Laparoscopic myomectomy in peri- and post-menopausal women is safe, efficacious and associated with long-term patient satisfaction

Use of a microsurgical vascular clip system for temporary bilateral occlusion of the four main uterine vessels for laparoscopic enucleation of very large intramural uterine fibroids

Objectives

The goal of this study was to examine the safety, feasibility, and effectiveness of the use of a microsurgical temporary vascular clip system to facilitate the laparoscopic enucleation of very large intramural uterine fibroids.

Methods

In this retrospective study, the surgical outcomes of 26 patients who underwent laparoscopic myomectomy with temporary uterine vessel clipping for very large (the largest measured diameter ≥ 9 cm) symptomatic intramural uterine fibroids in two tertiary referral hospitals between September 2017 and March 2020 were examined. Titan-made vascular clips (YASARGIL^® Aneurysm Clip System) were used to temporarily occlude the bilateral uterine arteries and utero-ovarian vessels. Main outcomes included operating time, blood loss, number of leiomyomas and weight, conversion rate, intra- and postoperative complication rates, and length of hospital stay.

Results

Twenty six patients were included. Dominant intramural uterine fibroid diameters were 9–22 cm. The general characteristics of the patients were similar. The mean surgery duration and intraoperative blood loss were 175.3 ± 32.7 (range 120–250) min and 241.1 ± 103 (range 100–450) ml, respectively. The median postoperative drop in hemoglobin was 0.89 ± 0.75 g/dL. No patient required blood transfusion. No procedure was converted to laparotomy. No major intra- or postoperative complication occurred.

Conclusions

Laparoscopic myomectomy for very large intramural uterine fibroids can be performed safely and effectively, with less intraoperative blood loss, using vascular clips for temporary clamping of the bilateral uterine vessels.

Use of a microsurgical vascular clip system (Yasargil clip) in laparoscopic fibroid enucleation

This video demonstrates the use of a microsurgical temporary vascular clip system to facilitate laparoscopic enucleation of uterine fibroids. Throughout the course of the last three decades, the laparoscopic route has been established as the approach of choice in the surgical treatment of uterine fibroids. Laparoscopic fibroid enucleation is characterized by a low morbidity rate and a high patient satisfaction level. Especially when treating a large fibroid or multiple fibroids, the well-vascularized myometrium can constitute a technical challenge in endoscopic fibroid enucleation. Diffuse bleeding may lead to significant intraoperative hemorrhage. The extensive use of bipolar or monopolar diathermy, in order to achieve hemostasis, might lead to post-operative uterine wall necrosis with a potential risk of uterine rupture during subsequent pregnancies. To address this clinical challenge, we developed a technique with temporary interruption of the uterine blood supply by applying a microsurgical vascular clip (Yasargil vascular clip system, Aesculap, Tuttlingen, Germany) to the uterine artery and the utero-ovarian vessel arcade to minimize bleeding during endoscopic fibroid enucleation.

Use of a microsurgical vascular clip system (Yasargil clip) in laparoscopic fibroid enucleation

This video demonstrates the use of a microsurgical temporary vascular clip system to facilitate laparoscopic enucleation of uterine fibroids. Throughout the course of the last three decades, the laparoscopic route has been established as the approach of choice in the surgical treatment of uterine fibroids. Laparoscopic fibroid enucleation is characterized by a low morbidity rate and a high patient satisfaction level. Especially when treating a large fibroid or multiple fibroids, the well-vascularized myometrium can constitute a technical challenge in endoscopic fibroid enucleation. Diffuse bleeding may lead to significant intraoperative hemorrhage. The extensive use of bipolar or monopolar diathermy, in order to achieve hemostasis, might lead to post-operative uterine wall necrosis with a potential risk of uterine rupture during subsequent pregnancies. To address this clinical challenge, we developed a technique with temporary interruption of the uterine blood supply by applying a microsurgical vascular clip (Yasargil vascular clip system, Aesculap, Tuttlingen, Germany) to the uterine artery and the utero-ovarian vessel arcade to minimize bleeding during endoscopic fibroid enucleation.

Important considerations for women in the late reproductive and perimenopausal years desiring myomectomy

PURPOSE OF REVIEW

To review important considerations in the counseling and management of women over the age of 40 desiring a myomectomy for symptomatic fibroids.

RECENT FINDINGS

Women in the late reproductive and perimenopausal years may choose a myomectomy over a hysterectomy for reasons of fertility preservation or a personal desire to retain their uterus. Data suggest that laparoscopic myomectomy is a low-risk procedure that can be offered to older women, though the age-related risk of uterine malignancy must be evaluated.

SUMMARY

When assessing the surgical candidacy of older women desiring myomectomy, it is important to weigh a woman's fertility potential, surgical risk, and concerns about malignancy with her desire to preserve the uterus and autonomy to choose a procedure type.

Unexpected coexistent endometriosis in women with symptomatic uterine leiomyomas is independently associated with infertility, nulliparity and minor myoma size

PURPOSE

To determine risk factors for unexpected coexistent endometriosis in laparoscopic myomectomy for symptomatic uterine leiomyomas.

METHODS

This was a single-centre, retrospective cohort study conducted at a University Women's Hospital with a certified endometriosis centre. Data were collected from patients with symptomatic uterine leiomyomas who underwent laparoscopic myomectomy. The main outcome measured in the study was the presence of histologically confirmed endometriosis. Binary regression analysis was used to investigate risk factors for the coexistence of endometriosis. Postoperative complications were classified according to the Clavien-Dindo classification.

RESULTS

From 2014 to 2018, 223 patients underwent laparoscopic myomectomy for symptomatic leiomyomas, and 57 (25.6%) had unexpected endometriosis. Women with endometriosis significantly more frequently were nulliparous (66.7% vs. 51.2%; p = 0.04), had reported infertility (31.6% vs. 15.7%; p = 0.01) and smaller leiomyomas (mean diameter 4.92 cm) than women without endometriosis (mean diameter 6.02 cm; p = 0.006). Coexistent endometriosis significantly increased mean operative time (168.4 vs. 142.8 min; p = 0.05) while intra- and postoperative complications showed a similar distribution (p = 0.87) and length of hospital stay (p = 0.26). Binary regression analysis identified 2.3- and 2.2-fold increases in the risk of endometriosis for infertility (p = 0.042) and nulliparity (p = 0.041), respectively. Myoma size influenced the risk of endometriosis by a factor of 0.8 per cm (p = 0.037).

CONCLUSIONS

Coexistent endometriosis should be expected in leiomyoma patients particularly with nulliparity, infertility or minor myoma size as independent risk factors. Preoperative counselling should incorporate surgical therapy of coexisting endometriosis.

Postoperative Quality of Life and Sexual Function in Premenopausal Women Undergoing Laparoscopic Myomectomy for Symptomatic Fibroids: A Prospective Observational Cohort Study

Introduction

Uterine leiomyomas are the most common benign gynecologic tumors. To date laparoscopy myomectomy is the gold standard for treatment of symptomatic fibroids in reproductive-aged women. Detailed counseling about the effects of this procedure on postoperative sexuality and quality of life is important in these patients. However, available data on these subjects are limited and contradictory. The aim of this study was to assess sexual function and quality of life in premenopausal women undergoing laparoscopic myomectomy for symptomatic uterine fibroids.

Material and Methods

All premenopausal women who underwent laparoscopic myomectomy for symptomatic fibroids between April 2012 and August 2014 at a tertiary university center were enrolled in this prospective observational cohort study. Sexual function and quality of life were assessed for the pre- and postoperative (six months post-operatively) state using two validated questionnaires, the Female Sexual Function Index (FSFI) and the European Quality of Life Five-Dimension Scale (EQ-5D).

Results

Ninety-five of the 115 (83%) eligible patients completed the study. Overall a significant improvement in quality of life and sexual function was observed in the study cohort: Median FSFI (28 (18.7–35.2)) and EQ-5D scores (1 (0.61–1) after laparoscopic myomectomy were significantly higher than preoperative scores (21.2 (5.2–33.5); 0.9 (0.2–1); p ≤ 0.01). The number, position and localization of the largest fibroids were not correlated with pre- or postoperative sexual function or quality of life.

Conclusion

Laparoscopic myomectomy might have positive short-term effects on postoperative quality of life and sexual function in premenopausal women suffering from symptomatic fibroids.

Influence of the Preoperative Decision-Making Process on the Postoperative Outcome after Hysterectomy for Benign Uterine Pathologies

Introduction: The aim of this study was to assess whether the preoperative decision-making process might influence treatment success in premenopausal women undergoing hysterectomy for benign uterine pathologies Materials and Methods: All premenopausal women treated with hysterectomy for benign uterine pathologies between April 2011 and June 2013 at a tertiary university center were enrolled in this prospective observational cohort study. Five parameters of the preoperative decision-making process were assessed upon their correlation with postoperative quality of life, sexual function and patients' satisfaction. These outcome measures were assessed for the pre- and postoperative (six months after surgery) status using two validated questionnaires (EQ-5D and "female sexual function index" (FSFI). Patients' satisfaction with the postoperative outcome was assessed with a self-developed questionnaire. Results: 255 of 402 (63 %) patients completed the study. A correlation between the co-variables "interval between first counseling and decision to surgery", "subjectively perceived quality of the preoperative counseling" and "certainty in the decision for the intervention" and postoperative outcomes were found. The co-variables "person mainly responsible for election of hysterectomy mode" and "discussion of decision for surgery with others" showed no influence on postoperative patients-reported outcomes. Conclusion: We found a correlation between certain parameters of the preoperative decision-making process and postoperative patient-reported sexual function, quality of life and patients' satisfaction in premenopausal women undergoing hysterectomy for benign uterine pathologies. An optimization of these factors could contribute to an improvement in treatment outcomes.

Trends in laparoscopic surgery for hysterectomy in Korea between 2007 and 2009

AIMS

The aims of this study are to estimate the hysterectomy rate for benign disease and determine recent trends in laparoscopic surgery for hysterectomies, including subtotal, total, and radical hysterectomy, in Korea.

MATERIAL AND METHODS

Computerized discharge summaries from private and public hospitals for 2007-2009 were obtained from the Health Insurance Review & Assessment Service. All records listing subtotal and total hysterectomies for benign disease and radical hysterectomies in women aged ≥ 16 years in each period were selected (n = 99,388). All women living in Korea aged ≥ 16 years were the denominator population. Laparoscopic surgery was identified when the code for laparoscopic materials was used. Statistical analysis included a trend test.

RESULTS

The hysterectomy rates for benign disease were 1.48, 1.49, and 1.52/1000 women aged ≥ 16 years in 2007, 2008, and 2009, respectively, and the overall rate was 1.49/1000 women. The trend increased (P for trend <0.001). The use of laparoscopy for subtotal and total hysterectomies accounted for 43.1% in 2007, 47.7% in 2008, and 52.0% in 2009, which showed a clear increasing trend (P for trend <0.001). The use of laparoscopy for radical hysterectomies comprised 26.7%, 28.7%, and 38.2% of cases in 2007, 2008, and 2009, respectively, an increased trend (P for trend <0.001).

CONCLUSION

The hysterectomy rate for benign disease increased between 2007 and 2009 in Korea. Application of laparoscopy during subtotal, total, and radical hysterectomies has increased significantly.

Standardised Registration of Surgical Complications in Laparoscopic-Gynaecological Therapeutic Procedures Using the Clavien-Dindo Classification

Introduction: The registration of complications represents an important component in the evaluation of surgical therapeutic procedures. The aim of the present study was to examine the frequency of occurrence as well as the severity of surgical complications after laparoscopic-gynaecological operations in a standardised manner using the Clavien-Dindo system. Material and Methods: Altogether 7438 treatment courses after laparoscopic-gynaecological interventions by 9 working groups were evaluated. Covariates recorded were the technical complexity of the operation, type of study cohort, study size, data acquisition as well as study centre. Target variables recorded were the surgical morbidity rate, subdivided into mild (Clavien-Dindo grade I-II) and severe complications (Clavien-Dindo grade III-V). In addition, a binary logistic regression analysis for the mentioned covariates and the occurrence of surgical complication was carried out. Results: 946 complications were recorded (overall complication rate: 13 %). These included 664 mild complications (8.9 %) and 305 severe complications (4.1 %). A correlation was found between the covariates technical complexity (relative risk [rR] 1.37; p < 0.01), study size (rR: 0.35; p < 0.01) and study centre (rR 0.19; p < 0.01) and the occurrence of surgical complications. Conclusion: By means of a standardised registration of complications using the Clavien-Dindo classification it appears to be possible to limit the methodologically caused underestimation of surgical morbidity in the retrospective evaluation of gynaecological-endoscopic therapeutic procedures. Factors decisively influencing the surgical morbidity of gynaecological-laparoscopic therapeutic procedures are the respective operative experience of the treating facility as well as the technical complexity of the intervention.

Long-term risk of fibroid recurrence after laparoscopic myomectomy

OBJECTIVE

The use of laparoscopic myomectomy as a surgical treatment for uterine leiomyoma is associated with low intraoperative morbidity and short hospitalization. Limited data about the long-term outcome of this surgical approach are available. The aims of this study were to estimate the risk of uterine fibroid recurrence after laparoscopic myomectomy and to identify factors contributing to the rate of fibroid relapse.

STUDY DESIGN

Between 1996 and 2003, 331 patients underwent laparoscopic myomectomy to treat uterine leiomyoma in our hospital; 224 of these patients consented to participate in our 2009 follow-up survey. Clinical symptomatic uterine leiomyoma recurrence was defined as relapse. Recurrence rates at 24 and 60 months post-operatively were calculated for the study population. Fisher's exact tests were used to examine the impacts of factors previously linked to an increased risk of fibroid recurrence, including (1) patient age at the time of initial surgery, (2) pre-operative body mass index, (3) number and localization of uterine leiomyoma removed, and (4) pregnancy and (5) delivery after laparoscopic myomectomy on fibroid recurrence in our study cohort.

RESULTS

We observed 75 recurrences in 224 patients. The cumulative risk of recurrence was 4.9% at 24 months and 21.4% at 60 months post-operatively. An age of 30-40 years and the presence of more than one fibroid at the time of initial laparoscopic myomectomy were identified as factors significantly increasing the risk of symptomatic recurrence after laparoscopic myomectomy (31.25% and 38.71%, respectively; both p<0.01).

CONCLUSION

Patients with multiple uterine leiomyoma and those in the third decade of life should be counselled thoroughly about the risk of recurrence prior to laparoscopic myomectomy. The low observed recurrence rate in peri- and postmenopausal patients in our study may support the use of laparoscopic myomectomy as a uterus-preserving surgical alternative beyond the reproductive period.