Pre-myomectomy uterine artery embolisation minimises operative blood loss

Women with massive fibroids (extending beyond the level of the umbilicus) are conventionally offered a hysterectomy, rather than myomectomy, which is considered too technically challenging, with risks of excessive haemorrhage. Some women desire fertility, or may simply wish to preserve their uterus. Uterine artery embolisation is a relatively new treatment for fibroids, and complication rates are thought to be high with massive fibroids. We have performed uterine artery embolisation immediately prior to myomectomy, and found a reduction in blood loss. Uterine artery embolisation may be a useful adjunct to surgery in women with massive fibroids or for whom uterine artery embolisation alone is considered inadequate primary treatment, those with previous myomectomy where surgery might be complicated by extensive adhesions, in Jehovah's Witnesses and in other women who refuse blood transfusion.     

Endoscopic management of uterine fibroids

Uterine fibroids are the most common benign tumours of the uterus. Management depends on the symptoms, location and size of the fibroids, and the patient's desire to conceive. Surgical management of uterine fibroids has changed from laparotomy to minimally invasive surgery. Uterine fibroids are usually asymptomatic and do not require treatment. Laparoscopic myomectomy is the best treatment option for symptomatic women with uterine fibroids who wish to maintain their fertility. The authors' criteria for laparoscopic myomectomy are a fibroid of <15 cm in size, and no more than three fibroids with a size of 5 cm. Compared with laparotomy, laparoscopic myomectomy has the advantages of small incisions, short hospital stay, less postoperative pain, rapid recovery and good assessment of other abdominal organs. Due to the concern of decreased ovarian reserve, uterine artery embolization is not advisable for these women. In addition, it is associated with high risks of miscarriages, preterm delivery and postpartum bleeding. Laparoscopic myolysis causes severe adhesion formation. Women with submucous fibroids receive myomectomy by hysteroscopy. For women who have completed their family, laparoscopic hysterectomy could be performed. Most fibroids can be managed endoscopically either by laparoscopy or hysteroscopy. Surgeon expertise, especially laparoscopic suturing, is crucial. Laparoscopic myomectomy is still the best treatment option for symptomatic women with uterine fibroids who wish to maintain their fertility. Hysteroscopic myomectomy is an established surgical procedure for women with excessive uterine bleeding, infertility or repeated miscarriages.     

Myomectomy for uterine myomas through ultramini-laparotomy

Uterine fibroids are the most common benign tumors in the female reproductive tract during the reproductive years. Among the options in the treatment spectrum, myomectomy is always considered one of the best choices in the management of women with symptomatic uterine fibroids who wish to preserve future fertility. Myomectomy through conventional exploratory laparotomy may be the most familiar surgical approach. However, with the advances being made in techniques and instruments, there are many alternative approaches to myomectomy, including mini-laparotomy, ultramini-laparotomy, laparoscopy, laparoscopy-aided, and vaginal and hysteroscopic approaches. The focus of this review article is limited to discussing the use of the ultramini-laparotomy approach to completing myomectomy in the management of the uterine fibroids.     

Fertility and pregnancy outcomes after uterine artery occlusion with or without myomectomy

Uterine artery occlusion (UAO) is one of the minimally invasive procedures used to treat uterine fibroids. It has demonstrated the potential to reduce fibroid growth and related symptoms with few complications and adverse effects. Meanwhile, it may preserve the uterus and ovarian blood supply to allow pregnancy in women with symptomatic fibroids. Similarly, myomectomy is an alternative to hysterectomy in the treatment of symptomatic fibroids, especially for patients who want to maintain fertility. However, only few articles have focused on fertility and pregnancy outcomes after the combined procedures of UAO and myomectomy. We reviewed the effects of UAO with or without myomectomy on fertility and pregnancy outcomes by searching the MEDLINE biomedicine database, using uterine artery occlusion, myomectomy and pregnancy as key words. In conclusion, conception and term pregnancy were possible after these procedures, but evidence on whether risks of abortion and preterm birth have been increasing simultaneously remains inconclusive. Therefore, good counseling on benefits and risks of pregnancy outcomes before performing these procedures is mandatory.     

Uterine Myomas: Treatment Options

Myomas (also called fibroids) are the most common solid pelvic tumors. Treatment options for myomas include medical and surgical management. The goals of medical management are to shrink the myoma and reduce its blood supply. Surgical interventions include therapies for women who wish to preserve fertility or retain their uterus. Newer treatment options include myomectomy achieved through an abdominal, laparoscopic, or hysteroscopic approach. Nurses assess and counsel women regarding treatment options.     

The impact of uterine artery embolization on fertility and pregnancy outcome

PURPOSE OF REVIEW: Uterine artery embolization for management of symptomatic fibroids is an effective and increasingly popular treatment option. There are several studies evaluating the effects of uterine artery embolization on later pregnancies; however, the effects on fertility are still largely uncertain. This paper reviews the current literature on the effects of this technique on fertility and pregnancy outcome. RECENT FINDINGS: Two recent studies have reported pregnancy rates following uterine artery embolization in women seeking pregnancy. A small, third study reported preliminary results in a randomized controlled trial comparing uterine artery embolization with myomectomy in women wishing to preserve fertility. SUMMARY: The body of medical literature supports use of uterine artery embolization as an effective treatment for symptoms of vaginal bleeding and pelvic pressure from uterine fibroids. Patient selection is critical in determining the appropriateness of this treatment option. Myomectomy remains the standard of care for women with symptomatic fibroids seeking fertility preservation.     

Uterine artery embolisation for the treatment of symptomatic uterine fibroids: short-term results of work in progress

Bilateral uterine artery embolisation (UAE) was used to treat 11 women with symptomatic uterine fibroids. Uterine volume and dominant fibroid volume were assessed quantitatively by ultrasonography both before and at two and six months post procedure. Both uterine arteries were occluded effectively in all of the women, and the procedure was well tolerated, with hospital stays limited to 24-48 hours in all cases. An improvement of symptoms occurred in 10 of the 11 women. There were no significant complications. The mean percentage reductions in uterine volume and dominant fibroid volume at six months following the procedure were 45.32% and 56.34%, respectively. Bilateral uterine artery embolisation for the treatment of uterine fibroids is a minimally invasive technique with very good clinical results. This procedure may be considered as an alternative to hysterectomy, or myomectomy in properly selected cases.     

Modern management of uterine fibroids

Uterine fibroids are the most common tumor of the reproductive tract in women of reproductive age. Although they are benign tumors that are often asymptomatic, uterine fibroids may cause debilitating symptoms in many women, such as abnormal uterine bleeding, abdominal pain, increased abdominal girth, urinary frequency, constipation, pregnancy loss, dyspareunia, and in some cases infertility. Several approaches are available for the treatment of uterine fibroids. These include pharmacologic options, such as hormonal therapies and gonadotropin-releasing hormone agonists; surgical approaches, such as hysterectomy, myomectomy, myolysis, laparoscopic uterine artery occlusion, magnetic resonance imaging-guided focused ultrasound surgery, and uterine artery embolization. The choice of approach may be dictated by factors such as the patient's desire to become pregnant in the future, the importance of uterine preservation, symptom severity, and tumor characteristics. New treatment options for uterine fibroids would be minimally invasive, have long-term data demonstrating efficacy and safety, have minimal or no incidence of fibroid recurrence, be easy to perform, preserve fertility, and be cost effective. New treatment approaches are under investigation, with the goals of being effective, safe, and less invasive.     

Uterine artery embolization as a treatment option for uterine myomas

Information is still being collected on the long-term clinical responses and appropriate patient selection for UAE. Prospective RCTs have not been performed to compare the clinical results from UAE with more conventional therapies for symptomatic uterine leiomyomata. At least three attempts at conducting such RCTs have been unsuccessful because of poor patient accrual that related to differing patient expectation and desires, clinical bias, insurance coverage, and the tendency that patients who have exhausted other treatment options may be disposed more favorably to less invasive treatments. Other comparative studies have serious limitations. For example, the retrospective study that compared outcomes after abdominal myomectomy with UAE suggested that patients who received UAE were more likely to require further invasive treatment by 3 years than were recipients of myomectomy. Lack of randomization introduced a selection bias because women in the group that underwent UAEwere older and were more likely to have had previous surgeries. A prospective study of "contemporaneous cohorts," which excluded patients who had sub-mucosal and pedunculated subserosal myomas, sought to compare quality of life measures and adverse events in patients who underwent UAE or hysterectomy. The investigators concluded that both treatments resulted in marked improvement in symptoms and quality of life scores, but complications were higher in the group that underwent hysterectomy over 1 year. In this study,however, a greater proportion of patients who underwent hysterectomy had improved pelvic pain scores. Furthermore, hysterectomy eliminates uterine bleeding and the risk for recurrence of myomas. Despite the lack of controlled studies that compared UAE with conventional surgery, and despite limited extended outcome data, UAE has gained rapid acceptance, primarily because the procedure preserves the uterus, is less invasive, and has less short-term morbidity than do most surgical options.The cost of UAE varies by region, but is comparable to the charges for hysterectomy and is less expensive than abdominal myomectomy. The evaluation before UAE may entail additional fees for diagnostic testing, such as MRI, to assess the uterine size and screen for adenomyosis. Other centers have recommended pretreatment ultrasonography, laparoscopy, hysteroscopy, endometrial biopsy, and biopsy of large fibroids to evaluate sarcoma. Generally,after UAE the recovery time and time lost from work are less; however, the potential need for subsequent surgery may be greater when compared with abdominal myomectomy. Any center that offers UAE should adhere to published clinical guidelines,maintain ongoing assessment of quality improvements measures, and observe strict criteria for obtaining procedural privileges. After McLucas advocated that gynecologists learn the skill to perform UAE for managing symptomatic myomas, the Society of Interventional Radiology responded with a precautionary commentary on the level of technical proficiency that is necessary to maintain optimum results from UAE. The complexity of pelvic arterial anatomy, the skill that is required to master modern coaxial microcatheters, and the hazards of significant patient radiation exposure were cited as reasons why sound training and demonstration of expertise be obtained before clinicians are credentialed to perform UAE.A collaboration between the gynecologist and the interventional radiologist is necessary to optimize the safety and efficacy of UAE. The primary candidates for this procedure include women who have symptomatic uterine fibroids who no longer desire fertility, but wish to avoid surgery or are poor surgical risks. The gynecologist is likely to be the primary initial consultant to patients who present with complaints of symptomatic myomas. Therefore, they must be familiar with the indications, exclusions, outcome expectations, and complications of UAE in their particular center. When hysterectomy is the only option, UAE should be considered. Appropriate diagnostic testing should aid in the exclusion of most, but not all, gynecologic cancers and pregnancy. Other contraindications include severe contrast medium allergy, renal insufficiency, and coagulopathy. MRI may be used to screen women before treatment in an attempt to detect those who have adenomyosis; patients should be aware that UAE is less effective in the presence of solitary or coexistent adenomyosis. Because some women may experience ovarian failure after UAE, additional studies to determine basal follicle-stimulating hormone and estradiol before and after the procedure may provide insight into UAE-induced follicle depletion.UAE is a unique new treatment for uterine myomas, and is no longer considered investigational for symptomatic uterine fibroids. There is international recognition that data are needed from RCTs that compare UAE with surgical alternatives. Current efforts to provide prospective objective assessment of treatment outcomes and complications after UAE will help to optimize patient selection and clinical guidelines. FIBROID should provide critical data for the assessment of safety and outcomes measures for women who receive UAE for symptomatic uterine myomas.     

Effects of bilateral ligation of the uterine and ovarian vessels in dogs

Devascularization of the nonpregnant uterus and oviducts by ligation of both uterine and both ovarian arteries was studied in 48 mongrel dogs. There were no postoperative complications or morbidity. At the time of the second laparotomy, the tissues appeared to be viable. This report suggests that bilateral uterine and ovarian artery ligation is without hazard. Whether this observation can be applied to the pregnant human uterus remains to be proven.     

Laparoscopic Mesh Sacrohysteropexy With Concurrent Laparoscopic Myomectomy for Treatment of Multiple Myomas: Case Report and Literature Review

Conservative surgical management of uterine prolapse with uterine conservation has become an alternative treatment in women who wish to maintain their uterus. Vaginal and abdominal approaches for uterine suspension have been described and reported. Certain concomitant pathologic conditions of the uterus such as uterine myomas have been considered in some patients to be a contraindication to conservative surgery. Herein we report the case of a 55-year-old woman with symptomatic uterine prolapse with multiple myomas who desired uterine preservation and was successfully treated via laparoscopic myomectomy and laparoscopic mesh sacrohysteropexy.     

Laparoscopic uterine artery ligation for treatment of symptomatic adenomyosis

STUDY OBJECTIVE: To investigate the effect of laparoscopic uterine artery ligation on symptomatic adenomyosis. DESIGN: Prospective pilot study (Canadian Task Force classification II-2). SETTING: Tertiary care major teaching hospital. PATIENTS: Twenty women with symptomatic adenomyosis. INTERVENTION: Laparoscopic ligation of bilateral uterine arteries with hemoclips and electrocoagulation of bilateral uterine ovarian vessels. MEASUREMENTS AND MAIN RESULTS: Patients underwent sonographic measurement of uterine size, and recorded amount of menstruation and dysmenorrhea preoperatively and postoperatively. Six months postoperatively, mean uterine size had decreased by an amount ranging from 0.4% to 74.0%. Two of nine women achieved remission of the mass effect of an enlarged uterus. Thirteen of 16 patients achieved bleeding control and 5 returned to eumenorrhea or hypomenorrhea. Twelve of 16 patients achieved control of dysmenorrhea and 6 were analgesic free. However, nine women experienced nonmenstrual pain after surgery, three of whom underwent hysterectomy later. Treatment was rated as satisfactory by 15% of patients, but 45% were dissatisfied. Seventeen women would have refused to undergo the procedure if they could make the decision again. CONCLUSION: Poor satisfaction in this preliminary study suggests that symptomatic adenomyosis may not be effectively treated by laparoscopic uterine artery ligation.     

保留子宫动脉上行支子宫楔形切除术在临床的应用

目的 探讨应用保留子宫动脉上行支子宫楔形切除术治疗子宫良性病变的有效性和安全性。方法 对30例子宫良性病变需子宫切除者进行保留子宫动脉上行支的子宫楔形切除术，分别测定手术前后血清性激素水平、双侧子宫血流参数及子宫大小(研究组)。选同期行单纯肌瘤挖除术25例(对照组1)、全子宫切除术30例(对照组2)，比较三组术中出血量、手术时间、术后病率与对照组有无差异。结果 研究组术后月经量明显减少，子宫小于正常，双侧子宫血流速度降低，手术前后血清性激素水平无明显改变，提示子宫肌瘤引起的子宫血流动力学改变有所恢复。此术式对卵巢功能无影响；术中出血量、手术时间、术后病率与对照组无差异。结论 保留子宫动脉上行支的子宫楔形切除术是治疗子宫肌瘤等良性病变可供选择的好的保守手术方法。     

The “Trick” Knot—A Modified Technique of the Removable “Shoelace” Knot for Temporary Ligation of the Uterine Artery at Its Origin

Study ObjectiveTo demonstrate the “trick” knot, a technique of temporary ligation of the uterine artery at origin, a modification of the previously published “shoelace” knot.DesignA video demonstration.SettingA private hospital.InterventionBilateral uterine arteries at origin are exposed after dissection of the peritoneum over the triangle formed by the round ligament, the infundibulopelvic ligament, and the pelvic sidewall [Video 1]. A 60-cm long free polyglactin absorbable suture with preformed knots at each end is introduced around the skeletonized uterine artery. Using a single throw, the “trick” knot is made by pulling out a loop of thread. The end is cut short, and the same suture is used to similarly ligate the other uterine artery. Each knot thus formed has a free end and a knotted end. Laparoscopic myomectomy is performed. On completion of the procedure, the knot is released by pulling the free end, restoring the blood supply to the uterus.ConclusionBilateral uterine artery ligation, although an effective method to curb bleeding during a laparoscopic myomectomy, when performed permanently, may lead to undesirable outcomes in women who wish to preserve fertility 1, 2, 3. Methods for temporary ligation of the uterine artery at origin, such the removable vascular clips, are thus regarded justifiable [4]. In contrast to the removable “shoelace” knot, which uses a loop to make a throw, the technique of performing the “trick” knot mimics the steps of forming a regular intracorporeal knot [5]. This makes the latter technically easier and hence faster to perform, while still being as economic and reproducible as the former.     

The role of uterine artery embolization in the management of uterine fibroids

PURPOSE OF REVIEW: Uterine artery embolization is increasingly being offered as an alternative to hysterectomy and myomectomy for the treatment of symptomatic uterine fibroids. This review is intended to evaluate the role of this technique in the management of uterine fibroids using information provided from recently published literature. RECENT FINDINGS: A growing body of literature supports the efficacy of uterine artery embolization in relieving fibroid-related menorrhagia, pelvic pain and pressure symptoms and in substantially reducing the fibroid size in most patients. Recent publications also show significant improvements in health-related quality of life and high long-term satisfaction rates. The procedure is associated with shorter hospitalization and recovery times and lower morbidity rates compared with conventional surgical treatments. However, serious complications, such as uterine infarction or infection leading to emergency hysterectomy, have been reported in a few cases, and considerable work is currently underway to determine how the safety of the procedure can be enhanced. Although no long-term data on subsequent fertility are yet available, early reports on ovarian function and pregnancy outcomes after uterine artery embolization are encouraging. SUMMARY: Based on current evidence, uterine artery embolization can be considered a valuable alternative to surgical therapy in the management of well-selected women with symptomatic uterine fibroids. Additional research is needed to help define the place of this technique for women who desire future pregnancy.     

Management of abnormal uterine bleeding

Bleeding disorders are one of the most frequent gynecological problems. The causes of bleeding disorders, and their frequency in particular, vary depending on the age of the woman affected. In premenopause and perimenopause, the most frequent causes are hormonal, in up to 90 % of cases, as well as organic changes in the uterus such as myomas, adenomyosis uteri, or endometrial polyps, in up to 70 % of cases. Coagulation defects cause increased bleeding, particularly in girls and young women, with no other recognizable cause. The treatment of bleeding disorders is causally based, although if the woman does not wish to have children, the therapeutic algorithm in many cases leads to similar symptomatic measures. The following therapeutic approaches, listed in order of increasing efficacy, are mainly used in the treatment of increased bleeding: gestagen, estrogen-gestagen combination, levonorgestrel (Mirena) and endometrial ablation or myoma enucleation, with comparable success rates, and finally hysterectomy. Embolization of the uterine artery in myomas or adenomyosis uteri, nonsteroidal anti-inflammatory drugs, and antifibrinolytic agents represent alternatives that may be useful in individual cases. The paper provides an overview of the various causes, useful diagnostic measures, and treatment options in uterine bleeding disorders.     

Review of myomectomy

Uterine fibroids (also called leiomyomas or myomas) are the most common disorder among women of reproductive age, with an incidence of between 20% and 80%; they are often detected incidentally in routine healthy examinations, through bimanual pelvic and/or ultrasound examination, because uterine fibroids are rarely associated with symptoms. Sometimes, uterine fibroids may be complicated by a variety of symptoms, including menstrual disturbance (e.g., menorrhagia, dysmenorrhea, intermenstrual bleeding), pressure symptoms, bloated sensation, increased urinary frequency, bowel disturbance, or pelvic pain; therefore definite treatment is requested. Hysterectomy may be the first choice for women who have completed their child-birth; however, many women may prefer to keep the uterus if the uterine fibroids-related symptoms can be appropriately controlled. Among these conservative therapies, myomectomy may be one of the most popular methods for the woman who would like to preserve her future fertility, as the majority of symptoms can be relieved by myomectomy; this contributes to the value of this review. This review addresses the use of myomectomy in the management of symptomatic uterine fibroids.     

Impact of pelvic radiotherapy on the female genital tract and fertility preservation measures

Radiotherapy to the pelvis can have a major and deleterious impact on the female genital tract. Despite significant advances in the technical delivery of radical pelvic radiotherapy there remains no way to avoid delivering substantial radiation doses to the ovaries and uterus for patients undergoing treatment for gynaecological cancers. Due to improved cure rates from radical chemo-radiotherapy and social trends toward delayed childbirth many women treated for cervical cancer with radical chemo-radiotherapy will wish to attempt to preserve their fertility. Whilst there are now established and emerging techniques for preserving ovarian function and ovarian tissue, there remains the difficulty of the irradiated uterus which, even if pregnancy can be achieved, results in an increased risk for pregnancy-related complications. Future developments may offer women in this difficult situation more and improved options for fertility preservation.     

Uterine fibroids and their treatment

Uterine fibroids are the most common benign disease of women. They occur in women under 30 years of 20-30% for women over 30 years in 50%. The most frequent indication for hysterectomy, uterine fibroids are just. Symptoms of uterine fibroids are various forms of pelvic pain and trouble from the oppression of the surrounding organs, irregular uterine bleeding and fertility disorders resulting from the inability to conceive or recurrent pregnancy loss. Problems of surgical treatment of fibroids applies not only to symptomatic patients who wish to preserve the uterus, but also women who have uterine fibroids negatively affect their reproduction. Treatment of uterine fibroids include monitoring, administration of medications and surgical techniques that preserve either the uterus or not. In recent years the conservatives have extended performance of minimally invasive surgery, which is a common feature of the endoscopic approach, or uterine fibroid devascularization. Gynecologist surgeon must be familiar with the history of the patient and based on history and examination to consider which procedure is best for the patient.     

Prospective clinical and sonographic assessment of uterine artery embolization as the treatment of symptomatic uterine leiomyomata

OBJECTIVE: To evaluate the effectiveness of the uterine artery embolization as the treatment of symptomatic uterine leiomyomata. PATIENTS AND METHODS: Eighty-five women with symptoms caused by uterine leiomyomata underwent uterine artery embolization as an alternative to surgery from january 1997 to june 2000. The effectiveness of this method was evaluated by clinical and sonographic examination. RESULTS: The recession average was of 18.9 months. There were ten failures. We had immediate failures (n = 5) with a case of technical failure, one endometrium cancer, one adenomyosis, one larger subserosal leiomyomata and one parametrial leiomyomata. We had recurrences (n = 5) with the occurrence of new leiomyomatas (1 intramural and 3 submucosal) and an evolution of previous leiomyomata. The average volume reduction was 51% for the uterus and 65% for the main fibroid at one year follow-up. Minor complications occurred in 5%. Permanent amenorrhoea was observed for 3.75% of the women. Using cox model, no predictive factors of embolisation effectiveness were found. DISCUSSION AND CONCLUSION: In the treatment of symptomatic uterine leiomyoma, uterine artery embolization is an effective alternative to surgery. After one year and half, we had 12.5% of failures.