Gonadotropin-releasing hormone agonist treatment before abdominal myomectomy: a controlled trial

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.     

Successful pregnancy in a woman with symptomatic fibroids who underwent laparoscopic bipolar coagulation of uterine vessels

OBJECTIVE: To report a case of successful pregnancy after laparoscopic bipolar coagulation of uterine vessels (LBCUV). DESIGN: Case report. SETTING: University-affiliated tertiary referral center. PATIENT(S): One woman, treated with LBCUV for symptomatic fibroids, who subsequently had a successful pregnancy. INTERVENTION(S): Laparoscopic bipolar coagulation of uterine arteries and anastomotic sites of uterine arteries with ovarian arteries. MAIN OUTCOME MEASURE(S): Patient evaluation by physical and ultrasound examinations. RESULT(S): Complete resolution of menorrhagia and dysmenorrhea was found after LBCUV. Reduction in fibroid size was seen by ultrasound. Two months later, the patient conceived a singleton pregnancy without the use of assisted reproductive technologies. The woman delivered by cesarean section. Neither myoma recurrence nor abnormality in uterine function was observed. CONCLUSION(S): Although fecundity- and pregnancy-related complications after LBCUV for managing uterine fibroids are still unclear, this first case report of successful pregnancy after LBCUV is promising. LBCUV might be a safe and effective alternative to myomectomy and hysterectomy.     

The excision of uterine fibroids by vaginal myomectomy: a prospective study

OBJECTIVE: To evaluate the clinical effectiveness and safety of the excision of uterine fibroids by vaginal myomectomy. DESIGN: Prospective study. SETTING: A gynecology department of a university teaching hospital. PATIENT(S): Women with menorrhagia, pelvic pain, symptoms of pressure, or subfertility attributable to moderate-sized uterine fibroids who otherwise would have required abdominal or laparoscopic myomectomy. INTERVENTION(S): Vaginal myomectomy. MAIN OUTCOME MEASURE(S): The feasibility of vaginal surgery, operative complications, postoperative recovery, and relief of symptoms. RESULT(S): Myomectomy was completed vaginally in 32 (91.4%) of 35 patients and none required hysterectomy. The overall operating time was 78 minutes, the estimated operative blood loss was 313 mL, and the mean postoperative hospital stay was 4 days. Pelvic hematomas developed in 4 patients, and one colpotomy required resuture. Seventy-four percent of the women reported relief of their symptoms at 3 months' follow-up. Three patients have had full-term pregnancies since the operation. CONCLUSION(S): Myomectomy can be performed by the vaginal route in selected cases with low morbidity and a good short-term success rate. Unlike open myomectomy, it requires no skin incision, and unlike laparoscopic myomectomy, it can be used in patients who have numerous, relatively large, and intramural fibroids.     

MR imaging evaluation of fibroid clearance following open myomectomy for massive/multiple symptomatic fibroids

Purpose

To evaluate the technical success of total fibroid clearance at open myomectomy for massive and/or multiple symptomatic fibroids using MR imaging (MRI) as the imaging modality.

Methods

The study group comprised 27 women [mean age 37.4?±?6.9?years (range 27–53)] who underwent open myomectomy for the treatment of massive/multiple symptomatic fibroids at our institution between January 2009 and April 2010. Myomectomy was performed with the intention of achieving complete fibroid clearance. Pre- and postmyomectomy MRI was performed to assess changes in uterine volume and fibroid burden. Periprocedural data (including blood loss and complications) and relief of clinical symptoms at follow-up were also recorded.

Results

The mean time to MRI and clinical follow-up was 10?months (range 6–15?months). The mean uterine volume premyomectomy was 795?±?580?cc and postmyomectomy was 123?±?70?cc (p?<?0.001). The mean percentage reduction in uterine volume was 80.3?% (range 43.0–98.1?%). Of the 10/27 (37.0?%) women with residual fibroids at follow-up: 7 patients had fibroids measuring up to 1?cc in volume, 3 patients had fibroids measuring up to 6?cc. Postoperative adnexal seromas were observed in 6/27 (22.2?%) patients. The clinical success rates of myomectomy amongst the 22/27 (81?%) responders were: 73?% for menorrhagia, 64?% for pain, and 36–64?% for mass-related symptoms.

Conclusions

Using MRI, we have confirmed that open myomectomy can achieve total or near-total fibroid clearance in the majority of patients with massive and/or multiple fibroids.     

Uterine fibroids--do size and location determine menstrual blood loss?

OBJECTIVE: To investigate any potential effect of fibroid size and distribution on menstrual blood loss (MBL). STUDY DESIGN: Retrospective comparative study of 50 women with symptomatic fibroids who underwent uterine imaging and objective MBL measurement prior to uterine artery embolisation between 1999 and 2002. SETTING: West of Scotland Gynaecology and radiology departments. METHOD: Uterine imaging was by magnetic resonance imaging (MRI) in all but one case and MBL was performed using the alkaline haematin technique. Fibroid characteristics were assessed by an experienced radiologist unaware of the MBL measurements. RESULTS: Thirty-three (66%) women had objective menorrhagia with a MBL in excess of 80 ml per period. The commonest location of fibroids was intramural; these particular fibroids also had the largest diameter and the greatest uterine volume. There was a negative relationship between MBL and the diameter of the largest fibroid (r = -0.419, P < 0.01). All but two women (both of whom had subserosal fibroids alone) demonstrated distortion of the uterine cavity. All women with submucosal fibroids presented with menorrhagia. CONCLUSION: This study found that MBL correlated with neither fibroid size nor location. However, all the women with sub-mucosal fibroids had menorrhagia with a MBL greater than 80 ml.     

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.

     

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.     

Is myomectomy always the best choice for infertile women with symptomatic uterine fibroids?

Uterine artery embolization (UAE) is still regarded by most gynaecologists as contraindicated for women with symptomatic fibroids and otherwise unexplained infertility. For such patients, myomectomy is the usual option. We performed UAE as treatment of menorrhagia in an infertile woman with multiple subserosal and intramural fibroids who had previously failed multiple myomectomy. UAE resulted in durable symptom relief and substantial reduction of the uterine and fibroid size. The patient conceived spontaneously 20 months after UAE and progressed through pregnancy uneventfully. At 38 weeks of gestation, she underwent elective cesarean section and delivered a normal, healthy, 3180-g fetus without complications. The present case demonstrates that in symptomatic women with multiple subserosal and intramural fibroids and otherwise unexplained infertility, UAE may have symptomatic and reproductive outcomes superior to those of myomectomy.     

Laparoscopic bipolar coagulation of uterine vessels: a new method for treating symptomatic fibroids

OBJECTIVE: To evaluate the effects of laparoscopic bipolar coagulation of uterine vessels in treating symptomatic fibroids. DESIGN: Prospective clinical study. SETTING: University-affiliated tertiary referral center. PATIENT(S): Eighty-seven women with symptomatic fibroids warranting surgical treatment and wanting to retain their uteri. INTERVENTION(S): Laparoscopic bipolar coagulation of uterine arteries and anastomotic sites of uterine arteries with ovarian arteries. MAIN OUTCOME MEASURE(S): Percentage reduction in the dominant fibroid size and clinical response evaluation. RESULT(S): Eighty-five (97.7%) of 87 patients underwent technically successful laparoscopic coagulation of uterine vessels without intraoperative complications. The mean follow-up time was 10.2 months. Symptomatic improvement was reported in 76 (89.4%) of 85 patients, including 18 (21.2%) with complete resolution of symptoms. Significant reductions in the dominant fibroid size (average, 76%) and the uterine volume (average, 46%) were sonographically demonstrated. Two patients conceived 4 and 9 months, respectively, after treatment. Three (3.5%) premenopausal women became postmenopausal postoperatively. CONCLUSION(S): Laparoscopic bipolar coagulation of uterine vessels appears to be a promising new method for treating fibroid-related menorrhagia and pelvic pain.     

Management of uterine fibroids in Enugu, Nigeria.

A 5-year review of management of uterine fibroids at the university of Nigeria Teaching Hospital Enugu revealed that symptomatic uterine fibroids constituted 9.8% of all gynaecological admissions. The peak incidence n = 51 (26.8%) was in the age range of 31 - 35 years and the majority of the women n = 77 (40.5%) were nulliparous. The main clinical features were lower abdominal discomfort, menorrhagia and associated infertility. There was no medical management. The surgical management consisted of myomectomy by laparotomy (60%); total abdominal hysterectomy (24.7%); total abdominal hysterectomy and bilateral salpingo-oophorectomy (12.1%), and polypectomy (3.2%). There was no endoscopic surgery available. Postoperative morbidity was high but there was no mortality. Uterine fibroids mostly managed by myomectomy at laparotomy remains a major public health problem in Enugu Nigeria.     

Features of uterine fibroids treated by abdominal myomectomy at Nnewi, Nigeria.

Seventy-two women with symptomatic uterine fibroids were treated by abdominal myomectomy from January 1994 to December 1996. Important features were a mean age of 32.3 years (range 25-49 years) and parity of 0 to 6; 83% ( n = 60) were nulliparous and 68% ( n = 49) were unmarried. The average estimated blood loss was 480 ml with 1.6 g/dl mean haemoglobin drop and 15.3% required blood transfusion. Complications were mild and infrequent; 7% ( n = 5) had mild wound infection and 16.7% ( n 12) had a febrile complication. The average hospital stay was 8.1 days. There was no mortality. In this study, symptomatic uterine fibroids requiring abdominal myomectomy predominantly affected young women who were mainly unmarried and nulliparous. Although the the operation was safe and well tolerated, preoperative GnRH(a) is recommended to reduce fibroid size and need for blood transfusion.     

Value of hysteroscopy prior to uterine artery embolisation for fibroids: a hospital based retrospective study

This study was undertaken to evaluate the value of routine hysteroscopy prior to uterine artery embolisation (UAE) for symptomatic uterine fibroids. The study design used is hospital-based retrospective study, and the setting is in a large teaching hospital. We analysed the hospital record of 115 women who were scheduled to undergo UAE at our institution between January 2008 and April 2011. All women had outpatient hysteroscopic assessment of uterine cavity prior the decision to carry out UAE. The mean uterine size on palpation was 15.4 (standard deviation (SD) 3.5) weeks gestation equivalent. Hysteroscopy was successfully completed in 112 (97.4 %). In the women who were hysteroscoped, 50 (44.6 %) had no submucous fibroids; 50 (44.6 %) had type II fibroids, and 12 (10.7 %) were found to have type I or 0 fibroids. All 12 women with type 0 or I submucous fibroids were offered hysteroscopic (n?=?11) or vaginal (n?=?1) myomectomy prior to UAE, but only four agreed. Of these four cases, two cancelled their planned UAE because of symptomatic improvement. The remaining two women, as well as the eight, who declined surgery, underwent UAE. There were no cases of infection, spontaneous expulsion of a fibroid or the need for surgical intervention in this group. This pilot study shows that hysteroscopy prior to UAE changes management in only a small proportion of cases. Selective hysteroscopy, following MRI scanning, may be a more logical protocol to identify women with intracavitary fibroids, who may benefit from hysteroscopic or vaginal myomectomy.     

Transient ovarian failure: a complication of uterine artery embolization

OBJECTIVE: To report a case of transient ovarian failure shortly after arterial embolization for treatment of uterine fibroids, followed by recovery of ovarian function. DESIGN: Case report. SETTING: A university-based hospital. PATIENT: A 49-year-old woman with menorrhagia and anemia secondary to uterine fibroids and refractory to medical management. The follicle-stimulating hormone (FSH) level on cycle day 3 before the procedure was 8.2 mIU/mL. INTERVENTION(S): Bilateral uterine artery embolization for treatment of menorrhagia. MAIN OUTCOME MEASURE(S): Serum FSH level. RESULT(S): The patient developed amenorrhea and hot flashes 3 months after uterine artery embolization. Her serum FSH level at that time was 140.1 mIU/mL. Four months later, uterine bleeding resumed; her serum FSH level was 2.1 mIU/mL. CONCLUSION(S): Uterine artery embolization may hasten ovarian failure. This procedure should be reserved for women who have completed their child-bearing or are poor candidates for myomectomy. Patients should be counseled appropriately about the risk of possible ovarian failure.     

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.

Treatment with GnRH agonists before myomectomy and the risk of short-term myoma recurrence

Twenty-four women with symptomatic multiple uterine myomas were allocated randomly to treatment with buserelin, 1200 micrograms/day intranasally, for 3 months followed by myomectomy (n = 8) or to immediate myomectomy (n = 16). Pre-operative treatment with buserelin reduced the mean uterine volume from 432 (SD 165) to 242 (SD 82) ml (P less than 0.01) but intra-operative blood loss and postoperative morbidity were not significantly less in this group. Six months after operation, pelvic examination was normal in all the patients. However, ultrasonography with transvaginal probe demonstrated the presence of myomas of less than 1.5 cm in five women (63%) treated pre-operatively with the analogue and in two women (13%) who underwent immediate surgery (P less than 0.05). Induction of a period of hypo-oestrogenism before myomectomy seems to favour short-term recurrence of uterine myomas, limiting the efficacy of surgery.     

Effectiveness of short-term administration of tibolone plus gonadotropin-releasing hormone analogue on the surgical outcome of laparoscopic myomectomy

OBJECTIVE: To evaluate whether administration of tibolone changes the effectiveness of GnRH analogue administered before laparoscopic myomectomy. DESIGN: Prospective, randomized, open, placebo-controlled clinical trial. SETTING: Department of Gynecology and Obstetrics, University of Naples Federico II, Naples, Italy. PATIENT(S): 66 women with symptomatic uterine leiomyomas. INTERVENTION(S): Treatment for 2 months with leuprolide acetate and iron tablets, plus tibolone (group A) or placebo tablets (group B); or with leuprolide acetate and iron tablets (group C). MAIN OUTCOME MEASURE(S): Laparoscopic myomectomy at the end of treatment. Operative time and blood loss during surgery were recorded. Uterine volume, volume and number of uterine leiomyomas, volume and echogenicity of the largest uterine leiomyomas, hematologic data, and myoma-related symptoms were evaluated at baseline and 1 week before and after surgery. RESULT(S): Uterine and leiomyomata volume and myoma-related symptoms were significantly reduced and hematologic variables improved significantly in groups A and B, compared with baseline values and with group C. Operative time and blood loss were significantly less in groups A and B than in group C. After surgery, hematologic variables were significantly worse in group C compared with groups A and B. During the study no significant difference was detected between groups A and B. CONCLUSIONS: Administration of tibolone administration in patients treated with GnRH analogue before laparoscopic myomectomy does not change the effectiveness of the analogue administered alone.     

Uterine fibroids. Embolization: state-of-the-art

Uterine artery embolization is a radiological procedure consisting in occluding the perifibroid arterial plexus to induce fibroid ischemia. To date, with more than 50,000 women treated worldwide, embolization seems to be a valuable alternative to hysterectomy and multiple myomectomies particularly in women with severe menorrhagia. Embolization should ideally be performed in case of intramural or submucosal uterine fibroids. It must be preferrably realized in case of multiple fibroids, be they intramural or submucosal (when hysteroscopic resection is not feasible). Complication rates are low if large calibrated microspheres are used to perform embolization and if pedunculated subserosal fibroids are excluded. In case of associated adenomyosis clinical recurrence seems more frequent. The role of embolization as an alternative to a single myomectomy, particularly in young women desiring future pregnancy remains a matter of debate and should be evaluated with clinical randomized trials. Pluridisciplinary management of women is the key to a widespread acceptance of uterine artery embolization in the management of uterine fibroids.     

Goserelin acetate to avoid hysterectomy in pre-menopausal women with fibroids requiring surgery

OBJECTIVE: To obtain information on the efficacy of repeated short cycles of GNRH agonist treatment in order to avoid hysterectomy in near-menopausal women with symptomatic fibroids. STUDY DESIGN: 72 pre-menopausal women (mean age 50 years) with one or more uterine fibroids >10 cm in diameter, symptomatic menorrhagia lasting three months or more and haemoglobin=9 g/dl entered the study. The patients were randomized with ratio of approximately 1:4 to: (a) immediate surgery; or (b) treatment with goserelin acetate. Patients randomized to goserelin acetate received a first cycle of 3.6 mg depot once every 28 days for four months. They were followed-up for three years. If menorrhagia was observed during the follow-up the woman was given goserelin acetate 3.6 mg depot for another three months. In case of further menorrhagia, a third cycle of goserelin acetate 3.6 mg depot for three months was given. After the third cycle of therapy if there was still menorrhagia, the patient underwent hysterectomy plus bilateral oophorectomy. RESULTS: A total of 13 women were assigned to the immediate surgery group and 59 to goserelin. Three years after trial entry a total of 23 women allocated to goserelin acetate treatment had undergone hysterectomy. CONCLUSION: This study suggests that GNRH agonists are efficacious for avoiding hysterectomy in women near menopause with uterine fibroids.     

Treatment with GnRH agonists before myomectomy and the risk of short-term myoma recurrence

Summary. Twenty-four women with symptomatic multiple uterine myomas were allocated randomly to treatment with buserelin, 1200μg/day intranasally, for 3 months followed by myomectomy ( n = 8) or to immediate myomectomy ( n = 16). Pre-operative treatment with buserelin reduced the mean uterine volume from 432 (SD 165) to 242 (SD 82) ml ( P < 0.01) but intra-operative blood loss and postoperative morbidity were not significantly less in this group. Six months after operation, pelvic examination was normal in all the patients. However, ultrasonography with transvaginal probe demonstrated the presence of myomas of < 1.5 cm in five women (63%) treated pre-operatively with the analogue and in two women (13%) who underwent immediate surgery (P < 0.05). Induction of a period of hypo-oestrogenism before myomectomy seems to favour short-term recurrence of uterine myomas, limiting the efficacy of surgery.     

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.