Intramyometrial vasopressin as a haemostatic agent: Is it really safe?

Pharmacologic Interventions to Minimize Fluid Absorption at the Time of Hysteroscopy: A Systematic Review and Meta-analysis

OBJECTIVE

To assess which interventions are effective in reducing fluid absorption at the time of hysteroscopy.

DATA SOURCE

Ovid MEDLINE, Ovid EMBASE, PubMed (non-MEDLINE records only), EBM Reviews-Cochrane Central Register of Controlled Trials (CENTRAL), ClinicalTrials.gov , and Web of Science were searched from inception to February 2022 without restriction on language or geographic origin.

METHODS OF STUDY SELECTION

Following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, all English-language, full-text articles reporting fluid balance, with an intervention and comparator arm, were included. Title and abstract screening and full-text review were completed independently by two authors. Conflicts were resolved through discussion and consensus. Studies' risk of bias was assessed using the Cochrane Risk of Bias Tool for RCTs and the Newcastle-Ottawa Scale for observational studies.

TABULATION, INTEGRATION, AND RESULTS

The search identified 906 studies, 28 of which were eligible for inclusion, examining the following interventions: gonadotropin-releasing hormone (GnRH) agonist; ulipristal acetate; vasopressin; danazol; oxytocin; and local, general, and regional anesthesia. A significant reduction in mean fluid absorption was seen in patients preoperatively treated with danazol (-175.7 mL, 95% CI -325.4 to -26.0) and a GnRH agonist (-139.68 mL, 95% CI -203.2, -76.2) compared with patients in a control group. Ulipristal acetate and type of anesthesia showed no difference. Data on type of anesthesia and vasopressin use were not amenable to meta-analysis; however, four studies favored vasopressin over control regarding fluid absorption. Mean operative time was reduced after preoperative treatment with ulipristal acetate (-7.1 min, 95% CI -11.31 to -2.9), danazol (-7.5 min, 95% CI -8.7 to -6.3), and a GnRH agonist (-3.3 min, 95% CI -5.6 to -0.98).

CONCLUSION

Preoperative treatment with a GnRH agonist and danazol were both found to be effective in reducing fluid absorption and operative time across a range of hysteroscopic procedures. High-quality research aimed at evaluating other interventions, such as combined hormonal contraception, progestin therapy, and vasopressin, are still lacking in the literature.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42021233804.

Effect and safety of diluted vasopressin injection on bleeding during robot-assisted laparoscopic myomectomy: a protocol for a randomised controlled pilot trial

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.

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

Objectives

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

Methods

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

Results

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

Conclusions

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

Assessment of the perioperative effect of vasopressin in patients undergoing laparoscopic myomectomy: A double-blind randomised study

Background and Aims:

Myomectomy is associated with perioperative bleeding. The aim of the study is to evaluate the effect of intramyometrial vasopressin on blood loss and the associated cardiovascular complications during myomectomy.

Methods:

The study included 194 patients classified into two groups- 1) Vasopressin group: the vasopressin was diluted as 0.1 unit/ml and 15 ml was injected by the surgeon in the plane between the myometrium and the myoma. 2) Control group: The patients received an equal amount of normal saline. The monitored parameters included the amount of blood loss, required blood transfusion, heart rate, mean arterial blood pressure, the incidence of hypertension, hypotension, bradycardia, tachycardia, electrocardiogram (ECG) changes and the blood troponin I level.

Results:

The heart rate decreased significantly in both groups, but the decrease was lower with vasopressin than the control group through the time points T3 to T5 (P < 0.05) The mean arterial blood pressure increased significantly in both groups, but the increase was higher with vasopressin than the control group through T3 to T5 (P < 0.05). The amount of blood loss decreased significantly with vasopressin than the control groups (P = 0.001). The number of transfused packed red blood cells was lower with vasopressin than the control group (P = 0.001). The incidence of hypertension, bradycardia and atrial extrasystole was higher with vasopressin than the control group (P = 0.005, P = 0.012, P = 0.033, respectively).

Conclusion:

Intramyometrial vasopressin decreases blood loss and blood transfusion, but it is associated with cardiovascular complications that may be serious as reported in other studies. Therefore, anaesthesiologists and gynaecologists must follow the precautions to avoid and minimise the incidence of complications with intramyometrial vasopressin.

Laparoscopic uterine artery bipolar coagulation plus myomectomy vs traditional laparoscopic myomectomy for "large" uterine fibroids: comparison of clinical efficacy

PURPOSE

Laparoscopic myomectomy is the uterus-preserving surgical approach of choice in case of symptomatic fibroids. However, it can be a difficult procedure even for an experienced surgeon and can result in excessive blood loss, prolonged operating time and postoperative complications. A combined approach with laparoscopic uterine artery occlusion and simultaneous myomectomy was proposed to reduce these complications. The aim of this study was to evaluate the safety and efficacy of the combined laparoscopic approach in women with symptomatic "large" intramural uterine fibroids, compared to the traditional laparoscopic myomectomy alone.

METHODS

Prospective nonrandomized case-controlled study of women who underwent a conservative surgery for symptomatic "large" (≥ 5 cm in the largest diameter) intramural uterine fibroids. The "study group" consisted of women who underwent the combined approach (laparoscopic uterine artery bipolar coagulation and simultaneous myomectomy), while women who underwent the traditional laparoscopic myomectomy constituted the "control group". A comparison between the two groups was performed, and several intraoperative and postoperative outcomes were evaluated.

RESULTS

No significant difference in the overall duration of surgery between women of the "study group" and "control group" emerged; however, a significantly shorter surgical time for myomectomy was observed in the "study group". The intraoperative blood loss and the postoperative haemoglobin drop were significantly lower in the "study group". No difference in the postoperative pain between groups emerged, and the postoperative hospital stay was similar in the two groups.

CONCLUSIONS

The laparoscopic uterine artery bipolar coagulation and simultaneous myomectomy is a safe and effective procedure, even in women with symptomatic "large" intramural uterine fibroids, with the benefit of a significant reduction in the intraoperative blood loss when compared to the traditional laparoscopic myomectomy.