Prevention and Management of Complications in Laparoscopic Myomectomy

Surgical Outcomes and Complications of Myomectomy: A Prospective Cohort Study

STUDY OBJECTIVE

To investigate postoperative surgical and non-surgical complications that occur within 30 days following myomectomy procedures, whether laparoscopic or via open surgery.

DESIGN

Prospective cohort study SETTING: Del Ponte Women's and Children's Hospital, Varese, Italy.

PATIENTS

Women undergoing myomectomy either with laparoscopic or open surgery from July 2020 to June 2023 INTERVENTIONS: Data of consecutive patients who underwent abdominal myomectomy procedures, either via laparoscopy or open abdominal surgery were collected. The study examined patient characteristics, size and location of fibroids, surgical data, and complications. Univariate and multivariable analyses were employed to identify factors contributing to postoperative Clavien-Dindo grade ≥ II complications.

MEASUREMENTS AND MAIN RESULTS

Overall 383 patients were included in the study. The univariate analysis showed intramural fibroid type (p = .0009), large fibroid size (p = .03), and extended operative times (p = .05) were associated with postoperative complications. Open surgical approach (p <.001) and uterine cavity opening (p = .02) also contributed to complications. Postoperative anemia emerged as the most prevalent complication. In the multivariable analysis, the open surgical approach emerged as the only independent factor associated with an increased risk of grade ≥ II complications (odds ratio 7.37; p <.0001).

CONCLUSION

In this study we found an increased likelihood of complications in case of open myomectomy. While the presence of potential selection bias may have impacted this finding, it could provide valuable insights for clinicians and surgical teams in the strategic planning of myomectomy procedures.

Factors related to clearance of the small pelvic cavity during gynecologic laparoscopic surgery

AIM

To identify factors influencing the Trendelenburg angle required during laparoscopic gynecological surgery.

METHODS

Patients who underwent laparoscopic surgery at a single university hospital between May 1, 2019, and March 31, 2021 were enrolled. Data were extracted from the medical records, while magnetic resonance imaging scans and all laparoscopic surgery videos were retrospectively reviewed to assess the presence of the small intestine in the pelvic cavity as well as the adhesions at each site. Groups with and without the small intestine in the pelvic cavity, and those requiring a Trendelenburg angle above or below 13° were compared.

RESULTS

In total, 219 patients were examined. The Trendelenburg angle was significantly higher (p = 0.004), while a significant increase in ovarian adhesions was observed (p = 0.033; odds ratio [OR], 2.30; 95% confidence interval [CI], 1.05-5.01) in the group without the presence of the small intestine in the pelvic cavity. Furthermore, the group requiring a Trendelenburg angle of ≥13° had significantly thicker subcutaneous fat (p = 0.044) and more ileal adhesions (p = 0.040, OR, 1.82; 95% CI, 1.03-3.23) than the group with an angle of <13°.

CONCLUSION

Cases of ileal adhesions or thick subcutaneous fat are more likely to require a Trendelenburg angle of ≥13°. Therefore, Trendelenburg complications should be considered in this group. In addition, ovarian adhesions make it more difficult to exclude the small intestine from the small pelvic cavity, and may be associated with endometriosis.

Adverse outcomes related to morcellation in Total Laparoscopic Hysterectomy

OBJECTIVE

This study aimed to comprehensively evaluate the complications associated with morcellation in Total Laparoscopic Hysterectomy (TLH) procedures, providing evidence-based insights to enhance patient safety and surgical efficacy.

DATA SOURCES

A comprehensive literature search was conducted using multiple databases, including PubMed, EMBASE, Google Scholar, and Cochrane Central Register of Controlled Trials. The inclusion criteria were Studies that focused on morcellation and morcellation-related complications were included. The risk of bias in the included studies was assessed using established evaluation scales.

METHODS OF STUDY SELECTION

Thirteen studies investigating complications associated with morcellation in TLH (Total Laparoscopic Hysterectomy) were included in this review.This review covers intraoperative blood loss, length of hospital stay, loss of bag integrity, mean uterine specimen and weight, morcellation time, operation time, and TLH morcellation complications.

TABULATION, INTEGRATION, AND RESULTS

The selected studies covered different approaches and aspects related to this procedure, providing valuable insights into the factors associated with complications and efficacy of the technique in various clinical settings.This review highlights the importance of evaluating and considering complications associated with morcellation in TLH.

CONCLUSION

The findings of this review provide valuable insights into complications associated with morcellation in TLH. Clinicians could use this information to make informed decisions, implement safe protocols, and improve patient care. Addressing these complications will enhance the safety and efficacy of morcellation for TLH. Ethical Compliance: All procedures performed in this study involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

Prophylactic Use of Uterine Artery Embolization to Decrease Bleeding in Laparoscopic Myomectomy: A Case Report

Uterine fibroids, or leiomyomas, are the most frequent benign tumors affecting the female reproductive system, particularly during the reproductive years. The case report that follows presents the diagnosis and treatment of uterine fibroids in a female patient. The 33-year-old female patient in this instance arrived at the tertiary rural hospital with an abnormally large, bloated belly. Upon examination and imaging, it was discovered that the patient had multiple fibroids growing inside her uterus. Here, we present a successful management of uterine leiomyoma with laparoscopic myomectomy where we performed uterine artery embolization before surgical management in order to minimize blood loss during surgery. The case highlights the significance of collaboration between gynecologists, surgeons, and interventional radiologists. Thanks to their combined expertise, the patient was given a variety of treatment options, such as minimally invasive treatments, surgical interventions, and medication therapy. Decision considerations included the consequences of fibroids and the patient's age and desire to preserve fertility. The effect of fibroids on her life expectancy is taken into account. This case emphasizes how important it is to embolize the uterine arteries before having a myomectomy to cure large uterine leiomyomas successfully.

Risk of hysterectomy at the time of myomectomy: an underestimated surgical risk

OBJECTIVE

To evaluate the risk of hysterectomy at the time of myomectomy and the associated 30-day postoperative morbidity.

DESIGN

Cohort study.

PATIENTS

Patients who underwent myomectomies identified from the American College of Surgeons' National Surgical Quality Improvement Program from 2010 to 2021.

INTERVENTION

Unplanned hysterectomy at the time of a myomectomy procedure.

MAIN OUTCOME MEASURES

The Current Procedural Terminology codes were used to identify myomectomies performed with or without concurrent hysterectomy. Preoperative characteristics and morbidity outcomes were obtained. The univariate analysis was performed using the chi-square and Fisher exact tests, as appropriate. Multivariate logistic regression reported risk factors for individuals who underwent hysterectomy at the time of myomectomy. P values of <.05 were considered statistically significant.

RESULTS

A total of 13,213 individuals underwent myomectomy, and 399 (3.0%) had a hysterectomy performed during myomectomy. Concurrent hysterectomy was most frequently performed with the laparoscopic approach (7.1%), followed by the abdominal (3.2%) and hysteroscopic (1.9%) approaches. Age ≥43 years, obesity class II and higher, American Society of Anesthesiologists (ASA) class greater than II, tobacco use, longer operative time (>85 minutes), and laparoscopic approach were associated with a significantly increased risk of hysterectomy. When adjusting for age, body mass index, race, ASA class, case type, surgical approach, operative time, preoperative transfusion, preoperative hematocrit, and high fibroid burden, an increased odds of hysterectomy was noted for white race, longer operative time, ASA class III or higher, obesity, laparoscopic approach, and low fibroid burden. Patients who underwent concurrent hysterectomy had a longer median length of hospital stay (2 vs. 1 day), longer median operative time (161 vs. 126 minutes), increased intraoperative/postoperative blood transfusions (14.5% vs. 9.0%), and higher rates of organ/space surgical site infections (1.5% vs. 0.5%) and return to surgery (2.0% vs. 0.7%) than those who did not (P<.05). The risk of a major complication within 30 days of myomectomy increased in patients who underwent concurrent hysterectomy after adjusting for relevant confounders (adjusted odds ratio, 2.4; 95% confidence interval, 1.8-3.2).

CONCLUSION

The risk of hysterectomy during a myomectomy is higher than previously reported. The patient age of ≥43 years, obesity, white race, ASA class III or higher, longer operative time, and laparoscopic approach were associated with higher odds of hysterectomy. Identification of patients with these risk factors can aid in patient counseling and surgical planning, which may help reduce the unexpectedly high rates of hysterectomy at planned myomectomy.

Laparoscopic myomectomy complications: META analysis on RCTs and review of large cohort studies

Complications of myomectomy are generally rare and highly dependent on the surgeons' skills and selection of patients. Haemorrhage, direct injury, post-operative pain and fever present as intra and peri-operative complications, while adhesions are considered late complications. 21 RCTs and 15 meta-analyses have been conducted to date, with the last comprehensive meta-analysis being published in 2009. The main disadvantage of the previous meta-analysis included incomplete selection of studies, inclusion of studies with small sample sizes, and major heterogeneity of methods used between studies. The aim of this meta-analysis comparing laparoscopic myomectomy (LMy) to open conservative myomectomy is to provide an updated review of the type, frequency and severity of complications. These results can direct teaching efforts and guidelines and give updated advice to gynaecologists. A literature search was conducted on PubMed and Google scholar for RCTs on this topic. 276 studies were identified and 19 RCTs ultimately met the criteria for inclusion in the meta-analysis and subsequent heterogeneity assessment. The results showed that laparoscopic myomectomy has a more favourable outcome with regards to several complications when compared with laparotomy. Laparoscopic myomectomy is significantly associated with lower Hg drop (WMD = -0.48, 95% CI [-0.89, -0.07], p = 0.02179); lower incidence of post-operative fever (RR = 0.43, 95% CI [0.29, 0.64], p < 0.001); lower levels of pain at 48Hrs post-op (WMD = -0.88, 95% CI [-1.63, -0.014], p = 0.02020) and decreased analgesia requests (RR = 0.49, 95% CI [0.37, 0.64], p < 0.0001). Prophylaxis use was associated with less adhesions (RR = 0.064, 95% CI [0.44, 0.92], p = 0.01), although not enough data was available to draw conclusions regarding specific prophylactic agents. No differences were found between LMy and laparotomy for blood loss (WMD = -13.6494, 95% CI [-44.48, 17.18], p = 0.38553) or pain at 24Hrs post-op (WMD = -0.19, 95% CI [-0.55, 0.18], p = 0.32136). These findings support previously published meta-analyses. Given the right indications of the surgery and training of the surgeon, LMy seems to be most preferable to laparotomy in achieving a better clinical result with fewer complications.

Visualisation of microvascular flow in benign uterine disorders: a pilot study of a new diagnostic technique

BACKGROUND

Uterine disorders have clear overlapping symptoms and ultrasound discrimination is not always easy. Accurately measuring vascularity is of diagnostic and prognostic value. Power Doppler is limited to imaging only the larger vessels. Assessment of the microvasculature requires advanced machine settings.

OBJECTIVES

In this pilot study, we aimed to test the feasibility of microvascular flow imaging of benign uterine disorders.

MATERIAL AND METHODS

Two experienced gynaecologists (JH, RL) randomly applied power Doppler and MV-flowTM mode during a single day, in ten patients each visiting the outpatient clinic. Images of eight patients were labelled with a diagnosis by the attending physicians and collected as coded data.

MAIN OUTCOME MEASURES

Microvascular flow images of normal uterine architecture including the fallopian tube, and of benign disorders such as fibroids, adenomyosis, endometriosis and uterine niches were collected. For both Doppler techniques, qualitative descriptive evaluation of the vascular architecture and a quantitative vascular index of fibroids were provided. Finally, we evaluated the effect of the cardiac cycle.

RESULTS

All microvascular flow images showed more distinctive vascular structures than visible on power Doppler. Calculating a vascular index for fibroids on 2D MV-flowTM images was easily performed on-site. During the cardiac cycle a higher vascular index (VI 75.2) is obtained in systole as compared with diastole (VI 44.0).

CONCLUSION

Microvascular flow imaging allowed detailed visualisation of the uterine vascular architecture and is easy to use.

WHAT IS NEW?

Microvascular flow imaging may be of added value for diagnosing uterine disorders, as well as for pre- and post-operative assessment of suited surgical techniques. Yet, validation with histology and clinical outcomes is required.

Laparoscopic myomectomy - The importance of surgical techniques

Laparoscopy is a routine procedure for benign gynecological tumors. Although the laparoscopic approach for myomas is a common procedure, it can be challenging. To improve outcomes, research regarding port access, suture type, morcellation, and complication management remains ongoing. Myomectomy is the main surgical option for patients seeking uterus-sparing procedures to maintain future fertility. The laparoscopic technique is the most important in these cases, given that possible complications can impact fertility and pregnancy outcomes. Herein, we reviewed and collated the available data regarding different suture techniques, including advantages, difficulties, and possible long-term impacts.

Gonadotropin-Releasing Hormone agonist (GnRH-a) Pretreatment before Hormone Replacement Therapy Does Not Improve Reproductive Outcomes of Frozen-Thawed Embryo Transfer Cycle in Older Patients with Intrauterine Fibroid: A Retrospective Cohort Study

BACKGROUND

Surgery in elder patients with intermural fibroids delays pregnancy, and GnRH-a can shrink uterine fibroids to a certain extent; therefore, for geriatric patients with fibroids, determining whether GnRH-a pretreatment before frozen-thawed embryo transfer (FET) can improve its success rate remains to be studied. We conducted this study to research whether GnRH-a pretreatment before hormone replacement treatment (HRT) could optimize the reproductive outcomes compared with others preparations in geriatric patients with intramural fibroids.

METHODS

According to the endometrial preparation, patients were divided into a GnRH-a-HRT group, a HRT group and a natural cycle (NC) group. The live birth rate (LBR) was the first outcome, and the clinical pregnancy outcome (CPR), the miscarriage rate, the first trimester abortion rate and the ectopic pregnancy rate were the secondary outcomes.

RESULTS

A total of 769 patients (aged 35 years or older) were included in this study. No significant difference was observed in the live birth rate (25.3% vs. 17.4% vs. 23.5%, p = 0.200) and the clinical pregnancy rate (46.3% vs. 46.1% vs. 55.4%, p = 0.052) among the three endometrial preparation regimens.

CONCLUSION

In this study, for the geriatric patient with the intramural myoma, the pretreatment with GnRH-a did not show any advantage over the NC and HRT preparation groups before the FET, and the LBR was not significantly increased.

Effect of Parecoxib Sodium Combined with Dexmedetomidine on Analgesia and Postoperative Pain of Patients Undergoing Hysteromyomectomy

Background

Propofol combined with remifentanil is the most common anesthesia method in laparoscopic hysteromyomectomy. However, whether the combination of the two is helpful to patients undergoing hysteromyomectomy still requires unclear.

Objective

To determine the effect of parecoxib sodium combined with dexmedetomidine on analgesia and postoperative pain of patients undergoing hysteromyomectomy.

Methods

Altogether, 72 patients receiving hysteromyomectomy in our hospital from February 2017 to March 2019 were enrolled. Among them, 35 patients treated with parecoxib sodium were assigned to the control group, while the rest 37 patients treated with parecoxib sodium combined with dexmedetomidine were assigned to the research group. The following items of the two groups were evaluated: visual analog scale (VAS) score, mechanical pain threshold (MPT), Riker sedation-agitation scale (RSAS) score, and expression of serum cortisol and melatonin.

Results

At 12 and 24 h after operation, the VAS score of the research group was lower than that of the control group (P < 0.05), and at 6, 12, and 24 h after operation, the MPT of the research group was notably higher than that of the control group (P < 0.05). In addition, at 10 min after extubation, the research group got notably lower RSAS score than the control group (P < 0.05). Before extubation and at 20 min after extubation, the research group showed notably higher melatonin expression and notably lower serum cortisol expression than the control group (both P < 0.05).

Conclusion

Parecoxib sodium combined with dexmedetomidine can effectively control the postoperative pain of patients undergoing hysteromyomectomy, reduce the incidence of agitation, and effectively control serum cortisol and melatonin in them.

Successful pregnancy after presurgical uterine artery embolization in the management of a very large cervical myoma: A case report

Although fibroids are the most common benign tumors of the uterus in women of reproductive age, cervical fibroids are rarely seen. Since cervical fibroids are located deep in the pelvis, the incidence of complications in surgery is high. Among these complications bleeding is the most common, due to poor access to myoma, difficulty in suturing and repair, and distortion of vital neighboring structures. Each case should be managed individually to minimize bleeding. To decrease bleeding in patients who wish to retain their fertility, intraoperative interventions include vasoconstrictors such as vasopressin and adrenaline, uterotonics such as oxytocin, misoprostol or ergometrines, uterine artery clamping, internal iliac artery balloon occlusion catheters, and tourniquets; preoperative interventions include gonadotropin releasing-hormone analogues and uterine artery embolization. We present a case of a 40-year-old woman who had a large cervical myoma and a desire for future fertility. To overcome technical difficulties and reduce intraoperative bleeding during myomectomy, presurgical uterine artery embolization was performed. The patient conceived spontaneously after the operation and a healthy baby was delivered by cesarean section.

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Cervical myoma is rare.

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Preoperative uterine artery embolization decreases blood loss and helps preserve the uterus during myomectomy.

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In pregnant patients with a history of uterine artery embolization the risk of miscarriage, placental insertion anomalies, postpartum hemorrhage and intrauterine growth restriction is increased.

The Comparison of Life Quality between Ultrasound-Guided High-Intensity Focused Ultrasound and Laparoscopic Myomectomy for the Treatment of Uterine Fibroids

Objective

This study is aimed at comparing the uterine fibroids patients' postoperative living quality between ultrasound-guided high-intensity focused ultrasound (HIFU) and laparoscopic myomectomy.

Materials and Methods

A total of 164 patients were included with uterine fibroids who underwent laparoscopic myomectomy and HIFU in Cangzhou Central Hospital from September 2020 to November 2021. This study divided these objects into HIFU group and laparoscopic group, and both groups were followed up 6 months after surgery. After obtaining the results, Uterine Fibroid Symptom and health-related Quality Of Life questionnaire (UFS-QOL) and 36-Item Short Form Health Survey (SF-36) were performed before and after treatment to assess patient outcome.

Results

After treatments, the living quality in both groups was significantly improved compared with that before surgery, which had statistical significant (P < 0.05). After treatment, the scores of the two scales in HIFU group were significantly better than those in the laparoscopic group (P < 0.05).

Conclusion

In comparison with laparoscopic myomectomy, ultrasound-guided high-intensity focused ultrasound could improve the life quality of patients more effectively than traditional laparoscopic myomectomy and was helpful to the recovery and prognosis of uterine fibroids after treatment. The outcomes will provide a reference for clinicians to select a more appropriate treatment for uterine fibroids.

The effect of temporary uterine artery ligation on laparoscopic myomectomy to reduce intraoperative blood loss: A retrospective case–control study

Objective

Study Design

Results

Conclusions

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The surgical technique for laparoscopic myomectomy is introduced.

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Temporary uterine artery ligation decreases the volume of intraoperative blood loss.

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Temporary uterine artery ligation is less invasive than permanent occlusion.

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Temporary uterine artery ligation does not require the use of any special devices, such as clips.

Efficacy and Satisfaction Evaluation of Rapid Rehabilitation Nursing Intervention in Patients with Laparoscopic Myomectomy

Objective. To evaluate the efficacy and satisfaction of rapid rehabilitation nursing in patients with laparoscopic myomectomy. Methods. In this retrospective study, a total of 60 patients scheduled for a laparoscopic myomectomy in our hospital from January 2019 to February 2022 were enrolled and assigned at a ratio of 1 : 1 to receive either routine nursing (routine group) or rapid rehabilitation nursing (study group) according to different nursing methods. Outcome measures included nursing efficiency and nursing satisfaction. Results. Rapid rehabilitation nursing resulted in less intraoperative blood loss, shorter postoperative exhaust time and hospital stay, and a lower incidence of bladder irritation ( $123.56\pm 30.68$ , $22.54\pm 5.07$ , $5.70\pm 1.06$ , and 4.55%) versus the routine nursing ( $185.78\pm 32.78$ , $31.02\pm 5.28$ , $7.57\pm 2.19$ , 18.18%) ( $P<0.05$ ). Rapid rehabilitation nursing was associated with a lower incidence of complications (3.33%) versus routine nursing (20.00%) ( $P<0.05$ ). The eligible patients receiving rapid rehabilitation nursing showed a significantly higher satisfaction (96.67%) versus routine nursing (80.00%) ( $P<0.05$ ). Conclusion. Rapid rehabilitation nursing is effective in the nursing of patients after laparoscopic myomectomy by minimizing the physical and mental stress of patients, shortening the length of hospital stay, reducing the occurrence of related complications, and boosting the quality of life of patients, so it is worthy of clinical application.

Can the application of a temporary uterine tourniquet during an abdominal myomectomy reduce bleeding?

Objective

Uterine fibroids are common, benign uterine tumours. The three most common surgical treatment approaches for uterine fibroids are laparoscopic, robotic and abdominal myomectomies. Bleeding is a risk with all three approaches. The present study compared post-operative and pregnancy outcomes in patients with bilateral uterine artery occlusion who underwent an abdominal myomectomy, with or without a temporary uterine tourniquet.

Material and Methods

This retrospective study included patients with intra-mural fibroids (≥5 cm) who underwent an abdominal myomectomy. The patients were divided into two groups according to the use or non-use of a temporary uterine tourniquet. Post-operative and pregnancy outcomes in the tourniquet use and non-use groups were compared. The association of the number of uterine fibroids removed (≤3 vs >3) with laboratory parameters was also evaluated.

Results

A total of 84 patients were included, divided into use (n=36) and non-use (n=48) of the temporary tourniquet. There was a statistically significant difference between the groups with >3 myomas removed and with a uterine tourniquet applied and not applied in terms of reduction in hemoglobin and hematocrit, transfusion amounts, operation times and lengths of hospitalization in favour of the uterine tourniquet use group (p=0.019, p=0.023, p=0.012, p=0.044 and p=0.036, respectively). Bilateral uterine arterial occlusion using a temporary uterine tourniquet had no negative effects on pregnancy outcomes.

Conclusion

A temporary uterine tourniquet may be an effective method for reducing the amount of perioperative bleeding in patients with multiple, large-sized myomas located close to vascular structures.

Familial Predisposition to Leiomyomata: Searching for Protective Genetic Factors

In order to determine genetic loci associated with decreasing risk of uterine leiomyomata (UL), a genome-wide association study (GWAS) was performed. We analyzed a group of patients with a family history of UL and a control group consisting of patients without uterine fibroids and a family predisposition to this pathology. Six significant single nucleotide polymorphisms were selected for PCR-genotyping of a large data set of patients with UL. All investigated loci (rs3020434, rs11742635, rs124577644, rs12637801, rs2861221, and rs17677069) demonstrated the lower frequency of minor alleles within a group of women with UL, especially in a subgroup consisting of patients with UL and a familial history of leiomyomata. We also found that the minor allele frequencies of these SNPs in our control group were higher than those across the Caucasian population in all. Based on the obtained data, an evaluation of the common risk of UL was performed. Further work will pave the way to create a specific SNP-panel and allow us to estimate a genotype-based leiomyoma incidence risk. Subsequent studies of genetic variability in a group of patients with a familial predisposition to UL will allow us to make the prediction of the development and course of the disease more individualized, as well as to give our patients personalized recommendations about individual reproductive strategies.

Giant broad ligament leiomyoma with postoperative infection diagnosed with contrast-enhanced ultrasound: Case report and literature review

A 33-year-old woman of giant broad ligament leiomyoma with myxoid degeneration was misdiagnosed as ovarian tumor. The patient underwent a transabdominal myomectomy and developed a pelvic infection after operation diagnosed with contrast-enhanced ultrasound. She was cured and ultimately discharged after symptomatic treatment. Only 21 cases of giant broad ligament leiomyomas with a diameter larger than 12 cm were included. The present systematic review aimed to increase awareness of the clinical characteristics and treatment methods of giant broad ligament leiomyoma, and reduce the rates of misdiagnosis and postoperative complications.

Evolution of laparoscopic myomectomy and description of two hemostatic techniques in a large teaching gynecological center

OBJECTIVE

To provide a description of laparoscopic myomectomy and the two hemostatic techniques performed over the last 11 years in a single reference center for gynecology and obstetrics and to evaluate the factors associated with favorable surgical outcomes.

STUDY DESIGN

We retrospectively analyzed 625 who underwent laparoscopic myomectomy from January 2009 to December 2019.

RESULTS

Of 625 patients, 437 (69.8%) were symptomatic. The most common symptoms were heavy uterine bleeding (33.2%). 188 patients (30.1%) were asymptomatic but were operated in 77 cases (12.3%) for rapid fibroid growth, 32 (5.1%) for uterine cavity distortion and, in 45 cases (8.6%), the myomectomy was indicated during a surgery for other medical reason due to its accessibility. In 173 cases (27.9%) intramyometrial adrenaline was injected and in 246 cases (39.7%) a temporary blockage of the uterus blood supply was performed. Only 35 (5.6%) patients presented complications, of which, 14 (40%) were hemorrhagic. These hemorrhagic complications were more frequent when intramyometrial adrenaline was used (5,8%) than after the temporary clipping of the uterine arteries and infundibulopelvic ligaments (0,8%; p < 0,001). In the multivariate logistic regression model, the only factor statistically associated with favorable surgical outcome was the use of temporary clipping of the uterine arteries at their origin and infundibulopelvic ligaments as hemostatic technique during the surgery.

CONCLUSION

Laparoscopic myomectomy was generally safe with a high level of favorable outcomes. The temporary clipping of uterine arteries and infundibulopelvic ligaments presented fewer intraoperative bleedings compared with injecting intramyometrial adrenaline.

A Systematic Review of Minimally Invasive Treatments for Uterine Fibroid-Related Bleeding

Newer minimally invasive techniques provide treatment options for symptomatic uterine fibroids while allowing uterus preservation. The objective of this review was to analyze the efficacy of uterine-preserving, minimally invasive treatment modalities in reducing fibroid-related bleeding. A comprehensive search was conducted of PubMed, Embase, PsycINFO, ClinicalTrials.gov, Scopus, and Cochrane Library databases from inception to July 2020. English-language publications that evaluated premenopausal women with fibroid-related bleeding symptoms before and after treatment were considered. Randomized controlled trials were assessed for bias with the established Cochrane Risk of Bias Tool 2.0 and observational studies were assessed for quality under the New Castle-Ottawa Scale guidelines. Eighty-four studies were included in the review, including 10 randomized controlled trials and 74 observational studies. Six studies on myomectomy demonstrated overall bleeding symptom improvement in up to 95.9% of patients, though there was no significant difference between mode of myomectomy. Forty-one studies on uterine artery embolization reported significant reduction of fibroid-related bleeding, with symptomatic improvement in 79 to 98.5% of patients. Three studies suggested that embolization may be superior to myomectomy in reducing fibroid-related bleeding. Six studies reported that laparoscopic uterine artery occlusion combined with myomectomy led to greater reduction of bleeding than myomectomy alone. Fifteen studies demonstrated significantly reduced bleeding severity after radiofrequency ablation (RFA). Additional research is needed to establish the superiority of these modalities over one another. Long-term evidence is limited in current literature for magnetic resonance-guided focused ultrasound surgery, cryomyolysis, microwave ablation, and laser ablation.

Clinical Value of Body Mass Index and Waist-Hip Ratio in Clinicopathological Characteristics and Prognosis of Uterine Leiomyomata

Objective

To explore the relationship between body mass index (BMI) and waist-to-hip ratio (WHR) and clinicopathological characteristics and prognosis of uterine leiomyomata (UL).

Methods

A retrospective analysis of the clinical data of 133 patients with UL admitted to our hospital from September 2018 to August 2019. According to the BMI standard, the patients were divided into the normal group (n = 32), the super-recombination group (n = 45), and the obesity group (n = 56). According to WHR, the patients were divided into the normal body group (n = 32) and the obesity body group (n = 101). The prognosis of all patients with UL at 3 months postoperatively was evaluated. The relationship between BMI patients and clinical characteristics in different groups was compared, and univariate analysis and multivariate logistic regression model were used to analyze the factors affecting the prognosis of UL patients.

Results

The proportion of UL patients in the overweight/obese group was higher than that of the normal group, the proportion of the obese body group was higher than that of the normal body group, and the proportion of the good prognosis group was higher than that of the poor prognosis group (P < 0.05). The difference between the overweight/obese group and the normal group and the obese body group and the normal body group was irregular vaginal bleeding, the number of tumors, and the diameter of the lesion (P < 0.05), and the differences between the degenerations in the obese body group and the normal body group were statistically significant (P < 0.05). Multivariate analysis showed that BMI, WHR, surgical method, and tumor location were all independent risk factors that affected the prognosis of the surgery (P < 0.05).

Conclusion

Elevated BMI and WHR can be accompanied by an increased risk of UL. Obesity is a risk factor for UL. Overweight/obese women are more clinically pathological than normal patients, and overweight/obese patients have worse surgical prognosis than normal patients. In order to reduce the prevalence of UL and improve the clinicopathological characteristics and prognosis of patients, clinically obese women should be instructed to use reasonable diet and exercise to control weight.

Uterine Fibroids and Infertility

Infertility is a disease of the reproductive system defined by the failure to achieve a clinical pregnancy after 12 months or more of regular unprotected sexual intercourse. Uterine fibroids are the most common tumor in women, and their prevalence is high in patients with infertility. Fibroids may be the sole cause of infertility in 2–3% of women. Depending on their location in the uterus, fibroids have been implicated in recurrent pregnancy loss as well as infertility. Pregnancy and live birth rates appear to be low in women with submucosal fibroids; their resection has been shown to improve pregnancy rates. In contrast, subserosal fibroids do not affect fertility outcomes and their removal does not confer any benefit. Intramural fibroids appear to reduce fertility, but recommendations concerning their treatment remain unclear. Myomectomy should be discussed individually with the patient; other potential symptoms such as dysmenorrhea or bleeding disorders should be included in the indication for surgery.

Uterine Fibroids in Black Women: A Race-Stratified Subgroup Analysis of Treatment Outcomes After Laparoscopic Radiofrequency Ablation

Background: The disease and treatment burden of uterine fibroids (UF) in Black women is substantially greater compared with other racial groups, with higher rates of complications and poorer outcomes with both hysterectomy and myomectomy. The inequities in the access Black women have to minimally invasive routes of surgery contribute to their burden of illness. Laparoscopic radiofrequency ablation (LAP-RFA) is a minimally invasive, safe, and effective uterine-sparing treatment option. Methods: This subgroup analysis of the LAP-RFA Pivotal Trial stratified outcomes by race comparing White women (n = 28, 21%) versus Black women (n = 46, 34%). Results: At baseline, Black women had more fibroids on average (7.3 vs. 3.7; P ≤ 0.001), a greater symptom severity score (SSS) (P ≤ 0.001), and a lower health-related quality of life (HRQoL) score (P = 0.005) than White women. At 36 months post-treatment with LAP-RFA, the statistical differences that existed with baseline SSS and HRQoL score were eliminated between Black and White women. Menstrual blood loss (140.1 mL vs. 127.02 mL; P = 0.44) and mean fibroid volume reduction (47.5 cm³ vs. 36.0 cm³; P = 0.17) were similar between Black and White women at 12 months. Although not statistically significant, the intraoperative total blood loss and uterine blood loss was lower in Black women than White women, despite greater operative time (160 minutes vs. 137 minutes; P = 0.09). Conclusions: These results are promising in providing an alternative uterine-sparing option for Black women and may help to provide a minimally invasive option that can address some of the racial inequities in care for Black women with UF.

Benign metastasising leiomyoma with endometrial carcinoma, with a differential diagnosis of metastatic lung cancer

Benign metastasising leiomyoma (BML) is a rare disease in which histologically benign uterine fibroids spread throughout the body. It is thought to originate from the hematogenous metastasis of myoma cells following myomectomy. To date, BML has been noted in patients with respiratory symptoms, even during regular checkups. There are few case reports of co-occurrence with gynaecological cancer. We report the case of a suspected stage IVb carcinoma based on preoperative examination for endometrial cancer, that indicated lung metastasis. However, postoperative pathology revealed a grade 1, pT1a pN0 tumour. We suspected BML based on the discrepant findings and history of myomectomy, and this was confirmed by lung biopsy. In metastatic lesions of a carcinoma patient with a history of myomectomy, the co-occurrence of BML should be considered when there is discrepancy between the preoperative suspected stage and postoperative pathology.

Analysis of hidden blood loss and its influential factors in myomectomy

OBJECTIVE

This study was performed to quantify hidden blood loss (HBL) and explore its influential factors in myomectomy.

METHODS

Two hundred nine patients who underwent myomectomy by laparotomy or laparoscopy from 1 January 2017 to 31 December 2018 were analyzed. Each patient's estimated blood volume and total blood loss (TBL) were calculated by the Nadler formula and Gross formula, respectively. The HBL was calculated by subtracting the visible blood loss (VBL) from the TBL. A multivariate linear stepwise analysis was applied to identify the influential factors of HBL in myomectomy.

RESULTS

The mean perioperative VBL and estimated TBL during myomectomy were 137.81 ±104.43 and 492.24 ± 225.00 mL, respectively. The mean HBL was 354.39 ± 177.69 mL, which accounted for 71.52% ± 15.75% of the TBL and was two to three times higher than the VBL. The duration of surgery, number of removed leiomyomas, and location of removed leiomyomas were independent risk factors for HBL in myomectomy.

CONCLUSIONS

HBL accounted for a significant percentage of TBL in myomectomy. A full understanding of the HBL in perioperative blood management may improve patients' postoperative rehabilitation.

The Significant Risk Factors of Intra-Operative Hemorrhage during Laparoscopic Myomectomy: A Systematic Review

Laparoscopic myomectomy (LM) is becoming increasingly common in the management of uterine myomas and is usually offered regardless of the number, location, and size of the myomas. It has a generally low rate of periprocedural complications and is preferred to laparotomy for several reasons that are not limited to decreased length of hospital stay, number of sutures, smaller incisions, and decreased pain. However, blood loss during LM remains a challenge. To be able to stratify patients and provide better management after LM, it is crucial to identify these predictors of blood loss. Therefore, the aim of this review was to identify the risk factors for periprocedural blood loss after laparoscopic uterine myomectomy. According to our data synthesis, age, body mass index, and phase of the menstrual cycle do not seem to affect the blood loss during LM. Conversely, size and number of myomas, as well as operative time, was directly related to the increase of blood loss.