Laparoscopic myomectomy for symptomatic uterine myomas

OBJECTIVE: To evaluate the safety, efficacy, and techniques of laparoscopic myomectomy as treatment for symptomatic uterine myomas. DESIGN: Medline literature review and cross-reference of published data. RESULTS: Results from randomized trials and clinical series have shown that laparoscopic myomectomy provides the advantages of shorter hospitalization, faster recovery, fewer adhesions, and less blood loss than abdominal myomectomy when performed by skilled surgeons. Improvements in surgical instruments and techniques allows for safe removal and multilayer myometrial repair of multiple large intramural myomas. Randomized trials support the use of absorbable adhesion barriers to reduce adhesions, but there is no apparent benefit of presurgical use of GnRH agonists. Pregnancy outcomes have been good, and the risk of uterine rupture is very low when the myometrium is repaired appropriately. CONCLUSION(S): Advances in surgical instruments and techniques are expanding the role of laparoscopic myomectomy in well-selected individuals. Meticulous repair of the myometrium is essential for women considering pregnancy after laparoscopic myomectomy to minimize the risk of uterine rupture. Laparoscopic myomectomy is an appropriate alternative to abdominal myomectomy, hysterectomy, and uterine artery embolization for some women.     

Laparoscopic myomectomy and abdominal myomectomy

Most women develop myomas during their lifetimes; however, 80% are asymptomatic. When symptoms are determined to be caused by myomas, a number of management options exist that include "watchful waiting," medical therapy, surgery, or more recently uterine artery embolization and focused ultrasound. Myomectomy, either abdominal or laparoscopic, is an approach particularly suited for those women who wish future fertility. It seems clear that, in well trained and experienced hands, well-selected patients can have myomectomy performed under laparoscopic direction. Very large myomas are not as suitable for the laparoscopic approach, but are amenable to a uterine conserving procedure via laparotomy that is facilitated by a number of preoperative and intraoperative measures aimed to minimize or replace operative blood loss. These techniques should provide selected women a uterine conserving procedure with reduced morbidity.     

Bilateral ascending uterine artery ligation vs. tourniquet use for hemostasis in cesarean myomectomy. A comparison

OBJECTIVE: To comparatively investigate the effects of using bilateral ascending uterine artery ligation and tourniquet use on intraoperative and postoperative blood loss during myomectomy in cesarean cases. STUDY DESIGN: A total of 70 pregnant women diagnosed with myomas in the prenatal period were included in this randomized, prospective study. They were admitted to our department during the study period. Fifty-two patients who underwent cesarean myomectomy were randomly divided into 2 equal groups. In the first group bilateral ascending uterine artery ligation and myomectomy were performed after lower uterine segment transverse cesarean section. The second group served as the control group; myomectomy was performed with a tourniquet. For statistical analysis, Mann Whitney U, chi 2 and Wilcoxon Rank tests were used. Spearman correlation analysis (rs, n, p) was used for analysis of correlation between the duration of the myomectomy operation and blood loss and number of enucleated myoma nuclei during myomectomy. RESULTS: Total intraoperative blood loss, total operation duration, number of enucleated myoma nuclei (Mann Whitney U test) and febrile morbidity (chi 2 test) were similar in the 2 groups (P > .05). A significant positive correlation was established between the duration of the myomectomy operation and loss of blood and number of enucleated myoma nuclei during myomectomy (rs = .9, n = 52, P = .000). Urgent laparotomy and bilateral internal iliac artery ligation had to be performed in 1 patient in the tourniquet group who had a postoperative hemorrhage. CONCLUSION: Despite the fact that bilateral ascending uterine artery ligation and tourniquet use had similar outcomes with regard to intraoperative blood loss in cesarean myomectomy cases, the efficacy of ligation on blood loss in the postoperative period continues owing to its permanence. The tourniquet method is not effective in the postoperative period since the tourniquet is removed at the end of the operation. Therefore, bilateral ascending uterine artery ligation may be preferable in cesarean myomectomy cases.     

Laparoscopic Variants of Temporary Uterine Artery Ligation

ObjectiveLaparoscopic uterine artery ligation may be performed during myomectomy or other uterine invasive procedures to reduce the amount of blood loss during surgery. In this video, the authors describe 3 different laparoscopic techniques to approach the uterine artery.DesignStep-by-step video demonstration of 3 different surgical techniques.SettingPrivate hospital in Curitiba, Paraná, Brazil.InterventionsThe main steps of uterine artery ligation are described in detail as well as different laparoscopic variants to this procedure.Anterior ApproachThe impression of the uterine vessels can usually be seen anteriorly and laterally to the uterine cervix. After identification of the path of the uterine arteries, the peritoneum of the anterior cul-de-sac is opened over the vessels and the uterine artery is carefully dissected next to the lateral border of the uterine cervix. This dissection must be performed with extreme caution because the uterine veins are very close to the artery. Venous bleeding at this point of the dissection can be very difficult to control without ligating the vessels. After circumferential dissection of the artery, temporary occlusion is conducted using 2-0 polyester suture.Posterior Approach, Lateral to the Infundibulopelvic LigamentFor ligation of the uterine artery posteriorly to the uterus and laterally to the pelvic infundibulum, opening of the peritoneum of the broad ligament should start immediately below the round ligament, parallel and medial to the external iliac vessels toward the base of the pelvic infundibulum. The avascular space is dissected by blunt dissection (traction and countertraction), identifying the lateral (external iliac vessels) and medial (pelvic infundibulum and the ureter attached to the peritoneum of the ovarian fossa) landmarks. The external iliac artery is dissected cranially to find the bifurcation of the common iliac artery and the internal iliac artery. The first medial branch of the anterior division of the internal iliac usually is the uterine artery. After circumferential dissection of the uterine artery, it may be ligated according to the same technique described above.Medial ApproachFor the medial approach, the peritoneum should be opened medial to the infundibulopelvic ligament. The assistant grasps the infundibulopelvic ligament, creating a peritoneal tent. Immediately after broad ligament opening, anatomic landmarks are identified. First, the ureter is identified and medialized. For the identification of vascular anatomy, movement of the obliterated umbilical artery is made active, which reduces the risk of error to ligate the uterine artery. After circumferential dissection of the artery, it may be ligated according to the same technique described above.ConclusionLaparoscopic uterine artery ligation may be performed during laparoscopic myomectomy to reduce intraoperative blood loss. According to the position of the myomas within the uterus as well as the uterine volume, the surgeon may choose among 1 of the above-mentioned techniques to perform. This technique could also be applied to other types of invasive uterine procedures to reduce blood loss. Standardization of these techniques could help to reduce the laparoscopic learning curve.     

Laparoscopic-Assisted Myomectomy with Bilateral Uterine Artery Occlusion/Ligation

Study ObjectiveConventional laparoscopic myomectomy (CLM) and robotic-assisted myomectomy (RAM) are limited in the number and size of myomas that can be removed, whereas abdominal myomectomy (AM) is associated with increased complications and morbidity. Here we evaluated the surgical outcomes of these myomectomy techniques compared with those of laparoscopic-assisted myomectomy (LAM), a hybrid approach that combines laparoscopy and minilaparotomy with bilateral uterine artery occlusion or ligation to control blood loss.DesignRetrospective chart review (Canadian Task Force classification II-1).SettingSuburban community hospital.PatientsWomen age ≥18 years with nonmalignant indications.InterventionA total of 1313 consecutive CLMs, RAMs, AMs, and LAMs performed between January 2011 and December 2013.Measurements and Main ResultsOur review included 163 CLMs (12%), 156 RAMs (12%), 686 AMs (52%), and 308 LAMs (23%). Although the average number, size, and total weight of leiomyomas removed were comparable in the LAM and AM groups (9.1, 8.13 cm, and 391 g, respectively, vs 9.0, 7.5 cm, and 424 g; p < .0001), the number and weight of myomas were significantly greater in those 2 groups compared with the CLM and RAM groups (2.9 and 217 g, respectively, and 2.9 and 269 g; p < .0001). The intraoperative complication rate was highest in the RAM group, and the postoperative complication rate was highest in the AM group, both of which were approximately 3 times greater than the rates in the LAM group. There was no statistically significant difference in postoperative complication rates between the CLM and LAM groups.ConclusionLAM with uterine artery occlusion/ligation is a viable approach for removing large tumor loads while minimizing blood loss and precluding the need for power morcellation.     

Cervical Myomectomy with Uterine Artery Ligation at Its Origin

This study was performed to examine the feasibility, blood loss, duration of surgery, and complications in patients with cervical myomas in whom the uterine artery was ligated before myomectomy. Laparoscopic cervical myomectomy was performed in 12 women with cervical myomas and menorrhagia. The uterine artery was ligated at its origin from the internal iliac as an initial step to reduce the blood loss. Myomectomy was subsequently performed, and the myomas were enucleated by incising the capsule anteriorly or posteriorly depending on their location. Hysterectomy was not necessary in any patient. Even large cervical myomas were removed with minimal blood loss. Laparoscopic cervical myomectomy is a minimally invasive and technically safe procedure.     

Hand-assisted laparoscopy for megamyomectomy. A case report

BACKGROUND: In cases of uterine myomas of massive size, minimally invasive laparoscopic or laparoscopically assisted myomectomy techniques are not feasible alternatives to traditional laparotomy. This report introduces the use of hand-assisted laparoscopy, a novel approach that permits the insertion of the hand into the abdomen through a glove-sized incision while preserving the pneumoperitoneum, as an alternative to laparotomy for patients with massive myomas unsuitable for conventional laparoscopic myomectomy. CASE: A 28-year-old nullipara requested minimally invasive myomectomy and fertility preservation for the treatment of a massively enlarged uterus reaching the level of the liver. Myomectomy was safely performed by hand-assisted laparoscopy using the Pneumo Sleeve System (Dexterity, Blue Bell, Pennsylvania), a 7.5-cm transverse suprapubic incision and a 1-cm umbilical laparoscopic incision. Surgery lasted 120 minutes, and the estimated blood loss was 250 mL. The total weight of the myomas was 3,120 g. The patient was discharged on the second postoperative day and had an uneventful recovery. CONCLUSION: The successful outcome of this initial case suggests that hand-assisted laparoscopic myomectomy is a feasible and safe minimal-access option that could effectively replace routine laparotomy in patients with massive uterine enlargement.     

Laparoscopic Myomectomy: An Alternative Approach to Tackling Submucous Myomas?

Study ObjectiveTo evaluate the differences in perioperative outcomes and immediate complication rates between laparoscopic myomectomy for submucous myomas and laparoscopic myomectomy for myomas in other locations.DesignRetrospective cohort study.SettingUniversity-affiliated hospital in London.PatientsA total of 350 patients with symptomatic uterine myomas underwent laparoscopic myomectomy. Thirty-three of these were performed for submucous myomas (group 1), and 317 were for myomas in other uterine locations (group 2).InterventionsAnalysis of prospectively collected data on patient demographics, myoma characteristics, perioperative outcomes, and immediate complications.Measurements and Main ResultsPatient demographics, including age, body mass index, and parity, were similar in the 2 groups. No significant differences in myoma characteristics were seen between groups 1 and 2, including the mean dimension of largest myoma (7.1 vs 7.8 cm, respectively; p = .35), mean number of myomas removed (3.8 vs 4.1; p = .665), and mean mass of myomas removed (142.0 g vs 227.3 g; p = .186). There were also no significant between-group differences in any perioperative outcomes, including mean blood loss (226.8 mL vs 266.4 mL; p = .373), duration of surgery (103 minutes vs 113 minutes; p = .264), and duration of hospital stay (1.4 days vs 1.7 days; p = .057). No complications arose from laparoscopic resection of submucous myomas.ConclusionLaparoscopic myomectomy for submucous myomas has similar perioperative outcomes and immediate complications as laparoscopic myomectomy for other myomas and can be considered for large or type 2 submucous myomas.     

Traditional surgical approaches to uterine fibroids: abdominal myomectomy and hysterectomy

Abdominal myomectomy and hysterectomy remain the traditional treatment of large symptomatic uterine myomas. The preoperative indications for abdominal myomectomy or hysterectomy must be clearly evaluated and delineated avoid unnecessary intervention. There appears to be an increasing trend toward expectant management for asymptomatic uterine myomas. Women should consider the options of myomectomy and hysterectomy when their symptoms are severe enough to warrant intervention and the benefits of intervention outweigh the risks. The advantages and disadvantages of preoperative medical also must be addressed before intervention. The factors influencing the choice of therapy seem to be strongly dependent on both the patient and physician preferences. A clinical approach to abdominal myomectomy in patients with infertility and repetitive miscarriage has been presented in this chapter. The rapid development and use of minimally invasive innovations and adjunctive medical therapies has provided clinicians with a wealth of alternatives. A practical and cost-effective approach based on the data currently available have been presented; however, there remains a paucity of prospective randomized data to evaluate and compare the effectiveness and safety of these alternative treatments to abdominal myomectomy and hysterectomy. Future studies should help define the optimal candidates for traditional surgical treatment with abdominal myomectomy and hysterectomy.     

Isobaric (gasless) laparoscopic uterine myomectomy. An overview

The aim of this review has been to assess the usefulness and effectiveness of isobaric (gasless) laparoscopic myomectomy using a subcutaneous abdominal wall lifting system, and to evaluate the advantages and disadvantages of this technique in comparison with the conventional laparoscopic myomectomy using pneumoperitoneum. Laparoscopy using CO2 is more frequently employed for small or medium-sized myomas. Furthermore, multiple myomectomies (>or=3 myomas per patient) are performed rarely. Gasless laparoscopy permits the removal of large intramural myomas overcoming the difficulties associated with laparoscopic myomectomy using pneumoperitoneum. It appears to offer several advantages over conventional laparoscopy, such as elimination of the adverse effects and potential risks associated with CO2 insufflation; use of conventional laparotomy instruments that facilitate several steps of the procedure; reduced operative times and costs. Indeed, this procedure associates the advantages of laparoscopy and minimal access surgery with those of using the laparotomic instruments that are more reliable for uterine closure. The only advantage of the laparoscopy with pneumoperitoneum is the tamponade effect generated by the gas on the small vessels, thus reducing intraoperative bleeding. Laparoscopic myomectomy using CO2 remains the preferred minimally invasive approach for small and medium-sized myomas and when the total number of myomas removed does not exceed 2 or 3. Gasless laparoscopic myomectomy could be mainly indicated for removal of large intramural myomas (>or=8 cm) and/or for multiple myomectomies (>or=3 myomas per patient). Anyhow, further controlled studies are needed to evaluate entirely their respective indications.     

Laparoscopic-ultraminilaparotomic myomectomy (LUM)-laparoscopic-ultraminilaparotomic embolized myomectomy (LUEM). Surgical techniques

Laparoscopic myomectomy has been performed for more than 20 years. More recently other techniques such as laparoscopically assisted vaginal myomectomy (LAVM) and laparoscopically assisted myomectomy (LAM) have also been introduced. Laparoscopic-ultraminilaparotomic myomectomy (LUM) and laparoscopic-ultraminilaparotomic embolized myomectomy (LUEM), a new surgical technique which integrates laparoscopy and ultraminilaparotomy and embolization, has been created by our group and has been found to be superior to the conventional laparoscopy for the treatment of uterine fibromas especially in large myomas > 9 cm. This technique allows us to apply a suture on the uterine incision totally similar to the suture of a conventional laparotomy, by using the small breach of the cutaneous incision of the uterine morcellator (25 mm) and drawing the uterus below this abdominal aperture. This kind of surgical procedure is associated with presurgical embolization, that we call LUEM (laparoscopic ultraminilaparotomic embolized myomectomy) of the afferent vessels to the myoma in myomas with diameters equal or superior to 14 cm to avoid blood loss during the surgical procedure. Between June 1999 and March 2002, a total of 62 patients wishing to become pregnant were treated with this method. LUM allows us to increase the feasibility and safety of the operation, while assuring a better stability of the uterine suture and reduction of surgical time. LUEM has the advantages of LUM but permits in an absolutely hemostatic situation the application of laparoscopy in the surgery of large myomas superior to 14 cm.     

Intranasal buserelin versus surgery in the treatment of uterine leiomyomata: long-term follow-up

Forty-two women with symptomatic uterine myomas, candidates for myomectomy or hysterectomy, were randomized to 6 months' treatment with buserelin 1200 micrograms/day intranasally (n = 22) or immediate surgery (n = 20). After buserelin treatment or operation the patients were followed for at least 12 months. Buserelin was well tolerated, the uterine volume fell from 465 +/- 168 to 273 +/- 88 cm3, and hemoglobin values normalized in all anemic patients. Rapid myoma regrowth was observed in all patients in the buserelin group after treatment withdrawal. Pregnancy occurred during follow-up in one of five buserelin-treated myomectomy candidates. Menorrhagia recurred in eight of 15 buserelin-treated hysterectomy candidates, and a hysterectomy was required but no transfusion was needed. Two women entered natural menopause and were considered cured. In the surgery group all operations were uneventful: three women conceived after myomectomy, whereas four of the patients that underwent hysterectomy required transfusions. Thus buserelin treatment appears to be indicated for infertile patients when surgery is contra-indicated or could cause adhesions, and for hysterectomy candidates in perimenopausal age and/or with secondary anemia.     

Laparoscopic Myomectomy: Do Size,Number, and Location of the Myomas Form Limiting Factors for Laparoscopic Myomectomy?

STUDY OBJECTIVE: To assess whether it is possible for an experienced laparoscopic surgeon to perform efficient laparoscopic myomectomy regardless of the size, number, and location of the myomas. DESIGN: Prospective observational study (Canadian Task Force classification II-1). SETTING: Tertiary endoscopy center. PATIENTS: A total of 505 healthy nonpregnant women with symptomatic myomas underwent laparoscopic myomectomy at our center. No exclusion criteria were based on the size, number, or location of myomas. INTERVENTIONS: Laparoscopic myomectomy and modifications of the technique: enucleation of the myoma by morcellation while it is still attached to the uterus with and without earlier devascularization. MEASUREMENTS AND MAIN RESULTS: In all, 912 myomas were removed in these 505 patients laparoscopically. The mean number of myomas removed was 1.85 +/- 5.706 (95% CI 1.72-1.98). In all, 184 (36.4%) patients had multiple myomectomy. The mean size of the myomas removed was 5.86 +/- 3.300 cm in largest diameter (95% CI 5.56-6.16 cm). The mean weight of the myomas removed was 227.74 +/- 325.801 g (95% CI 198.03-257.45 g) and median was 100 g. The median operating time was 60 minutes (range 30-270 minutes). The median blood loss was 90 mL (range 40-2000 mL). Three comparisons were performed on the basis of size of the myomas (<10 cm and >or=10 cm in largest diameter), number of myomas removed (or=5 myomas), and the technique (enucleation of the myomas by morcellation while the myoma is still attached to the uterus and the conventional technique). In all these comparisons, although the mean blood loss, duration of surgery, and hospital stay were greater in the groups in which larger myomas or more myomas were removed or the modified technique was performed as compared with their corresponding study group, the weight and size of removed myomas were also proportionately larger in these groups. Two patients were given the diagnosis of leiomyosarcoma in their histopathology and 1 patient developed a diaphragmatic parasitic myoma followed by a leiomyoma of the sigmoid colon. Six patients underwent laparoscopic hysterectomy 4 to 6 years after the surgery for recurrent myomas. One conversion to laparotomy occurred and 1 patient underwent open subtotal hysterectomy for dilutional coagulopathy. CONCLUSION: Laparoscopic myomectomy can be performed by experienced surgeons regardless of the size, number, or location of the myomas.     

Disseminated peritoneal leiomyomatosis: an unusual complication of laparoscopic myomectomy

INTRODUCTION: We report a case of disseminated peritoneal leiomyomatosis arising after laparoscopic myomectomy. CASE REPORT: The patient presented with a large abdominopelvic mass 9 months post laparoscopic myomectomy. Clinical examination and imaging revealed a mass lying separately from the uterus and the ovaries. The large myoma and several small peritoneal myomas were removed by a laparotomy. CONCLUSION: Disseminated leiomyomas have rarely been reported after laparoscopic myomectomy and hysterectomy. They could be bits left after morcellation or could be parasitic myomas. Hence, this rare condition must be kept in mind whenever a patient presents with abdominal masses following myomectomy or hysterectomy.     

Preoperative Hematocrit Level and Associated Risk of Transfusion for Myomectomy Based on Myoma Burden and Surgical Route

Study ObjectiveTo determine the association between preoperative hematocrit level and risk of blood transfusion for laparotomic and laparoscopic myomectomy based on myoma burden and surgical route.DesignA cohort study of prospectively collected data.SettingAmerican College of Surgeons National Surgical Quality Improvement Program participating institutions.PatientsA total of 26 229 women who underwent a laparotomic or laparoscopic myomectomy from 2010 to 2020.InterventionsThe primary outcome assessed was the risk of transfusion based on preoperative hematocrit level. This was evaluated with respect to myoma burden and surgical route.Measurements and Main ResultsThere were 26 229 women who underwent a myomectomy during the study interval, 2345 women (9%) of whom required a blood transfusion. Compared with patients who did not require transfusion, those who did had lower median preoperative hematocrit levels (34.7 vs 38.2). Patients were stratified by surgical approach (laparotomic vs laparoscopic) and myoma burden (1–4 myomas/weight ≤250 g or ≥5 myomas/weight >250 g) using Current Procedural Terminology codes (58140, 58146, 58545, 58546). In all categories, there was an inverse relationship between blood transfusion and preoperative hematocrit level with increasing risk depending on preoperative hematocrit range. The odds ratios comparing hematocrit level of 29% with 39% were 6.16 (95% confidence interval [CI], 5.15–7.36), 4.92 (95% CI, 4.19–5.78), 4.85 (95% CI, 3.72–6.33), and 5.2 (95% CI, 3.63–7.43) for patients with laparotomic (1–4 myomas/≤250 g, ≥5 myomas/>250 g) and laparoscopic myomectomy (1–4 myomas/≤250 g, 5 myomas/>250 g), respectively.ConclusionIncremental increases in hematocrit result in a significantly decreased risk of blood transfusion at the time of myomectomy.     

Factors affecting early surgical intervention after uterine artery embolization

Uterine artery embolization (UAE) is an effective technique for the management of uterine myoma. However, complications of this procedure can be serious, including uterine infection and bowel necrosis in conjunction with necrosis of subserous or pedunculated myomas. Treatment failure is more likely to occur in the presence of submucosal myoma associated with a uterine infection or a large myoma of more than 8 cm. Accordingly, patients whose primary symptoms include submucosal myoma and menorrhagia are best treated with a hysteroscopic myomectomy or hysterectomy. The role of the gynecologist is crucial for most effective management and safe use of uterine artery embolization. TARGET AUDIENCE: Obstetricians & Gynecologists, Family Physicians LEARNING OBJECTIVES: After completion of this article, the reader will be able to list the complications of uterine artery embolization for fibroids, to describe postembolization syndrome, and identify the myomas that are more likely to fail uterine artery embolization.     

The occasional need for myomectomy.

Only occasionally is there a good indication for either abdominal myomectomy or vaginal myomectomy. Among 3205 patients who had major gynecologic operations, 1022 had leiomyofibromas; 718 needed abdominal hysterectomy, 253 needed vaginal hysterectomy, and only 51 were treated by myomectomy. Vaginal myomas and a few submucous uterine myomas were excised vaginally. Parasitic myomas and a few intramural myomas were excised abdominally. Indications, symptoms, number, size, tissue characteristics, methods, subsequent fertility, and subsequent pelvic operations are all discussed. In 26 of these patients, myomas were discovered during other conservative gynecologic operations, requiring decision-making during operations; criteria are discussed.     

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.     

Incidence of Leiomyosarcoma at Surgery for Presumed Uterine Myomas in Different Age Groups

Study ObjectiveTo evaluate the incidence of leiomyosarcoma (LMS) at surgery for presumed uterine myomas according to different age groups.DesignA retrospective cohort study.SettingA tertiary referral hospital.PatientsAll women undergoing surgery for presumed uterine myomas between January 1, 2006, and December 31, 2016.InterventionsLaparoscopic myomectomy, laparotomic myomectomy, total hysterectomy, or hysteroscopic myomectomy.Measurements and Main ResultsA total of 1398 patients underwent surgery for presumed uterine myomas. The incidence of LMS was 2.15 per 1000 surgeries (n = 3, 1/466, 0.2%). In women under 40 years old, the incidence of occult LMS was 0 (0/561). In women between 40 and 49 years old, 190 myomectomies were performed (28% of the surgeries), and the rate of LMS was 1.49 per 1000 (n = 1, 1/673, 0.15%). In women over 49 years old, a total hysterectomy was performed in 82.3% of the cases, and the incidence of LMS was 12.2 per 1000 surgeries (n = 2, 1/82, 1.2%).ConclusionThe incidence of occult LMS in patients under 40 years old undergoing surgery for presumed uterine myomas was 0. These findings are suggestive that the use of power morcellation in this population may be safe.     

Temporary clipping of the uterine artery during laparoscopic myomectomy—a new technique and the results of first cases

Bleeding is the most common complication in laparoscopic myomectomy. In this paper, we describe a new technique using Yasargil aneurysm clips to reduce blood loss during laparoscopic myomectomy by clipping the uterine arteries temporarily. Over a 7-month period, 13 patients with uterine fibroids larger than 5 cm underwent laparoscopic myomectomy with temporary clipping of both uterine arteries at their origin from the internal iliac artery. We assessed the clinical data of perioperative blood loss, operating time, hospital stay, complications, haemoglobin decrease and uterine artery Doppler flow prior to and after the procedure. No serious perioperative complications occurred. The mean number of removed fibroids was 7.5 (range 1–30), with an average total weight of 421 g (range 160–960 g). Mean Hb pre- vs. postoperatively was 12.5 g/cl vs. 10 g/cl. There was no significant change in the uterine artery flow prior to and after surgery. No transfusion was given to any of the patients. We conclude that temporary clipping of the uterine arteries prior to laparoscopic myomectomy is a safe procedure for controlling excessive blood loss without jeopardising the uterine blood supply.