A randomized comparison of vasopressin and tourniquet as hemostatic agents during myomectomy

One case report and literature review of arrhythmia caused by pituitrin

Arrhythmias are perceived as a complication of pituitrin. However, injecting a standard dose of pituitrin via vein causes different arrhythmias. In our case, a 35-year-old female patient was admitted to the hospital due to a productive cough with sputum for 5 days and two occasions of massive hemoptysis. After 1 day of treatment using 500 ml normal saline with 10u pituitrin, the sputum was filled with small amounts of kermesinus bloodstains. When pituitrin was stopped without any other treatment, all presenting symptoms gradually subsided after half an hour, and the ECG returned to normal. Therefore, when treating massive hemoptysis by administering pituitrin intravenously, it is necessary to exercise great precaution and therapeutic measures.

Reducing blood loss during laparoscopic myomectomy using a tourniquet loop around the lower uterine segment

OBJECTIVE

To present a simple and effective hemostatic technique using a tourniquet loop during laparoscopic myomectomy.

DESIGN

Pericervical tourniquet has been proven to be a safe and effective measure to reduce blood loss during open myomectomy. However, the use of a tourniquet in laparoscopic myomectomy has been rarely reported probably because the application is difficult and troublesome. In our technique, a prefabricated tourniquet loop, adapted from a Foley catheter, is applied around the lower segment of the uterus. It is easy to apply a tourniquet loop around the lower uterine segment during laparoscopic myomectomy. There is no need to make a window in the broad ligament to apply a pericervical tourniquet or triple tourniquets. Meanwhile, complete blockage of blood supply from the uterine artery and utero-ovarian anastomoses may ensure better hemostasis.

SETTING

A tertiary hospital.

PATIENT(S)

The patient was a 34-year-old woman with uterine leiomyoma and a desire for future fertility. She had been suffering from urinary frequency and chronic bladder pressure for the past 6 months. Magnetic resonance imaging confirmed 2 intramural masses measuring 96 mm × 91 mm and 25 mm × 13 mm at the anterior uterine wall.

INTERVENTION(S)

Institutional review board and ethics committee approval was obtained. Laparoscopic myomectomy was performed with the application of a tourniquet loop around the lower segment of the uterus (step-by-step video demonstration): homemade tourniquet loop formation using a 14-Fr latex Foley catheter; trocar placement with 2 umbilical ports (10 mm and 5 mm) and a 5-mm port at the lower-left quadrant of the abdomen; application of a tourniquet loop around the lower uterine segment; tumor enucleation and myometrial closure; removal of the tourniquet loop and a check for bleeding; contained specimen extraction via the merged umbilical incision; and inspection of the abdominal cavity and closure of the merged umbilical incision.

MAIN OUTCOME MEASURE(S)

Feasibility of using a tourniquet loop as an effective hemostatic technique in laparoscopic myomectomy.

RESULT(S)

The surgery lasted for approximately 90 minutes, and the tourniquet time was approximately half an hour. The estimated blood loss was only 20 mL. Her hemoglobin value on day 1 after the surgery was 131 g/L, the same as the preoperative level. Pathology confirmed the diagnosis of leiomyoma. The patient was discharged 2 days after the surgery with no complications. During follow-up, the patient reported that there was no discomfort and that her menses were normal. Her fallopian tubes were patent in the hysterosalpingogram. Her ovarian function, which was assessed by serum follicle-stimulating hormone concentration (5.34 mIU/mL) on day 3 of her menstrual cycle and antimüllerian hormone level (2.01ng/mL), was in the normal range. She was suggested to conceive 1 year after the procedure.

CONCLUSION(S)

Application of a tourniquet loop around the lower uterine segment is a simple and effective hemostatic technique during laparoscopic myomectomy. Randomized prospective studies are needed to determine the hemostatic effect of the laparoscopic use of a tourniquet loop and its impact on fertility and ovarian function.

Lipoleiomyomas of the Uterine Cervix: A New Series including the First Recurrent Case and the First Systematic Literature Review

Uterine leiomyomas usually arise from the uterine body (95%), and rarely from the cervix (0.6%) or other urogenital sites. Lipoleiomyomas are benign, uncommon variants of leiomyomas (0.03-0.2%), histologically composed of smooth muscle cells and mature adipocytes; they usually occur in the uterine body and exceptionally in the cervix. We performed the first systematic literature review of cervical lipoleiomyomas (PRISMA guidelines), presenting five new cases. Including our series, thirty-one detailed cases were reported in the literature (mainly in Asia). The age range was 35-74 years, revealing a higher mean age than conventional cervical leiomyomas (46.5 vs. 39.4 years). Patients were usually multiparous (94%), typically complaining of vaginal bleeding (11/31, 36%), pelvic/abdominal pain (10/31, 32%), and/or urinary disturbances (6/31, 19%) 1 week to 10 months before presentation. Clinical examination revealed a pedunculated tumor (48%), or prolapse of ≥1 pelvic organs (16%). Twenty-four (77%) patients underwent total hysterectomy ± additional surgery; simple myomectomy/excision was performed in five (16%) cases. Only one (3%) of our cases recurred 2 years after partial excision; no evidence of disease was found 13 years after recurrence excision. Adipocytes occupied ≤50% of the tumor volume. Hyaline or myxoid changes and cartilaginous metaplasia were uncommon histological findings. Surgically challenging cases or pregnant patients may require expert gynecologists. Interventional radiology or conservative treatments were rarely proposed.

Effect and safety of diluted vasopressin injection on bleeding during robot-assisted laparoscopic myomectomy: a protocol for a randomised controlled pilot trial

INTRODUCTION

Even though the injection of diluted vasopressin into the uterus is expected to reduce intraoperative bleeding with decreased adverse effects during robot-assisted laparoscopic myomectomy (RALM), there is a lack of relevant trials to show its effect and safety. Thus, this study was designed to compare the effect and safety of vasopressin injection on bleedings based on dilution levels of vasopressin with constant volumes during RALM.

METHODS AND ANALYSIS

This is a randomised controlled pilot trial, where a total of 39 patients will be randomly divided into three experimental groups in a 1:1:1 ratio. All patients will be classified into the three groups based on the dilution level of vasopressin: group 1-a solution prepared by mixing 20 units of vasopressin with 100 mL of normal saline to make a total of 100 mL; group 2-a solution prepared by mixing 20 units of vasopressin with 200 mL of normal saline to make a total of 100 mL and group 3-a solution prepared by mixing 20 units of vasopressin with 400 mL of normal saline to make a total of 100 mL. During RALM, we will inject diluted vasopressin at different concentrations with a total of 100 mL. As the primary endpoint, estimated blood loss would be compared. As secondary endpoints, we will check the level of haemoglobin and haematocrit, operation time, amount of transfusion, and the period of hospitalisation. In addition, we will check other complications related to vasopressin injection.

ETHICS AND DISSEMINATION

This pilot study has been approved by the Institutional Review Board of the Seoul National University Hospital (No. H-2011-107-1174). All potential subjects will be provided written informed consent. The results of this study will be published in peer-reviewed journals and be presented at academic conferences.

TRIAL REGISTRATION NUMBERS

NCT04874246 and CKCT0006225.

Assessment of the perioperative effect of vasopressin in patients undergoing laparoscopic myomectomy: A double-blind randomised study

Background and Aims:

Myomectomy is associated with perioperative bleeding. The aim of the study is to evaluate the effect of intramyometrial vasopressin on blood loss and the associated cardiovascular complications during myomectomy.

Methods:

The study included 194 patients classified into two groups- 1) Vasopressin group: the vasopressin was diluted as 0.1 unit/ml and 15 ml was injected by the surgeon in the plane between the myometrium and the myoma. 2) Control group: The patients received an equal amount of normal saline. The monitored parameters included the amount of blood loss, required blood transfusion, heart rate, mean arterial blood pressure, the incidence of hypertension, hypotension, bradycardia, tachycardia, electrocardiogram (ECG) changes and the blood troponin I level.

Results:

The heart rate decreased significantly in both groups, but the decrease was lower with vasopressin than the control group through the time points T3 to T5 (P < 0.05) The mean arterial blood pressure increased significantly in both groups, but the increase was higher with vasopressin than the control group through T3 to T5 (P < 0.05). The amount of blood loss decreased significantly with vasopressin than the control groups (P = 0.001). The number of transfused packed red blood cells was lower with vasopressin than the control group (P = 0.001). The incidence of hypertension, bradycardia and atrial extrasystole was higher with vasopressin than the control group (P = 0.005, P = 0.012, P = 0.033, respectively).

Conclusion:

Intramyometrial vasopressin decreases blood loss and blood transfusion, but it is associated with cardiovascular complications that may be serious as reported in other studies. Therefore, anaesthesiologists and gynaecologists must follow the precautions to avoid and minimise the incidence of complications with intramyometrial vasopressin.

A double-blind randomized trial on subendometrial injection of vasopressin to control bleeding in postpartum hysterectomy due to abnormally invasive placenta

OBJECTIVE

To investigate the effect of subendometrial vasopressin injection in patients with abnormally invasive placenta (AIP), who underwent cesarean section and hysterectomy.

METHODS

This randomized double-blinded clinical trial was conducted on pregnant women diagnosed with AIP grade 4 and 5 by ultrasonography during cesarean section. Women were randomly divided into two equal groups including group 1 (vasopressin) and group 2 (control) who underwent 20 units of vasopressin and 20 cc normal saline injection, respectively. Vasopressin and placebo were injected subendometrially 1 cm medial to the uterine vessels into the lower uterine segment. The exclusion criteria include presence of myocardial infarction, cardiomyopathy, congestive heart failure, uncontrolled hypertension, chronic obstructive pulmonary disease, pelvic malignancy. The outcome of the study was total quantitative blood loss during the cesarean section. We estimated blood loss by measuring the blood volume in one of the suction bottles with addition for weight changes of mops, pads, and soaked linen savers.

RESULTS

Sixty patients were recruited into the study, 30 as the vasopressin group and 30 as the controls; with no excluded case. The amount of bleeding in the vasopressin group was significantly lower compared with that in the control group (P < 0.001). In the vasopressin group, 83.4% of patients had bleeding of less than 1.5 L, while only 3.3% of the control women had bleeding of less than 1.5 L (relative risk = 5). In addition, the number of injected packed cells was lower in the vasopressin group (P < 0.001).

CONCLUSION

It was shown that vasopressin injection can help prevent excess hemorrhage and the subsequent risks of anemia or blood transfusions during abdominal hysterectomy in women with AIP.

Current Treatment Options for Cervical Leiomyomas: A Systematic Review of Literature

Background and objectives: Cervical leiomyomas are a rare benign disease. Although they are mainly treated surgically, currently, there is not a standardized treatment for cervical leiomyomas. This study aims to summarize current literature evidence about treatment options for cervical leiomyomas. Materials and methods: A systematic research of the literature was conducted in Scopus, PubMed/MEDLINE, ScienceDirect, and the Cochrane Library, including observational prospective and retrospective studies, case series and case reports. We collected data regarding studies related to treatment options for cervical leiomyomas, evaluating the following aspects: study design, population, treatment type, rate of surgical complications, and fertility outcome. Results: According to literature research, 38 articles were included. Among 214 patients, the weighted average age was 39.4 years-old; 23 patients were pregnant. Most of the leiomyomas (78%) were extracervical; in 22% of cases (29 patients) were intracervical; 188 patients (88%) received surgical treatment, 6 (3%) received exclusive conservative management and 21 (10%) underwent interventional radiology treatment. One hundred twenty-seven patients (67.5%) underwent myomectomy, while 54 (28.7%) and 7 (3.7%) hysterectomy and trachelectomy, respectively. Cervical myomectomy was performed by open surgery in 21 out of 127 cases (16.5%), while in 92 (72.4%) and 6 (4.7%) patients the surgical approach was performed by traditional and robot-assisted laparoscopy, respectively. The total rate of surgical complications was 5.6%. Conclusion: Surgery is the primary therapeutic option for cervical leiomyomas with a low rate of surgical complications. Interventional radiology techniques have reported promising but still limited results.

Effectiveness of laparoscopic ultrasonography in laparoscopic myomectomy

INTRODUCTION

Laparoscopic myomectomy (LM) has become increasingly common in recent years because it minimizes invasiveness. However, myoma can recur after myomectomy. Therefore, we began using laparoscopic ultrasonography, which involves inserting a probe into the peritoneal cavity via a trocar and placing it in direct contact with the uterus. During surgery, this enables the detection of myomas as a small as 1 mm in diameter, which are often undetectable on MRI. Here, we report the effectiveness of laparoscopic ultrasonography.

METHODS

The subjects were 26 women who underwent LM at our institution from February 2015 to December 2016. Preoperative MRI was performed, and all myomas detected on MRI were removed during LM. Laparoscopic ultrasonography was then performed to assess for residual myomas, which were removed.

RESULTS

In six patients (23%), residual myomas were identified on laparoscopic ultrasonography after the first enucleation of the myomas detected on preoperative MRI. All detected residual myomas, the largest of which was less than 10 mm in diameter, were removed.

CONCLUSION

Small myomas undetectable on preoperative MRI were detected on laparoscopic ultrasonography and removed.

Control of postpartum hemorrhage in women with placenta accreta spectrum using prophylactic balloon occlusion combined with Pituitrin intra-arterial infusion

OBJECTIVES

The aim of this study is to evaluate the efficacy of prophylactic internal iliac artery balloon occlusion combined with Pituitrin intra-arterial infusion in the control of postpartum hemorrhage in women with placenta accreta spectrum (PAS).

METHODS

This is a prospective and non-randomized controlled study. The participants were assigned into three groups: without balloon catheterization (non-BC) group, balloon catheterization (BC) group, and Pituitrin combined with balloon catheterization (PBC) group. The primary outcomes were estimated blood loss (EBL) and the units of transfused packed red blood cells (PRBC). The secondary outcome was the incidence of hysterectomy.

RESULTS

A total of 100 participants were recruited between August 2013 and November 2018 and assigned into the respective groups as follows: 27 in the non-BC group, 22 in the BC group, and 51 in the PBC group. No statistical differences were found in demographic characteristics among the three groups. There was a trend of lower EBL, PRBC, and hysterectomy rate in the BC group than those in the non-BC group, while all values showed no significant differences (all p > 0.05). Patients in the PBC group had significantly lower EBL, PRBC, and hysterectomy rate compared with those in the non-BC group (all p < 0.05). Linear regression analysis revealed that the PBC (vs. others) was negatively correlated with EBL and the non-BC (vs. others) independently predicted more EBL.

CONCLUSIONS

Balloon occlusion combined with Pituitrin infusion is an effective treatment method which significantly reduced EBL, PRBC, and hysterectomy rate in patients with PAS.

KEY POINTS

• Internal iliac artery balloon occlusion combined with Pituitrin intra-arterial infusion can significantly decrease EBL, PRBC, and hysterectomy rate during cesarean section in patients with PAS. • Cesarean section without balloon occlusion and placenta accreta depth are two independent risk factors for EBL in patients with PAS.

Comparing perioperative vaginal misoprostol with intraoperative pericervical hemostatic tourniquet in reducing blood loss during abdominal myomectomy: A randomized controlled trial

Objective:

To compare the effectiveness of perioperative vaginal misoprostol with intraoperative pericervical hemostatic tourniquet in reducing blood loss during abdominal myomectomy.

Material and Methods:

A randomized controlled trial involving women with uterine leiomyoma who underwent abdominal myomectomy was conducted at a tertiary facility in Nigeria. Participants were recruited after they gave informed consent and randomized into group I (single dose 400 μg vaginal misoprostol one-hour before surgery) and group II (intraoperative pericervical hemostatic tourniquet). Eighty participants (40 in each group) were recruited. Uterine size was measured in centimeters above the pubic symphysis, and blood loss estimation involved direct volume measurement and gravimetric methods. The main outcome measures were intraoperative blood loss, blood transfusion, and recourse to hysterectomy. Ethical approval and trial registration were obtained; the data were analyzed using the SPSS software version 21.0; p<0.05 was considered significant.

Results:

Participants in group I had higher mean intraoperative blood loss (931.89±602.13 vs 848.40±588.85 mL, p=0.532), intra-operative blood transfusion rates (60 vs 55%; p=0.651) and mean units of blood transfused (1.30±1.20 vs 1.20±1.30; p=0.722) compared with group II. The mean uterine size (19.50±6.93 vs 20.05±6.98 cm; p=0.725) and number of fibroid nodules (11.25±7.99 vs 11.45±8.22; p=0.912) were comparable. The change in post-operative hematocrit was 2.66±2.21% vs 3.24±2.85% (p=0.315) and post-operation blood transfusion was 2.5 vs 5% (p=0.556). There was no recourse to hysterectomy in either of the study groups. While adverse effects of misoprostol occurred in 5 (12.5%) participants of group I.

Conclusion:

The effectiveness of perioperative vaginal misoprostol is comparable to intra-operative hemostatic pericervical tourniquet in reducing blood loss during abdominal myomectomy.

Oxytocin infusion reduces bleeding during abdominal myomectomies: a randomized controlled trial

PURPOSE

To evaluate the effectiveness of oxytocin infusion to reduce intraoperative bleeding during abdominal myomectomies.

METHODS

This randomized, parallel group, blinded study was conducted between October 2017 and May 2018. Patients undergoing abdominal myomectomies were randomized 1:1 either to the oxytocin group or to the control group (saline). In the oxytocin group, 10 IU oxytocin in 500 ml of saline at a rate of 120 ml/h was given during the course of the operation. The primary outcome of this study was to measure intraoperative blood loss between the study groups. Correlation and multiple regression analysis were performed to illustrate factors associated with intraoperative blood loss during the myomectomy.

RESULTS

The mean intraoperative blood loss during the surgery was 489.20 ± 239.72 ml in the oxytocin group and was 641.40 ± 288.21 ml in the control group. The hemoglobin decline was more evident in the control group than in the oxytocin group. Positive correlations were also observed between the intraoperative blood loss and number of fibroids removed during the surgery, largest fibroid removed and weight of fibroids removed. The use of oxytocin infusion during the myomectomy resulted in a reduction of bleeding in the regression model.

CONCLUSION

Intravenous oxytocin infusion is a safe and practical method to reduce intraoperative blood loss during the abdominal myomectomy.

[Prevention of bleeding during laparotomic myomectomy in Sub-Saharan Africa: Contribution to the tourniquet on the uterine isthmus]

OBJECTIVES

To appreciate the decrease of bleeding by myomectomy by the use of a tourniquet on the uterine isthmus.

METHODS

We conducted a case-control retrospective study from March 2014 to February 2016 in the Gynecology and obstetrics Department of the university hospital of Yopougon (Abidjan, Ivory Coast). It interested 100 patients of which 50 had a myomectomy with the tourniquet on the uterine isthmus and 50 without the tourniquet. None of the patients received pre-operative preventive treatment. The criteria for comparison were the blood loss per operative and the pre-and post-operative hemoglobin levels.

RESULTS

The average age of patients was 33 years. Nulliparous women were the group most affected (68% of our patients) with 32% infertile women in the group with the tourniquet and 18% in the group without the tourniquet. Patients without tourniquet presented more bleeding than patients with tourniquet (X2=13.61) with a higher proportion of anemic patients in the group without the tourniquet. The differences were significant. The tourniquet has made it possible to realize the resection of a larger number of myoma. The duration of hospital stay was 4 days on average in both groups and no complications were observed.

CONCLUSIONS

The application of a tourniquet on the uterine isthmus during laparotomic myomectomy has a benefit in reducing intraoperative blood loss.

Comparison of intramyometrial vasopressin plus rectal misoprostol with intramyometrial vasopressin alone to decrease blood loss during laparoscopic myomectomy: Randomized clinical trial

OBJECTIVE

To compare the efficacy and safety of intramyometrial vasopressin plus rectal misoprostol with intramyometrial vasopressin alone to reduce blood loss during laparoscopic myomectomy.

STUDY DESIGN

A randomized, single-blind, controlled trial was conducted at All India Institute of Medical Sciences, New Delhi, India. Sixty women with symptomatic leiomyoma scheduled for laparoscopic myomectomy were recruited for the study. Thirty women received intramyometrial vasopressin plus rectal misoprostol (30 min before procedure) (Group I) and 30 women received intramyometrial vasopressin alone (Group II) during laparoscopic myomectomy. The primary outcome measure was intra-operative blood loss during surgery. Secondary outcome measures included decrease in postoperative haemoglobin, ease of enucleation of myomas, duration of surgery, need for additional haemostatic measures or blood transfusion, intra- and postoperative morbidity, and duration of hospital stay.

RESULTS

The baseline demographic features and characteristics of leiomyomas were comparable in both groups. The mean (±standard deviation) blood loss in Group I was 139 ± 96.7 ml, which was significantly less than that for Group II (206 ± 101.2 ml) (p = 0.008). The mean postoperative haemoglobin was 11.6 ± 1.3 g/dl in Group I and 10.0 ± 1.2 g/dl in Group II (p = 0.001). Although blood loss was not clinically significant in either group, the decrease in haemoglobin was significantly higher in Group II. The mean score for ease of enucleation (surgeon-rated measure) was significantly lower in Group I (2.6 ± 1.1) compared with Group II (3.4 ± 1.1) (p = 0.029). Intra- and postoperative vital signs, duration of surgery, need for blood transfusion and postoperative morbidity were comparable in both groups.

CONCLUSIONS

The addition of rectal misoprostol to intramyometrial vasopressin led to a significant reduction in blood loss and decreased the postoperative drop in haemoglobin. The combination also improved the ease of enucleation of myomas.

Vasopressin during Laparoscopic Myomectomy: Does It Really Extend Its Limits?

STUDY OBJECTIVE

Τo investigate whether the use of vasopressin played an important role in the safe expansion of the indications of laparoscopic myomectomy in our practice.

DESIGN

A retrospective comparison of prospectively collected data (Canadian Task Force classification II2).

SETTING

A gynecologic endoscopy unit in a tertiary university hospital.

PATIENTS

One hundred fifty patients undergoing laparoscopic myomectomy; 50 were treated without the use of any vasoconstrictive agent (group 1), and 100 were treated with intraoperative intramyometrial injection of dilute vasopressin (20 IU/100 mL normal saline) (group 2).

INTERVENTIONS

Laparoscopic myomectomy.

MEASUREMENTS AND MAIN RESULTS

We compared the 2 groups in terms of size, number, and type of myomas; estimated blood loss (EBL); procedure length; transfusion rates; laparoconversion rates; and rates of complications. Two cases in group 1 (4%) were laparoconverted versus none (0%) in group 2. Overall, the mean EBL was 321.8 ± 246.0 mL in group 1 compared with 147.8 ± 171.8 mL in group 2, respectively (p <.001). Additionally, EBL was significantly lower in the vasopressin group in all of the study's subgroups of patients stratified according to the size and number of myomas. Procedure length did not differ significantly between the 2 groups (130.8 ± 49.5 vs 115.6 ± 49.4 minutes, p = .078). The risk factors for prolongation of the procedure included size and number of myomas independently of vasopressin. The rates of hypercapnea and subcutaneous emphysema were higher in group 1. The risk factors for hypercapnea and subcutaneous emphysema included the size and intramural position of the largest myoma. Vasopressin was not associated with serious cardiovascular adverse events.

CONCLUSIONS

Vasopressin is effective in reducing blood loss during laparoscopic myomectomy. Although experienced surgeons may achieve comparable operation times without vasopressin, even in the most challenging cases, blood loss may still be considerable. The occurrence of hypercapnea is higher in untreated cases and may contribute to laparoconversion.

Recurrence of uterine myoma after myomectomy: Open myomectomy versus laparoscopic myomectomy

AIM

Open myomectomy (OM) was previously frequently performed; however, laparoscopic myomectomy (LM) has recently become more common. Nevertheless, myoma can recur after both LM and OM. In this study, we report our retrospective investigation of myoma recurrence by comparing LM and OM.

METHODS

A total of 474 patients underwent LM and 279 patients underwent OM. The patients were followed-up postoperatively from six months to eight years. Recurrence was confirmed when a myoma with a diameter of ≥ 1 cm was detected. Post-LM, post-OM and cumulative recurrence rates were investigated, and a Cox hazard test was performed.

RESULTS

The cumulative recurrence rates between the two groups were 76.2% (LM) vs. 63.4% (OM) at eight years postoperatively. A log-rank test revealed a significant difference between the two groups. Cox hazard testing revealed that LM, a larger number of enucleated myoma masses and the absence of postoperative gestation significantly contributed to the postoperative recurrence rate.

CONCLUSIONS

LM yielded a higher recurrence rate than OM, likely a result of manual myoma removal in OM, which is a more exhaustive extraction of smaller myoma masses than performed in LM. In other words, fewer residual myoma masses after OM contribute to a lower postoperative recurrence rate.

The utility and effectiveness of an internal iliac artery balloon occlusion catheter in surgery for large cervical uterine fibroids

OBJECTIVE

Surgery for uterine cervical fibroids is difficult because of restricted surgical access and risks such as intraoperative bleeding or injury to other organs. The internal iliac artery balloon occlusion catheter (IIABOC) provides effective hemostasis for placenta previa and atonic hemorrhage, and is increasingly used in surgery for uterine fibroids for controlling intraoperative hemorrhage. We investigated the efficacy and safety of the IIABOC for controlling intraoperative bleeding in total abdominal hysterectomies (TAH) and abdominal myomectomies (AM) for large cervical fibroids.

MATERIAL AND METHODS

From 2007 to 2014, the IIABOC was used in 22 cases (12 for TAH and 10 for AM) in which cervical fibroids fully occupied the pelvic cavity. Intraoperative blood loss, operating time, sample weight, use of blood transfusion, and injury to other organs were assessed.

RESULT

Mean blood loss, operative time, and sample weight in the IIABOC cases were 510 mL, 178 min, and 2550 g for TAH; and 727.5 mL, 157.5 min, and 1850 g for AM. Blood loss divided by sample weight in IIABOC cases was significantly lower than that in non-IIABOC cases during the same time period, for both TAH and AM. Allogeneic blood transfusion was not necessary, and complications of injury to other organs did not occur in any of the 22 cases.

CONCLUSIONS

For large cervical fibroids with limited operating space, surgery was performed under bleeding control by occlusion of the internal iliac artery with an IIABOC. This technique enables control of hemorrhage and safe operative management in gynecological surgery.

Transient occlusion of uterine arteries in laparoscopic uterine surgery

BACKGROUND AND OBJECTIVES

This study was conducted to determine the feasibility and effectiveness of transient occlusion of the uterine arteries (TOUA) during laparoscopic surgery for benign uterine tumors, with preservation of fertility.

METHODS

Patients with uterine myoma or adenomyoma underwent laparoscopic uterine surgery, with or without TOUA, performed by a single surgeon (Y.-S.K.). Surgical outcomes included operative time; occurrence of intraoperative injury of blood vessels, nerves, and pelvic organs; and intraoperative blood loss.

RESULTS

Of the 168 surgical patients included in this study, 144 were enrolled consecutively during the study period, and 24 had undergone adenomectomy before the study period. A total of 104 women (70 with myoma; 34 with adenomyoma) seeking uterine preservation underwent laparoscopic surgery with TOUA for benign uterine tumors. Sixty-four women (40 with myoma; 24 with adenomyoma) underwent surgery without TOUA. The mean total surgical time of the TOUA groups was 74.85 minutes for uterine myoma and 84.09 minutes for uterine adenomyoma. The mean estimated blood loss during laparoscopic myomectomy and adenomyomectomy was less in the TOUA groups than in the non-TOUA groups (109 vs. 203.4 mL in myomectomy, P < .05; 148.1 vs. 158.9 mL in adenomyomectomy; P < .05). Time to perform TOUA was 13.9 minutes in laparoscopic myomectomy and 7.33 minutes in laparoscopic adenomyomectomy. The hospital stay of the TOUA groups was 3.32 days for uterine myoma and 3.82 days for uterine adenomyoma. No intraoperative conversion to laparotomy was necessary, and no major complications occurred during any of the procedures.

CONCLUSION

Laparoscopic uterine surgery with TOUA could be a safe and effective surgical method for women with symptomatic benign uterine tumors who wish to preserve fertility.

Hemostatic Techniques for Myomectomy: An Evidence-Based Approach

Uterine leiomyomas are the most common benign gynecologic tumor. They are also a significant cause of morbidity, necessitating treatments ranging from hormonal suppression to surgical intervention. Myomectomy, the removal of these highly vascular tumors, offers significant quality of life and fertility-sparing benefit for patients affected by uterine leiomyomas but with a risk of substantial intraoperative blood loss. This risk of hemorrhage leads not only an increased transfusion rate but also he need for hysterectomy and other potential operative complications. Numerous medical and surgical techniques have been developed to minimize potentially significant blood loss during abdominal, laparoscopic, and robotic-assisted myomectomies. Combined with judicious preoperative assessment, these techniques substantially enhance patient safety during a myomectomy and outcomes during recovery.

Techniques to reduce blood loss during open myomectomy: a qualitative review of literature

Open myomectomy is the most adopted surgical strategy in the conservative treatment of uterine fibroids. According to several studies, the likelihood that a woman could develop uterine myomas is estimated around 75% by the age of 50. Open myomectomy is nonetheless a complicated surgery in terms of blood loss and need for transfusion. Many strategies have been published with the aim of limiting intra and post-operative bleeding complications. The scope of this review is to describe in detail the different techniques reported in literature focusing on their validity and safety.

Transient occlusion of uterine arteries in laparoscopic uterine surgery

Background and Objectives:

This study was conducted to determine the feasibility and effectiveness of transient occlusion of the uterine arteries (TOUA) during laparoscopic surgery for benign uterine tumors, with preservation of fertility.

Methods:

Patients with uterine myoma or adenomyoma underwent laparoscopic uterine surgery, with or without TOUA, performed by a single surgeon (Y.-S.K.). Surgical outcomes included operative time; occurrence of intraoperative injury of blood vessels, nerves, and pelvic organs; and intraoperative blood loss.

Results:

Of the 168 surgical patients included in this study, 144 were enrolled consecutively during the study period, and 24 had undergone adenomectomy before the study period. A total of 104 women (70 with myoma; 34 with adenomyoma) seeking uterine preservation underwent laparoscopic surgery with TOUA for benign uterine tumors. Sixty-four women (40 with myoma; 24 with adenomyoma) underwent surgery without TOUA. The mean total surgical time of the TOUA groups was 74.85 minutes for uterine myoma and 84.09 minutes for uterine adenomyoma. The mean estimated blood loss during laparoscopic myomectomy and adenomyomectomy was less in the TOUA groups than in the non-TOUA groups (109 vs. 203.4 mL in myomectomy, P < .05; 148.1 vs. 158.9 mL in adenomyomectomy; P < .05). Time to perform TOUA was 13.9 minutes in laparoscopic myomectomy and 7.33 minutes in laparoscopic adenomyomectomy. The hospital stay of the TOUA groups was 3.32 days for uterine myoma and 3.82 days for uterine adenomyoma. No intraoperative conversion to laparotomy was necessary, and no major complications occurred during any of the procedures.

Conclusion:

Laparoscopic uterine surgery with TOUA could be a safe and effective surgical method for women with symptomatic benign uterine tumors who wish to preserve fertility.

Interventions to reduce haemorrhage during myomectomy for fibroids

BACKGROUND

Benign smooth muscle tumours of the uterus, known as fibroids or myomas, are often symptomless. However, about one-third of women with fibroids will present with symptoms that are severe enough to warrant treatment. The standard treatment of symptomatic fibroids is hysterectomy (that is surgical removal of the uterus) for women who have completed childbearing, and myomectomy for women who desire future childbearing or simply want to preserve their uterus. Myomectomy, the surgical removal of myomas, can be associated with life-threatening bleeding. Excessive bleeding can necessitate emergency blood transfusion. Knowledge of the effectiveness of the interventions to reduce bleeding during myomectomy is essential to enable evidence-based clinical decisions. This is an update of the review published in The Cochrane Library (2011, Issue 11).

OBJECTIVES

To assess the effectiveness, safety, tolerability and costs of interventions to reduce blood loss during myomectomy.

SEARCH METHODS

In June 2014, we conducted electronic searches in the Cochrane Menstrual Disorders and Subfertility Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL and PsycINFO, and trial registers for ongoing and registered trials.

SELECTION CRITERIA

We selected randomised controlled trials (RCTs) that compared potential interventions to reduce blood loss during myomectomy to placebo or no treatment.

DATA COLLECTION AND ANALYSIS

The two authors independently selected RCTs for inclusion, assessed the risk of bias and extracted data from the included RCTs. The primary review outcomes were blood loss and need for blood transfusion. We expressed study results as mean differences (MD) for continuous data and odds ratios for dichotomous data, with 95% confidence intervals (CI). We assessed the quality of evidence using GRADE methods.

MAIN RESULTS

Eighteen RCTs with 1250 participants met our inclusion criteria. The studies were conducted in hospital settings in low, middle and high income countries.Blood lossWe found significant reductions in blood loss with the following interventions: vaginal misoprostol (2 RCTs, 89 women: MD -97.88 ml, 95% CI -125.52 to -70.24; I(2) = 43%; moderate-quality evidence); intramyometrial vasopressin (3 RCTs, 128 women: MD -245.87 ml, 95% CI -434.58 to -57.16; I(2) = 98%; moderate-quality evidence); intramyometrial bupivacaine plus epinephrine (1 RCT, 60 women: MD -68.60 ml, 95% CI -93.69 to -43.51; low-quality evidence); intravenous tranexamic acid (1 RCT, 100 women: MD -243 ml, 95% CI -460.02 to -25.98; low-quality evidence); gelatin-thrombin matrix (1 RCT, 50 women: MD -545.00 ml, 95% CI -593.26 to -496.74; low-quality evidence); intravenous ascorbic acid (1 RCT, 102 women: MD -411.46 ml, 95% CI -502.58 to -320.34; low-quality evidence); vaginal dinoprostone (1 RCT, 108 women: MD -131.60 ml, 95% CI -253.42 to -9.78; low-quality evidence); loop ligation of the myoma pseudocapsule (1 RCT, 70 women: MD -305.01 ml, 95% CI -354.83 to -255.19; low-quality evidence); and a fibrin sealant patch (1 RCT, 70 women: MD -26.50 ml, 95% CI -44.47 to -8.53; low-quality evidence). We found evidence of significant reductions in blood loss with a polyglactin suture (1 RCT, 28 women: MD -1870.0 ml, 95% CI -2547.16 to 1192.84) or a Foley catheter (1 RCT, 93 women: MD -240.70 ml, 95% CI -359.61 to -121.79) tied around the cervix. However, pooling data from these peri-cervical tourniquet RCTs revealed significant heterogeneity of the effects (2 RCTs, 121 women: MD (random) -1019.85 ml, 95% CI -2615.02 to 575.32; I(2) = 95%; low-quality evidence). There was no good evidence of an effect on blood loss with oxytocin, morcellation or clipping of the uterine artery.Need for blood transfusion We found significant reductions in the need for blood transfusion with vasopressin (2 RCTs, 90 women: OR 0.15, 95% CI 0.03 to 0.74; I(2) = 0%; moderate-quality evidence); peri-cervical tourniquet (2 RCTs, 121 women: OR 0.09, 95% CI 0.01 to 0.84; I(2) = 69%; low-quality evidence); gelatin-thrombin matrix (1 RCT, 100 women: OR 0.01, 95% CI 0.00 to 0.10; low-quality evidence) and dinoprostone (1 RCT, 108 women: OR 0.17, 95% CI 0.04 to 0.81; low-quality evidence), but no evidence of effect on the need for blood transfusion with misoprostol, oxytocin, tranexamic acid, ascorbic acid, loop ligation of the myoma pseudocapsule and a fibrin sealant patch.There were insufficient data on the adverse effects and costs of the different interventions.

AUTHORS' CONCLUSIONS

At present there is moderate-quality evidence that misoprostol may reduce bleeding during myomectomy, and low-quality evidence that bupivacaine plus epinephrine, tranexamic acid, gelatin-thrombin matrix, a peri-cervical tourniquet, ascorbic acid, dinoprostone, loop ligation and a fibrin sealant patch may reduce bleeding during myomectomy. There is no evidence that oxytocin, morcellation and temporary clipping of the uterine artery reduce blood loss. Further well designed studies are required to establish the effectiveness, safety and costs of different interventions for reducing blood loss during myomectomy.

Interventions to reduce haemorrhage during myomectomy for fibroids

BACKGROUND

Uterine myomas (fibroids) are benign tumours of the uterus. Myomectomy, the surgical removal of myomas, can be associated with life-threatening bleeding and prolonged postoperative stay. Knowledge of the effectiveness of the interventions to reduce bleeding during myomectomy is essential to enable evidence-based clinical decisions. This is an update of the review published in The Cochrane Library Issue 3, 2009.

OBJECTIVES

To assess the effectiveness, safety, tolerability, and costs of interventions to reduce blood loss during myomectomy.

SEARCH STRATEGY

Electronic searches were undertaken in the Cochrane Menstrual Disorders and Subfertility Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 3), MEDLINE (1950 to February 2011), EMBASE (1980 to February 2011), CINAHL (1982 to February 2011), and PsycINFO (1801 to February 2011).

SELECTION CRITERIA

Only randomised controlled trials (RCTs) that compared the use of interventions to reduce blood loss during myomectomy to placebo or no treatment were included.

DATA COLLECTION AND ANALYSIS

The two authors independently selected RCTs for inclusion, assessed the methodological quality of trials, and extracted data. We expressed study results as mean differences (MD) for continuous data and odds ratios for dichotomous data, with 95% confidence intervals (CI).

MAIN RESULTS

Twelve RCTs with 674 participants met our inclusion criteria. The interventions were intramyometrial vasopressin (two RCTs), intravenous oxytocin (two RCTs), peri-cervical tourniquet (two RCTs), and one RCT each for vaginal misoprostol, gelatin thrombin matrix, chemical dissection with sodium-2-mercaptoethane sulfonate (mesna), intramyometrial bupivacaine plus epinephrine, tranexamic acid, and myoma enucleation by morcellation. We found significant reductions in blood loss with misoprostol (MD -149.00 ml, 95% CI -229.24 to -68.76), vasopressin (MD -298.72 ml, 95% CI -593.10 to -4.34; I(2) = 99%), bupivacaine plus epinephrine (MD -68.60 ml, 95% CI -93.69 to - 43.51), tranexamic acid (MD -243 ml, 95% CI -460 to -25.98), peri-cervical tourniquet (MD -289.44, 95% CI -406.55 to -172.32; I(2) = 95%), and gelatin-thrombin matrix (MD -545.00 ml, 95% CI -593.26 to -496.74). There was no evidence of an effect on blood loss with oxytocin or morcellation. None of the interventions significantly increased myomectomy-related complications. The trials did not assess the costs of the different interventions.

AUTHORS' CONCLUSIONS

There is limited evidence that misoprostol, vasopressin, bupivacaine plus epinephrine, tranexamic acid, gelatin thrombin matrix, peri-cervical tourniquet, and mesna may reduce bleeding during myomectomy. Bupivacaine plus epinephrine has limited clinical importance compared with other interventions as the clinical impact was small. There is no evidence that oxytocin and morcellation reduce blood loss. Further well designed studies are required to establish effectiveness, safety and the costs of different interventions for reducing blood loss during myomectomy.

The effect of uterine blood supply cutoff during myomectomy

BACKGROUND AND OBJECTIVE

Myomectomy is considered a highly morbid procedure due to the risk of high intraoperative blood loss. Meticulous surgical techniques can reduce operative morbidity. Our aim was to evaluate and compare the intraoperative blood loss between two surgical techniques: 1) the uterine vascular cutoff technique and 2) the classical technique.

DESIGN AND SETTING

Retrospective chart review conducted between 1 July 2008 until 30 June 2010 in a tertiary care referral center to compare surgical outcomes of two groups.

PATIENTS AND METHODS

The sample included 136 patients: 30 patients had their surgeries performed with the uterine vascular cutoff technique, and the remainder (106 patients) had myomectomies performed with the classical technique. The uterine vascular cutoff technique was performed by the same surgeon for all 30 patients, whereas myomectomy with the classical technique was performed by several gynecologists.

RESULTS

There was no significant difference between the two groups in parity and operation time; however, patients in the first group had a statistically significant higher mean age (39.1 [7.6] vs 35.8 [6.9] years; P=.025) and, on average, bigger fibroid size by gestational week (20.1 [7.3] vs 17 [5.2] weeks; P=.0094), with standard deviation shown in parentheses. There was a statistically significant lesser drop in hemoglobin concentration among patients in the first group (1.23 [1.2] vs 2.25 [1.4] g/dL; P=.0003), and the postoperative hemoglobin was significantly higher in the first group (10.5 [1.6] vs 9.7 [1.7] g/dL; P=.036). The hospital stay was shorter for patients in the first group (5.8 [1.7] vs 7.1 [2.9] days; P=.031).

CONCLUSION

The vascular cutoff technique leads to less intraoperative blood loss without increasing the operative time, patients tolerate this technique very well, and the technique is associated with shorter hospital stay, all of which could contribute to less postoperative morbidity.

Comparison of the efficacy of the pulsed bipolar system and conventional electrosurgery in laparoscopic myomectomy - a retrospective matched control study

OBJECTIVE

Comparing the safety and effectiveness of the pulsed bipolar (PK) system and conventional electrosurgery in laparoscopic myomectomy (LM).

MATERIALS AND METHODS

Retrospective chart review of 194 women with symptomatic uterine fibroids undertaken LM was performed. Cases of LMs with PK cutting forceps were compared with a matched control group of standard LMs with conventional electrosurgery. Outcome measures for both groups were studied comparatively in terms of the length of operative time, amount of blood loss, requirement of blood transfusion and length of hospital stay.

RESULTS

The two groups were matched by age, body mass index, parity, previous cesarean delivery, size, number, and weight of fibroids. Amount of blood loss was significantly greater in electrosurgery group than in PK group at 243.8 ± 150.4mL versus 190.4 ± 178.5mL (p=0.025). Length of operation, hospitalization time, hemoglobin decrease, and requirement of blood transfusion were not significantly different.

CONCLUSION

Our findings indicate that PK system is more effective in LM when compared with conventional electrosurgery. PK system has advantage over conventional electrosurgery in less blood loss and may offer an alternative option for patients undergoing LM.

Vasopressin versus a combination of vasopressin and tourniquets: a comparison of blood loss in patients undergoing abdominal myomectomies

OBJECTIVE

To compare blood loss and need for blood transfusions in women who underwent abdominal myomectomies after receiving vasopressin or combined vasopressin and tourniquet.

METHODS

A retrospective chart review was performed reviewing abdominal myomectomies that took place at our institution. Subjects were divided into three groups: no intervention, vasopressin, or combined vasopressin and tourniquet. Blood loss, need for blood transfusion, and drop in hemoglobin and hematocrit were compared across all groups.

RESULTS

One-hundred and thirty-two subjects were included in the study. No statistically significant difference was found between groups in blood loss, drop in hemoglobin or hematocrit, or blood transfusions.

CONCLUSION

Combined vasopressin and tourniquets was not associated with a statistically significant decrease in blood loss or need for blood transfusion.