Laparoscopic temporary clipping of uterine artery during laparoscopic myomectomy

Purpose

Our aim is to study the feasibility and effect of bilateral laparoscopic temporary occlusion of uterine arteries by special vascular clamps on blood loss during laparoscopic myomectomy.

Methods

Of 166 women with symptomatic uterine myomas necessitating surgical intervention who wished to retain their uteri, 80 underwent laparoscopic uterine artery clipping and myomectomy (experimental group) and 86 received laparoscopic myomectomy only (control group). Main outcome measures were operating time, number and weight of leiomyomas, blood loss, Doppler examination of the uterine arteries and complications of procedure.

Results

In the experimental group the median hemoglobin drop measured on day 3 postoperatively was 1.2?g/dl. In the control group the mean hemoglobin drop measured on day 3 postoperatively was 1.45?g/dl. The time needed to put the clips in place (the time from the opening of the retroperitoneum and the positioning of the clips) varied between 6 and 40?min. No patient required blood transfusion. There were no conspicuous complications.

Conclusion

The use of the clips has proved to be statistically effective in reducing hemoglobin loss during laparoscopic myomectomy.     

Uterine rupture at 33rd week of gestation after laparoscopic myomectomy with signs of fetal distress. A case report and review of literature

Objective

We describe a case of uterine rupture (UR) during pregnancy after laparoscopic myomectomy (LM) and discuss the risk factors of UR.

Comparison of Long-Term Fertility Outcomes after Myomectomy: Relationship with Number of Myomas Removed

Study Objective

To determine if the number of myomas removed during myomectomy for symptomatic relief affects long-term fertility outcomes in reproductive-aged women.

Comparison of robotic-assisted laparoscopic myomectomy outcomes with laparoscopic myomectomy

Purpose

This study aimed at comparing short-term outcomes of patients who underwent robotic-assisted laparoscopic myomectomy and laparoscopic myomectomy.

Methods

From January 2008 to August 2010, prospective data including 15 consecutive patients who underwent robotic-assisted myomectomy (RALM) with the da Vinci surgical system were recorded. These cases were compared with a retrospective cohort of 23 patients who underwent laparoscopic myomectomy (LM). Patient demographics, fibroid characteristics and peri-operative data (operative time, anesthesia time, set-up time, console time for robotic cohort, Estimated blood loss (EBL), length of hospital stay, conversion to laparotomy and operative complications were collected in both groups.

Results

Mean operative time for the robotic group was 138.73 ± 39.51 min compared with 140.57 ± 38.17 min for the laparoscopy group (p = 0.887). No significant differences were noted between RALM versus LM for hospital stay (1.67 ± 0.58 vs. 1.87 ± 0.67 days, p = 0.369) and EBL (101.33 ± 39.84 vs. 119.78 ± 43.70 ml, p = 0.549). The numbers, size and location of myomas removed for two groups were similar. None of the cases in both groups required conversion to laparotomy. There were no significant intra-operative and post-operative complications in either group.

Conclusion

RALM appears to provide the same surgical outcomes when compared with traditional laparoscopic myomectomy.     

Myomectomy using purse-string suture during cesarean section

Background

Conventionally, myomectomy during cesarean section is reserved only for pedunculated myomas because resection of myomas at the time of cesarean section usually stimulates profuse bleeding.

Cases

Thirty-one patients underwent myomectomy using purse-string suture during cesarean section. Myoma could be excised without profuse bleeding, while an assistant maintains strong tension on the purse-string suture around the myoma. The suture was tightened and tied immediately after complete resection of the myoma and then stitches of another purse-string suture were placed alternately with each previous stitch in the inner side of the first suture. We have used this method for more than 3 years and have not observed failures and serious complications, such as late hemorrhage and uterine rupture during a subsequent pregnancy.

Conclusion

Myomectomy using purse-string suture during cesarean section is a safe, useful, and convenient technique.

     

Fertility,pregnancy outcomes and deliveries following myomectomy: experience of a French Caribbean University Hospital

Background

Myoma is the most common benign tumor in women of childbearing age, with a high frequency in Afro-Caribbean than in other women. Depending on their number, size and location, myomas are suspected to be a cause of infertility. Conservative treatment by myomectomy is possible for symptomatic patients wishing to preserve their fertility.

Purpose

The aim of this study was to evaluate the fertility of patients undergoing myomectomy in the University Hospital of Pointe-à-Pitre, Guadeloupe.

Methods

We conducted a retrospective study including all patients under age 42 who had conservative surgery from January 1st, 2005 to December 31st, 2009. The main judgment criteria were the occurrence of postoperative pregnancy and its outcome.

Results

Of 297 operated patients, 220 were interviewed by phone (74.1 %), 124 (56.3 %) had tried to obtain a pregnancy and 54 patients (43.5 %) had 66 pregnancies (59.1 % being live births and 25.8 % miscarriages). For fertility after surgery, univariate analysis identified the number (more than 6, P = 0.0027) and an intramural location (P = 0.027) of myomas as negative factors and multivariate analysis identified age (over 35 years, RR = 2.45) and the association of other causes of infertility (RR = 2.21) as negative factors for pregnancy.

Conclusion

The modest conception rate (43.5 %) after myomectomy among those women trying to obtain a pregnancy may be linked to the specificities of our population, and in particular its relatively high age and the frequent association of multiple causes of infertility.     

Limits and complications of laparoscopic myomectomy: which are the best predictors? A large cohort single-center experience

Purpose

To determine whether a correlation exists between size, location, type of myomas and perioperative outcomes.

Methods

This is a observational study in women undergone to laparoscopic myomectomy (LM) because of single symptomatic myoma >4 cm in diameter. We collected data about general features, surgical outcomes, intraoperative/postoperative complications and time to return to normal activity.

Results

A total of 444 patients (mean age 36.7 ± 6.4 years) resulted eligible for the study. Myomas sized between 8 and 12 cm were linked to an increased amount of blood loss (significantly higher in intramural than subserosal myoma). The removal of intramural myomas >8 cm and the subserosal ones >12 cm required a significant longer surgical time. Patients returned 17.9 ± 9.5 days after surgery to their personal activities. Six cases (1.35 %) required conversion to laparotomy, and only in two cases blood transfusion was necessary.

Conclusion

Myomas size and type represent the best predictors of surgical difficulties and possible intrapostoperative complications. Intramural myomas >8 cm and subserosal ones >12 cm should be considered as a challenging procedure. LM remains the gold standard approach because of very low perioperative complication rate and faster return to normal activity.     

The Role of Pelvic Ultrasound in Preoperative Evaluation for Laparoscopic Myomectomy

Study Objective

To determine the accuracy of pelvic ultrasonography (US) in preoperative evaluation before laparoscopic myomectomy.

Laparoscopic myomectomy: a 6-year follow-up single-center cohort analysis of fertility and obstetric outcome measures

Purpose

To evaluate fertility, pregnancy and delivery outcomes after laparoscopic myomectomy (LM) during long-term follow-up.

Methods

In this single-center retrospective observational study, data were analyzed from 59 women aged 23–42 years with the desire to have children and who underwent LM for symptomatic uterine leiomyoma between January 2001 and December 2006 and subsequently delivered at our hospital.

Results

During a mean follow-up period of 73.55 months, the post-LM conception rate was 68 %. The proportion of miscarriages (n = 16) among all pregnancies (n = 55) was lower after (24 %) than before (43 %) LM. Thirty-nine (46 %) deliveries were primary cesarean sections (CSs). CS was performed due to patients’ preference, placental complications, and uterine rupture (UR). Labor was successful in 62 % of all vaginal delivery trials. UR and placental complications occurred in 10 and 13 % of all pregnancies, respectively.

Conclusions

LM reduced the abortion rate and increased the CS rate in our cohort. UR risk may have been affected by suturing technique, the size and location of myomas removed.     

Laparoendoscopic single-site myomectomy using conventional laparoscopic instruments and glove port technique: Four years experience in 109 cases

Objective

To report a single surgeon's experience with 109 laparoendoscopic single-site myomectomy (LESS-M) using conventional laparoscopic instruments and a homemade glove port system.

Myomectomy during caesarean: a retrospective evaluation of 16 cases

Aim

To evaluate the results and complications of myomectomy carried out during caesarean section.

Materials and method

A retrospective study of 16 patients who underwent myomectomy concurrently with caesarean section in our clinic between January 2009 and September 2012 was conducted. The pre- and postoperative haemoglobin values, number, size and total volume of excised fibroid nodules, location of fibroids, duration of operation, and duration of hospital stay of all patients were retrospectively investigated.

Results

While the most common leiomyoma was transmural myoma, with ten cases encountered, the most common location was in the corpus anterior, where transmural myomas were seen in five patients. The volume of the excised leiomyomata ranged from 84 to 3.300 cm³. The average preoperative haemoglobin value of our patients was 11.4 g/dl, while the postoperative value was 10.3 g/dl. Of 16 patients included in the study, two required blood transfusions due to excessive bleeding. Uterine defects caused by the myomectomy were closed without problems in all patients, and no patient required a hysterectomy. The average time for the myomectomy and caesarean section procedure was 56.1 min. All patients were discharged without problems an average of 3.25 days after the operation.

Conclusion

Myomectomy carried out during caesarean section is a trusted surgical intervention regardless of the size of leiomyomata.     

Laparoscopic Myomectomy with Temporary Bilateral Uterine Artery Occlusion Compared with Traditional Surgery for Uterine Myomas: Blood Loss and Recurrence

Study Objective

To compare the surgical technique of temporary bilateral uterine artery blockage with titanium clips in laparoscopic myomectomy with traditional surgery for uterine myomas to determine efficacy, ability to control bleeding, and recurrence.

Laparoscopic uterine artery bipolar coagulation plus myomectomy vs traditional laparoscopic myomectomy for “large” uterine fibroids: comparison of clinical efficacy

Purpose

Laparoscopic myomectomy is the uterus-preserving surgical approach of choice in case of symptomatic fibroids. However, it can be a difficult procedure even for an experienced surgeon and can result in excessive blood loss, prolonged operating time and postoperative complications. A combined approach with laparoscopic uterine artery occlusion and simultaneous myomectomy was proposed to reduce these complications. The aim of this study was to evaluate the safety and efficacy of the combined laparoscopic approach in women with symptomatic “large” intramural uterine fibroids, compared to the traditional laparoscopic myomectomy alone.

Methods

Prospective nonrandomized case–controlled study of women who underwent a conservative surgery for symptomatic “large” (≥ 5 cm in the largest diameter) intramural uterine fibroids. The “study group” consisted of women who underwent the combined approach (laparoscopic uterine artery bipolar coagulation and simultaneous myomectomy), while women who underwent the traditional laparoscopic myomectomy constituted the “control group”. A comparison between the two groups was performed, and several intraoperative and postoperative outcomes were evaluated.

Results

No significant difference in the overall duration of surgery between women of the “study group” and “control group” emerged; however, a significantly shorter surgical time for myomectomy was observed in the “study group”. The intraoperative blood loss and the postoperative haemoglobin drop were significantly lower in the “study group”. No difference in the postoperative pain between groups emerged, and the postoperative hospital stay was similar in the two groups.

Conclusions

The laparoscopic uterine artery bipolar coagulation and simultaneous myomectomy is a safe and effective procedure, even in women with symptomatic “large” intramural uterine fibroids, with the benefit of a significant reduction in the intraoperative blood loss when compared to the traditional laparoscopic myomectomy.

     

Pregnancy after uterine artery embolization for the treatment of myomas: a case series

Purpose

Uterine artery embolization (UAE) has become an alternative therapy for the treatment of symptomatic myomas. The questions of fertility and pregnancy outcome after uterine artery embolization are still not answered. The study presents the results of pregnancies after UAE. The main goal was to evaluate the course of these pregnancies and concentrate on possible complications.

Methods

This was a prospective study from June 2009 till October 2011. Patients with symptomatic uterine myomas were included. The evaluation of the symptoms was done by quality of life questionnaire and bleeding charts. UAE was performed by superselective microcatheterization technique. Women still planning pregnancy were included in the study after signing detailed informed consent. Pregnant women after UAE were followed as high-risk pregnancies.

Results

A total of 98 patients underwent uterine artery embolization for symptomatic myomas; 21 expressed their wish to become pregnant, out of which 6 had successful spontaneous conception (23.08 %) and 1 patient was pregnant twice, and altogether there were seven pregnancies. During gestation and delivery, there was no serious complication. There was one missed abortion and one placental retention. Myomas did not show growth pattern during pregnancy.

Conclusions

Data from further prospective, randomized trials comparing fertility and pregnancies after UAE with other treatment modalities are needed. UAE, with the new techniques of superselective microcatheterization, could be, in the future, a possible approach even in women with future maternity plans.     

Pisat’s Visual Vasopressor Injection Needle: A New Device for Increasing Patient Safety in Laparoscopic Myomectomy

Introduction

The use of vasopressin and other vasoconstrictive agents to reduce blood loss during laparoscopic myomectomy significantly reduces blood loss and operative time. However, serious cardiovascular complications following the use of intra-myometrial injection of vasopressin solution have also been reported. Most of these side effects are believed to be due to inadvertent intravascular injection of vasopressin solution.

Aims and Objectives

To describe a new design of an injection needle, Pisat’s Visual Vasopressor Injection Needle (VVIN), that can be used during laparoscopic myomectomy to minimise the incidence of an inadvertent intravascular injection of a vasoconstrictor solution.

Results

A total of 53 patients who underwent laparoscopic myomectomy at various hospitals in Mumbai, India, were studied over a period of two years. Out of these, 23 patients were operated upon using a standard 5-mm laparoscopic injection needle, and 30 patients were operated upon by using a VVIN. Out of the 23 patients in whom a regular needle was used, four patients (17.39%) demonstrated a significant (over 20 percent of pre-injection value) but transient elevation in pulse and blood pressure readings at 1-min post-injection. This gradually returned to baseline at 10 min after the injection. None of the 30 patients in whom VVIN was used after confirming a negative aspiration demonstrated any significant change in post-injection pulse or blood pressure recordings.

Conclusions

Using a VVIN during a laparoscopic myomectomy enables the surgeon to detect an inadvertent vascular puncture very early, even in a small calibre blood vessel, and with much more sensitivity than a regular needle. This increases patient safety during the intra-myometrial injection of a vasoconstrictive agent during myomectomy and reduces the incidence of catastrophic complications.

     

Retrospective Study on Laparoscopic Management of Ectopic Pregnancy

Purpose

To evaluate various laparoscopic methods for management of tubal ectopic pregnancy and study the incidence of ectopic pregnancy including the incidence of cornual ectopic pregnancy and conversion to laparotomy during laparoscopic procedure.

Methods

A retrospective study was conducted in North Point Hospital, Delhi, on all laparoscopies conducted in 4 years, i.e., from January 2008 to December 2011.

Results

Incidence of ectopic pregnancy was 4.62 % (out of all laparoscopic surgeries over 4 years) and that for cornual pregnancy was 4.65 % (out of all ectopic pregnancies); no laparotomy was done for the management of ectopic pregnancy. The site of ectopic pregnancy in the tubal pregnancy varied, with 76.75 % in the ampullary region, 16.27 % isthumic, 2.33 % fimbrial, and 4.65 % in the cornual region. Salpingectomy was done in 53.5 % cases and 46.5 % of patients underwent a conservative approach in the form of salpingostomy.

Conclusion

The laparoscopic management of ectopic pregnancy is a safe and effective option with greatly reduced morbidity.     

A novel modification of conventional laparoscopic myomectomy using manual assistance for multiple uterine myomas

Objectives

To evaluate the efficacy and feasibility of finger-assisted laparoscopic myomectomy for multiple myomas.

Study design

A total of 565 patients with symptomatic myomas underwent finger-assisted laparoscopic myomectomy between January 2006 and March 2011 to remove multiple myomas at our center. Laparoscopic myomectomy technique was modified, and involved the insertion of two fingers into the vagina to elevate the uterus, while one or two fingers of the other hand were inserted into the abdomen through a suprapubic 15-mm trocar port for palpation of small myomas, which did not distort the uterine contour.

Results

The mean (SD; range) patient age was 38.26 years (5.84; 25–48 years). The diameter of the largest myoma in each case was 6.13 cm (1.21; 4–15 cm). The total number of myomas enucleated in the initial enucleation was 2228. There were 597 additional myomas enucleated with finger-assisted guidance. The mean diameter of the additionally enucleated myomas was 1.1 cm (range, 0.2–2.5 cm), which was significantly smaller than those of the initially enucleated myomas (p = 0.002). The mean operative time was 97.1 min (30.2; 35–180 min). The decrease in postoperative hemoglobin concentration was 1.6 g/dL (0.7; 0.4–3.2 g/dL). During the operation, no patients required a blood transfusion. Six patients developed postoperative fever. There was no occurrence of bowel or urinary tract injury. The mean postoperative hospital stay was 3.2 days (0.9; 2–6 d). All procedures were successfully completed without the need for laparotomy.

Conclusions

Finger-assisted laparoscopic myomectomy is a feasible and safe approach in the surgical treatment of multiple myomas.     

A Multicenter Study Evaluating the Effect of Ulipristal Acetate during Myomectomy

Study Objective

To compare surgical experience at myomectomy between patients with myomas pretreated with ulipristal acetate versus no pretreatment.

A pilot study of Foley’s catheter balloon for prevention of intrauterine adhesions following breach of uterine cavity in complex myoma surgery

Purpose

During abdominal myomectomy for removal of multiple fibroids, the uterine cavity may be breached. Repair of the breach is associated with a risk of development of intrauterine adhesions. We conducted a pilot study to evaluate the effectiveness of temporary placement of a Foley’s catheter balloon inflated with 30 ml normal saline into uterine cavity at the end of surgery to prevent this complication.

Methods

Retrospective cohort study. When the uterine cavity was breached during open myomectomy, it was repaired with a No. 2-0 vicryl suture. A Foley catheter balloon was inserted into the uterine cavity at the end of the procedure, and the balloon distended with 30 ml of normal saline. The balloon was removed on the fourth post-operative day. Follow-up hysteroscopy was performed after 6 months.

Results

At the time of follow-up hysteroscopy 6 months after the myomectomy, we found no intrauterine adhesions in 16 consecutive women treated with balloon, compared to 3 out of 10 (30 %) historical controls where the balloon was not used.

Conclusion

A Foley catheter balloon inserted into the uterine cavity following breach and repair of the uterine cavity at open myomectomy appears to prevent the formation of intrauterine adhesions.     

Two novel classification systems for uterine fibroids and subsequent uterine reconstruction after myomectomy

Objective

Laparoscopic approaches are the gold standard surgical treatment for intramural and subserous fibroids, whereas submucosal myomas can be treated via hysteroscopy. Removal of intramural myomas often requires a subsequent reconstruction of the uterine wall that ranges from single- to multiple-layer sutures to complex reconstructions. Several classification systems are currently used to characterize uterine fibroids, all of which focus on the assessment of submucosal fibroids during hysteroscopic myomectomy. There are no classification systems for the comprehensive localization of fibroids or for uterine reconstruction after myomectomy. Therefore, the aim of this study was to validate a new scoring system developed by our group to classify uterine leiomyoma as well as a standardized assessment scoring system for uterine reconstruction after surgical myomectomy.

Methods/Patients

To validate the uterine fibroid and uterine reconstruction classification systems, a retrospective review of 136 patients undergoing surgical myomectomy and uterine reconstruction at a single tertiary institution was performed. The age of the patient, duration of surgery, number, size, and location of excised fibroids, number of uterine incisions, level of uterine reconstruction, desire for future pregnancies, pre- and postoperative hemoglobin concentrations, duration of postoperative hospitalization, and operating surgeon were obtained by medical chart review. For each patient, a specific fibroid score and the level of uterine reconstruction were determined according to the classification systems. Correlations between the uterine fibroid and reconstruction scores, as well as between the classification scores and perioperative parameters, were analyzed.

Results

The newly developed classification system for uterine fibroids incorporates the number, location, and size of myomas, as well as the number of uterine incisions required for myomectomy. The uterine reconstruction scoring system comprises four levels of reconstruction, ranging from no reconstruction to advanced reconstruction. Outcomes from 136 patients showed a correlation between uterine fibroid and uterine reconstructive scores. High fibroid scores were correlated with higher levels of reconstruction. Both scoring systems showed associations with the duration of surgery, intraoperative blood loss, and days of hospitalization.

Conclusions

This study presents the first scoring system for uterine fibroids that incorporates all possible fibroid locations and a standardized assessment of uterine reconstruction. Scoring systems were validated in a large cohort, and a correlation was identified between uterine fibroid and uterine reconstruction scores. In daily clinical practice, this scoring system allows a better planning of surgery, specifically of the estimated duration of surgery, blood loss, and time of hospitalization.