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Ma Y, Li L, Yu L, He W, Yi L, Tang Y, Li J, Zhong Z, Wang M, Huang S, Xiong Y, Xiao P, Huang Y. Optimization of Diagnosis-Related Groups for 14,246 Patients with Uterine Leiomyoma in a Single Center in Western China Using a Machine Learning Model. Risk Manag Healthc Policy 2024; 17:473-485. [PMID: 38444948 PMCID: PMC10913598 DOI: 10.2147/rmhp.s442502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 02/23/2024] [Indexed: 03/07/2024] Open
Abstract
Background Uterine leiomyoma (UL) is one of the most common benign tumors in women, and its incidence is gradually increasing in China. The clinical complications of UL have a negative impact on women's health, and the cost of treatment poses a significant burden on patients. Diagnosis-related groups (DRG) are internationally recognized as advanced healthcare payment management methods that can effectively reduce costs. However, there are variations in the design and grouping rules of DRG policies across different regions. Therefore, this study aims to analyze the factors influencing the hospitalization costs of patients with UL and optimize the design of DRG grouping schemes to provide insights for the development of localized DRG grouping policies. Methods The Mann-Whitney U-test or the Kruskal-Wallis H-test was employed for univariate analysis, and multiple stepwise linear regression analysis was utilized to identify the primary influencing factors of hospitalization costs for UL. Case combination classification was conducted using the exhaustive chi-square automatic interactive detection (E-CHAID) algorithm within a decision tree framework. Results Age, occupation, number of hospitalizations, type of medical insurance, Transfer to other departments, length of stay (LOS), type of UL, admission condition, comorbidities and complications, type of primary procedure, other types of surgical procedures, and discharge method had a significant impact on hospitalization costs (P<0.05). Among them, the type of primary procedure, other types of surgical procedures, and LOS were the main factors influencing hospitalization costs. By incorporating the type of primary procedure, other types of surgical procedures, and LOS into the decision tree model, patients were divided into 11 DRG combinations. Conclusion Hospitalization costs for UL are mainly related to the type of primary procedure, other types of surgical procedures, and LOS. The DRG case combinations of UL based on E-CHAID algorithm are scientific and reasonable.
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Affiliation(s)
- Yuan Ma
- Department of Medical Record Management, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, People’s Republic of China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, People’s Republic of China
| | - Li Li
- Department of Medical Record Management, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, People’s Republic of China
| | - Li Yu
- Department of Medical Record Management, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, People’s Republic of China
| | - Wei He
- Department of Medical Record Management, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, People’s Republic of China
| | - Ling Yi
- Department of Medical Record Management, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, People’s Republic of China
| | - Yuxin Tang
- Department of Medical Record Management, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, People’s Republic of China
| | - Jijie Li
- Department of Medical Record Management, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, People’s Republic of China
| | - Zhigang Zhong
- Department of Prevention, Office of Cancer Prevention and Treatment, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, Cancer Hospital Affiliate to University of Electronic Science and Technology of China, Chengdu, Sichuan, People’s Republic of China
| | - Meixian Wang
- National Center for Birth Defects Monitoring, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, People’s Republic of China
| | - Shiyao Huang
- Chinese Evidence-Based Medicine Center, West China Hospital, Sichuan University, Chengdu, Sichuan, People’s Republic of China
- NMPA Key Laboratory for Real World Data Research and Evaluation in Hainan, Chengdu, Sichuan, People’s Republic of China
| | - Yiquan Xiong
- Chinese Evidence-Based Medicine Center, West China Hospital, Sichuan University, Chengdu, Sichuan, People’s Republic of China
- NMPA Key Laboratory for Real World Data Research and Evaluation in Hainan, Chengdu, Sichuan, People’s Republic of China
| | - Pei Xiao
- Medical Insurance Office, West China Fourth Hospital, Sichuan University, Chengdu, Sichuan, People’s Republic of China
| | - Yuxiang Huang
- Department of Medical Record Management, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, People’s Republic of China
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Lee EJ, Park SJ, Kim Y, Lim H, Lee S, Yim GW, Song G, Kim HS. Effect and safety of diluted vasopressin injection on bleeding during robot-assisted laparoscopic myomectomy: a protocol for a randomised controlled pilot trial. BMJ Open 2022; 12:e056145. [PMID: 36115677 PMCID: PMC9486176 DOI: 10.1136/bmjopen-2021-056145] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
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.
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Affiliation(s)
- Eun Ji Lee
- Department of Obstetrics and Gynecology, Chung-Ang University Hospital, Seoul, Korea (the Republic of)
| | - Soo Jin Park
- Department of Obstetrcis and Gynecology, Seoul National University Hospital, Seoul, Korea (the Republic of)
| | - Yup Kim
- Department of Obstetrcis and Gynecology, Seoul National University Hospital, Seoul, Korea (the Republic of)
| | - Hyunji Lim
- Department of Obstetrcis and Gynecology, Seoul National University Hospital, Seoul, Korea (the Republic of)
| | - Seungmee Lee
- Department of Obstetrics and Gynecology, Keimyung University School of Medicine, Daegu, Korea (the Republic of)
| | - Ga Won Yim
- Department of Obstetrics and Gynecology, Dongguk University College of Medicine, Goyang, Korea (the Republic of)
| | - Gwonhwa Song
- Institute of Animal Molecular Biotechnology and Department of Biotechnology, Korea University, Seoul, Korea (the Republic of)
| | - Hee Seung Kim
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Korea (the Republic of)
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Stebbings C, Latif A, Gnananandan J. Torsion of a parasitic leiomyoma: a rare but important differential in women presenting with lower abdominal pain. BMJ Case Rep 2021; 14:14/1/e232797. [PMID: 33504515 PMCID: PMC7843348 DOI: 10.1136/bcr-2019-232797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
A 39-year-old multiparous Afro-Caribbean woman attended the emergency department with sudden-onset severe right iliac fossa pain. Her inflammatory markers were mildly elevated. Computerised tomography of the abdomen demonstrated features of fat stranding in the right iliac fossa suspicious of acute appendicitis. The scan also noted uterine leiomyomas. The patient was taken to theatre for an emergency diagnostic laparoscopy where her appendix was found to be macroscopically normal. A necrotic heavily calcified parasitic leiomyoma was seen in the right adnexa, free of the uterus and adherent to the greater omentum on a long torted pedicle. The parasitic leiomyoma was successfully removed piecemeal laparoscopically. Complications of leiomyomas, namely, torsion and necrosis, are important differentials in women presenting with sudden-onset lower abdominal pain. A history of sudden-onset severe lower abdominal pain with a background of known leiomyoma should prompt the clerking surgeon to consider a complication of leiomyoma as part of the differential diagnoses.
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Affiliation(s)
| | - Ahmed Latif
- General Surgery, Lewisham and Greenwich NHS Trust, London, UK
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Tran AP, Al Naber J, Tambor ES, Myers ER. Addressing heterogenous outcomes in uterine fibroid research: a call to action. Am J Obstet Gynecol 2020; 223:75.e1-75.e5. [PMID: 32199924 DOI: 10.1016/j.ajog.2020.03.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 02/27/2020] [Accepted: 03/12/2020] [Indexed: 01/20/2023]
Abstract
Uterine fibroid tumors are the most common benign pelvic tumors in women, with complications that include heavy menstrual bleeding, pelvic pain, reproductive complications, and bulk-related symptoms. Although the majority of uterine fibroid tumors are asymptomatic, those women who experience symptoms can experience substantial burdens on quality of life and daily functioning. Comparative effectiveness reviews of available medical, surgical, and radiologic treatments have found that a lack of high-quality data to inform treatment decisions is, in part, due to the use of heterogeneous outcomes and instruments in clinical studies. With multiple new interventions emerging, this call-to-action encourages the development and use of a core outcome set that will capture the most relevant, patient-important outcomes in late-phase and after-marketing therapeutic trials for uterine fibroid tumors. The core outcome set should be developed by a diverse, multistakeholder group comprised of key healthcare decision-makers. Development and uptake of a core outcome set ensures that a consistent, collaboratively vetted set of outcomes will be accessible across different studies and promotes transparency for innovators who seek to anticipate the evidence needs of patients, providers, payers, regulators, and other stakeholders.
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Affiliation(s)
- Annie P Tran
- Center for Medical Technology Policy, Baltimore, MD
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Xie L, Liu Y, Wang D, Liu C, Zhou H, Lin Z, Lu H. Application of a 'Baseball' Suture Technique in Uterine Myomectomy Following Laparoscopic Enucleation of Uterine Leiomyoma (Fibroid). Med Sci Monit 2018; 24:3042-3049. [PMID: 29742071 PMCID: PMC5968838 DOI: 10.12659/msm.909143] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background The aim of this study was to evaluate the safety and efficacy of a ‘baseball’ suture technique for uterine myomectomy incision closure in laparoscopic surgical enucleation of uterine leiomyoma (fibroid). Material/Methods The study included 20 patients who underwent laparoscopic myomectomy with a ‘baseball’ suture technique, compared with 20 patients who underwent laparoscopic myomectomy with a standard suture method. Clinical characteristics, perioperative and follow-up data were compared between the two groups. Results For the study group, compared with the standard or control group, had a significantly reduced operation time (60.15±9.97 min vs. 71.85±9.74 min) and suturing time (18.05±4.71 min vs. 28.35±3.13 min) (both p<0.05), significantly less intraoperative blood loss (93.25±19.62 ml vs. 121.50±24.87 ml) (p<0.05) and significantly less reduction in postoperative hemoglobin levels (8.9±1.97 g/L vs. 11.15±2.23 g/L) (p<0.05). There were no statistically significant differences between the two groups in duration of the use of the indwelling drainage tube, drainage volume, or time to recovery of gastrointestinal function (all, p>0.05). Following surgery, blood transfusion was given to one patient in the study group and two patients in the control group. One patient from each group had a fever. There was no significant difference in pregnancy outcomes between the two groups. Conclusions The ‘baseball’ suture technique for closure of the uterine incision is a safe and effective method for use in laparoscopic myomectomy. However, the long-term recovery outcomes require further study.
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Affiliation(s)
- Lingling Xie
- Department of Gynecologic Oncology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China (mainland)
| | - Yunyun Liu
- Department of Gynecologic Oncology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China (mainland)
| | - Dongyan Wang
- Department of Gynecologic Oncology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China (mainland)
| | - Changhao Liu
- Department of Gynecologic Oncology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China (mainland)
| | - Hui Zhou
- Department of Gynecologic Oncology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China (mainland)
| | - Zhongqiu Lin
- Department of Gynecologic Oncology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China (mainland)
| | - Huaiwu Lu
- Department of Gynecologic Oncology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China (mainland)
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Lewis TD, Malik M, Britten J, San Pablo AM, Catherino WH. A Comprehensive Review of the Pharmacologic Management of Uterine Leiomyoma. BIOMED RESEARCH INTERNATIONAL 2018; 2018:2414609. [PMID: 29780819 PMCID: PMC5893007 DOI: 10.1155/2018/2414609] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Accepted: 12/13/2017] [Indexed: 12/22/2022]
Abstract
Uterine leiomyomata are the most common benign tumors of the gynecologic tract impacting up to 80% of women by 50 years of age. It is well established that these tumors are the leading cause for hysterectomy with an estimated total financial burden greater than $30 billion per year in the United States. However, for the woman who desires future fertility or is a poor surgical candidate, definitive management with hysterectomy is not an optimal management plan. Typical gynecologic symptoms of leiomyoma include infertility, abnormal uterine bleeding (AUB)/heavy menstrual bleeding (HMB) and/or intermenstrual bleeding (IMB) with resulting iron-deficiency anemia, pelvic pressure and pain, urinary incontinence, and dysmenorrhea. The morbidity caused by these tumors is directly attributable to increases in tumor burden. Interestingly, leiomyoma cells within a tumor do not rapidly proliferate, but rather the increase in tumor size is secondary to production of an excessive, stable, and aberrant extracellular matrix (ECM) made of disorganized collagens and proteoglycans. As a result, medical management should induce leiomyoma cells toward dissolution of the extracellular matrix, as well as halting or inhibiting cellular proliferation. Herein, we review the current literature regarding the medical management of uterine leiomyoma.
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Affiliation(s)
- Terrence D. Lewis
- Program in Adult & Reproductive Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health (NIH), Bethesda, MD, USA
- Department of Obstetrics and Gynecology, Uniformed Services University of the Health Sciences (USUHS), Bethesda, MD, USA
- Department of Obstetrics and Gynecology, Walter Reed National Military Medical Center (WRNMMC), Bethesda, MD, USA
| | - Minnie Malik
- Department of Obstetrics and Gynecology, Uniformed Services University of the Health Sciences (USUHS), Bethesda, MD, USA
| | - Joy Britten
- Department of Obstetrics and Gynecology, Uniformed Services University of the Health Sciences (USUHS), Bethesda, MD, USA
| | - Angelo Macapagal San Pablo
- Program in Adult & Reproductive Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health (NIH), Bethesda, MD, USA
| | - William H. Catherino
- Program in Adult & Reproductive Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health (NIH), Bethesda, MD, USA
- Department of Obstetrics and Gynecology, Uniformed Services University of the Health Sciences (USUHS), Bethesda, MD, USA
- Department of Obstetrics and Gynecology, Walter Reed National Military Medical Center (WRNMMC), Bethesda, MD, USA
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Dvorská D, Braný D, Danková Z, Halašová E, Višňovský J. Molecular and clinical attributes of uterine leiomyomas. Tumour Biol 2017; 39:1010428317710226. [DOI: 10.1177/1010428317710226] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Dana Dvorská
- Division of Molecular Medicine, Biomedical Center Martin, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovakia
- Clinic of Gynecology and Obstetrics, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovakia
| | - Dušan Braný
- Division of Molecular Medicine, Biomedical Center Martin, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovakia
- Clinic of Gynecology and Obstetrics, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovakia
| | - Zuzana Danková
- Division of Oncology, Biomedical Center Martin, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovakia
| | - Erika Halašová
- Division of Molecular Medicine, Biomedical Center Martin, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovakia
| | - Jozef Višňovský
- Clinic of Gynecology and Obstetrics, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovakia
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Prise en charge des léiomyomes utérins. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2017; 38:S550-S576. [PMID: 28063565 DOI: 10.1016/j.jogc.2016.09.063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Sesti F, Cosi V, Calonzi F, Ruggeri V, Pietropolli A, Di Francesco L, Piccione E. Randomized comparison of total laparoscopic, laparoscopically assisted vaginal and vaginal hysterectomies for myomatous uteri. Arch Gynecol Obstet 2014; 290:485-91. [DOI: 10.1007/s00404-014-3228-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2013] [Accepted: 03/24/2014] [Indexed: 10/25/2022]
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Hysteroscopic enucleation in toto of submucous type 2 myomas: long-term follow-up in women affected by menorrhagia. J Minim Invasive Gynecol 2013; 21:426-30. [PMID: 24291491 DOI: 10.1016/j.jmig.2013.11.007] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2013] [Revised: 11/11/2013] [Accepted: 11/17/2013] [Indexed: 11/23/2022]
Abstract
STUDY OBJECTIVE To evaluate long-term efficacy of type 2 myoma enucleation in toto. DESIGN Longitudinal retrospective study (Canadian Task Force classification II-2). SETTING University obstetrics and gynecology clinic. PATIENTS One hundred twelve women with menorrhagia and at least 1 type 2 submucous myoma who underwent hysteroscopic myoma enucleation in toto. INTERVENTION Clinical long-term follow-up. MEASUREMENTS AND MAIN RESULTS Success of the procedure and influence of myoma characteristics on recurrence of menorrhagia were evaluated. Mean (SD) follow-up was 58.4 (19.1) months. The success of the procedure was 88.4% (99 patients). Seventeen patients (15.2%) underwent a 2-step procedure. Among patients with relapsed menorrhagia, 10 (8.9%) underwent a repeat operation. Statistical analysis showed that number and diameter of myomas did not influence the outcome. Localization in the posterior wall of the uterus, compared with other sites, was associated with a higher percentage of resolution of menstrual symptoms (p = .03). There was no significant relationship between myomas features and risk of symptom recurrence during follow-up. The 2-step myomectomy was performed in patients with myomas >30 mm in diameter (p < .001). CONCLUSION Hysteroscopic enucleation in toto of type 2 myomas is a safe and effective technique in long-term management of premenopausal women with menorrhagia.
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Tinelli A, Mettler L, Malvasi A, Hurst B, Catherino W, Mynbaev OA, Guido M, Alkatout I, Schollmeyer T. Impact of surgical approach on blood loss during intracapsular myomectomy. MINIM INVASIV THER 2013; 23:87-95. [DOI: 10.3109/13645706.2013.839951] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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GnRH agonists: do they have a place in the modern management of fibroid disease? J Obstet Gynaecol India 2012; 62:506-10. [PMID: 24082548 DOI: 10.1007/s13224-012-0206-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2012] [Accepted: 05/26/2012] [Indexed: 10/27/2022] Open
Abstract
In the management of women with fibroid disease, GnRH agonists (GnRHa) are frequently used to reduce volume and vascularity before myomectomy, apparently to render the operation easier and reduce operative blood loss, and to enable a transverse supra-pubic incision instead of a midline vertical one. They induce amenorrhoea and thus aid in the correction of pre-operative anaemia. Other gynaecologists use GnRHa to shrink sub mucous fibroids greater than 5 cm in diameter to facilitate access and reduce blood loss and operating time at transcervical resection. GnRHa are also occasionally used as a temporizing measure in women with symptomatic fibroids within the climacteric. We argue against the use of GnRHa in the management of fibroid disease because they are not cost effective, render myomectomy more difficult to apply because they destroy tissue planes, the more difficult enucleation in fact increasing rather than reducing peri-operative blood loss and operating time. When used before myomectomy, they increase the risk of 'recurrence' because they obscure smaller fibroids that 'recur' when the effects of the GnRHa wear off, and are associated with side effects in situations where they confer no benefits, or where alternative cheaper drugs with fewer side effects are available.
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Abstract
Uterine leiomyomas (also called myomata or fibroids) are the most common gynecologic tumors in the United States. The prevalence of leiomyomas is at least 3 to 4 times higher among African American women than in white women. Pathologically, uterine leiomyomas are benign tumors that arise in any part of the uterus under the influence of local growth factors and sex hormones, such as estrogen and progesterone. These common tumors cause significant morbidity for women and they are considered to be the most common indication for hysterectomy in the world; they are also associated with a substantial economic impact on health care systems that amounts to approximately $2.2 billion/year in the United States alone. Uterine myomas cause several reproductive problems such as heavy or abnormal uterine bleeding, pelvic pressure, infertility, and several obstetrical complications including miscarriage and preterm labor. Surgery has traditionally been the gold standard for the treatment of uterine leiomyomas and has typically consisted of either hysterectomy or myomectomy. In recent years, a few clinical trials have evaluated the efficacy of orally administered medications for the management of leiomyoma-related symptoms. In the present review, we will discuss these promising medical treatments in further detail.
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Affiliation(s)
- Mohamed Sabry
- Center for Women Health Research (CWHR), Meharry Medical College, Nashville, TN, USA
- Department of Obstetrics and Gynecology, Faculty of Medicine, Sohag University, Egypt
| | - Ayman Al-Hendy
- Center for Women Health Research (CWHR), Meharry Medical College, Nashville, TN, USA
- Department of Obstetrics and Gynecology, Center for Women Health Research, Meharry Medical College, Nashville, TN, USA
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Marret H, Ouldamer L. [Surgical treatment of subserosal fibroids: the cons]. GYNECOLOGIE, OBSTETRIQUE & FERTILITE 2011; 39:454-457. [PMID: 21752689 DOI: 10.1016/j.gyobfe.2011.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Affiliation(s)
- H Marret
- Pôle de gynécologie, obstétrique, médecine fœtale, reproduction humaine et génétique, hôpital Bretonneau, CHU de Tours, 2 boulevard Tonnellé, Tours cedex, France.
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Marret H. [Peri- or postmenopausal myomectomy: the cons]. GYNECOLOGIE, OBSTETRIQUE & FERTILITE 2010; 38:700-704. [PMID: 21050791 DOI: 10.1016/j.gyobfe.2010.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Affiliation(s)
- H Marret
- Service de gynécologie, pôle de gynécologie, obstétrique, médecine fœtale, reproduction humaine et génétique, hôpital Bretonneau, CHU de Tours, 2, boulevard Tonnellé, 37044 Tours cedex, France.
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Single-port laparoscopic myomectomy using a new single-port transumbilical morcellation system: initial clinical study. J Minim Invasive Gynecol 2010; 17:587-92. [PMID: 20576473 DOI: 10.1016/j.jmig.2010.04.009] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2009] [Revised: 04/07/2010] [Accepted: 04/23/2010] [Indexed: 11/23/2022]
Abstract
STUDY OBJECTIVE To evaluate the feasibility of single-port laparoscopic myomectomy with transumbilical morcellation and suturing. DESIGN Continuing prospective study (Canadian Task Force classification II-3). SETTING University hospital. PATIENTS Fifteen patients who underwent single-port laparoscopic myomectomy between September 2008 and October 2009 to remove single or multiple uterine myomas, at least 1 in each patient measuring greater than 4 cm in diameter. INTERVENTIONS All single-port laparoscopic myomectomy procedures were performed by a single surgeon (Dr. Y.W. Kim). Myomas were extracted transumbilically by cutting the myomas into smaller pieces with a knife or a conventional electromechanical morcellator. After making a single 1.5- to 2.0-cm umbilical incision, the single-port system, created with a wound retractor and a surgical glove, was inserted. All operations were performed using conventional rigid straight laparoscopic instruments. Laparoscopic suturing was performed in intramural myomas and some subserosal myomas. MEASUREMENTS AND MAIN RESULTS Patient mean (SD; range) age was 38.3 (5.6; 29-49) years. The number of myomas per patient was 1.6 (1.4; 1-6). The diameter of the largest myomas was 6.1 (1.5; 4.2-9.6) cm. In 4 patients, only a knife was required for transumbilical extraction of myomas, and in 11 patients, transumbilical morcellation with an electromechanical morcellator with or without a knife was used. Transumbilical drainage tubes were inserted into the pelvic cavity in 11 of 15 patients. Operative time was 96.7 (33.8; 35-150) minutes. The decrease in postoperative hemoglobin concentration was 1.8 (1.2; 0.4-3.6) g/dL. During the operations, no patients required blood transfusion. No patients developed postoperative fever. Neither bowel injury nor urinary tract injury occurred in any patient. The postoperative hospital stay was 3.1 (0.8; 2-4) days. CONCLUSION Single-port transumbilical morcellation using a conventional electromechanical morcellator with or without a knife is feasible. Single-port laparoscopic myomectomy is an alternative method with cosmetic advantage.
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Zullo F, Falbo A, Iuliano A, Oppedisano R, Sacchinelli A, Annunziata G, Venturella R, Materazzo C, Tolino A, Palomba S. Randomized controlled study comparing the Gynecare Morcellex and Rotocut G1 tissue morcellators. J Minim Invasive Gynecol 2010; 17:192-9. [PMID: 20226407 DOI: 10.1016/j.jmig.2009.11.009] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2009] [Revised: 10/29/2009] [Accepted: 11/10/2009] [Indexed: 11/29/2022]
Abstract
STUDY OBJECTIVE To evaluate the effectiveness of the Gynecare Morcellex tissue morcellator (Ethicon, Inc., Somerville, NJ) in laparoscopic supracervical hysterectomy and myomectomy. DESIGN Randomized controlled trial (Evidence I). SETTING University department of obstetrics and gynecology. PATIENTS Seventy-four patients with symptomatic uterine myomas scheduled for laparoscopic supracervical hysterectomy or myomectomy. INTERVENTIONS Laparoscopic supracervical hysterectomy and myomectomy followed by tissue morcellation using the Gynecare Morcellex (experimental group) or the Rotocut G1 morcellator (Karl Storz GmbH & Co. KG, Tuttlingen, Germany) (control group). MEASUREMENTS AND MAIN RESULTS Patient characteristics and surgical data were noted for both groups. No difference was detected between groups in any parameters assessed, whereas a significant difference (p <.05) in handling score was detected in the experimental group compared with the control group. CONCLUSION The Gynecare Morcellex is an effective instrument with excellent safety and handling.
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Affiliation(s)
- Fulvio Zullo
- Department of Obstetrics, University Magna Graecia of Catanzaro, Catanzaro, Italy
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Pansky M, Cowan BD, Frank M, Hampton HL, Zimberg S. Laparoscopically assisted uterine fibroid cryoablation. Am J Obstet Gynecol 2009; 201:571.e1-7. [PMID: 19716538 DOI: 10.1016/j.ajog.2009.06.028] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2009] [Revised: 05/13/2009] [Accepted: 06/12/2009] [Indexed: 10/20/2022]
Abstract
OBJECTIVE The objective of the study was to develop a safe and effective cryoablation technique for the treatment of uterine fibroids. STUDY DESIGN This was a multicenter pilot case series to evaluate cryoablation of uterine fibroids using laparoscopically assisted placement of 17-gauge cryoablation needles. Patient satisfaction was documented with a validated Uterine Fibroid Symptom and Quality of Life (UFS-QOL) questionnaire. Procedural efficacy was evaluated by assessing fibroid shrinkage. Treatment was followed by assessments at 3, 6, and 12 months. RESULTS Median fibroid volume reduction was 43.3% (19 patients) and 66.4% (15 patients) at 6 and 12 months, respectively. Median UFS-QOL score improvement was 61.9% and 66.7% at 6 and 12 months, respectively. Additionally, patients experienced marked improvement of bleeding and fibroid bulk symptoms. The median Symptom Severity Score at baseline was 50, 25.0 (-59%) at 6 months, and 12.5 (-66.7%) at 12 months. CONCLUSION These pilot data indicate that uterine fibroid cryoablation is a safe and effective minimally invasive alternative to treat symptomatic uterine fibroids.
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Palomba S, Zupi E, Falbo A, Russo T, Marconi D, Zullo F. New tool (Laparotenser) for gasless laparoscopic myomectomy: a multicenter-controlled study. Fertil Steril 2009; 94:1090-6. [PMID: 19481738 DOI: 10.1016/j.fertnstert.2009.04.030] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2009] [Revised: 03/30/2009] [Accepted: 04/14/2009] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To assess feasibility and safety of a new surgical instrument-Laparotenser-in the procedure of gasless laparoscopic myomectomy. DESIGN Multicenter controlled study. SETTING Academic departments of obstetrics and gynecology, Italy. PATIENT(S) Thirty patients scheduled for gasless laparoscopic myomectomy (experimental group) and another group of 30 patients from our historical records that have undergone traditional laparoscopic myomectomy, matched with the cases for number of fibroids and for size of the main fibroid (control group). INTERVENTION(S) Gasless laparoscopic myomectomy using Laparotenser. MAIN OUTCOME MEASURE(S) Surgical data. RESULT(S) No significant differences in total operative time, postoperative ileus, hospitalization, time to return to full activity/work, and complication rates were observed between groups. Intraoperative blood loss, hemoglobin level, and surgical difficulty were significantly higher in the experimental than in the control group. Postoperative pain and number of analgesic vials used were significantly lower in the experimental group than in the control group. CONCLUSION(S) Although performed during the learning curve period, the use of the Laparotenser instrument in gasless laparoscopic myomectomy is a safe procedure.
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Affiliation(s)
- Stefano Palomba
- Department of Obstetrics & Gynecology, University Magna Graecia, Catanzaro, Italy.
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Experience with laparoscopic-assisted vaginal hysterectomy for the enlarged uterus. Arch Gynecol Obstet 2009; 280:425-30. [PMID: 19184075 DOI: 10.1007/s00404-009-0944-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2008] [Accepted: 01/09/2009] [Indexed: 02/01/2023]
Abstract
OBJECTIVE The aim of this study is to evaluate the effect of uterine weight on the perioperative and postoperative outcomes of laparoscopically assisted vaginal hysterectomy (LAVH) for benign gynecological conditions. METHODS In a retrospective observational study, 367 patients underwent LAVH (type I laparoscopic hysterectomy) for benign disorders at the Department of Gynecology at the Istanbul Bakirkoy Women and Children Hospital. Patients were divided into two groups with uterine weight <500 g and uterine weight > or =500 g. Outcome measures for both groups were studied comparatively in terms of length of operative time, pain score, amount of blood loss, requirement of blood transfusion, and length of hospital stay. RESULTS There were no differences in patients' mean age, parity, gravidity, rate of postmenopausal state, previous pelvic surgery, and body mass index. The most common indications for surgery were myoma and abnormal uterine bleeding. The duration of operation, estimated blood loss and requirement of blood transfusion were significantly less for <500 g group than for > or =500 g group. Three women in the <500 g group sustained a blood loss in excess of 500 ml. By comparison, 18 women in the > or =500 g group sustained a blood loss in excess of 500 ml (P = 0.000). Total complication rate was 8.7%. Postoperative ileus and febrile morbidity were the most common complications. No significant difference was noted in overall complications between groups (P = 0.13). During the vaginal part of the procedure bladder injury occurred in one patient who had uterine weight > or =500 g. CONCLUSION LAVH is a safe and efficient way to manage benign uterine disease and despite the increased operating time and blood loss, LAVH can be safely performed for enlarged uterus.
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Mukhopadhaya N, De Silva C, Manyonda IT. Conventional myomectomy. Best Pract Res Clin Obstet Gynaecol 2008; 22:677-705. [DOI: 10.1016/j.bpobgyn.2008.01.012] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Palomba S, Zupi E, Falbo A, Russo T, Marconi D, Tolino A, Manguso F, Mattei A, Zullo F. A multicenter randomized, controlled study comparing laparoscopic versus minilaparotomic myomectomy: reproductive outcomes. Fertil Steril 2007; 88:933-41. [PMID: 17434505 DOI: 10.1016/j.fertnstert.2006.12.047] [Citation(s) in RCA: 109] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2006] [Revised: 12/20/2006] [Accepted: 12/27/2006] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To assess the reproductive outcomes after minilaparotomic and laparoscopic myomectomy in patients wishing to conceive. DESIGN Randomized controlled trial. SETTING Departments of obstetrics and gynecology of the universities of Catanzaro, Rome, and Florence, Italy. PATIENT(S) One hundred thirty-six women with symptomatic uterine leiomyomas or unexplained infertility. INTERVENTION(S) Laparoscopic and minilaparotomic myomectomy. MAIN OUTCOME MEASURE(S) Pregnancy, abortion, and live-birth rates. RESULT(S) Between the laparoscopic and minilaparotomic groups no difference was observed in cumulative pregnancy, live-birth, and abortion rates, whereas pregnancy and live-birth rates per cycle, and time to first pregnancy and live-birth were significantly higher in the laparoscopic than in the minilaparotomic group. Categorizing the patients according to surgical indication for myomectomy, cumulative pregnancy rate, pregnancy, and live-birth rates per cycle, and time to first pregnancy and live-birth were significantly better after laparoscopic myomectomy in symptomatic patients, whereas all reproductive outcomes were similar between the two groups in patients with unexplained infertility. CONCLUSION(S) Minilaparotomic and laparoscopic myomectomy improves in a similar manner the reproductive outcomes in patients with unexplained infertility, whereas the laparoscopic approach provides the best benefits in fertile patients with symptomatic leiomyomas.
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Affiliation(s)
- Stefano Palomba
- Department of Obstetrics & Gynecology, University Magna Graecia of Catanzaro, Catanzaro, Italy.
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Etiology, symptomatology, and diagnosis of uterine myomas. Fertil Steril 2007; 87:725-36. [PMID: 17430732 DOI: 10.1016/j.fertnstert.2007.01.093] [Citation(s) in RCA: 373] [Impact Index Per Article: 21.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2006] [Revised: 01/11/2007] [Accepted: 01/11/2007] [Indexed: 11/18/2022]
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Laparoscopic myomectomy: feasibility and safety—a retrospective study of 762 cases. ACTA ACUST UNITED AC 2006. [DOI: 10.1007/s10397-006-0190-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Abstract
Leiomyomas (fibroids) are common estrogen-dependent uterine tumours that cause significant morbidity for women and a substantial economic impact on health delivery systems. Currently, there is no effective medical treatment option for this condition-hysterectomy is the mainstay of management. This is not an attractive choice for many women, especially patients desiring to preserve their fertility potential. Gene therapy is becoming a clinical reality, with more than 600 clinical trials worldwide. Researchers have recently attempted to develop a gene-therapy-based approach for the ablation of uterine fibroids. The localized nature of this condition and its accessibility using different imaging or endoscopic techniques make it an attractive target for direct delivery of gene-based vectors. Recent work from our laboratory suggests the potential use of a dominant-negative form of estrogen receptor (ER) to inactivate estrogen signalling in leiomyoma cells and induce apoptosis. Our in vivo data in a mouse model demonstrate the ability of an adenovirus-expressing dominant-negative ER to arrest leiomyoma growth. We and others also have described the utility of the herpes simplex virus-thymidine kinase (HSV-TK) plus ganciclovir (GCV) suicide gene-therapy system to effectively eradicate leiomyoma cells by utilizing the bystandard effect phenomena and the high expression of gap-junction protein in these tumours. Further work on rat models will pave the way for future leiomyoma gene-therapy clinical trials and allow the realization of gene therapy as a viable non-surgical option for this common problem in women's health.
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Affiliation(s)
- Ayman Al-Hendy
- Department of Obstetrics & Gynecology, University of Texas Medical Branch, 301 University Boulevard, Galveston, TX 77555, USA.
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Affiliation(s)
- Tommaso Falcone
- Department of Obstetrics and Gynecology, Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA.
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Banu NS, Manyonda IT. Alternative medical and surgical options to hysterectomy. Best Pract Res Clin Obstet Gynaecol 2005; 19:431-49. [PMID: 15985257 DOI: 10.1016/j.bpobgyn.2005.01.006] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The range of alternatives to hysterectomy includes 'expanded' oral medical regimens, the levonorgestrel-releasing intrauterine system (LNG-IUS), a wide range of endometrial ablative techniques, and-where fibroids are the primary pathology-myomectomy and uterine artery embolization. Since research has shown that hysterectomy is a highly effective treatment, these alternatives must be assessed against the recognized high satisfaction rates and improved quality of life reported following hysterectomy. Additional issues that would also need to be addressed include complication rates, side-effects, and cost-effectiveness. For women with prolonged abnormal uterine bleeding, recent research suggests that hysterectomy is significantly superior to an expanded medical treatment regimen for health-related quality-of-life measures. Satisfaction with treatment, and health-related quality of life and psychosocial well-being, are reportedly similar between hysterectomy and the LNG-IUS, but the latter has the advantage of reduced cost. Endometrial ablation reduces menstrual blood flow, but its benefits relative to hysterectomy lessen over time. No large-scale studies have adequately compared uterine artery embolization or myomectomy to hysterectomy. Perhaps the most telling finding from recent research with respect to the place of alternative therapies to hysterectomy is that the existence or advent of these alternatives has not reduced hysterectomy rates, but merely increased treatment options and interventions for excessive menstrual loss.
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Affiliation(s)
- Nassera S Banu
- Department of Obstetrics and Gynaecology, St George's Healthcare NHS Trust, Blackshaw Road, Tooting, London SW17 0QT, UK
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Manyonda I, Sinthamoney E, Belli AM. Controversies and challenges in the modern management of uterine fibroids. BJOG 2004; 111:95-102. [PMID: 14723744 DOI: 10.1046/j.1471-0528.2003.00002.x] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Isaac Manyonda
- Department of Gynaecology, St George's Healthcare NHS Trust, London, UK
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