Morbidity, fertility and pregnancy outcomes after myoma enucleation by laparoscopy versus laparotomy

Clinical comparison of laparoscopic and open surgical approaches for uterus-preserving myomectomy: a retrospective analysis on patient-reported outcome, postoperative morbidity and pregnancy outcomes

PURPOSE

Uterine fibroids pose clinical challenges due to varied symptoms and impact on fertility. Aim of this research is to compare open and laparoscopic myomectomy, with focus on evaluating their effects on patients' quality of life and analyzing their implications for pregnancy outcomes.

METHODS

This retrospective study compares open and laparoscopic myomectomy outcomes in 168 patients treated October 2017 and July 2023. Preoperative characteristics and postoperative outcomes in terms of symptoms and pregnancy outcomes were examined.

RESULTS

The patient cohort comprised patients with a high symptom burden. Only 51.2% expressing a desire for future pregnancies, highlighting diverse motivations for uterus-preservation. No significant differences were observed in preoperative symptoms. Larger and multiple myomas were associated with a higher likelihood of laparotomy. Recurrence rates were lower after laparoscopy (10.2% vs. 23.8%, p = 0.02). Cesarean section recommendations were more frequent post-laparotomy group (36.6% vs. 86.6%, p = 0.000). Morbidities and satisfaction showed no significant differences between approaches, with slightly better bleeding improvement after laparotomy. Despite similar pregnancy outcomes, a high proportion of patients did not conceive postoperatively (75.4%). Among patients who became pregnant postoperatively (n = 31), most patients conceived after one year or more, with no dependence on the surgical approach (p = 0.227).

CONCLUSION

Both open and laparoscopic myomectomy surgeries showed high patient satisfaction, symptom alleviation, and comparable pregnancy results. A preference emerged for laparoscopy in terms of cesarean section recommendations and recurrence risk. Laparoscopic procedures tended to offer higher operative satisfaction and fewer complications. The study emphasized the complexity of therapeutic decision-making.

Reproductive outcomes of high-intensity focused ultrasound ablation and myomectomy for uterine fibroids: a systematic review and meta-analysis

RESEARCH QUESTION

Does high-intensity focused ultrasound (HIFU) ablation have comparable reproductive outcomes to myomectomy for patients with uterine fibroids?

DESIGN

A systematic review and a meta-analysis of data extracted from published studies up to March 2024.

RESULTS

Through a more structured analysis, HIFU treatment yielded a pooled pregnancy rate of 23.3% (95% CI 11.5 to 37.6%) and a pooled live birth rate (LBR) of 17.3% (95% CI 7.8 to 29.3%), significantly lower than those after myomectomy, which had a pooled pregnancy rate of 56.9% (95% CI 45.6 to 67.9%) and a pooled LBR of 44.1% (95% CI 34.9 to 53.4%) (P = 0.0001 and P = 0.0003, respectively). After controlling for patient age, ultrasound-guided HIFU studies reported significantly lower pregnancy rate and LBR compared with myomectomy. Moreover, studies enrolling younger patients and explicitly recruiting those desiring to conceive reported better reproductive outcomes.

CONCLUSIONS

Patients with uterine fibroids undergoing HIFU treatment and desiring to preserve their uteri resulted in poorer reproductive outcomes compared with myomectomy. Although uterine fibroids are now the number one disease that receives HIFU treatment worldwide, the overall quality in design and execution of HIFU studies on reproductive outcomes for women with uterine fibroids leaves much room for improvement. Above all, comparative trials against the standard of care are badly needed.

Exploring Surgical Strategies for Uterine Fibroid Treatment: A Comprehensive Review of Literature on Open and Minimally Invasive Approaches

Background and Objectives: Uterine myomas represent one of the most prevalent pathologies affecting the female population. These benign neoplasms originate from the smooth muscular cells of the uterus, and they can be either single or multiple. Often associated with debilitating symptoms such as pelvic heaviness, pain, constipation, and urinary dysfunctions, the surgical management of myomectomy exhibits considerable variability. This diversity in approaches is influenced by factors such as the number and size of myomas, the patient's age, and overall clinical conditions. This study aims to elucidate and compare the advantages and disadvantages of different surgical approaches, specifically endoscopic procedures versus open surgery, providing valuable insights for clinical decision making. Materials and Methods: A comprehensive bibliographic search spanning from 2013 to 2023 was systematically conducted across databases including Medline, Embase, the Cochrane Database of Systematic Reviews, and ClinicalTrials.gov. The search utilized keywords such as "myomectomy laparoscopic and open", "myomectomy open and minimally invasive", "myomectomy open and laparoscopic", and "myomectomy open vs. laparoscopic." The research methodology, along with predetermined inclusion and exclusion criteria, was established prior to the search, ensuring a systematic and rigorous approach. Subsequently, data analysis was carried out. Results: Following the study selection process, 25 articles met the eligibility criteria for inclusion in this analysis. The average numbers of myomas were 3.7 (ranging from 1 to 13.7) and 5.4 (ranging from 1 to 13.5) for the minimally invasive surgery and open surgery groups, respectively. In terms of myoma size, the total averages across studies were 7 cm (ranging from 4.8 to 14) for the minimally invasive group and 8 cm (ranging from 3.9 to 11.2) for the open surgery group. The average pregnancy and delivery rates were 29.7% (ranging from 1.8 to 100) for the minimally invasive group and 28.5% (ranging from 1.8 to 100) for the open surgery group. Regarding complications, the average rate was 14.2% (ranging from 0 to 50) for the endoscopic group and 22.3% (ranging from 0 to 60.3) for the laparotomic group. Conclusions: In conclusion, a critical factor influencing the choice of surgical approach is primarily the size and quantity of fibroids. The mini-laparotomic approach emerges as a viable alternative to endoscopy, demonstrating favorable surgical outcomes and aesthetic results. Interestingly, the type of surgical procedure appears to have no significant impact on the pregnancy rate.

Towards a clinical consensus on the management of pregnancy and birth after laparoscopic and open myomectomy: A survey of obstetricians and gynaecologists

OBJECTIVES

The primary aim was to assess if a clinical consensus regarding the management of pregnancy post myomectomy existed amongst consultant obstetricians and gynaecologists. Secondary objectives were to evaluate factors which influence the clinician's decision making in this group of women.

STUDY DESIGN

Electronic survey sent to all consultants working in the North Central and East London deanery, Kent Surrey and Sussex deanery and Imperial NHS Trust to assess opinions on mode of birth post myomectomy, intervals advised to pregnancy post myomectomy, factors influencing the management of delivery in the scarred uterus post myomectomy, opinions on induction of labour and questions relating to operative notes.

RESULTS

209 consultant responses received between 07/03/2022-07/05/2022 (44% response rate); 77% (161/209) practicing obstetricians and gynaecologists, 10% (21/109) pure gynaecologists and 13% (27/209) pure obstetricians. The majority would support a vaginal birth after open myomectomy (75%) and laparoscopic myomectomy (79%). No consensus was found as to the optimal time interval between myomectomy and pregnancy. Higher frequency of performing myomectomy and a greater level of experience were significantly associated with a shorter interval to pregnancy advised. The most important operative factors influencing decision to support trial of labour post myomectomy were breach of uterine cavity; location of fibroids removed and number of incisions on the uterus. 77% believe women should be given a choice regarding mode of delivery post myomectomy in a similar way to previous LSCS. 82.8% would support enrolment of patients into a prospective trial to investigate delivery post myomectomy.

CONCLUSIONS

We present a comprehensive survey of clinician opinions on pregnancy post myomectomy demonstrating that the majority of consultant obstetricians and gynaecologists sampled would support vaginal birth post myomectomy; counselling patients in a similar way to VBAC; a standardised myomectomy operation note and enrolment of patients in a future prospective trial. Wide variation in opinion regarding interval to pregnancy post myomectomy has been highlighted. We believe this information will facilitate counselling discussions and empower women with subsequent pregnancies after myomectomy to make an informed decision on mode of birth post myomectomy.

HIFU as an alternative modality for patients with uterine fibroids who require fertility-sparing treatment

OBJECTIVES

To compare pregnancy outcomes after high-intensity focused ultrasound ablation (HIFU), myomectomy and uterine artery embolization (UAE) for fertility-sparing patients with uterine fibroids and to investigate the possible mechanism of improving pregnancy by HIFU.

MATERIALS AND METHODS

A meta-analysis of 54 studies containing 12,367 patients was conducted to compare the pregnancy outcomes of three fertility-sparing therapies. And a retrospective self-control study of 26 patients with uterine fibroids from May 2019 to December 2020 was performed to assess the blood flow impedance of bilateral uterine arteries before and after HIFU.

RESULTS

In the analysis by treatment option, the pregnancy rate after myomectomy was 0.43 (95% CI 0.36-0.49), which was higher than 0.18 (95% CI 0.10-0.26) after HIFU, the latter was significantly higher than that after UAE (ratio 0.08, 95% CI 0.06-0.10). The miscarriage rate after HIFU was 0.08 (95% CI 0.04-0.12), which was similar to 0.15 (95% CI 0.09-0.21) after myomectomy and also similar to 0.16 after UAE (95% CI 0.01-0.30). In the subgroup analysis, women who received ultrasound guided HIFU (USgHIFU) were more likely to have ideal pregnancy outcomes than that after magnetic resonance imaging-guided HIFU. The pulsatility index and resistance index on the right side were significantly higher 3 months after HIFU than before (1.637 ± 0.435 vs. 1.845 ± 0.469; p = 0.033; 0.729 ± 0.141 vs. 0.784 ± 0.081, p = 0.039).

CONCLUSIONS

HIFU, especially USgHIFU, may be an alternative fertility-sparing modality for patients with uterine fibroids over 40 years old. HIFU may contribute to improving pregnancy rates by elevating uterine blood flow impedance.

Comparison of surgical and obstetric outcomes in women with uterine leiomyomas after laparoscopic vs. abdominal myomectomy: A single-center cohort study

Our aim was to study the advantages, complications and obstetrical outcomes of laparoscopic myomectomy (LM) compared with abdominal myomectomy (AM). We conducted a retrospective cohort study at La Paz University Hospital that included LMs and AMs performed between 2012 and 2018, analyzing 254 myomectomies (142 AMs [55.7%] and 112 LMs [43.9%]). The mean number of fibroids was 1.8 ± 1.5 and 3 ± 2.9 for the LM and AM groups, respectively (p < 0.006). The mean size of the largest myoma was 7.6 cm ± 2.7 cm and 10.2 cm ± 5.4 cm for the LM and AM groups, respectively (p < 0.001). LMs were associated with longer surgical times (p < 0.001) and shorter hospitalizations (p = 0.001). There were no significant differences in the intraoperative and postoperative complication rates (p = 0.075 and p = 0.285 for LM and AM, respectively). The subsequent pregnancy rate was higher for the LM group (30.8% vs. 16.8%, p = 0.009), with a vaginal delivery rate of 69% and no cases of uterine rupture.

Analysis of hidden blood loss and its influential factors in myomectomy

OBJECTIVE

This study was performed to quantify hidden blood loss (HBL) and explore its influential factors in myomectomy.

METHODS

Two hundred nine patients who underwent myomectomy by laparotomy or laparoscopy from 1 January 2017 to 31 December 2018 were analyzed. Each patient's estimated blood volume and total blood loss (TBL) were calculated by the Nadler formula and Gross formula, respectively. The HBL was calculated by subtracting the visible blood loss (VBL) from the TBL. A multivariate linear stepwise analysis was applied to identify the influential factors of HBL in myomectomy.

RESULTS

The mean perioperative VBL and estimated TBL during myomectomy were 137.81 ±104.43 and 492.24 ± 225.00 mL, respectively. The mean HBL was 354.39 ± 177.69 mL, which accounted for 71.52% ± 15.75% of the TBL and was two to three times higher than the VBL. The duration of surgery, number of removed leiomyomas, and location of removed leiomyomas were independent risk factors for HBL in myomectomy.

CONCLUSIONS

HBL accounted for a significant percentage of TBL in myomectomy. A full understanding of the HBL in perioperative blood management may improve patients' postoperative rehabilitation.

Intraoperative and Postoperative Complications Following Open, Laparoscopic, and Hysteroscopic Myomectomies in Saudi Arabia

Background

The aim of this study was to broaden our knowledge regarding the complications of myomectomy to better understand how to prevent them from occurring. Another aim was to compare surgical approaches, especially with the current research limitations surrounding this topic in Saudi Arabia.

Methods

This retrospective study was conducted in a cohort of 263 women who underwent surgical myomectomy, without any exclusion criteria. We used our hospital electronic medical records program called Phoenix to obtain all the data regarding clinical presentation, intraoperative findings, intraoperative and postoperative complications, and hospital stay, and then statistically analyzed these findings.

Results

Results were divided depending on the type of surgery. The mean age of open, laparoscopic, and hysteroscopic myomectomy groups were 40.82 years, 42.05 years, and 44.43 years, respectively. There were 213 (80.98%) open, 34 (12.93%) laparoscopic, and 16 (6.09%) hysteroscopic myomectomies. The most common indication in all groups was bleeding. The mean estimated blood loss and duration of surgery for open, laparoscopic, and hysteroscopic myomectomy groups were: 576.13 mL and 103.05 min, 333.21 mL and 56.91 min, and 306.29 mL and 104.19 min, respectively. The total complication rate for each group was 10.8% in open, 2.94% in laparoscopic, and 6.25% in hysteroscopic myomectomies.

Conclusion

Laparoscopy is considered the more effective option for myomectomy than both laparotomy and hysterectomy in terms of surgery duration, hospital stay, and prevalence of complications. However, it is a technically challenging operation that requires experienced surgeons to perform. Based on the information we gathered, we recommend our institute to implement laparoscopy instead of laparotomy myomectomy, which is the current standard procedure in our hospital.

How noninvasive treatment of uterine fibroids affects endometrial receptivity: a prospective cohort study

OBJECTIVE

To investigate the effect of the ultrasonic energy during MRI-guided high-intensity focused ultrasound ablation (HIFU) of uterine fibroids on molecular and tissue markers of endometrial receptivity in women of reproductive age.

MATERIAL AND METHODS

A prospective cohort study of 60 women of reproductive age was conducted. The main group consisted of 32 patients suffering from the symptomatic course of uterine fibroids who received treatment with HIFU ablation of uterine fibroids. The control group consisted of 28 healthy fertile women examined voluntarily. The endometrium obtained with pipelle biopsy on days 20-22 of the cycle was examined by scanning electron microscopy and immunohistochemistry before and three months after the treatment. The results were processed by the method of variation statistics using the SPSS 22.0.

RESULTS

The focused ultrasound rays passing through the endometrium did not cause any change in the maturation rate or the state of intercellular contacts. At the same time, a significant increase in the frequency of asynchronous maturation of pinopodia was found to be 14.28% before HIFU versus 50.00% after HIFU; p = .021 and the number of heteromorphic secretory cells 5.88% before HIFU versus 53.33% after HIFU; p = .002 in implantation endometrium. A significant decrease in the stromal expression of CD95^+bright in the endometrium to the level comparable with control values was observed after HIFU (from 70.22 ± 9.77 c/s to 48.81 ± 5.47 c/s; p < .001; the control level - 47.80 ± 2.13 c/s). The ratio and expression of steroid receptors, proliferation markers, p53-dependent apoptosis and its blockers, regulators and markers of angiogenesis, LIF and LIF-R signaling molecules in the stroma and endometrial glands did not change significantly after treatment.

CONCLUSION

This study did not reveal any significant negative effects of HIFU ablation of uterine fibroids on endometrial receptivity in women of reproductive age.

Fertility and obstetrical outcomes after robot-assisted laparoscopic myomectomy

OBJECTIVE

To evaluate fertility after robot-assisted laparoscopic myomectomy (RALM) in terms of pregnancy rates, and obstetrical outcomes.

PATIENTS

This is a retrospective cohort of RALM performed for symptomatic leiomyomas among women who want to conceive. Medical data were retrospectively reviewed. An office hysteroscopy was prescribed 3 months after the surgery.

RESULTS

Fifty-three patients were included. The mean number of myomas was 2 ± 1.5 with a mean size of 69 ± 17.7 mm. A breach of the cavity was noticed in 15.1% of the cases. Two cases of intrauterine adhesions were diagnosed and treated during the post-operative office hysteroscopy (5.7%). Clinical pregnancy rates were 52.8% with a live birth rate of 41.5% in patients desiring pregnancy. A caesarean section was performed in 17 cases (70.8%). No case of uterine rupture was reported.

CONCLUSION

More than half of the patients became pregnant after RALM. A low rate of obstetrical complications was reported, with no uterine ruptures, highlighting the promise of this technique for infertile patients.

Three-dimensionally-printed models in reproductive surgery: systematic review and clinical applications

INTRODUCTION

3D printing has wide application in medicine while it provides customizability and precision for anatomical model development. Our aims were to perform a systematic review and to explore the use of 3D printing applications on human reproduction and reproductive surgery.

EVIDENCE ACQUISITION

We have performed a systematic review in PubMed database to assess previous publications within 3D printing in human reproduction and gynecology. We have developed 3D models according to patients' magnetic resonance images (MRI). MRI were transformed into DICOM images that originated our 3D virtual models and PolyJet technology was applied for the printing process. We included two infertile patients in reproductive age with surgical indication for hysteroscopy septoplasty and myomectomy.

EVIDENCE SYNTHESIS

Of 1965 studies searched, we excluded 1934 publications based on their titles. Abstracts of 31 remained studies were read, and 24 studies were selected for full-text analysis. We included 11 studies for the systematic review, based on our eligibility criteria. We have designed four 3D models (uterus, ovaries, uterine cervix and uterus with fibroids) that provided enriched information to improve pre-surgical planning, medical training, fertility-sparing surgery, patient comprehension of surgical procedures and assisted reproduction applications.

CONCLUSIONS

3D models for human reproduction are feasible. They might improve assisted reproductive techniques, help in pre-surgical planning for reproductive surgeries, and provide accurate measures of ovarian reserve. Besides, we see future applications in endometrioma research and in the fabrication of devices, such as embryo transfer catheter and a 3D printed embryo.