryk University and the University Hospital Brno.
MAIN MEASURES: The group of 212 patients with symptomatic uterine fibroids detected by ultrasound. 90 patients (42.5%) underwent laparoscopic myomectomy (LM) and 122 patients (57.5%) underwent open laparotomic myomectomy (OM). In the selected group we were observing the common number of exstirpated uterine fibroids, their size, anatomical localisation, depth of invasion of dominant exstirpated uterine fibroid in relation to uterine wall.
METHODS: Both groups of patients were randomised into two parts. The group LM with GnRH pretreatment contained 42 patients (19,8 %) and control group with no pre-treatment 48 patients (22.7%). Laparotomic part of study was divided into two groups with preoperative application of GnRH analogues 44 patients (36,7 %) and control group OM with no application 44 patients (20.8%). The main outcome measures were peroperative blood loss, duration of surgery, the length of hospital stay, evidence of per- and postoperative complications and the final results by second look laparoscopy (SLL).
RESULTS: In the observed group LM with pre-treatment of GnRh analogues there was significantly higher volume of blood loss (p = 0.0003), significantly longer duration of surgery (p = 0.0063) and significantly higher lenght of hospital stay (p = 0.0025) compared with control group. We have not found a significant difference in the incidence of peroperational converse to laparotomy, final result of neoformation of uterus wall and occurrence of postoperative adhesions by SLL in observed LM group compared with control group. In the observed OM group with pre-treatment of GnRH analogues there was no significant difference in: peroperative blood loss (p = 0.5324), duration of surgery (p = 0.3927) neither average length of hospital stay compared with control group. In the OM group, there was significantly lower incidence of recidives of uterine fibroids observed by SLL (p = 0.0025) and no significant difference of occurrence of postoperative adhesions compared with control group. We have not found significant difference in the incidence of peroperative complications, early and late postoperative complications in group of LM and OM in comparison with control groups.
CONCLUSION: Application of GnRH analogues in observed group of patients before LM and OM have not lead to improvement of peroperative results in comparison with control group. Pre-treatment of GnRh analogues before OM have lead to significant drop in recidives of uterine fibroids observed by SLL (p = 0.0025) compared with control group.
OBJECTIVE: To evaluate if pre-operative GnRH-a modify uterine leiomyoma pseudocapsule and the possible clinical effects of these changes.
STUDY DESIGN: The study was performed at the University Federico II of Naples on 33 premenopausal patients submitted to laparotomic myomectomy after treatment with triptorelin depot. 29 untreated patients formed the control group. The operating time, the intraoperative bleeding and the prompt identification of the cleavage plan between myoma and myometrium were evaluated. The pseudocapsule features and the immunoexpression of PCNA and CD34 in this area were studied.
RESULTS: Treated patients showed lower blood loss and not clearly identifiable cleavage plan, but without any significant increase in the operating time. Treated lesions showed less evident border between myoma and myometrium and lower PCNA and CD34 pseudocapsule immunoexpression than untreated ones.
CONCLUSION: We propose the changes of leiomyoma pseudocapsule as partial explanations of the reported clinical and surgical findings after pre-operative GnRH-a.
OBJECTIVE: To ascertain whether adjuvant gonadotropin-releasing hormone (GnRH) agonist therapy decreases blood loss during abdominal myomectomy.
DESIGN: Randomized controlled trial.
SETTING: Academic reproductive surgery center.
PATIENT(S): One hundred premenopausal women requiring first-line conservative surgery for symptomatic intramural or subserous fibroids.
INTERVENTION(S): Eight weeks of treatment with depot triptorelin before myomectomy or immediate surgery.
MAIN OUTCOME MEASURES: Intraoperative blood loss, operating time, degree of difficulty of the procedure, and short-term rate of fibroid recurrence.
RESULT(S): Mean (+/-SD) intraoperative blood loss was 265 +/- 181 mL in triptorelin recipients and 296 +/- 204 in patients who had immediate surgery (mean difference, -31 mL [95% CI, -108 to 46 mL]). No significant differences were observed in blood loss according to uterine volume, number of fibroids removed, or total length of myometrial incisions. Most procedures in either group were of routine difficulty. On ultrasonography 6 months after myomectomy, four women in the GnRH agonist group and one in the immediate surgery group had tumor recurrence.
CONCLUSION(S): Treatment with a GnRH agonist before abdominal myomectomy has no significant effect on intraoperative blood loss. Thus, systematic use of medical therapy before abdominal myomectomy does not seem to be justified.
The aim of this study was to evaluate uterine adhesions after myomectomy and peritoneal fibrinolytic capacity in women treated with gonadotrophin-releasing hormone agonist (GnRHa) before surgery. A prospective observational study comprised 15 infertile women who underwent myomectomy. Before surgery, 10 were treated with buserelin acetate (900 microg/day) for 10-12 weeks followed by additional postoperative treatment with GnRHa for 4 weeks (GnRHa group) and five received no treatment (control group). Peritoneal fluid specimens were taken at the beginning of myomectomy and the adhesions were estimated by second-look surgery (caesarean section or laparoscopy). Levels of plasminogen activator (PA) and PA inhibitor (PAI) were determined by enzyme-immunosorbent assays. Pre- and postoperative GnRHa therapy significantly reduced adhesion formation compared with control groups (adhesion scores; 0.2 +/- 0.4 vs. 2 +/- 1, P<0.0001). GnRHa group showed a significant decrease in PAI level (P<0.0001) but no significant change in PA level, suggesting increased fibrinolytic capacity in peritoneal fluid from GnRHa-treated patients. These data suggest that GnRHa therapy is successful in preventing adhesion formation after myomectomy. GnRHa-induced shift to more fibrinolytic activity, mainly because of a decreased level of PAI, may play a critical role in the mechanism of the GnRHa's action on postoperative adhesion development.
To compare surgical experience of laparoscopic/robotic myomectomy in premenopausal patients pretreated with ulipristal acetate (UPA) with women not hormonally pretreated.
DESIGN:
A retrospective, multicenter cohort study of laparoscopic/robotic myomectomy procedure videos (Canadian Task Force Classification III).
SETTING:
Multiple university-affiliated tertiary care hospitals.
PATIENTS:
Fifty-five premenopausal women who underwent laparoscopic/robotic myomectomy for intramural myomas and were either pretreated with 3 months of UPA or had no hormonal pretreatment.
INTERVENTIONS:
Laparoscopic/robotic myomectomy surgical videos were independently reviewed by 2 gynecologists blinded to whether or not patients received pretreatment with UPA. Each procedure was scored using a novel 22-point surgical global rating tool containing 6 subscales: depth of myometrial incision, ease of myoma-myometrium cleavage plane identification, ease of myoma detachment, blood loss during myoma detachment, myometrial blood loss after myoma detachment, and myoma consistency.
MEASUREMENTS AND MAIN RESULTS:
Participating surgeons submitted 55 videos of laparoscopic/robotic myomectomy procedures recorded over a 3-year period (2012-2015). Fifty met the inclusion criteria (25 UPA-treated patients and 25 patients without hormonal pretreatment). Patients treated with UPA were more likely to be older than patients with no medical pretreatment (mean age = 33.5 vs 38.3 years, p = .002). There were no statistically significant differences regarding other baseline characteristics such as the largest diameter of myoma removed, the number of myomas removed, or the estimated blood loss. There was no difference in the physician assessors' mean global rating score for patients with UPA pretreatment versus no pretreatment (12.4 vs 13.4, p = .23). Within the 6 subscales, no differences were observed between the 2 groups. Each video was graded independently by 2 assessors, and there was high inter-rater agreement for the total score and each subscale.
CONCLUSION:
There was no difference in surgical experience for myomectomies of patients pretreated with UPA versus those without medical pretreatment.
