Comparison of intramural myomectomy scar after laparotomy or laparoscopy

Cystic Adenomyoma in Pregnancy: A Case Report

Cystic adenomyomas (CA) are rare. They primarily affect adolescents and young women in their fertile years. Therefore, fertility and pregnancy outcome are of pivotal relevance in this patient collective. Apart from the guidelines of the European Society of Human Reproduction and Embryology (ESHRE) on the management of endometriosis in general, there are no specific treatment recommendations for CA and, as far as our research shows, no data illustrating the behavior of a CA over the course of pregnancy. Thus, we report the case of a 32-year-old 1-gravida, 1-para, preconceptionally diagnosed with a CA by ultrasound. After thoroughly discussing further treatment options, the decision was made to opt for a more conservative approach and not perform surgery before attempting a next pregnancy. The patient conceived spontaneously and sonographic monitoring of the CA throughout pregnancy showed complete regression of the cystic component during the second trimester. A healthy baby was delivered at term by an uncomplicated elective cesarean section. Following a review of the literature and taking into account the course of our case, we propose the feasibility of a conservative, non-surgical approach in women with a CA and the desire to conceive.

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.

Pregnancy outcomes and associated factors for uterine rupture: an 8 years population-based retrospective study

Background

Uterine rupture is an obstetrical emergency with serious undesired complications for laboring mothers resulting in fatal maternal and neonatal outcomes. The aim of this study was to assess the incidence of uterine rupture, its association with previous uterine surgery and vaginal birth after caesarean section (VBAC), and the maternal and perinatal implications.

Methods

This is a population-based retrospective study. All pregnant women treated for ruptured uterus in one center between 2013 and 2020 were included. Their information retrieved from the medical records department were reviewed retrospectively.

Results

A total of 209,112 deliveries were included and 41 cases of uterine rupture were identified. The incidence of uterine rupture was 1.96/10000 births. Among the 41 cases, 16 (39.0%) had maternal and fetal complications. There were no maternal deaths secondary to uterine rupture, while perinatal fatality related to uterine rupture was 7.3%. Among all cases, 38 (92.7%) were scarred uterus and 3 (7.3%) were unscarred uterus. The most common cause of uterine rupture was previous cesarean section, while cases with a history of laparoscopic myomectomy were more likely to have serious adverse outcomes, such as fetal death. 24 (59.0%) of the ruptures occurred in anterior lower uterine segment. Changes in Fetal heart rate monitoring were the most reliable signs for rupture.

Conclusions

Incidence of uterine rupture in the study area, Shanghai, China was consistent with developed countries. Further improvements in obstetric care and enhanced collaboration with referring health facilities were needed to ensure maternal and perinatal safety.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-04415-6.

Vaginal birth after prior myomectomy

OBJECTIVE

The aim of this retrospective cohort study was to evaluate the obstetrical and perinatal outcomes of vaginal birth in case of pregnancies achieved after prior myomectomy. We also analyzed how operative characteristics at the time of surgery might influence the choice of obstetricians about mode of delivery.

STUDY DESIGN

We analyzed retrospectively all women who underwent laparoscopic (LPS) or laparotomic (LPT) myomectomy between January 2002 and December 2014, in a network of three Institutions belonging to the University of Milano Bicocca, Italy. Women were contacted by phone interview and only cases with available follow-up data and who had a subsequent pregnancy were included. Operative characteristics and subsequent obstetrical outcomes were recorded and analyzed.

RESULTS

469 women who underwent myomectomy were contacted by phone interview, and 152 pregnancies were achieved after surgery, 96 after LPS and 56 after LPT. A total of 110 pregnancies ended in deliveries at ≥24 weeks. Seventy-three (66.4%) women had trial of labor after myomectomy (TOLAM), while 24 (21.8%) had a planned cesarean delivery (CD). Sixty-six (90.4%) of the TOLAM cases successfully accomplished vaginal delivery. No cases of uterine rupture (UR) were reported, and all deliveries ended in live births. The incidence of Neonatal Intensive Care Unit admission was 14.5% (16/110), with no cases of perinatal death. Comparing the surgical details at the time of myomectomy, the incidence of uterine cavity entered was significantly higher in planned CD group compared to TOLAM cases (p < 0.001). No other significant difference between the two groups was reported.

CONCLUSIONS

A successful vaginal delivery was accomplished by 90.4% of women who had TOLAM, without any case of UR or severe maternal and perinatal complications. TOLAM may be considered and offered as feasible and relatively safe option. Obstetricians' attitude toward mode of delivery after prior myomectomy seems to be influenced by the reported entry into the uterine cavity at the time of surgery.

Utility of Laparoscopic Uterine Myomectomy as a Treatment for Infertility with No Obvious Cause Except for Uterine Fibroids

Objectives:

Uterine fibroids are capable of causing infertility, but there are no definite criteria for which laparoscopic uterine myomectomy (LM) is known to be beneficial. To investigate the usefulness of LM, we examined pregnancy rates in patients with infertility with no obvious cause except for the presence of uterine fibroids.

Materials and Methods:

We retrospectively reviewed the clinical records at Suzuki Memorial Hospital between June 2010 and August 2014. We found 60 eligible patients (LM group, 46; non-LM group, 14). The criteria for performing LM were a maximal fibroid diameter of 40 mm or more or the presence of >4 fibroids.

Results:

The duration of infertility before the first visit was significantly longer in the LM group; although there was no significant difference in the mean patient age and body mass index. Pregnancy was achieved in 45.7% of patients (21/46) in the LM group and 28.6% (4/14) in the non-LM group. There were no pregnancies in patients with >10 fibroids. The postoperative pregnancy rate in the LM group was comparable to previously reported pregnancy rates.

Conclusions:

Our criteria for performing LM in patients with no obvious cause for infertility except for uterine fibroids seem appropriate, especially when the fibroids are large and the number of fibroids is between 4 and 9. However, our results suggest that the effectiveness of LM is low in patients with 10 or more uterine fibroids.

Characteristics of uterine rupture after laparoscopic surgery of the uterus: clinical analysis of 10 cases and literature review

Objective

An increasing trend of uterine rupture (UR) after laparoscopic surgery of the uterus (LSU) has been observed. Although the overall incidence is extremely low, UR may have catastrophic outcomes. Therefore, investigation of its potential risk factors is important.

Methods

We retrospectively reviewed the medical data of 10 women who developed UR after LSU performed at our hospital from October 2003 to October 2016 and conducted a literature review.

Results

All cases of UR occurred during the third trimester of pregnancy. The surgeries contributing to UR were laparoscopic myomectomy, adhesion decomposition, and salpingectomy, resulting in unfavorable outcomes especially for the fetus. Diathermy was routinely used for hemostasis, and multilayer suturing was not adequately performed in many cases. The posterior wall was the most common site of UR in most cases. Silent rupture with unremarkable symptoms was not rare. Similar risk factors were identified in the literature review.

Conclusions

Excessive use of energy equipment and the lack of multilayer suturing were the most common characteristics of UR after LSU. A history of LSU should always be considered a risk factor for UR.

Laparoscopy or laparotomy as the way of entrance in myoma enucleation

PURPOSE

Uterine myomas are the main cause of benign uterine diseases in premenopausal women. Objective of the present paper is to investigate the current best treatment modalities of myomas, depending on age of the patient and her desire to preserve fertility, as well as on clinical presentation of this pathology, such as size, number, and location of fibroids and, furthermore, on surgical experience of the gynecologist.

METHODS

The design of our work is a systematic literature review of existing studies, reviews, and meta-analysis conducted in PubMed and Cochrane Library to identify relevant literature. Commonly, the myomectomy is to be recommended in women desiring to preserve fertility when myomas are associated with symptoms such as excessive bleeding, pelvic discomfort, or palpable abdominally fibroids. The decision of surgical approach for myomectomy should be individualized, depending on size and location, as well as on surgeon's experience. The different modalities of myomectomy, laparoscopic, hysteroscopic, robotic-assisted, or laparotomic are in detail presented in the paper, according to Society of Obstetricians and Gynecologists of Canada (SOGC) clinical practice guidelines and taking into consideration possible concerns of myomectomy such as uterine rupture, development of adhesions, and myomas' recurrence.

Suturing method as a factor for uterine vascularity after laparoscopic myomectomy

OBJECTIVE

To evaluate the vascularity of the myometrium after laparoscopic myomectomy sutured by two different methods using contrast-enhanced Magnetic Resonance Imaging.

STUDY DESIGN

Twenty-eight women who had symptomatic leiomyomas and underwent laparoscopic myomectomy between June 2013 and July 2014 were included in the present study. In the first half period, continuous sutures were used in 12 patients, and in the latter half period, single interrupted sutures were used in 16 patients. Contrast-enhanced Magnetic Resonance Imaging was used 3 or 6 months after surgery to evaluate vascularity after laparoscopic myomectomy. We defined avascularity index as the percentage of avascular area after surgery to cross sectional area of myoma before surgery. The Wilcoxon rank-sum test was applied to compare avascularity indeces in the two study groups.

RESULTS

At 3 months after surgery, avascularity index in continuous sutures group was significantly higher than that in single interrupted sutures group (median 5.0 vs.1.2, p<0.001), suggesting a poorer vascular recovery of the myometrium sutured continuously.

CONCLUSION

Simple interrupted suturing might be superior to continuous suturing in terms of vascularity evaluated using contrast enhanced Magnetic Resonance Imaging.

Perspectives of obstetricians on labour and delivery after abdominal or laparoscopic myomectomy

OBJECTIVE

Because of concerns about uterine rupture, many obstetricians recommend elective Caesarean section for women with a prior myomectomy. This practice has led to an increased rate of elective CS and subsequently of repeat Caesarean sections. The purpose of this study was to evaluate the perspectives of obstetricians on labour and delivery after abdominal or laparoscopic myomectomy.

METHODS

We conducted a survey of 49 practising obstetricians from July 2012 to January 2013, using a standard questionnaire. This included questions on labour and delivery after myomectomy by laparotomy or laparoscopy.

RESULTS

Overall, the inter-respondent agreement was fair (kappa 0.3; P < 0.001). There was no significant difference in the likelihood that respondents would allow vaginal delivery after myomectomy by laparotomy and by laparoscopy (27% and 14% if the uterine cavity was entered and 76% and 71% if the uterine cavity was not entered, respectively). However, the likelihood that respondents would allow vaginal delivery was significantly reduced if the uterine cavity was entered, regardless of the surgical approach (P < 0.001). Entry into the uterine cavity during myomectomy also significantly increased the likelihood that obstetricians would recommend elective CS rather than induction of labour. There was no significant difference in practice regarding the use of oxytocin with amniotomy, oxytocin infusion, or prostaglandins.

CONCLUSION

Despite a lack of evidence, obstetricians consider entry into the uterine cavity at myomectomy to be an important factor in determining the method of delivery, the use of oxytocin, and delivery by elective Caesarean section. This was independent of the myomectomy approach.

Thrombospondin-1 and thrombospondin-2 mRNA and TSP-1 and TSP-2 protein expression in uterine fibroids and correlation to the genes COL1A1 and COL3A1 and to the collagen cross-link hydroxyproline

Uterine fibroids are composed of altered collagen fibrils and represent an arrested response to injury-initiating fibrosis. In many tissues, TSP-1 is secreted by adult macrophages and monocytes upon wounding and is involved in the activation of transforming growth factor beta. In the absence of TSP-1, the orchestrated process of wound healing is impaired. The authors obtained tissue from the edge and center of fibroids at the time of hysterectomy and compared them with adjacent myometrium. The pattern of TSP-1 and TSP-2 expression was correlated to that of COL1A1 and COL3A1. Collagen and hydroxyproline were increased in fibroids. Thrombospondin-1 was consistently underexpressed in both the edge and center of the fibroids, while COL1A1 and COL3A1 were consistently overexpressed. However, TSP-2 was inconsistently expressed. These findings lead to the conclusion that the underexpression of TSP-1 may contribute to the overall development of uterine fibroids.