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.     

MRI evaluation of the uterine structure after myomectomy

Myomectomy is a good indication for women with uterine leiomyoma who desire to preserve their child-bearing potential. However, there are still no reports about how long it takes the uterus to reach a stable state after myomectomy. We evaluated the changes in uterine structure during the recovery process after myomectomy by MR images. MR images were used to analyze the time-dependent changes in the length of the uterine cavity, the volume of the uterus, recovery of the junctional zone, prevalence of modification of the endometrium, and uterine structure in the region of the enucleated myoma. The cavity length and the volume of the uterus, and the myometrium were stabilized at six weeks after the myomectomy. With regard to the endometrium, 12 weeks were required for it to achieve a stable state after myomectomy. However, even at 12 weeks postoperatively, 14.2% of the cases showed an unusual view near the uterine incision on MR images. We concluded that the recovery process is complete at 12 weeks after the operation if there are no clear findings of hematoma or edema formation in the myometrium on MR images.     

Laparoscopic devascularization of uterine myomata followed by enucleation of the myomas by direct morcellation

Most intraoperative conversions of laparoscopic myomectomy to laparotomy reported in the literature occur because of intraoperative bleeding. Devascularization of a uterine myoma at the start of myomectomy would help reduce the blood supply to the uterus and hence to the myoma. Another advantage of the procedure is that the need to separate the myoma from the uterus completely before morcellation, as in conventional laparoscopic myomectomy, is obviated. The tumor can be enucleated only up to about half its circumference by standard enucleation before morcellation is begun. Traction accorded by the 15-mm traumatic serrated-edge claw forceps of the morcellator during morcellation causes progressive separation of the myoma from the uterine wall, thus completing enucleation. In two patients, myomas were devascularized at the outset of myomectomy, in one by intracorporeal suturing of uterine vessels and in the other by laparoscopic bipolar coagulation of uterine vessels.     

Restitutio ad integrum of myometrium after myomectomy. Different results in pregnant and non-pregnant patients

BACKGROUND: The aim of this study is to check whether there exists a difference in restitutio ad integrum of the uterus after myomectomy performed during Caesarean section and out of pregnancy. METHODS: Two different groups are considered: Group A (n=8) that underwent myomectomy during Caesarean section; Group B (n=10) in which myomectomy was performed out of pregnancy. All patients were followed with serial scan evaluations. RESULTS: The results showed a much more complete and faster absorption of hyperplasia and hypertrophy surrounding fibroid nodules when myomectomy was performed during Caesarean section. CONCLUSIONS: A later pregnancy in patients who underwent myomectomy during Caesarean section might have a favourable outcome, possibly reaching a term gestation and vaginal delivery.     

疤痕子宫短期内妊娠的安全性分析

目的:了解子宫手术疤痕形成后两年内妊娠的结局,并评估疤痕子宫再次妊娠的安全性和可行性。方法:收集我院2003年1月1日至2009年4月30日101例子宫疤痕形成后两年内妊娠的中晚期孕妇,前次手术系子宫肌瘤剔除术43例(42.6%),前次手术系剖宫产58例(57.4%)。分析再次妊娠原因、再次妊娠距离前次手术的时间、再次妊娠的结局。结果:不同部位、不同大小肌瘤、不同手术途径、肌瘤剔除术后不同阶段的妊娠结局,差异均无统计学意义(P>0.05)。结论:有妊娠要求的疤痕子宫患者可考虑手术6个月后开始妊娠,但应密切注意子宫收缩情况和予以适当的产科处理。     

Isthmic uterine fibroids: the dynamics of growth

The isthmus of uterus is different from the rest of uterus and cervix in anatomic as well as functional aspects. The tumors arising from it may be subjected to a different set of forces which may predispose to growth in a tangential or horizontal direction. A young woman who underwent myomectomy for a large isthmic myoma is presented and the growth dynamics are discussed.     

子宫肌瘤剔除术后子宫破裂危险因素分析

子宫肌瘤是妇科最常见的盆腔良性肿瘤,常影响女性月经周期和月经量,有时影响育龄妇女的妊娠,子宫肌瘤剔除术是保留生育功能最常用的治疗方法。但子宫肌瘤剔除术后妊娠存在子宫破裂的风险,是威胁母儿生命安全最严重的产科并发症之一。近年来随着妇科内镜技术的广泛应用,子宫肌瘤剔除术后子宫破裂时有报道,但其危险因素及预防措施尚未达成共识,因此有必要总结分析子宫肌瘤剔除术后子宫破裂的相关研究及可能的危险因素,从而规范手术技术。术中应减少电热器械的过度使用,尽量避免进入宫腔破坏子宫内膜完整性,仔细缝合子宫肌层,术后合理的避孕时间及个体化选择终止妊娠方式,以降低术后妊娠子宫破裂的风险。     

Caesarean myomectomy

This study was conducted at Korle Bu Teaching Hospital and Family Health Hospital, Accra, Ghana, between April 2000 and January 2001 to compare the efficacy and safety of myomectomy done at caesarean section with the application of a tourniquet with caesarean section without myomectomy. Twenty four patients were recruited into the study. Average haemoglobin of patients both pre and post-operatively was 11.73 g/dl and 9.90 g/dl for patients who had caesarean section with myomectomy and 12.07 g/dl and 10.34 g/dl in the other group in which caesarean section without myomectomy was performed. The average duration of operation was longer in patients who had caesarean section and myomectomy (62.08 mins) than those who had caesarean section alone (50.83 mins). The drop in average haemoglobin for patients who had caesarean section and myomectomy was 1.83 while those who had caesarean section alone was 1.73. This was not significant. The fibroid nodules removed ranged from one solitary nodule to six nodules with an average diameter of 6 cm. Eighty five per cent of the fibroids were intramural and in the body of the uterus. Uterine involution was normal and there were no significant complications during the puerperium. We conclude that there is no significant difference in intra-operative and post-operative morbidity and blood loss in performing caesarean section alone and caesarean section with myomectomy when a tourniquet is applied.     

Occult traumatic rupture of the uterus followed by spontaneous rupture in subsequent pregnancy; a case report

All efforts and objectives in obstetrics are aimed primarily at the protection of the mother and the baby. With the recognition of obstetrics as a science and art basic principles of the mechanism of labor were the first to be studied. Disproportion, relative or absolute, with the classical picture of prolonged labor and risk of rupture is seldom seen today with the availability of modern obstetrical care. The answer to the problem of disproportion has been cesarean section.Rupture of the uterus is not always associated with the problem of disproportion. Malpresentations managed by version and extraction have proved to be the greatest single cause of traumatic rupture of the uterus. Donnelly reports 39 cases of ruptured uteri in 101,127 deliveries and of these 12 were traumatic ruptures, and 8 were caused by version and extraction.Rupture of the uterus may be classified as spontaneous, traumatic, and rupture of the scar of previous cesarean sections. The case reported represents a combination of an occult traumatic rupture of the uterus followed by a spontaneous rupture in a subsequent pregnancy.The purpose of this case report is to point out that an occult rupture of the uterus can and does occur, but is probably reported as a spontaneous rupture in a following pregnancy. A diagnostic sign in the immediate puerperium, namely, shoulder pain due to pneumoperitoneum, if recognized, can establish a diagnosis of rupture of the uterus.     

Rupture of a pregnant unscarred uterus in an early secondary trimester: a case report and brief review

Rupture of a pregnant uterus in early pregnancy and an unscarred uterus are extremely rare, and some non-specific symptoms might appear before this occurrence. We report the case of a multiparous woman (gravida 3, para 2) with uterine fundal rupture in her early second trimester (17+ weeks of gestational age), who presented upper abdominal discomfort and vomiting for 3 days, and progressed into sudden acute abdomen and shock. During emergent laparotomy, the entire amniotic sac was found in the peritoneal cavity with a rupture of the uterine fundus. Although we could not confirm that the appearance of upper gastrointestinal symptoms and severe vomiting was associated with uterine rupture in this pregnant woman, abdominal symptoms or signs might be a hint or cause of severe catastrophic pregnancy-related complications.     

Long term follow up of hysteroscopic myomectomy assessed by survival analysis

Objective To identify patient characteristics which affect outcome after hysteroscopic myomectomy for submucous fibroids.
Design Prospective observational study.
Setting A university teaching hospital.
Sample One hundred and twenty-two consecutive patients treated by hysteroscopic myomectomy for submucous leiomyoma over a period of almost eight years.
Methods Hysteroscopic electroresection of the leiomyoama using a continuous flow resectoscope.
Main outcome measures The avoidance of further surgery and patient satisfaction.
Results The average age of the patients at the time of their surgery was 424 years. A total of 194 fibroids were removed. The mean follow up period was 2.3 years (range 1–7.6). Of those asked, 71.4% were satisfied with the results of surgery. Sixteen women required further surgery for fibroids, and six ultimately underwent hysterectomy. Survival analysis showed that the risk of further surgery was 21% at four years after the myomectomy, and 0% thereafter. Univariate regression analysis suggested that outcome was significantly better in older women, and in cases where the uterus was equivalent in size to I 6 weeks of gestation, the fibroid was I 3 cm in diameter and mainly intracavitary, and the proce- dure time was I 20 minutes. The influence of hormonal pre-treatment and the number of fibroids excised was not statistically significant. After multivariate regression analysis, only overall uterine size and the position of the fibroid being removed were found to significantly influence the success of surgery.
Conclusions Hysteroscopic myomectomy is an effective way to manage patients with symptomatic submucous leiomyomata, particularly when the uterus is not grossly enlarged and the fibroid(s) are mainly inside the uterine cavity.     

Rupture of the uterus in labour: a review of 14 cases in a general hospital.

This study aimed to identify the risk factors and clinical presentations associated with rupture of the uterus in labour and to determine material and fetal outcomes. Rupture of the uterus is a potentially devastating complication of childbirth and remains one of the major causes of maternal and perinatal mortality and morbidity.     

Laparoscopic Repair of a Post-Myomectomy Spontaneous Uterine Perforation Accompanied by a Bizarre Tumor Resembling Polypoid Endometriosis

Among various long-term complications after previous myomectomy, increasing risk of uterine rupture or dehiscence during pregnancy, and in particular during labor, has been widely recognized. In contrast, the world literature includes no case report of spontaneous uterine perforation or rupture after myomectomy in a nonpregnant woman, and only 1 case of iatrogenic uterine perforation after uterine artery embolization has been reported. Recently, we encountered an extremely rare case of spontaneous uterine perforation after previous myomectomy accompanied by a bizarre tumor resembling polypoid endometriosis, which was successfully treated via laparoscopic surgery. The patient reported genital bleeding and lower abdominal pain. Preoperative magnetic resonance imaging and intraoperative findings clearly demonstrated the presence of a uterine wall defect and a multicystic tumor that had developed from the perforated portion of the uterus. The patient underwent successful laparoscopic surgery for repair of the perforated uterus and resection of the tumor. The clinicopathologic diagnosis of the tumor was tentatively confirmed as an endometriosis-like lesion resembling polypoid endometriosis. We speculate that the cause of the tumor was retrograde menstruation, as in the pathogenesis of endometriosis.     

Long term follow up of hysteroscopic myomectomy assessed by survival analysis.

OBJECTIVE: To identify patient characteristics which affect outcome after hysteroscopic myomectomy for submucous fibroids. DESIGN: Prospective observational study. SETTING: A university teaching hospital. SAMPLE: One hundred and twenty-two consecutive patients treated by hysteroscopic myomectomy for submucous leiomyoma over a period of almost eight years. METHODS: Hysteroscopic electroresection of the leiomyoama using a continuous flow resectoscope. MAIN OUTCOME MEASURES: The avoidance of further surgery and patient satisfaction. RESULTS: The average age of the patients at the time of their surgery was 42.8 years. A total of 194 fibroids were removed. The mean follow up period was 2.3 years (range 1-7.6). Of those asked, 71.4% were satisfied with the results of surgery. Sixteen women required further surgery for fibroids, and six ultimately underwent hysterectomy. Survival analysis showed that the risk of further surgery was 21% at four years after the myomectomy, and 0% thereafter. Univariate regression analysis suggested that outcome was significantly better in older women, and in cases where the uterus was equivalent in size to < or = 6 weeks of gestation, the fibroid was < or = 3 cm in diameter and mainly intra-cavitary, and the procedure time was < or = 20 minutes. The influence of hormonal pre-treatment and the number of fibroids excised was not statistically significant. After multivariate regression analysis, only overall uterine size and the position of the fibroid being removed were found to significantly influence the success of surgery. CONCLUSIONS: Hysteroscopic myomectomy is an effective way to manage patients with symptomatic submucous leiomyomata, particularly when the uterus is not grossly enlarged and the fibroid(s) are mainly inside the uterine cavity.     

子宫肌瘤剔除术中如何发现隐匿肌瘤

子宫肌瘤是女性最常见的生殖系统良性肿瘤,子宫肌瘤剔除术为保守性手术方式,包括开腹、腹腔镜和阴式等多种手术途径,但术后有复发风险。文章探讨如何在子宫肌瘤剔除术中发现隐匿肌瘤,提高子宫肌瘤剔除术的治疗效果,减少复发。     

Rupture of an unscarred uterus with misoprostol induction: case report and review of the literature

Uterine rupture is a serious and often tragic complication that is life threatening to both mother and child. It occurs at a frequency of around 1% in patients with a previously scarred uterus. Rupture of an unscarred uterus is an unexpected and devastating complication of pregnancy. With the increased use of misoprostol as a labor-inducing agent, cases of rupture of an unscarred uterus following its use have been published in the literature. We report a case of uterine rupture in a multigravid woman with an intrauterine fetal death at 29 weeks' gestation whose labor was induced with misoprostol. A review of all cases of uterine rupture with misoprostol induction is also included. Excessive doses of misoprostol should be used with extreme caution in multiparous women and in patients with a previously scarred uterus even in the context of intrauterine fetal death or termination of pregnancy.     

Laparoscopic myomectomy: enucleation of the myoma by morcellation while it is attached to the uterus

STUDY OBJECTIVE: To evaluate the feasibility, blood loss, length of surgery, mean hospital stay, and complications of enucleation of a myoma by morcellation while it is still attached to the uterus and to compare the technique with the standard technique of laparoscopic myomectomy. DESIGN: Randomized study (Canadian Task Force classification II-2). SETTING: Private endoscopy center. PATIENTS: Forty-four patients with symptomatic myomas confirmed by ultrasound examination were included in the study from January 2000 through December 2001 and were randomized into two groups-A and B. The inclusion criteria were the presence of a uterus larger than 12 weeks (on bimanual examination), ultrasound confirmation of the presence of at least one myoma 7 cm or greater in size, and/or presence of three or more myomas greater than 5 cm in size. INTERVENTION: The technique of laparoscopic myomectomy by enucleation of a myoma by morcellation while it is still attached to the uterus was performed in all patients in Group A. The patients in Group B underwent laparoscopic myomectomy by the conventional technique of complete enucleation of the myoma followed by morcellation. MEASUREMENTS AND MAIN RESULTS: Forty-nine myomas were removed in group A and 35 in group B. The mean weight of the myomas removed in each patient was 600.5 +/- 369.1 g in group A (95% CI 452.83-748.17 g) and 584.2 +/- 411.1 g in group B (95% CI 404.05-764.45 g) (p = .706). The mean blood loss was 283.9 +/- 229.3 mL in group A (95% CI 192.20-375.72 mL) and 218.5 +/- 110.7 mL in group B (95% CI 169.96-267.04 mL) (p = .739), the mean hospital stay was 37.91 +/- 5.44 hours in group A (95% CI 35.74-40.10 hours) and 39.5 +/- 3.634 hours in group B (95% CI 37.91-41.09 hours) (p = .236). The mean length of surgery was significantly shorter in group A (97.7 +/- 27.06 min, 95% CI 86.88-108.54 minutes) as compared with that in group B (123 +/- 38.8 min 95% CI 106.93-140.57 minutes), (p = .013). CONCLUSION: Preliminary results suggest that laparoscopic myomectomy employing the technique of enucleation of a myoma by morcellation while it is still attached to the uterus is safe and efficient. It helps to overcome certain technical difficulties inherent in the standard technique of laparoscopic myomectomy. It may help to relax the inclusion criteria of patients with myoma for laparoscopic myomectomy based on the size of the myoma.     

Term delivery after repair of a uterine rupture during the second trimester in a previously unscarred uterus: a case report

BACKGROUND: Rupture of the unscarred gravid uterus is very rare. The event occurs mostly during the intrapartum period and is potentially catastrophic for both mother and fetus. The management in general is prompt termination of pregnancy and hysterectomy. CASE: A successful term delivery followed spontaneous rupture of the uterus during the second trimester and surgical repair. The uterus ruptured with no apparent risk factors at 26 weeks of gestation. The rent, at the right side of the fundus, was repaired without damaging the amniotic membrane. After the operation, the patient received tocolysis for irregular uterine contractions until 37 weeks' gestation and delivered a healthy, male infant by cesarean section. CONCLUSION: Spontaneous rupture of a nonlaboring, unscarred uterus, especially in the second trimester, is extremely rare. This report suggests that conservative treatment for spontaneous rupture of the uterus before fetal maturity may be considered as an alternative to hysterectomy.     

Silent rupture of unscarred uterus: an unusual presentation at second trimester abortion

Rupture of unscarred uterus during the second trimester is rare. A case of ruptured uterus in a multiparous woman is presented. To our knowledge, this might be the first reported case in the English literature of uterine rupture during second trimester termination of pregnancy using ethacridine lactate. This case is also rare as uterine rupture is presented with an insidious course rather than acute, thus delaying the diagnosis.     

Uterine rupture in second trimester abortion in a grand multiparous woman. A complication of misoprostol and oxytocin

Rupture of unscarred uterus during the second trimester is rare. There have been only 32 cases reported in the literature since 1968. A case of ruptured uterus in a grand multiparous woman is presented.To our knowledge, this might be the first reported case in the English literature of uterine rupture during second trimester termination of pregnancy using a prostaglandin E1 analogue (Misoprostol) and oxytocin.