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Favilli A, Mazzon I, Etrusco A, Dellino M, Laganà AS, Tinelli A, Chiantera V, Cicinelli E, Gerli S, Vitagliano A. The challenge of FIGO type 3 leiomyomas and infertility: Exploring therapeutic alternatives amidst limited scientific certainties. Int J Gynaecol Obstet 2024; 165:975-987. [PMID: 38009829 DOI: 10.1002/ijgo.15260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 10/28/2023] [Accepted: 11/08/2023] [Indexed: 11/29/2023]
Abstract
Uterine leiomyomas (ULs) are non-cancerous tumors composed of smooth muscle cells that develop within the myometrium and represent the most prevalent pathological condition affecting the female genital tract. Despite the volume of available research, many aspects of ULs remain unresolved, making it a "paradoxical disease" where the increase in available scientific literature has not been matched by an increase in solid evidence for clinical management. Fertility stands at the top of the list of clinical issues where the role of ULs is still unclear. The leiomyoma subclassification system, released by the International Federaion of Gynecology and Obstetrics (FIGO) in 2008, introduced a new and more effective way of categorizing uterine fibroids. The aim was to go beyond the traditional classification "subserosal, intramural and submucosal", facilitating a detailed examination of individual ULs impact on the female reproductive system. The "type 3 UL" is a special type of myoma, characterized by its complete myometrial development while encroaching the endometrium. It is a unique "hybrid" between a submucous and an intramural UL, that may exert a detrimental "double hit" mechanism, which is of particular interest in patients wishing pregnancy. To date, no robust evidence is available regarding the management of type 3 ULs. The aim of this narrative review is to provide a comprehensive overview of the physiopathological mechanisms that type 3 UL may exert on fertility, and to present new perspectives that may help us to better understand both the need for and the methods of treating this unique type of fibroid.
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Affiliation(s)
- Alessandro Favilli
- Section of Obstetrics and Gynecology, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
- Center of Perinatal and Reproductive Medicine, University of Perugia, Perugia, Italy
| | | | - Andrea Etrusco
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Palermo, Italy
| | - Miriam Dellino
- 1st Unit of Obstetrics and Gynecology, Department of Interdisciplinary Medicine (DIM), University of Bari, Bari, Italy
| | - Antonio Simone Laganà
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Palermo, Italy
| | - Andrea Tinelli
- Department of Obstetrics and Gynecology, CERICSAL (CEntro di RIcerca Clinico SALentino), Veris delli Ponti Hospital, Scorrano, Italy
| | - Vito Chiantera
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Palermo, Italy
- Unit of Gynecologic Oncology, National Cancer Institute - IRCCS - Fondazione "G. Pascale", Naples, Italy
| | - Ettore Cicinelli
- 1st Unit of Obstetrics and Gynecology, Department of Interdisciplinary Medicine (DIM), University of Bari, Bari, Italy
| | - Sandro Gerli
- Section of Obstetrics and Gynecology, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
- Center of Perinatal and Reproductive Medicine, University of Perugia, Perugia, Italy
| | - Amerigo Vitagliano
- 1st Unit of Obstetrics and Gynecology, Department of Interdisciplinary Medicine (DIM), University of Bari, Bari, Italy
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Lazaridis A, Hirsch M, Pistofidis G, Odejinmi F. Surgical management of uterine fibroids. Curr Opin Obstet Gynecol 2023; 35:440-445. [PMID: 37548229 DOI: 10.1097/gco.0000000000000903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/08/2023]
Abstract
PURPOSE OF REVIEW Fibroids are benign pelvic masses and constitute the most common gynaecological condition. They create a significant health and social burden to many women because of heavy menstrual bleeding and fibroid pressure symptoms. Many women will be faced with the dilemma of surgical management to improve their symptoms at some point of their reproductive age. The aim of this article is to identify current surgical management of fibroids describing the technical steps, advantages, disadvantages and risks of each method. RECENT FINDINGS The surgical management of fibroids remains challenging, as the overall prevalence, the clinical experience and the patient awareness is increasing because of an upgrade in our sonographic and magnetic resonance diagnostic tools. Unfortunately not every patient is able to benefit from tailor-made surgery that holistically evaluates individual needs including fertility aspirations. SUMMARY This article provides the most current synopsis of every available surgical modality for fibroid management. Large prospective multicentre cohort studies are needed to definitely determine the most suitable operation for any individual suffering with fibroids; and perhaps artificial intelligence may offer a valuable tool in the future data analysis.
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Affiliation(s)
- Alexandros Lazaridis
- Second Department of Obstetrics and Gynecology, 'Aretaieion' Hospital, Faculty of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Martin Hirsch
- Oxford Endometriosis CaRe Centre, Nuffield Department of Women's & Reproductive Health, University of Oxford, Oxford, UK
| | | | - Funlayo Odejinmi
- Whipps Cross Hospital, Barts Health, NHS Trust, Leytonstone, London, UK
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Palheta MS, Medeiros FDC, Severiano ARG. Reporting of uterine fibroids on ultrasound examinations: an illustrated report template focused on surgical planning. Radiol Bras 2023; 56:86-94. [PMID: 37168038 PMCID: PMC10165971 DOI: 10.1590/0100-3984.2022.0048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 08/04/2022] [Indexed: 05/13/2023] Open
Abstract
Uterine fibroids are the most common benign gynecologic tumors in women of reproductive age, and ultrasound is the first-line imaging modality for their diagnosis and characterization. The International Federation of Gynecology and Obstetrics developed a system for describing and classifying uterine fibroids uniformly and consistently. An accurate description of fibroids in the ultrasound report is essential for planning surgical treatment and preventing complications. In this article, we review the ultrasound findings of fibroids, detailing the main points to be reported for preoperative evaluation. In addition, we propose a structured, illustrated report template to describe fibroids, based on the critical points for surgical planning.
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Casadio P, Raffone A, Alletto A, Filipponi F, Raimondo D, Arena A, La Rosa M, Virgilio A, Franceschini C, Gubbini G, Franchini M, Paradisi R, Lenzi J, Travaglino A, Mollo A, Carugno J, Seracchioli R. Postoperative morphologic changes of the isthmocele and clinical impact in patients treated by channel-like (360°) hysteroscopic technique. Int J Gynaecol Obstet 2023; 160:326-333. [PMID: 35929843 PMCID: PMC10086996 DOI: 10.1002/ijgo.14387] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Revised: 07/06/2022] [Accepted: 07/28/2022] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To evaluate the changes in (1) residual myometrial thickness (RMT), (2) cesarean scar defect (CSD) size, and (3) clinical symptoms, before and after channel-like (360°) hysteroscopic resection for the treatment of CSD. METHODS A single-center, observational, prospective, cohort study was carried out enrolling all symptomatic patients of childbearing age, diagnosed with CSD and routinely scheduled for channel-like (360°) hysteroscopic resection from July 2020 to July 2021 at the Division of Gynecology and Human Reproduction Physiopathology, Department of Medical and Surgical Sciences, IRCCS Azienda Ospedaliero-Univeristaria di Bologna. University of Bologna, Italy. The primary outcome was the difference in mean RMT before and after the procedure. Secondary outcomes were the differences before and 4 months after the surgery in: (1) CSD size measured by transvaginal ultrasound, (2) visual analog scale (VAS) scores for the symptoms, and (3) abnormal uterine bleeding (AUB) rate. Lastly, patients' satisfaction was assessed by the global impression of improvement (PGI-I) score. RESULTS We found a significant difference before and after the procedure in: (1) mean RMT (+2.0 mm; P < 0.001); mean size of the CSD (base: +1.6 mm; height: -2.5 mm; transverse diameter: -3.2 mm; volume: -263.7 mm3 ; P < 0.001); (2) mean VAS score for dyspareunia (-5.84; P < 0.001), dysmenorrhea (-8.94; P < 0.001), pelvic pain (-2.94; P < 0.001); (3) AUB rate (91% vs. 3%; P < 0.001). Lastly, the mean PGI-I score ± SD was 1.7 ± 0.9. CONCLUSION Channel-like (360°) hysteroscopic resection for the treatment of patients with symptomatic CSD may lead to an increase in RMT, decrease in CSD, and improvement of symptoms after the procedure, with high patient satisfaction.
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Affiliation(s)
- Paolo Casadio
- Division of Gynaecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Antonio Raffone
- Division of Gynaecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.,Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Andrea Alletto
- Division of Gynaecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.,Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Francesco Filipponi
- Division of Gynaecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.,Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Diego Raimondo
- Division of Gynaecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Alessandro Arena
- Division of Gynaecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.,Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Mariangela La Rosa
- Division of Gynaecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.,Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Agnese Virgilio
- Division of Gynaecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.,Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Camilla Franceschini
- Division of Gynaecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.,Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Giampietro Gubbini
- Department of Gynecology, Madre Fortunata Toniolo Clinic, Bologna, Italy
| | - Mario Franchini
- Department of Obstetrics and Gynecology, Tuscany Health Agency, Florence, Italy
| | - Roberto Paradisi
- Division of Gynaecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Jacopo Lenzi
- Section of Hygiene, Public Health and Medical Statistics, Department of Biomedical and Neuromotor Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Antonio Travaglino
- Anatomic Pathology Unit, Department of Advanced Biomedical Sciences, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Antonio Mollo
- Gynecology and Obstetrics Unit, Department of Medicine, Surgery and Dentistry "Schola Medica Salernitana", University of Salerno, Baronissi, Italy
| | - Josè Carugno
- Obstetrics, Gynecology and Reproductive Science Department, University of Miami, Miller School of Medicine, Miami, Florida, USA
| | - Renato Seracchioli
- Division of Gynaecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.,Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
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Rusda M, Adnani MRJ. Uterine Evaluation Using Morphological Uterus Sonographic Assessment Diagnostic Protocol: A Literature Review. Open Access Maced J Med Sci 2022. [DOI: 10.3889/oamjms.2022.9294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background: Myometrial lesion is one of the major causes of the need for gynecologic surgeries. Ultrasonography (USG) is the primary modality in myometrial radiological examination. Thus a consistent procedure for reporting evaluation findings is needed.
Method: We reviewed literature from textbooks and journals from 2000 to 2019 containing information about myometrial sonographic evaluation.
Results: MUSA (Morphological Uterus Sonographic Assessment) is a consensus statement on terms, definitions, and measurements that may be used to describe findings and report the sonographic features of the myometrium using gray-scale sonography, colour/power Doppler and three-dimensional (3D) ultrasound imaging. The procedure consists of reports on the sonographic features of the uterine corpus, myometrium, and myometrial lesion.
Conclusion: The need for a standardized terminology to describe sonographic findings of the myometrium, both normal and pathological, has given this protocol an advantage to show its benefit, that is not only just for a clinical background but also research purposes. We suggest researchers and clinicians continue to develop further and study the relevance and use of the consensus, especially the correlation of sonographic findings with clinical and histological features.
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Dolmans MM, Cacciottola L, Donnez J. Conservative Management of Uterine Fibroid-Related Heavy Menstrual Bleeding and Infertility: Time for a Deeper Mechanistic Understanding and an Individualized Approach. J Clin Med 2021; 10:jcm10194389. [PMID: 34640407 PMCID: PMC8509802 DOI: 10.3390/jcm10194389] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 09/22/2021] [Accepted: 09/23/2021] [Indexed: 12/17/2022] Open
Abstract
(1) Background: Uterine fibroids are the most common form of benign uterine tumors, causing heavy menstrual bleeding (HMB), pelvic pain, infertility and pressure symptoms. Almost a third of women with uterine fibroids seek treatment. The objective of this review is to understand the mechanisms linking fibroids to these symptoms and evaluate different options for their management, particularly the place of gonadotropin-releasing hormone (GnRH) antagonist. (2) Methods: We gathered the most recent and relevant papers on the main fibroid-related symptoms and medical and surgical therapy for their treatment. Those reporting use of oral GnRH antagonists were investigated in detail. (3) Results: The mechanisms explaining myoma-related HMB and infertility were reviewed, as they are essential to a deeper mechanistic understanding and oriented approach. The choice of treatment depends on the number, size, and location of fibroids, and is guided by the patient’s age and desire to preserve her fertility. Economic impacts of myomas in terms of direct costs, lost workdays, and complications were found to be significant. Medical, surgical, and non-surgical strategies were analyzed in this context. Novel medical approaches with GnRH antagonist were explored and found to represent an effective new option. (4) Conclusion: The need for alternatives to surgical intervention is very real, especially for women seeking to preserve their fertility. New options now exist, with GnRH antagonists proven to treat fibroid symptoms effectively, opening the door to novel strategies for the management of myomas.
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Affiliation(s)
- Marie-Madeleine Dolmans
- Gynecology Department, Cliniques Universitaires St-Luc, Avenue Hippocrate 10, 1200 Brussels, Belgium;
- Gynecology Research Unit, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Avenue Mounier 52, 1200 Brussels, Belgium;
| | - Luciana Cacciottola
- Gynecology Research Unit, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Avenue Mounier 52, 1200 Brussels, Belgium;
| | - Jacques Donnez
- Université Catholique de Louvain, 1200 Brussels, Belgium
- Société de Recherche pour l’Infertilité (SRI), 143 Avenue Grandchamp, 1150 Brussels, Belgium
- Correspondence:
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Indraccolo U, Bini V, Favilli A. Likelihood of Accomplishing an In-Patient Hysteroscopic Myomectomy in a One-Step Procedure: A Systematic Review and Meta-Analysis. Biomed Res Int 2020; 2020:4208497. [PMID: 32090092 PMCID: PMC7015183 DOI: 10.1155/2020/4208497] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 11/20/2019] [Indexed: 11/17/2022]
Abstract
PURPOSE To assess the feasibility rate of one-step hysteroscopic myomectomy according to the technique adopted. METHODS In July 2016, PubMed, ClinicalTrials.gov, SCOPUS, Scielo, and AJOL databases were used for searching references. Series of in-patient hysteroscopic myomectomies reporting success rate in only one-step procedure, categorization of submucous fibroids, explanation of the surgical technique, and description of patients were considered eligible for meta-analysis (retrospective, prospective randomized studies). Two authors extracted the data. Rate of myomectomies accomplished in only a surgical step and rate of intraoperative complications were extracted per protocol. A modified GRADE score was used for quality assessment. Random-effect models were already assumed. Mean rates were compared among subgroups. RESULTS One thousand two hundred and fifty-seven studies were screened and 241 of these were read for eligibility. Seventy-eight series were included in qualitative synthesis and 24 series were included in quantitative synthesis. Wide heterogeneity was found. In series with <50% of G2 myomas treated, the slicing technique feasibility rate was 86.5% while techniques for enucleating the deep portion of the myomas showed a feasibility rate of 92.3% (p < 0.001). In series with ≥50% of G2 myomas treated, the slicing technique feasibility rate was 70.6% while techniques for enucleating the deep portion of myomas showed a feasibility rate of 88.4% (p < 0.001). In series with ≥50% of G2 myomas treated, the slicing technique feasibility rate was 70.6% while techniques for enucleating the deep portion of myomas showed a feasibility rate of 88.4% (. CONCLUSION In case of submucous myomas with intramural development, the slicing technique was correlated with a lower rate of in-patient hysteroscopic myomectomies accomplished in a one-step procedure and a higher complications rate.
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Affiliation(s)
- Ugo Indraccolo
- Department of Obstetrics and Gynaecology, USL Umbria 1, Alta Valle del Tevere Hospital, Città di Castello (PG), Umbria, Italy
| | - Vittorio Bini
- Department of Medicine, University of Perugia, Perugia, Italy
| | - Alessandro Favilli
- Department of Obstetrics and Gynaecology, USL Umbria 1, Alta Valle del Tevere Hospital, Città di Castello (PG), Umbria, Italy
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Tinelli A, Favilli A, Lasmar RB, Mazzon I, Gerli S, Xue X, Malvasi A. The importance of pseudocapsule preservation during hysteroscopic myomectomy. Eur J Obstet Gynecol Reprod Biol 2019; 243:179-184. [DOI: 10.1016/j.ejogrb.2019.09.008] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2019] [Revised: 09/08/2019] [Accepted: 09/16/2019] [Indexed: 11/29/2022]
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Favilli A, Mazzon I, Gerli S. Regarding "Multidisciplinary Approach in Large-sized Submucosal Myoma: Hysteroscopic Myomectomy after Uterine Artery Embolization". J Minim Invasive Gynecol 2018; 26:774-776. [PMID: 30580101 DOI: 10.1016/j.jmig.2018.09.789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Accepted: 09/26/2018] [Indexed: 10/27/2022]
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10
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Shokeir T. Regarding "Multidisciplinary Approach in Large-Sized Submucous Myoma: Hysteroscopic Myomectomy after Uterine Artery Embolization". J Minim Invasive Gynecol 2019; 26:369-70. [PMID: 30165186 DOI: 10.1016/j.jmig.2018.07.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Accepted: 07/20/2018] [Indexed: 10/28/2022]
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Mazzon I, Favilli A, Grasso M, Horvath S, Bini V, Di Renzo GC, Gerli S. Risk Factors for the Completion of the Cold Loop Hysteroscopic Myomectomy in a One-Step Procedure: A Post Hoc Analysis. Biomed Res Int 2018; 2018:8429047. [PMID: 29888280 DOI: 10.1155/2018/8429047] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Accepted: 03/31/2018] [Indexed: 01/01/2023]
Abstract
Introduction The aim of the study was to analyze which variables influenced the completion of a cold loop hysteroscopic myomectomy in a one-step procedure in a large cohort of patients. Materials and Methods A retrospective cohort study of 1434 cold loop resectoscopic myomectomies consecutively performed. The study population was divided into two groups according to the number of procedures needed to accomplish the treatment. Variables influencing the completion of hysteroscopic myomectomy in a one-step procedure were investigated. Results A total of 1434 resections were performed and 1690 myomas in total were removed. The procedure was accomplished in a one-step procedure in 1017 patients (83.7%), whereas 198 women (16.3%) needed a multiple-step procedure. The multivariate analysis showed that the size, the number of myomas, and the age of patients were significantly correlated with the risk of a multiple-step procedure. No correlation was revealed with the grading of myomas, parity, and the use of presurgical GnRH-agonist therapy. Conclusions In case of multiple fibroids, the intramural development of submucous myomas did not influence the completion of cold loop hysteroscopic myomectomy in a one-step procedure. The size of myomas and the age of patients were significantly correlated with the need to complete the myomectomy in a multiple-step procedure.
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Abstract
Uterine anatomy and uterine fibroids (UFs) characteristics have been classically considered as almost a unique issue in gynecology and reproductive medicine. Nowadays, the management of UF pathology is undergoing an important evolution, with the patient's quality of life being the most important aspect to consider. Accordingly, surgical techniques and aggressive treatments are reserved for only those cases with heavy symptomatology, while the clinical diagnostic based on size and number of UFs remains in a second plane in these situations. Moreover, the development of several noninvasive surgical techniques, especially the appearance of ulipristal acetate as a medical etiological treatment, has substantially changed the clinical indications. As a consequence, after almost 2 decades without relevant updates, it has been necessary to update the protocols for the management of UFs in the Spanish Society of Gynecology and Obstetrics twice. Accordingly, we believe that it is necessary to translate our experience to protocolize the medical care for patients with UFs, incorporating these new therapeutic options, and selecting the best treatment for them. We highlight the importance of achieving the patient's goals and decisions by improving the clinical diagnosis for these type of pathologies, allowing enhanced personalized treatments, as well as the reduction of potential risks and unnecessary surgeries.
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Affiliation(s)
- Aymara Mas
- Reproductive Medicine Research Group, Institute of Health Research La Fe, University and Polytechnic Hospital La Fe, Valencia, Spain.,Research and Development Department, Igenomix Foundation, Valencia, Spain
| | - Marta Tarazona
- Gynecology Department, University and Polytechnic Hospital La Fe, Valencia, Spain
| | - Joana Dasí Carrasco
- Gynecology Department, University and Polytechnic Hospital La Fe, Valencia, Spain
| | - Gloria Estaca
- Obstetrics and Gynecology Department, La Zarzuela Hospital, Madrid, Spain.,Obstetrics and Gynecology Department, Universidad Francisco de Vitoria, Madrid, Spain
| | - Ignacio Cristóbal
- Obstetrics and Gynecology Department, La Zarzuela Hospital, Madrid, Spain.,Obstetrics and Gynecology Department, Universidad Francisco de Vitoria, Madrid, Spain
| | - Javier Monleón
- Gynecology Department, University and Polytechnic Hospital La Fe, Valencia, Spain
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Abstract
Uterine fibroids (also known as leiomyomas or myomas) are the most common form of benign uterine tumors. Clinical presentations include abnormal bleeding, pelvic masses, pelvic pain, infertility, bulk symptoms and obstetric complications.Almost a third of women with leiomyomas will request treatment due to symptoms. Current management strategies mainly involve surgical interventions, but the choice of treatment is guided by patient's age and desire to preserve fertility or avoid 'radical' surgery such as hysterectomy. The management of uterine fibroids also depends on the number, size and location of the fibroids. Other surgical and non-surgical approaches include myomectomy by hysteroscopy, myomectomy by laparotomy or laparoscopy, uterine artery embolization and interventions performed under radiologic or ultrasound guidance to induce thermal ablation of the uterine fibroids.There are only a few randomized trials comparing various therapies for fibroids. Further investigations are required as there is a lack of concrete evidence of effectiveness and areas of uncertainty surrounding correct management according to symptoms. The economic impact of uterine fibroid management is significant and it is imperative that new treatments be developed to provide alternatives to surgical intervention.There is growing evidence of the crucial role of progesterone pathways in the pathophysiology of uterine fibroids due to the use of selective progesterone receptor modulators (SPRMs) such as ulipristal acetate (UPA). The efficacy of long-term intermittent use of UPA was recently demonstrated by randomized controlled studies.The need for alternatives to surgical intervention is very real, especially for women seeking to preserve their fertility. These options now exist, with SPRMs which are proven to treat fibroid symptoms effectively. Gynecologists now have new tools in their armamentarium, opening up novel strategies for the management of uterine fibroids.
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Affiliation(s)
- Jacques Donnez
- Professor EM, Catholic University of Louvain, Director, Société de Recherche pour l'Infertilité (SRI), 143 Avenue Grandchamp, B-1150 Brussels, Belgium
| | - Marie-Madeleine Dolmans
- Gynecology Department, Cliniques Universitaires St-Luc, Avenue Hippocrate 10, 1200 Brussels, Belgium; Pôle de Gynécologie, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Avenue Mounier 52, bte B1.52.02, 1200 Brussels, Belgium
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Capmas P, Voulgaropoulos A, Legendre G, Pourcelot A, Fernandez H. Hysteroscopic resection of type 3 myoma: a new challenge? Eur J Obstet Gynecol Reprod Biol 2016; 205:165-9. [DOI: 10.1016/j.ejogrb.2016.06.026] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Revised: 06/20/2016] [Accepted: 06/24/2016] [Indexed: 11/23/2022]
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15
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Korkmazer E, Tekin B, Solak N. Ultrasound guidance during hysteroscopic myomectomy in G1 and G2 Submucous Myomas: for a safer one step surgery. Eur J Obstet Gynecol Reprod Biol 2016; 203:108-11. [DOI: 10.1016/j.ejogrb.2016.03.043] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2016] [Revised: 03/21/2016] [Accepted: 03/29/2016] [Indexed: 11/16/2022]
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Di Spiezio Sardo A, Calagna G, Laganà AS, Vitale SG, Catena U, Scutiero G, Nappi C. Is Hysteroscopy Better than Ultrasonography for Uterine Cavity Evaluation? An Evidence-Based and Patient-Oriented Approach. Journal of Endometriosis and Pelvic Pain Disorders 2016; 8:87-93. [DOI: 10.5301/je.5000252] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Evaluation of the uterine cavity is an important part of the gynecological check, especially in symptomatic women and, over the last few decades, a number of technical and technological advancements has allowed a superb investigation of this organ. Traditionally, transvaginal ultrasound (TVUS) has been the first-line diagnostic tool for evaluating uterine diseases, also considering that gynecologists are familiar with the technique since it is included in the basic training in obstetrics and gynecology. Nevertheless, to date “office hysteroscopy” received growing attention since the development of smaller-diameter hysteroscopes which has made it possible to easily perform the hysteroscopy in ambulatory settings, obviating the need for anesthesia and dilatation of the cervical canal. According to our overview, none of the available methods for endometrial evaluation are ideal and each one has pros and cons. TVUS allows assessment of both the myometrium and the endometrium and typically offers greater patient comfort, but it has a higher false-negative rate in diagnosing focal intrauterine pathology. On the other hand, office hysteroscopy has the advantage of providing (most of the time) a real-time diagnosis avoiding anxiety, inconvenience and costs associated with follow-up appointments. The main advantage of the office hysteroscopy on the TVUS is the possibility to perform an operative phase if necessary during the examination itself. In fact, the modern smaller-diameter hysteroscopes have a working channel through which operative miniaturized instruments (mechanical instruments or bipolar electrodes) can be introduced, allowing the performance of target-eye biopsies and the “instant” treatment of most of uterine diseases in outpatient settings.
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Abstract
Background and Objectives: The purpose of this study is to assess the rate of persistent submucosal myomas and intrauterine scarring after hysteroscopic myomectomy, as well as to evaluate the preoperative and intraoperative sonohysterographic findings that will predict persistence of myomas, scarring, and the need for repeat surgery. Methods: Charts from all hysteroscopic myomectomies performed by a single surgeon between 2003 and 2011 were reviewed for preoperative, intraoperative, and postoperative sonohysterographic findings. Predictors included myoma number, diameter and percent extension into the cavity of the largest fibroid, and percent surgically resected. These predictors were assessed with postoperative sonohysterography. Statistics included t test, logistic regression, χ2 test, and Fisher exact test. Results: Among the 79 cases with postoperative sonohysterograms, 17 (21.5%) had persistent submucosal myoma, and 9 (11.4%) had intrauterine scarring on postoperative sonohysterogram. Repeat hysteroscopic myomectomy was required in 11 (13.9%), but none required lysis of adhesions. The myoma number was not a significant predictor. A higher percentage of myoma within the cavity (63.35% vs 44.89%, P < .05) and smaller myoma size (2.22 cm vs 3.31 cm, P < .01) were significant predictors of a complete resection, a normal postoperative sonohysterogram, and avoidance of repeat surgery. On regression analysis, the percent of the myoma resected was the most significant outcome predictor (P < .001). Conclusion: Larger myomas with a lower percent found within the uterine cavity are less likely to be completely resected. Percent resection at the time of surgery is the most significant predictor of a normal postoperative sonohysterogram, as well as the best predictor of the need for repeat surgery.
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Affiliation(s)
- Martin D Keltz
- Department of Obstetrics & Gynecology, St. Luke's Roosevelt Hospital Center, New York, NY, USA
| | - Alexis D Greene
- Department of Obstetrics & Gynecology, St. Luke's Roosevelt Hospital Center, New York, NY, USA
| | - Mary Breda Morrissey
- Department of Obstetrics & Gynecology, St. Luke's Roosevelt Hospital Center, New York, NY, USA
| | - Mario Vega
- Department of Obstetrics & Gynecology, St. Luke's Roosevelt Hospital Center, New York, NY, USA
| | - Erin Moshier
- Department of Obstetrics & Gynecology, St. Luke's Roosevelt Hospital Center, New York, NY, USA
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Di Spiezio Sardo A, Calagna G, Di Carlo C, Guida M, Perino A, Nappi C. Cold loops applied to bipolar resectoscope: A safe “one-step” myomectomy for treatment of submucosal myomas with intramural development. J Obstet Gynaecol Res 2015; 41:1935-41. [DOI: 10.1111/jog.12831] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2015] [Revised: 07/01/2015] [Accepted: 07/12/2015] [Indexed: 11/29/2022]
Affiliation(s)
- Attilio Di Spiezio Sardo
- Department of Neuroscience and Reproductive and Odontostomatological Sciences; University of Naples “Federico II”; Naples Italy
| | - Gloria Calagna
- Department of Obstetrics and Gynecology; University Hospital of Palermo “P.Giaccone”; Palermo Italy
| | - Costantino Di Carlo
- Department of Neuroscience and Reproductive and Odontostomatological Sciences; University of Naples “Federico II”; Naples Italy
| | - Maurizio Guida
- Department of Gynecology and Obstetrics; University of Salerno; Salerno Italy
| | - Antonio Perino
- Department of Obstetrics and Gynecology; University Hospital of Palermo “P.Giaccone”; Palermo Italy
| | - Carmine Nappi
- Department of Neuroscience and Reproductive and Odontostomatological Sciences; University of Naples “Federico II”; Naples Italy
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Affiliation(s)
- I Mazzon
- a "Arbor Vitae" Centre, Clinica Nuova Villa Claudia , Rome , Italy
| | - A Favilli
- b Department of Obstetrics and Gynecology , University of Perugia , Perugia , Italy
| | - M Grasso
- a "Arbor Vitae" Centre, Clinica Nuova Villa Claudia , Rome , Italy
| | - S Gerli
- b Department of Obstetrics and Gynecology , University of Perugia , Perugia , Italy
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Van den Bosch T, Dueholm M, Leone FPG, Valentin L, Rasmussen CK, Votino A, Van Schoubroeck D, Landolfo C, Installé AJF, Guerriero S, Exacoustos C, Gordts S, Benacerraf B, D'Hooghe T, De Moor B, Brölmann H, Goldstein S, Epstein E, Bourne T, Timmerman D. Terms, definitions and measurements to describe sonographic features of myometrium and uterine masses: a consensus opinion from the Morphological Uterus Sonographic Assessment (MUSA) group. Ultrasound Obstet Gynecol 2015; 46:284-98. [PMID: 25652685 DOI: 10.1002/uog.14806] [Citation(s) in RCA: 351] [Impact Index Per Article: 39.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/15/2014] [Revised: 01/18/2015] [Accepted: 01/27/2015] [Indexed: 05/14/2023]
Abstract
The MUSA (Morphological Uterus Sonographic Assessment) statement is a consensus statement on terms, definitions and measurements that may be used to describe and report the sonographic features of the myometrium using gray-scale sonography, color/power Doppler and three-dimensional ultrasound imaging. The terms and definitions described may form the basis for prospective studies to predict the risk of different myometrial pathologies, based on their ultrasound appearance, and thus should be relevant for the clinician in daily practice and for clinical research. The sonographic features and use of terminology for describing the two most common myometrial lesions (fibroids and adenomyosis) and uterine smooth muscle tumors are presented.
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Affiliation(s)
- T Van den Bosch
- Department of Obstetrics and Gynecology, University Hospitals KU Leuven, Leuven, Belgium
| | - M Dueholm
- Department of Obstetrics and Gynecology, Aarhus University Hospital, Aarhus, Denmark
| | - F P G Leone
- Department of Obstetrics and Gynecology, Clinical Sciences Institute L Sacco, University of Milan, Milan, Italy
| | - L Valentin
- Department of Obstetrics and Gynecology, Skåne University Hospital, Lund University, Malmö, Sweden
| | - C K Rasmussen
- Department of Obstetrics and Gynecology, Aarhus University Hospital, Aarhus, Denmark
| | - A Votino
- Department of Obstetrics and Gynecology, Brugmann University Hospital, Brussels, Belgium
| | - D Van Schoubroeck
- Department of Obstetrics and Gynecology, University Hospitals KU Leuven, Leuven, Belgium
| | - C Landolfo
- Department of Obstetrics and Gynecology, Sant' Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - A J F Installé
- KU Leuven, Department of Electrical Engineering (ESAT), STADIUS, Center for Dynamical Systems, Signal Processing and Data Analytics, Leuven, Belgium
- iMinds Medical IT, Leuven, Belgium
| | - S Guerriero
- Department of Obstetrics and Gynaecology, Azienda Ospedaliera Universitaria of Cagliari and University of Cagliari, Cagliari, Italy
| | - C Exacoustos
- Department of Biomedicine and Prevention, Obstetrics and Gynecological Clinic, University of Rome 'Tor Vergata', Rome, Italy
| | - S Gordts
- L.I.F.E. (Leuven Institute for Fertility & Embryology), Leuven, Belgium
| | - B Benacerraf
- Departments of Radiology and Obstetrics & Gynecology, Harvard Medical School, Boston, MA, USA
| | - T D'Hooghe
- Leuven University Fertility Centre, University Hospitals KU Leuven, Leuven, Belgium
| | - B De Moor
- KU Leuven, Department of Electrical Engineering (ESAT), STADIUS, Center for Dynamical Systems, Signal Processing and Data Analytics, Leuven, Belgium
- iMinds Medical IT, Leuven, Belgium
| | - H Brölmann
- Department of Obstetrics and Gynecology, VU University Medical Center, Amsterdam, The Netherlands
| | - S Goldstein
- Department of Obstetrics and Gynecology, New York University School of Medicine, New York, NY, USA
| | - E Epstein
- Department of Obstetrics and Gynecology, Karolinska University Hospital, Stockholm, Sweden
| | - T Bourne
- Department of Obstetrics and Gynecology, University Hospitals KU Leuven, Leuven, Belgium
- Queen Charlotte's and Chelsea Hospital, Imperial College, London, UK
| | - D Timmerman
- Department of Obstetrics and Gynecology, University Hospitals KU Leuven, Leuven, Belgium
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Mazzon I, Favilli A, Grasso M, Horvath S, Di Renzo GC, Gerli S. Is Cold Loop Hysteroscopic Myomectomy a Safe and Effective Technique for the Treatment of Submucous Myomas With Intramural Development? A Series of 1434 Surgical Procedures. J Minim Invasive Gynecol 2015; 22:792-8. [PMID: 25796220 DOI: 10.1016/j.jmig.2015.03.004] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Revised: 03/03/2015] [Accepted: 03/05/2015] [Indexed: 11/23/2022]
Abstract
STUDY OBJECTIVE To assess the safety and efficacy of cold loop hysteroscopic myomectomy in a large series of cases. DESIGN Retrospective study (Canadian Task Force Classification III). SETTING Arbor Vitae Center for Endoscopic Gynecology, Rome, Italy. PATIENTS A total of 1215 patients with 1 or more G1-G2 submucous myomas. INTERVENTION Cold loop hysteroscopic myomectomy. MEASUREMENT AND MAIN RESULTS A total of 1690 myomas were removed. A minimum of 1 to a maximum of 5 fibroids for each surgical procedure were totally removed. Out of 1215 patients, 1017 (83.7%) were treated with a single surgical procedure. Twelve intraoperative complications occurred (0.84%). No cases of uterine perforation with the thermal loop or clinical intravasation syndrome were reported. CONCLUSION Cold loop hysteroscopic myomectomy seems to represent a safe and effective procedure for the removal of submucous myomas with intramural development, while at the same time respecting the anatomic and functional integrity of the myometrium. The use of a cold loop in resectoscopic myomectomy is associated with a low rate of minor intraoperative complications and an absence of major complications. This could be of primary relevance with a view to fertility and future pregnancies.
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Donnez J, Donnez O, Dolmans MM. With the advent of selective progesterone receptor modulators, what is the place of myoma surgery in current practice? Fertil Steril 2014; 102:640-8. [DOI: 10.1016/j.fertnstert.2014.06.041] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2014] [Revised: 06/16/2014] [Accepted: 06/26/2014] [Indexed: 11/26/2022]
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Kamath MS, Kalampokas EE, Kalampokas TE. Use of GnRH analogues pre-operatively for hysteroscopic resection of submucous fibroids: a systematic review and meta-analysis. Eur J Obstet Gynecol Reprod Biol 2014; 177:11-8. [DOI: 10.1016/j.ejogrb.2014.03.009] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2013] [Revised: 02/19/2014] [Accepted: 03/06/2014] [Indexed: 11/18/2022]
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Mazzon I, Favilli A, Gerli S. Reply of the authors. Fertil Steril 2014; 101:e41. [PMID: 24726217 DOI: 10.1016/j.fertnstert.2014.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2014] [Accepted: 03/06/2014] [Indexed: 11/28/2022]
Affiliation(s)
| | - Alessandro Favilli
- Department of Obstetrics and Gynecology, University of Perugia, Perugia, Italy
| | - Sandro Gerli
- Department of Obstetrics and Gynecology, University of Perugia, Perugia, Italy
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Abstract
PURPOSE OF REVIEW Hysteroscopic myomectomy was a revolution for surgical treatment of symptomatic submucosal myoma. RECENT FINDINGS A new International Federation of Gynecology and Obstetrics classification for myoma was recently described. Type 0, 1 and 2 are submucosal like in the European Society for Human Reproduction and Embryology. An intraoperative ultrasound control should be done to avoid bowel lesion when the margin between the deepest part of the myoma and the serosa is less than 5-8 mm. For monopolar resection, glycine is used as distension medium and a high frequency current is required. The bipolar system is a newer electrosurgical system. The distension medium used is isotonic saline. The advantage of this energy is that with the same safety and efficacy as the monopolar system, isotonic saline as a distension medium instead of glycine seems to reduce the risk of metabolic complications. For bleeding outcome, a success rate from 70 to 99% has been reported by different studies; the success rate seems to decline as the follow-up period increases for fertility outcome, submucosal fibroids have negative impact on pregnancy rates in the case of spontaneous fertility as in the case of assisted reproduction technologies. SUMMARY Hysteroscopic resection of submucous myoma is a well tolerated procedure. Bipolar resection should be studied for safe diffusion. Fertility outcome and menorragia are both enhanced by hysteroscopic myomectomy.
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Ludwin A, Ludwin I, Pityński K, Basta P, Basta A, Banas T, Jach R, Wiecheć M, Grabowska R, Stangel-wójcikiewicz K, Milewicz T, Nocuń A. Transrectal Ultrasound-Guided Hysteroscopic Myomectomy of Submucosal Myomas With a Varying Degree of Myometrial Penetration. J Minim Invasive Gynecol 2013; 20:672-85. [DOI: 10.1016/j.jmig.2013.05.001] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2013] [Revised: 05/01/2013] [Accepted: 05/02/2013] [Indexed: 11/17/2022]
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Chen CH, Lee WL, Wang IT, Yen YK, Chiu LH, Tzeng CR, Liu WM. Hysteroscopic myomectomy using a two-micron continuous wave laser (RevoLix). Gynecol Minim Invasive Ther 2013. [DOI: 10.1016/j.gmit.2013.05.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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Haimovich S, Mancebo G, Alameda F, Agramunt S, Solé-Sedeno JM, Hernández JL, Carreras R. Feasibility of a new two-step procedure for office hysteroscopic resection of submucous myomas: results of a pilot study. Eur J Obstet Gynecol Reprod Biol 2013; 168:191-4. [DOI: 10.1016/j.ejogrb.2013.01.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2012] [Revised: 11/25/2012] [Accepted: 01/09/2013] [Indexed: 10/27/2022]
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Legendre G, Fallet C. [What to do with sub-mucosal type 2 myomas in the infertile woman?]. ACTA ACUST UNITED AC 2012; 41:H5-7. [PMID: 22445168 DOI: 10.1016/s0368-2315(12)70003-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- G Legendre
- Hôpital de Bicêtre, 78 rue du Général Leclerc, 94275 Le Kremlin Bicêtre cedex, France
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Leone FP. Should the myometrial free margin still be considered a limiting factor for hysteroscopic resection of submucous fibroids? A possible answer to an old question. Fertil Steril 2012; 97:e1-2; author reply e3. [DOI: 10.1016/j.fertnstert.2011.10.029] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2011] [Accepted: 10/24/2011] [Indexed: 12/01/2022]
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Casadio P, Youssef A, Savelli L, Ghi T, Spagnolo E, Guasina F, Seracchioli R. Reply of the Authors. Fertil Steril 2012; 97:e3. [DOI: 10.1016/j.fertnstert.2011.10.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Leone FPG, Calabrese S, Marciante C, Cetin I, Ferrazzi E. Feasibility and long-term efficacy of hysteroscopic myomectomy for myomas with intramural development by the use of non-electrical “cold” loops. ACTA ACUST UNITED AC 2012; 9:155-61. [DOI: 10.1007/s10397-011-0706-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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