Laparoscopic blockage of uterine artery and myomectomy

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.

DESIGN

Randomized, controlled, prospective study (Canadian Task Force classification I).

SETTING

Obstetrics and gynecology department in Jinhua Municipal Central Hospital.

PATIENTS

Women with symptomatic uterine myoma.

INTERVENTIONS

Sixty-four patients with symptomatic uterine myomas were randomly divided into trial (group A, n = 33) and control groups (group B, n = 31). Temporary bilateral uterine artery occlusion and myomectomy were used in group A and laparoscopic myomectomy only in group B. Operative time, perioperative bleeding, follow-up relief of menorrhagia, and recurrence of myomas were evaluated.

MEASUREMENTS AND MAIN RESULTS

All patients in this study underwent successful laparoscopic operation without intraoperative complications. Operative time between groups was not significantly different (p = .255 in single-myoma group and p = .811 in multiple-myoma group), blood loss in group A was notably lower than the conventional surgery group (p < .001). At final follow-up (2 years), recurrence rate and menorrhagia symptom relief were not statistically significant (p = .828 and p > .999, respectively). The fertility index of antimüllerian hormone showed no statistical difference between groups preoperatively or at 2 days, 3 months, 6 months, and 1 year postoperatively (p = .086, p = .247, p = .670, p = .753, and p = .857, respectively).

CONCLUSION

Temporary bilateral uterine artery occlusion during laparoscopic myomectomy does not increase mean operative time, offers a possible option to reduce blood loss effectively, improves menorrhagia, and does not impact recurrence rate compared with conventional surgery.

Laparoscopic technique for identifying the main trunk of the uterine artery by tracing its superior branch

AIM

To determine the feasibility of identifying the main trunk of the uterine artery by tracing its superior branch with a laparoscopic technique.

MATERIAL AND METHODS

Ten patients with symptomatic myomas who had indication for surgical intervention were enrolled in this prospective nonrandomized study between November 2009 and February 2010.The uterine artery was identified by tracing its superior branch with a laparoscopic technique, and then performing occlusion of the uterine artery. Estimated uterus weight, operating time, blood loss, and intraoperative complications were recorded.

RESULTS

Bilateral uterine arteries were successfully isolated in all cases (n = 10) without intraoperative complications. The estimated uterine weight was 290 g (220-370 g). The operation time from the opening of anterior peritoneum of the broad ligament to the occlusion of unilateral uterine artery was 3 min (2.3-6 min). The volume of estimated blood loss was less than 10 mL.

CONCLUSION

This pilot trial demonstrated that it was feasible to locate the main trunk of the uterine artery by tracing its superior branch. This technique provided a fast modality for laparoscopic surgery.

Laparoscopic transient uterine artery occlusion and myomectomy for symptomatic uterine myoma

OBJECTIVE

To compare clinical outcomes of laparoscopic transient uterine artery ligation plus myomectomy (LTUAL) to simple laparoscopic myomectomy (LM) for symptomatic myomas.

DESIGN

Comparative observational study.

SETTING

Medical centers.

PATIENT(S)

One hundred sixty-seven patients with symptomatic myomas.

INTERVENTION(S)

Eighty-four patients underwent LTUAL and LM; 83 patients underwent LM only.

MAIN OUTCOME MEASURE(S)

Operative time, blood loss, gonadal hormone level, uterine artery resistance index, menorrhea, pregnancy rate, and recurrence rate of myoma.

RESULT(S)

The intraoperative blood loss in the LTUAL group was lower than in the LM group. The menstrual blood volume (MBV) and the menstrual period of the LTUAO group was unchanged after operation relative to the prediseased volume. No significant difference was found in the resistance index of the uterine artery blood flow, the recurrence rate, and the fertility rate between the LTUAL and LM groups.

CONCLUSION(S)

LTUAL and LM are a promising surgical treatment for symptomatic uterine myoma and did not produce any appreciable adverse effect on fertility.

Use of uterine vessel occlusion in the management of uterine myomas: two different approaches

OBJECTIVE

To evaluate the difference between uterine artery occlusion alone (UAO) and combined (UVO) with simultaneous blockage of anastomosis between the uterine and ovarian vessels in the management of women with myomas in a 3-year follow-up.

DESIGN

Case-control study.

SETTING

University-associated hospital.

PATIENT(S)

One hundred ten patients with uterine fibroids.

INTERVENTION(S)

Forty-four patients underwent UAO and 66 patients UVO; patients were matched using a statistically generated selection of all UVOs performed during the same period.

MAIN OUTCOME MEASURE(S)

Outcomes were assessed by comparing surgical parameters, immediate postoperative recovery, and therapeutic outcomes.

RESULT(S)

During the 3-year follow-up, the majority of patients in both groups reported symptom relief (ranging from 61.5% to 84.6% in the UVO group and 31.6% to 77.3% in the UAO group, on the basis of different kinds of symptoms). However, symptom control seemed to be different between the two groups when the follow-up time was prolonged; for example, symptom control was better in the UVO group at the end of 3 years, especially for menorrhagia (76.5% vs. 34.5%). The fibroid size was smaller in the UVO group, resulting in a lower reintervention rate, compared with the UAO group (13.6% vs. 36.4%).

CONCLUSION(S)

If UVO is used for uterine fibroids, the 3-year efficacy might be better than that with UAO. This finding is worthy of further investigation.

Changes in uterine blood flow following laparoscopic myomectomy with or without uterine artery ligation on two- and three-dimensional power Doppler ultrasound

OBJECTIVE

To evaluate differences in uterine perfusion following laparoscopic myomectomy with or without uterine artery ligation (UAL).

METHODS

From November 2005 to July 2007, we enrolled prospectively 105 women with symptomatic myomas who were scheduled to undergo laparoscopic myomectomy (57 with UAL (study group) and 48 without (control group)). Power Doppler ultrasound was used to evaluate uterine artery resistance (RI) and pulsatility (PI) indices and peak systolic velocity (PSV) and three-dimensional (3D) power Doppler ultrasound was used to obtain vascularization (VI), flow (FI) and vascularization flow (VFI) indices of the uterine tissue, which were calculated by VOCAL (Virtual Organ Computer-aided AnaLysis) software.

RESULTS

Characteristics of the myomas, operative time and duration of hospital stay were comparable between the two groups, whereas the median (range) of estimated blood loss (50 (50-200) vs. 100 (50-900) mL, P = 0.001) and the frequency of excessive bleeding of > 500 mL (0% vs. 10%, P = 0.018) were significantly lower in the study group. The RI, PI and PSV were comparable between the two groups preoperatively, significantly lower in the study group 1 week after surgery (0.69 vs. 0.74, 1.31 vs. 1.76, and 34.08 vs. 47.49, respectively, P < 0.05), and comparable again 3 months later. The myometrial VI and VFI decreased after surgery and all three 3D power Doppler indices of the study group were similar to those of the control group throughout the study period.

CONCLUSION

Concurrent UAL during laparoscopic myom- ectomy reduces the intraoperative blood loss and frequency of excessive bleeding without permanently compromising uterine perfusion.

La myomectomie par cœlioscopie en 2007: état des lieux

With fifteen years of development, laparoscopy for myomectomy has proven its advantages. However, this technique remains controversial concerning its feasibility and the quality of uterine scar obtained. Laparoscopic myomectomy (LM) is usually indicated when number of myomas is less than 3 to 4 with a 8 to 9 cm maximal size. Surgical technique is standardized and intervention time becomes acceptable. Risk of conversion ranges between 1 to 3% when technique is realized by trained surgeon. Bleeding is less important compared with laparotomy and immediate postoperative complications are exceptional. Results concerning fertility are positive with more than 50% of infertile patient conceiving after surgery, this rate rising up to 61 to 76% for myomas isolated cause for infertility; these values can be compared with myomectomy realized by laparotomy. Postoperative adhesions seem to be less important after laparoscopy when compared with laparotomy but this point needs to be confirmed. Risk of uterine rupture is estimated between 0 to 1%, but this point needs for larger series evaluation and needs to be compared with pregnancies after laparotomy. Laparoscopic myomectomy is a feasible technique, safe for patients waiting for conception and has proven its interest in case of infertility.