Uterine artery ligation for management of uterine fibroids

Therapeutic management of uterine fibroid tumors: updated French guidelines

The medical management of symptomatic non-submucosal uterine fibroid tumors (leiomyomas or myomas) is based on the treatment of abnormal uterine bleeding by any of the following: progestogens, a levonorgestrel-releasing intrauterine device, tranexamic acid, nonsteroidal anti-inflammatory drugs, or GnRH analogs. Selective progesterone receptor modulators are currently being evaluated and have recently been approved for fibroid treatment. Neither combined estrogen-progestogen contraception nor hormone treatment of the menopause is contraindicated in women with fibroids. When pregnancy is desired, whether or not infertility is being treated by assisted reproductive technology, hysteroscopic resection in one or two separate procedures of submucosal fibroids less than 4 cm in length is recommended, regardless of whether they are symptomatic. Interstitial, also known as intramural, fibroids have a negative effect on fertility but treating them does not improve fertility. Myomectomy is therefore indicated only for symptomatic fibroids; depending on their size and number, and may be performed by laparoscopy or laparotomy. Physicians must explain to women the potential consequences of myomas and myomectomy on future pregnancy. For perimenopausal women who have been informed of the alternatives and the risks, hysterectomy is the most effective treatment for symptomatic fibroids and is associated with a high rate of patient satisfaction. When possible, the vaginal or laparoscopic routes should be preferred to laparotomy for hysterectomies for fibroids considered typical on imaging. Because uterine artery embolization is an effective treatment with low long-term morbidity, it is an option for symptomatic fibroids in women who do not want to become pregnant, and a validated alternative to myomectomy and hysterectomy that must be offered to patients. Myolysis is under assessment, and research on its use is recommended. Isolated laparoscopic ligation of the uterine arteries is a potential alternative to uterine artery embolization; it also complements myomectomy by reducing intraoperative bleeding. It is possible to use second-generation techniques of endometrial ablation to treat submucosal fibroids in women whose families are complete. Subtotal hysterectomy is a possible alternative to total hysterectomy for fibroid treatment, given that by laparotomy the former has a lower complication rate than the latter, while by laparoscopy, these rates are the same. In each case, the patient is informed about the benefit and risk associated with each therapeutic option.

Current and emerging treatments for uterine myoma - an update

Uterine myomas, the most common benign, solid, pelvic tumors in women, occur in 20%–40% of women in their reproductive years and form the most common indication for hysterectomy. Various factors affect the choice of the best treatment modality for a given patient. Asymptomatic myomas may be managed by reassurance and careful follow up. Medical therapy should be tried as a first line of treatment for symptomatic myomas, while surgical treatment should be reserved only for appropriate indications. Hysterectomy has its place in myoma management in its definitiveness. However, myomectomy, rather than hysterectomy, should be performed when subsequent childbearing is a consideration. Preoperative gonadotropin-releasing hormone analog treatment before myomectomy decreases the size and vascularity of the myoma but may render the capsule more fibrous and difficult to resect. Uterine artery embolization is an effective standard alternative for women with large symptomatic myomas who are poor surgical risks or wish to avoid major surgery. Its effects on future fertility need further evaluation in larger studies. Serial follow-up without surgery for growth and/or development of symptoms is advisable for asymptomatic women, particularly those approaching menopause. The present article is incorporated with multiple clear clinical photographs and simplified elaboration of the available management options for these tumors of uterine smooth muscle to facilitate clear understanding.

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

AIM

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSION

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

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

OBJECTIVE

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

DESIGN

Case-control study.

SETTING

University-associated hospital.

PATIENT(S)

One hundred ten patients with uterine fibroids.

INTERVENTION(S)

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

MAIN OUTCOME MEASURE(S)

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

RESULT(S)

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

CONCLUSION(S)

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