Pregnancy following laparoscopic myomectomy: preliminary results.

The objective of this study was to assess the outcome of pregnancy in a series of women who underwent laparoscopic myomectomy. A total of 115 women underwent laparoscopic myomectomy for pressure and pain (76.5%), abnormal bleeding (52.2%) and/or infertility (29.6%). Follow up data were obtained either by reviewing the patient's chart or returned questionnaire. Of the 115 women, there were 42 pregnancies in 31 patients. Two women were lost to follow-up. Of the remaining 40 pregnancies, six ended with vaginal delivery at term. Caesareans were performed in 22 cases, including 21 at term and one at 26 weeks gestation. Two pregnancies were associated with a normal delivery, but the mode of delivery is unknown. Eight resulted in first trimester pregnancy loss, one was an ectopic pregnancy, and one patient underwent elective termination. Spontaneous uterine rupture was not noted during pregnancy or at term in any of the cases. Average length of follow-up from the date of surgery was 43 months, with a range of 9-99 months. Our series did not confirm the hypothesis that laparoscopic myomectomy is associated with an increased risk for uterine dehiscence during pregnancy. However, a larger series is needed to make a conclusive judgement.     

Pregnancy outcomes following laparoscopic myomectomy and single-layer myometrial closure

BACKGROUND: To evaluate pregnancy outcomes following laparoscopic myomectomy and single-layer myometrial closure. METHODS: This study conducted at a private advanced endoscopy and assisted reproductive technology centre retrospectively evaluated outcomes of 115 women who had pregnancies subsequent to laparoscopic myomectomy. RESULTS: Of the 217 women followed up, 115 had pregnancies subsequent to a laparoscopic myomectomy. Of 141 pregnancies, there were 87 Caesarean sections, 19 vaginal deliveries, 29 abortions and 6 ectopic pregnancies. There were no incidents of uterine scar rupture in any of these pregnancies. CONCLUSIONS: Uterine rupture during pregnancies following laparoscopic myomectomy is rare following single-layer myometrial closure.     

Pregnancy outcome and deliveries following laparoscopic myomectomy

Uterine rupture after myomectomy by laparotomy is not a common occurrence. Some case reports of uterine rupture after laparoscopic myomectomy (LM) raise the question of the quality of the uterine scar produced when this technique is performed. In order to assess the outcome of pregnancies and deliveries after LM and to assess the risk of uterine rupture, we performed an observational study. Questionnaires were mailed to all women who had had LM for at least one intramural or subserosal myoma of more than 20 mm diameter and who were aged <45 years. Ninety-eight patients became pregnant at least once after LM, giving a total of 145 pregnancies. Among the 100 patients who had delivery, there were three cases of spontaneous uterine rupture. Because only one of these uterine ruptures occurred on the LM scar, the risk of uterine rupture was 1.0% (95% CI 0.0-5. 5%). Seventy-two patients (72.0%) had trials of labour. Of these, 58 (80.6%) were delivered vaginally. There was no uterine rupture during the trials of labour. Spontaneous uterine rupture seems to be rare after LM. This risk should not deter the use of LM if needed. When performing LM, particular care must be given to the uterine closure.     

妊娠期子宫肌瘤5例的剔除治疗体会

目的探讨子宫肌瘤剔除术在妊娠期的应用价值及安全性。方法对2003年10月～1005年4月我院实施的妊娠期子宫肌瘤剔除术5例进行回顾分析。结果妊娠10～21周手术3例，其中1例宫颈巨大肌瘤同时行人工流产，2例术后均足月分娩，孕足月剖宫产同时剔除肌瘤2例，均无不良反应。结论妊娠期子宫肌瘤剔除术是解决妊娠合并较大子宫肌瘤尤其是红色变性时的有效方法，只要时机选择恰当，手术方法和技巧正确，可避免严重并发症发生。     

Uterine dehiscence in a nullipara,diagnosed by MRI,following use of unipolar electrocautery during laparoscopic myomectomy: Case report

Uterine scar dehiscence following laparoscopic myomectomy (LM) is a rare event. We present a case of an magnetic resonance imaging-diagnosed uterine dehiscence in a primigravid patient at 29 weeks gestation, following a laparoscopic subserosal myomectomy, performed using unipolar electrocoagulation. Pregnant patients with a history of prior surgery where unipolar electrocoagulation is used on the uterus should be closely followed throughout pregnancy and uterine dehiscence or rupture should be part of the differential diagnosis when they present with abdominal pain.     

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.     

Successful myomectomy during pregnancy

BACKGROUND: Although leiomyomas usually remain asymptomatic during pregnancy, they may complicate its course. In this study, pregnancy outcome observed when myomectomy was performed during pregnancy in carefully selected patients is presented. METHODS: A prospective cohort study of 13 women who underwent myomectomy during pregnancy between January 1994 and December 2001. Surgical management of leiomyoma was required on the basis of characteristics of the myoma and symptoms. RESULTS: Among a total of 15,579 women registered at the authors' prenatal clinic, 622 consecutive pregnant women had sonographically identified myoma; hence, the incidence was 3.9% (95% CI 3.6-4.3%). The vast majority of these women was asymptomatic during pregnancy or managed conservatively (97.4%; 95% CI 96-98%). Among 622 pregnant patients with leiomyoma, 13 presented with complications during pregnancy that required surgical intervention (2.1%; 95% CI 0.9-3.2%), due to increase in lesion size causing discomfort and/or severe abdominal pain not responding to conservative management with analgesic and non-steroidal anti-inflammatory drug medication. In 92% of these cases, successful myomectomy was performed and the pregnancy progressed to term without further complications. CONCLUSIONS: These data provide reassurance for pregnant women with uterine myoma. Surgical management of uterine leiomyoma during pregnancy may be successfully performed in carefully selected patients.     

Fertility after laparoscopic myomectomy of large intramural myomas: preliminary results

Fertility outcome following laparoscopic myomectomy was evaluated.A prospective clinical study was carried out between October1990 and October 1993 in 21 infertile patients who underwentlaparoscopic myomectomy for a myoma measuring 3>;5 cm indiameter. The overall rate of intrauterine pregnancy was 333%(seven patients). Out of 12 patients with infertility factorsassociated with uterine myomas, three (25.0%) became pregnant,whereas four (44.4%) out of nine patients with no other associatedinfertility factor became pregnant. No uterine rupture was observed.Out of the seven pregnancies, four were spontaneous and beganwithin 1 year of the operation. The other three were achievedafter in-vitro fertilization in patients with associated infertilityfactors. In the four patients who gave birth by Caesarean section,no adhesions were found on the myomectomy scar. From these preliminaryresults, laparoscopic surgery for myomas seems to offer comparableresults with those obtained by laparotomy.     

Operative morbidity and reproductive outcome in secondary myomectomy: a prospective cohort study

BACKGROUND: This prospective study was designed to evaluate the operative morbidity and reproductive outcome in patients who had secondary myomectomy for recurrent symptomatic uterine fibroids. METHODS: A total of 58 women were subjected to a secondary myomectomy via the abdominal route. The operative morbidity such as blood loss, presence of adhesions and febrile index were estimated and the pregnancy outcome over a 2-4 year period of follow-up. RESULTS: The mean age and standard deviation (+/- SD) of the women was 35 (+/- 2.4) years. Nineteen patients (33%) had a postoperative temperature vertical line 100 degrees F and the estimated blood loss ranged from 159-2500 ml (median 700 ml). Seven patients (12%) required blood transfusion and one had a hysterectomy due to haemorrhage. Nine women (15.5%) became pregnant but only five (56%) had live births. Those with successful pregnancies tended to be younger with a mean age of 31.8 (+/- 2.6) years versus 35 (+/- 1.8) years, (P = 0.08, non-significant) and had fewer uterine leiomyomata; median with range values, 2 (1-6) versus 7 (6-15). The variables which best predicted the postoperative likelihood of pregnancy were; age, presence of tubal adhesions and the number of uterine fibroids. CONCLUSION: This prospective study showed a high operative morbidity and a poor fertility outcome after a repeat myomectomy. The factors affecting successful outcome in a logistic regression model were age, tubal adhesions and number of uterine fibroids.     

Fertility-sparing surgery, with subsequent pregnancy, in persistent gestational trophoblastic neoplasia: case report

Gestational trophoblastic neoplasia (GTN) is primarily a disease of women of reproductive age. In most instances, it is cured by surgical evacuation of the uterus, with persistent disease being very sensitive to chemotherapy. Hysterectomy, recommended for persistent chemotherapy-resistant uterine disease, may be unacceptable to the woman who wishes to maintain her fertility. Uterine resection of localized disease, with uterine reconstruction, may be a viable alternative. A case is presented of a woman with persistent uterine GTN, treated with localized uterine resection and reconstruction, followed by two successful pregnancies and deliveries. The literature is reviewed and potential pregnancy complications of this management, particularly uterine rupture, are discussed.     

Laparoscopic myomectomy in premenopausal women with and without preoperative treatment using gonadotrophin-releasing hormone analogues.

The present study was undertaken in order to evaluate the usefulness or otherwise of preoperative gonadotrophin-releasing hormone (GnRH) analogue treatment prior to laparoscopic myomectomy. From June 1993 through December 1996, 60 premenopausal women aged between 25 and 42 years and with a sonographic diagnosis of intramural or subserous myomas were selected for laparoscopic myomectomy at the Department of Obstetrics and Gynaecology of the Catholic University of The Sacred Heart, Rome. According to a computer-generated sequence, 30 patients were submitted to three cycles of GnRH analogue treatment prior to surgery, whereas no preoperative treatment was prescribed to the other 30 patients. Laparoscopic myomectomy was successfully performed in all patients for a total of 174 myomas excised laparoscopically. The patients' mean age, the number of myomas per patient, the mean diameter of the myomas, parity and estimated blood loss were similar in both groups. The operative time was significantly longer in the group of patients submitted to GnRH analogue treatment than that of the group of patients not submitted to any preoperative medical therapy (157.5 +/- 74.71 versus 112.33 +/- 54.71 min; P = 0.01). No intra-operative complications occurred. In no case was blood transfusion necessary. Two patients developed post-operative fever (temperature > 38 degrees C.). The mean length of hospital stay was 2.39 days and was similar in both groups. Thirteen spontaneous pregnancies occurred among 24 infertile patients (54.1%). The pregnancy rate for these patients was similar in both groups. The viable term delivery rate was 45.8%. The authors conclude that laparoscopic myomectomy is a feasible and safe procedure. The post-operative pregnancy rate for infertile patients is similar to that following laparotomic myomectomy. The present study suggests that preoperative GnRH analogue treatment does not offer any significant advantages for laparoscopic myomectomy.     

Recurrence of fibroids after myomectomy: a transvaginal ultrasonographic study

Frequency of recurrence of fibroids after myomectomy has beenevaluated in 145 women (median age 38 years, range 21–52)who underwent myomectomy. After surgery all women returned forfollow-up visit every 12 months after surgery. Transvaginalultrasound examination was performed routinely in every patientat 24 and 60 months and at 12, 36 and 48 months if there wereany abnormal pelvic findings or suspicious symptomatology. Atotal of 39 (27%) women gave birth after myomectomy. For thewhole series, the cumulative probability of recurrence (CPR)increased constantly during the study period reaching 51% in5 years. The 5-year CPR decreased with parity after myomectomy,being 55% for women with no childbirth after surgery and 42%(based on 13 recurrences, P < 0.01) for those who gave birth.     

Long-term results of laparoscopic myomectomy: recurrence rate in comparison with abdominal myomectomy

Laparoscopic myomectomy is still a debated procedure and there are conflicting opinions regarding the recurrence rate. Laparoscopic myomectomy may present a higher risk of recurrence compared with abdominal myomectomy. The aim of this investigation was to analyse the recurrence rate of myomas after surgery. From January 1991 to June 1998, 165 myomectomies were performed for symptomatic myomas measuring at least 3 cm in diameter and numbering seven or less per patient. During the first 3 years of this survey, 81 patients were randomized for abdominal or laparoscopic myomectomy. Transvaginal ultrasound examination was performed within 15-30 days of surgery and every 6 months for a post-operative period of 40 months. The two groups had similar pre-operative clinical features and the number and volume of myomas did not differ between the two groups. At the end of the study the group of abdominal myomectomies showed nine recurrences (23%) against 11 (27%) of the laparoscopic group. In order to evaluate the recurrence rate in relation to several risk factors, laparoscopic myomectomies were performed from 1991 in 84 patients who agreed to follow-up (and were not in the randomized group). Of these, 78 patients were evaluated with transvaginal ultrasound for a mean interval of 26 months and 17 (21.78%) recurrences were found. Most recurrences (75%) were seen at ultrasound between 10 and 30 months after surgery. The patient's age, pre- and post-operative gravidity and parity had no influence on recurrence. Neither the number of myomas removed nor the depth of penetration or size were positively associated with the risk of recurrence. However, an associated risk factor was pre-operative gonadotrophin-releasing hormone agonist treatment (P < 0.02). None of the women with recurrence required additional surgery. We conclude that laparoscopic myomectomy is a reliable procedure. The recurrence rate is similar to that seen after abdominal myomectomy.     

Laparoscopic myomectomy: predicting the risk of conversion to an open procedure

BACKGROUND: Laparoscopic myomectomy (LM) has some advantages over laparotomy; however, it is reputed to be technically difficult, and the risk of conversion to laparotomy might be an obstacle in using this procedure. The aim of this study was to identify the pre-operative factors affecting the risk of conversion to an open procedure (either laparoscopic assisted myomectomy or laparotomy), and to develop a simple prediction model based on available pre-operative data with the use of multiple logistic regression. METHODS: A total of 426 women presenting with a subserous or intramural myoma measuring 20 mm or more underwent LM between March 1989 and October 1999. Of these patients, 378 had successful LM. Forty eight patients [11.3%, 95% confidence interval (CI) 8.3--14.3] had a conversion to an open procedure. A total of 265 women had adequate pre-operative ultrasonography (US) and were used for the analysis. RESULTS: The best prediction model included four pre-operative factors that were found to be independently related to the risk of conversion: size > or = 50 mm at US (adjusted OR = 10.3; 95% CI = 2.8--37.9), intramural type (adjusted OR = 4.3; 95% CI = 1.3--14.5), anterior location (adjusted OR = 3.4; 95% CI = 1.3-9.0) and pre-operative use of gonadotrophin-releasing hormone (GnRH) agonists (adjusted OR = 5.4; 95% CI = 2.0--14.2). The regression coefficients were then scaled and rounded to integers to provide an estimate of the risk for conversion. For a given patient with selected characteristics the predicted risk varied from 0--73%. CONCLUSIONS: This prediction model provides a useful tool that enables multiple criteria to be taken into account simultaneously to help select cases for LM. GnRH agonists should been used only in selected cases. US evaluation is essential before performing LM.     

Spontaneous bilateral cornual uterine dehiscence early in the second trimester after bilateral laparoscopic salpingectomy and in-vitro fertilization: case report.

A bilateral cornual uterine dehiscence is reported, which occurred 14 weeks after in-vitro fertilization (IVF) in a patient having a medical history of previous bilateral salpingectomy via laparoscopy. Uterine rupture is a rare obstetric complication usually occurring during the third trimester of pregnancy within a uterus which has previously undergone an operation. Ectopic pregnancy is a well known complication of IVF. Post-salpingectomy cornual localization with rupture has also been published. Possible causes are discussed and the attention of the counselling physician is directed to the necessary awareness of such a complication in this high risk population. The reported case is an extreme rarity: a similar case has not been previously published in the literature.     

Uterine rupture in first or second trimester of pregnancy after in-vitro fertilization and embryo transfer

We report five cases of early rupture of cornual pregnancy withhistory of previous salpingectomy and cornual resection followingin-vitro fertilization (IVF) and embryo transfer. We discussthe predisposing factors, diagnostic and therapeutic modalitiesin these patients. A high index of suspicion is required foran early diagnosis. It is imperative that the physicians whocare for the patients be fully aware of the possibility of sucha complication in a high risk population; therefore, appropriatecounselling and close follow-up might help to avoid such obstetricalcatastrophes, by termination of pregnancy, either surgicallyor medically.     

Myomectomy during pregnancy and Caesarean section

Myomectomy was performed on a 31 year old primigravida duringthe 15th week of pregnancy due to a large myoma which was 23cm in diameter. At the 39th week of pregnancy, during the Caesareansection, eight fibroids obstructing the lower part of the uteruswere removed. There were no maternal or fetal complications.     

Prognostic factors of reproductive outcome after myomectomy in infertile patients

The objective of this study was to identify the prognostic factors for conception after myomectomy carried out in cases of infertility. A total of 91 infertile patients presenting at least one subserous or intramural myoma measuring >2 cm underwent myomectomy. The characteristics of the patients, myomata and associated infertility factors were collected in a uniform and systematic way. A postal questionnaire was sent to patients. For each of the various factors studied, the specific cumulative probability of spontaneous intrauterine conception was estimated using the Kaplan-Meier method. Multiple regression analysis was then carried out using Cox's proportional hazards model. The cumulative probability of spontaneous intrauterine conception at 2 years follow-up was 44% (95% confidence interval: 32-56%). The cumulative probability of conception was less after removal of a posterior or intramural myoma, after a sutured hysterotomy, and when accompanied by a male factor, associated tubal or ovulation pathology. The cumulative probability of conception was greater after ablation of myomata responsible for menometrorrhagia. The size, deforming effect on the cavity and age played no role in our sample. Our results indirectly suggest that post myomectomy adhesions could have an adverse effect on fertility. Myomata responsible for menometrorrhagia are also the cause of infertility. In the presence of an associated male, tubal or ovulatory factor, the results were poor and it was not possible to determine if a myomectomy should be performed in these cases in order to enhance fertility.     

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.     

Case report: Successful laparoscopic management of primary abdominal pregnancy

Overall, –1% of ectopic pregnancies are abdominal pregnancies,which can be life-threatening even when surgical interventionwith laparotomy is performed. We present a case in which abdominalpregnancy was successfully managed by operative laparoscopy.A 25 year old Japanese woman presented 6 weeks after her lastmenstruation with elevated basal body temperature, lower abdominalpain, and light vaginal bleeding. The urinary human chorionicgonadotrophin (HCG) concentration was 2137 IU/I, and laparoscopicfindings (i.e. the implantation site was the posterior serosaof the uterus with normal adnexae) established a diagnosis ofprimary abdominal pregnancy. The gestational product was completelyremoved by laparoscopic surgery with no uncontrollable lossof blood. The urinary concentration of HCG declined rapidlyand the patient made an uneventful recovery. Operative laparoscopyis a safe alternative for the management of appropriately selectedpatients with early abdominal pregnancy.