Fibroid Characteristics Research Articles

Prediction Models for Perioperative Blood Transfusion in Patients Undergoing Gynecologic Surgery: A Systematic Review.

This systematic review aimed to evaluate prediction models for perioperative blood transfusion in patients undergoing gynecologic surgery. Given the inherent risks associated with blood transfusion and the critical need for accurate prediction, this study identified and assessed models based on their development, validation, and predictive performance. The review included five studies encompassing various surgical procedures and approaches. Predicting factors commonly used across these models included preoperative hematocrit, race, surgical route, and uterine fibroid characteristics. However, the review highlighted significant variability in the definition of perioperative periods, a lack of standardization in transfusion criteria, and a high risk of bias in most models due to methodological issues, such as a low number of events per variable, inappropriate handling of continuous and categorical predictors, inappropriate handling of missing data, improper methods of predictor selection, inappropriate measurement methods for model performance, and inadequate evaluations of model overfitting and optimism in model performance. Despite some models demonstrating good discrimination and calibration, the overall quality and external validation of these models were limited. Consequently, there is a clear need for more robust and externally validated models to improve clinical decision-making and patient outcomes in gynecologic surgery. Future research should focus on refining these models, incorporating rigorous validation, and adhering to standardized reporting practices.

The Impact of Laparoscopic Myomectomy on Pregnancy Outcomes: A Systematic Review.

The objective of this systematic review is to investigate the impact of laparoscopic myomectomy techniques on pregnancy outcomes, with a specific focus on the correlation between the type of suture used during the procedure and the incidence of uterine rupture. Additionally, the study aims to examine how the localization and size of myomas, key factors in laparoscopic myomectomy, may influence fertility outcomes. extensive searches were conducted using MDPI, PubMed, Web of Science, and Cochrane Library databases from 2008 to November 2023. The study involved women of reproductive age diagnosed with fibroids who underwent surgical removal of fibroids using either laparotomy or laparoscopy. The evaluation of pregnancy outcomes focused on indicators such as live birth rates, miscarriage rates, stillbirth rates, premature delivery rates, and cases of uterine rupture. Quality assessment was systematically performed by employing the National Institutes of Health Study Quality Assessment Tools, with the subsequent formulation of clinical recommendations that were meticulously graded in accordance with the robustness of the underlying evidence. The pregnancy outcomes post-myoma treatment, as reflected in one of the presented tables, show a promising number of pregnancies and live births, but also indicate the potential risks of miscarriages and preterm births. The diversity in outcomes observed among various studies underscores the imperative for tailored patient care, as well as the necessity for additional research aimed at optimizing fertility and pregnancy outcomes following myoma treatment. This study offers insights into the criteria for patient selection and intraoperative methodologies specifically related to laparoscopic myomectomy. To enhance our understanding of the associations between fibroid characteristics (location, size) and reproductive outcomes, additional research is warranted, particularly through well-designed clinical trials.

Uterine fibroids and longitudinal profiles of the vaginal microbiota in a cohort presenting for transvaginal ultrasound.

Bacterial vaginosis, characterized in part by low levels of vaginal Lactobacillus species, has been associated with pro-inflammatory cytokines which could fuel uterine fibroid development. However, prior work on the associations between uterine fibroids and vaginal bacteria is sparse. Most studies have focused on assessment of individual taxa in a single sample. To address research gaps, we sought to compare short, longitudinal profiles of the vaginal microbiota in uterine fibroid cases versus controls with assessment for hormonal contraceptives (HCs), a possible confounder associated with both protection from fibroid development and increases in Lactobacillus-dominated vaginal microbiota. This is a secondary analysis of 83 reproductive-age cisgender women who presented for transvaginal ultrasound (TVUS) and self-collected mid-vaginal swabs daily for 1-2 weeks before TVUS (Range: 5-16 days, n = 697 samples). Sonography reports detailed uterine fibroid characteristics (N = 21 cases). Vaginal microbiota was assessed by 16S rRNA gene amplicon sequencing and longitudinal microbiota profiles were categorized by hierarchical clustering. We compared longitudinal profiles of the vaginal microbiota among fibroid cases and controls with exact logistic regression. Common indications for TVUS included pelvic mass (34%) and pelvic pain (39%). Fibroid cases tended to be older and report Black race. Cases less often reported HCs versus controls (32% vs. 58%). A larger proportion of cases had low-Lactobacillus longitudinal profiles (48%) than controls (34%). In unadjusted analysis, L. iners-dominated and low-Lactobacillus profiles had higher odds of fibroid case status compared to other Lactobacillus-dominated profiles, however these results were not statistically significant. No association between vaginal microbiota and fibroids was observed after adjusting for race, HC and menstruation. Results were consistent when number of fibroids were considered. There was not a statistically significant association between longitudinal profiles of vaginal microbiota and uterine fibroids after adjustment for common confounders; however, the study was limited by small sample size.

The Influence of Race/Ethnicity on the Transcriptomic Landscape of Uterine Fibroids.

The objective of this study was to determine if the aberrant expression of select genes could form the basis for the racial disparity in fibroid characteristics. The next-generation RNA sequencing results were analyzed as fold change [leiomyomas/paired myometrium, also known as differential expression (DF)], comparing specimens from White (n = 7) and Black (n = 12) patients. The analysis indicated that 95 genes were minimally changed in tumors from White (DF ≈ 1) but were significantly altered by more than 1.5-fold (up or down) in Black patients. Twenty-one novel genes were selected for confirmation in 69 paired fibroids by qRT-PCR. Among these 21, coding of transcripts for the differential expression of FRAT2, SOX4, TNFRSF19, ACP7, GRIP1, IRS4, PLEKHG4B, PGR, COL24A1, KRT17, MMP17, SLN, CCDC177, FUT2, MYO5B, MYOG, ZNF703, CDC25A, and CDCA7 was significantly higher, while the expression of DAB2 and CAV2 was significantly lower in tumors from Black or Hispanic patients compared with tumors from White patients. Western blot analysis revealed a greater differential expression of PGR-A and total progesterone (PGR-A and PGR-B) in tumors from Black compared with tumors from White patients. Collectively, we identified a set of genes uniquely expressed in a race/ethnicity-dependent manner, which could form the underlying mechanisms for the racial disparity in fibroids and their associated symptoms.

Predictors and Clinical Outcomes of Fibroid Expulsion After Uterine Artery Embolization.

To evaluate rates of fibroid expulsion after uterine artery embolization (UAE) and risk factors. Single-center retrospective study of UAEs for fibroids between 2016 and 2020. Preoperative UAE and patients with incomplete follow-up were excluded. Patients underwent MRI before and 3months after UAE and/or as indicated. Medical records were reviewed, and patient demographics, fibroid characteristics and clinical events were recorded. Fibroid expulsion included fibroid exposure to the endometrial cavity on MRI, and tissue loss/passage as observed clinically or on MRI. Symptoms were considered major if requiring additional clinic visits or treatment. Statistical tests included Chi-square, Fisher's exact test, and logistic regression models. One hundred ninety-nine women were included. Symptomatic fibroid expulsion occurred after 31 (16%) procedures: 16 minor and 15 major. Symptoms included vaginal discharge (n = 23), bleeding (n = 9), tissue passage (n = 9), cramping/pain (n = 3), and fever (n = 4). Fifteen women (8%) needed additional care, of whom 6 (3%) required invasive procedures (4 elective hysterectomies, 1 hysteroscopic resection, 1 transvaginal removal of passing tissue). The International Federation of Gynecology and Obstetrics (FIGO) classification was significantly associated with symptomatic fibroid expulsion (p = 0.001). Odds ratio for symptomatic expulsion and expulsion requiring additional care for FIGO 3-7 versus 0-2 fibroids was 0.32 (95% confidence interval, 0.14-0.71, p = 0.005) and 0.28 (95% confidence interval, 0.10-0.83, p = 0.02), respectively. Other factors were not consistently associated with expulsion. Fibroid expulsion after uterine artery embolization was more common than previously reported but mostly asymptomatic or minimally symptomatic. Women with FIGO ≤ 2 fibroids should be appropriately counseled regarding risk for expulsion.

Myomectomy in adult women of reproductive age: a propensity score-matched study for pregnancy rates.

To study whether it is better to perform or not a myomectomy, in terms of surgical and reproductive outcomes in patients of advanced reproductive age, by an observational prospective study in university-affiliated and Community Hospitals. 40years and older patients affected by non-submucous symptomatic uterine fibroids and desiring future fertility were enrolled and treated by laparoscopic intracapsular myomectomy by (LIM) or by open laparotomy (OIM), or by a non-surgical management as control group, while attempting to conceive. The primary outcome measures were fibroid characteristics, pre- and post-surgical parameters, pregnancy achievement; the secondary outcome measures were the spontaneous or ART pregnancy outcomes, eventual week of abortion and type of delivery. Propensity scores have been calculated with logistic regression for binary and continuous variables. 202 patients completed the study: 112 operated by LIM, 40 by OIM and 50 patients as control group. Patients undergoing OIM have a worse surgical outcome than LIM. No difference was seen in pregnancy either after myomectomy or control group during follow-up. In the LIM group, there were 44 pregnancies (39.2%), and in the OIM group, there were 9 (22.5%) and 16 in the control group (32%). The weeks of delivery were statistically greater for the control group versus the surgical groups, with no difference in Apgar score between the 3 groups. Patients aged over 40years did not show substantial differences in reproductive outcome, whether operated or not. Myomectomy in over 40-year-old patients has no detrimental effect on future pregnancy rates and over when compared to expectant management.

Sacral injury and influencing factors after ultrasonic ablation of uterine fibroids ≤30 mm from the sacrum

To study sacral injuries and influencing factors after ultrasonic ablation of uterine fibroids no more than 30 mm from the sacrum. A total of 406 patients with uterine fibroids who underwent percutaneous ultrasound ablation were analyzed retrospectively. All patients underwent contrast-enhanced magnetic resonance imaging (MRI) scans before and after high-intensity focused ultrasound. The abnormal signal intensity (low signal intensity on T1WI and high signal intensity on T2WI) on the postoperative MRIs was indicative of a sacral injury. The patients were divided into a sacrum injury group and a sacrum non-injury group. The relationship between fibroid characteristics, ultrasound ablation parameters, and injury was analyzed using univariate and multivariate analyses. There were 139 cases of sacral injury (34.24%). When the distance from the fibroid's dorsal side to the sacrum was 0-10 mm, the risk assessment showed that the danger of sacral injury increased by 1.85 times and 3.03 times compared with that at a distance of 11-20 or 21-30 mm. Furthermore, the risk of sacral injury increased by 1.89 times and 3.23 times when the therapeutic dose (TD) of a fibroid was >500 KJ compared with that of a fibroid with TD= 250-500 KJ and <250 KJ. A distance of 10 mm or less and a TD of >500 KJ were significantly correlated with sacral injury. The distance from the fibroid's dorsal side to the sacrum and the TD were the main causes of injury to the sacrum. A distance of 10 mm or less and a TD of >500 KJ carried higher injury risks, while a distance of 21-30 mm and a TD of <250 KJ were the most appropriate circumstances to reduce the risk of sacral injury.

8571 Prevalence of Baseline Lower Urinary Tract Symptoms in Women Planning to Undergo Hysterectomy for Uterine Fibroids

Study Objective Compare the prevalence of baseline lower urinary tract symptoms (LUTS) in women planning to undergo hysterectomy for fibroids versus abnormal uterine bleeding (AUB) and examine their association with fibroid characteristics Design This is a retrospective cohort study of 202 women planning to undergo hysterectomy for fibroids vs. AUB. The aim was to compare LUTS in those with vs without fibroids. Baseline demographics, fibroid characteristics, and urinary symptoms were collected. Urinary symptoms included stress and urge incontinence, dysuria, frequent bladder infections, hematuria, nocturia, incomplete emptying, urgency, and frequency. Fibroid characteristics included dominant fibroid size, location, and total uterine volume. A priori power analysis determined 97 participants were needed per group (194 total) to assess for a 20% difference in LUTS, with alpha = 0.05 and power = 0.8. 202 participants were included to account for missing data upon chart review. Setting N/A. Patients or Participants Participants were identified from a surgical database. They were eligible for inclusion if they were planning to undergo hysterectomy for fibroids or AUB from 2014-2019. Interventions N/A. Measurements and Main Results When assessing baseline LUTS in women planning to undergo hysterectomy for fibroids vs. AUB, there were no differences in individual symptoms (all p>0.05) or in prevalence of ‘any urinary symptom’ as a single variable (42.6 vs 45.5%, p=0.67). Dominant fibroid size >6cm was correlated with greater prevalence of ‘any urinary symptom’ (64.9% vs 40.4%, p=0.02), as well as difficulty passing urine (p=0.02), nocturia (p=0.04), and urinary frequency (p=0.04). When controlling for age, BMI, parity, chronic pelvic pain, and diabetes, fibroids >6cm remained significantly associated with the presence of lower urinary tract symptoms (OR 3.1, 95% CI 1.2-8.3). Conclusion Lower urinary tract symptoms are prevalent in women planning to undergo hysterectomy for fibroids, particularly in those with fibroids >6 cm. Future studies should evaluate how urinary symptoms change following hysterectomy. Compare the prevalence of baseline lower urinary tract symptoms (LUTS) in women planning to undergo hysterectomy for fibroids versus abnormal uterine bleeding (AUB) and examine their association with fibroid characteristics This is a retrospective cohort study of 202 women planning to undergo hysterectomy for fibroids vs. AUB. The aim was to compare LUTS in those with vs without fibroids. Baseline demographics, fibroid characteristics, and urinary symptoms were collected. Urinary symptoms included stress and urge incontinence, dysuria, frequent bladder infections, hematuria, nocturia, incomplete emptying, urgency, and frequency. Fibroid characteristics included dominant fibroid size, location, and total uterine volume. A priori power analysis determined 97 participants were needed per group (194 total) to assess for a 20% difference in LUTS, with alpha = 0.05 and power = 0.8. 202 participants were included to account for missing data upon chart review. N/A. Participants were identified from a surgical database. They were eligible for inclusion if they were planning to undergo hysterectomy for fibroids or AUB from 2014-2019. N/A. When assessing baseline LUTS in women planning to undergo hysterectomy for fibroids vs. AUB, there were no differences in individual symptoms (all p>0.05) or in prevalence of ‘any urinary symptom’ as a single variable (42.6 vs 45.5%, p=0.67). Dominant fibroid size >6cm was correlated with greater prevalence of ‘any urinary symptom’ (64.9% vs 40.4%, p=0.02), as well as difficulty passing urine (p=0.02), nocturia (p=0.04), and urinary frequency (p=0.04). When controlling for age, BMI, parity, chronic pelvic pain, and diabetes, fibroids >6cm remained significantly associated with the presence of lower urinary tract symptoms (OR 3.1, 95% CI 1.2-8.3). Lower urinary tract symptoms are prevalent in women planning to undergo hysterectomy for fibroids, particularly in those with fibroids >6 cm. Future studies should evaluate how urinary symptoms change following hysterectomy.

8798 Pressure-Induced Fibroid Ischemia: First-in-Human Experience with a Novel Device for Laparoscopic Treatment of Symptomatic Fibroids

Study Objective Assessment of feasibility of use of a novel fibroid treatment device intended to cause fibroid infarction by increasing intra-tumoral pressure. Design Prospective, single-arm, single-center. Follow up duration – 12 months post-procedure. Setting Subjects in dorsal lithotomy position; arms secured at the sides, shoulder pads in Trendelenburg position during laparoscopy. Surgeon on the subject's left, assistant on the subject's right; facing subject's legs. Laparoscopic tower at the midline of subject's legs. Patients or Participants Sixteen 30–50-year–old pre-menopausal black women indicated for hysterectomy with 2-6–cm type-2-, 3-, 4-, 5-, 6-, or 2-5-fibroids. Main exclusion criteria: prior myomectomy or surgical or minimally-invasive fibroid treatment, known/suspected pregnancy, pregnancy intent, prior pelvic surgery, ongoing anticoagulant therapy, life-threatening condition, contraindication for magnetic resonance imaging with gadolinium contrast. Eleven subjects completed the follow-up. Interventions The novel Empress fibroid treatment system comprises two handheld devices (OrbiTal, OrbiTight), a titanium ring, and a size-0 absorbable suture. OrbiTal was inserted into the abdominal cavity and a suture was passed around a fibroid. OrbiTight carrying the titanium ring was inserted thereafter, the suture was threaded through the ring, tightened, crimped, and left on the uterus outer surface. Multiple sutures could be placed. Measurements and Main Results Uterine and fibroid characteristics were calculated from fat-suppressed T1-weighted coronal, sagittal, and transverse planes on gadolinium-enhanced magnetic resonance images 1 day and 1,3, 6, and 12 months after the procedure. At 3 months, fibroid volume decreased by 36.3% (P=.002) and continued to decrease until the 12-month follow-up (60.4%; P=.008). There were no failed procedures. Improvement was observed at 3 months post-procedure in the Health-Related Quality of Life total, Energy/Mood, Control, and Sexual Function domains of the Uterine Fibroid Symptom and Quality of Life questionnaire. Serious adverse events, unanticipated risks were not reported. Conclusion Initial assessment of the device supports feasibility of the approach for fibroid treatment, does not reveal safety concerns. Assessment of feasibility of use of a novel fibroid treatment device intended to cause fibroid infarction by increasing intra-tumoral pressure. Prospective, single-arm, single-center. Follow up duration – 12 months post-procedure. Subjects in dorsal lithotomy position; arms secured at the sides, shoulder pads in Trendelenburg position during laparoscopy. Surgeon on the subject's left, assistant on the subject's right; facing subject's legs. Laparoscopic tower at the midline of subject's legs. Sixteen 30–50-year–old pre-menopausal black women indicated for hysterectomy with 2-6–cm type-2-, 3-, 4-, 5-, 6-, or 2-5-fibroids. Main exclusion criteria: prior myomectomy or surgical or minimally-invasive fibroid treatment, known/suspected pregnancy, pregnancy intent, prior pelvic surgery, ongoing anticoagulant therapy, life-threatening condition, contraindication for magnetic resonance imaging with gadolinium contrast. Eleven subjects completed the follow-up. The novel Empress fibroid treatment system comprises two handheld devices (OrbiTal, OrbiTight), a titanium ring, and a size-0 absorbable suture. OrbiTal was inserted into the abdominal cavity and a suture was passed around a fibroid. OrbiTight carrying the titanium ring was inserted thereafter, the suture was threaded through the ring, tightened, crimped, and left on the uterus outer surface. Multiple sutures could be placed. Uterine and fibroid characteristics were calculated from fat-suppressed T1-weighted coronal, sagittal, and transverse planes on gadolinium-enhanced magnetic resonance images 1 day and 1,3, 6, and 12 months after the procedure. At 3 months, fibroid volume decreased by 36.3% (P=.002) and continued to decrease until the 12-month follow-up (60.4%; P=.008). There were no failed procedures. Improvement was observed at 3 months post-procedure in the Health-Related Quality of Life total, Energy/Mood, Control, and Sexual Function domains of the Uterine Fibroid Symptom and Quality of Life questionnaire. Serious adverse events, unanticipated risks were not reported. Initial assessment of the device supports feasibility of the approach for fibroid treatment, does not reveal safety concerns.

8704 Evolving Referral Patterns and Management Following Implementation of a Multidisciplinary Fibroid Center

<h3>Study Objective</h3> Evaluate referral patterns and management of symptomatic fibroids following implementation of a multidisciplinary (minimally invasive gynecologic surgery [MIGS] and interventional radiology [IR]) fibroid center. <h3>Design</h3> Retrospective cohort study. <h3>Setting</h3> Academic medical center in New York, NY. <h3>Patients or Participants</h3> Patients who presented for initial fibroid consultation between January-June 2019 and January-June 2021. Consult providers included general gynecologists (GYN), MIGS, IR and others. <h3>Interventions</h3> In September 2020, our institution established a multidisciplinary fibroid center where patients had same-day consults with both MIGS and IR providers. Data were collected before and after implementation of the program with regards to patient demographics, fibroid characteristics, prior imaging and management, referral patterns, and management after consultation. <h3>Measurements and Main Results</h3> 615 patients met inclusion criteria: 273 patients in 2019 and 342 patients in 2021. Patients seen in 2021 were more likely to have previously tried medical management (30.1% vs 20.2%, p<0.01) and many had no prior treatment (53.2% vs 61.5%, p=0.04). There were more MIGS (65.5% vs 53.1%) and fewer general GYN (19.0% vs 25.6%, p=0.02) consultations in 2021. More patients presented for an additional opinion in 2021 (83.6% vs 67.0%, p<0.01), predominately with MIGS (58.8% vs 37.0%, p<0.01). General GYNs were more likely to refer to MIGS (79.3% vs 73.1%) and IR (16.0% vs 13.0%, p=0.046) in 2021. There was increased utilization of MRI imaging in 2021 among MIGS (66.5% vs 52.4%, p<0.01). Among patients who saw MIGS for consultation in 2021, more underwent uterine artery embolization (UAE) (13.8% vs 6.9%, p=0.04) and fewer underwent diagnostic hysteroscopy/dilation and curettage (11.7% vs 4.5%, p<0.01) within 1 year of consultation. <h3>Conclusion</h3> Many patients with symptomatic fibroids seek specialist opinions regarding their treatment options. A multidisciplinary fibroid management program with coordinated efforts between MIGS and IR allows for comprehensive counseling and may lead to more efficient and timely care and an increase in minimally invasive procedures including UAE.

Long term follow-up of uterine fibroids treated with microwave ablation: an up to 3-year observational study of volume, regrowth, and symptoms

Objective To study long-term effects in patients treated with microwave ablation (MWA) for symptomatic uterine fibroids and investigate fibroid characteristics predictive of successful treatment. Method Women who received MWA treatment for uterine fibroids in a previous study were included. A total of 16 patients underwent contrast enhanced MRI before treatment, postoperatively at 6 months and at long-term follow-up, to assess volumes of treated fibroids (n = 42). Long-term MRI was performed between 16 and 36 months after treatment [median 22 months, interquartile range (IQR) 18.5–27]. Validated questionnaires for evaluation of uterine fibroid symptoms and menstrual bleeding (UFS-QoL and PBAC) were used to assess long-term effects on symptoms. The degree of shrinkage was correlated to vascularization and T2 signal intensity (SI) at preoperative MRI and location of fibroids according to the FIGO classification, using the Mann–Whitney U test. Results Most patients (82%) reported improvement up to 3 years after treatment. Out of 42 treated fibroids, 35 (83%) continued to shrink over time with median relative volume reduction of 77% (IQR 39–95). For eight fibroids (19%) which showed low vascularization on the pretreatment MRI, there was less shrinkage compared to well-vascularized fibroids (p = 0.01). Most fibroids (79%) showed iso- to hyperintense T2 signal on preoperative MRI and showed a higher grade of shrinkage than hypointense fibroids (p = 0.02). Conclusion After microwave treatment improvement is maintained for most patients up to 36 months and most fibroids showed continuous shrinkage. Preoperative vascularization, high T2 SI and submucosal location predicted continuous volume reduction. However, to confirm this, larger studies are needed.

How to use power Doppler ultrasound in transvaginal assessment of uterine fibroids.

Measuring vascularization in uterine fibroids is important for their diagnosis, treatment and prognosis. Vascularization can be measured by power Doppler ultrasound. The power Doppler signal depends on fibroid characteristics and on a variety of ultrasound‐machine settings. Literature describing which machine settings influence the power Doppler signal is limited. Each manufacturer names settings and presets at their own discretion, with little information available publicly. Consistency of machine settings is important for correct interpretation of images in daily practice and is essential in yielding reproducible data for research. The aims of this paper, drawing from both a literature search and semistructured interviews with ultrasound‐machine engineers and clinical experts in gynecological ultrasound, were: (1) to provide comprehensive background information on ultrasound physics and fibroid characteristics; (2) to present an overview of machine settings relevant to both two‐ and three‐dimensional power Doppler, including power Doppler frequency, pulse repetition frequency, gain, wall‐motion filter, acoustic power, persistence and signal rise; and (3) to provide a step‐by‐step tutorial on the optimal settings for vascular evaluation of uterine fibroids using power Doppler. The step‐by‐step tutorial comprises six steps to optimize the power Doppler signal, create a preset and acquire a reliable three‐dimensional volume. This step‐by‐step tutorial should help research groups and clinicians to use power Doppler correctly and reproducibly in the evaluation of uterine fibroids. © 2022 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Association between uterine fibroids and antimüllerian hormone concentrations among African American women

To evaluate the extent to which uterine fibroids are associated with antimüllerian hormone (AMH) concentrations. Cross-sectional study. Baseline data from the Study of the Environment, Lifestyle, and Fibroids, which is a 5-year longitudinal study of African American women. A total of 1,643 women aged 23-35 years without a known history of fibroids. Fibroid presence. None. The primary outcome was percent difference in the mean AMH concentration between participants with fibroids and those without fibroids. The secondary outcomes were percent differences in the mean AMH concentrations in participants with different numbers, sizes, types, and positions of fibroids and the percent difference in the mean AMH concentration in participants with different uterine volumes. At least 1 fibroid was identified on ultrasound in 362 (22%) participants. There was a small difference in the mean AMH concentrations in participants with fibroids (age-adjusted model: -4.6%, 95% confidence interval (CI): -14.5% to 6.5%; multivariable model: -4.6%, 95% CI: -14.4% to 6.3%). The mean AMH concentrations were found to decrease with increasing fibroid number. Although differences in AMH concentrations were not statistically significant, compared with no fibroids, the mean percent differences in AMH concentrations for 1, 2-3, and ≥4 fibroids were -1.2% (95% CI: -13.2% to 12.5%), -7.1% (95% CI: -23.3% to 12.5%), and -17.5% (95% CI: -38.2% to 10.0%), respectively. There were no consistent associations between AMH concentrations and fibroid location, size, or uterine volume. The presence of fibroids was not materially associated with AMH concentrations. Other than a monotonic inverse relationship between fibroid number and AMH concentrations, no other fibroid characteristics were consistently or appreciably associated, although associations were imprecise.

Comparison of perioperative outcomes among robot-assisted, conventional laparoscopic, and abdominal/open myomectomies

Objective:To compare the perioperative results of myomectomy performed by robotic surgery (RM), laparoscopic surgery (LM), and open/abdominal surgery (OM).Material and Methods:We included 227 patients who underwent either robotic (n=66), laparoscopic (n=88), or abdominal (n=73) myomectomy at our hospital between 2016 and 2020. Retrospective medical records, including fibroid characteristics, demographic findings, and surgical outcomes, were compared.Results:The RM group had a significantly lower body mass index and significantly larger uterine size, myoma diameter, and myoma weight than the other groups. However, the OM group had the highest number of myoma. Moreover, the RM group had higher operative time and blood loss but significantly lower maximum visual analog scale values than the OM and LM groups. Hospitalization duration was significantly different among the groups. The rate of 1-day hospitalization was 56.2%, 64.8%, and 37.9% in the OM, LM, and RM groups, respectively. Furthermore, blood transfusion requirement was significantly higher in the OM group (12.3%) than in the LM and RM groups (0.0% and 4.5%, respectively).Conclusion:Minimally invasive myomectomy may be preferable, particularly for women of reproductive age. In women with large uterine size and myoma, robot-assisted LM is recommended.

Effects of Tranexamic Acid Administration at Time of Myomectomy with a Particular Focus on Fibroid Characteristics

<h3>Study Objective</h3> To compare the effect of tranexamic acid (TXA) administration on estimated blood loss (EBL) in patients undergoing myomectomy. <h3>Design</h3> Retrospective cohort study of women undergoing myomectomy between January 2015 and January 2020. <h3>Setting</h3> Academic-affiliated community hospital system. <h3>Patients or Participants</h3> All women (n=71). who underwent myomectomy with a Minimally Invasive Gynecologic Surgeon (MIGS) at a single institution between January 2015 and January 2020. <h3>Interventions</h3> In 2017, the MIGS department underwent a practice change and began routine administration of TXA to all myomectomy cases without an absolute contraindication. <h3>Measurements and Main Results</h3> Overall mean EBL was 236mL. There was no statistically significant difference in EBL between the TXA (184mL) and no TXA groups (266mL) (p=0.42). However, when stratified by fibroid characteristics, patients with total pathology fibroid weight >173g or a largest fibroid >73mm had a statistically significant decrease in EBL when they received TXA compared to those who did not (No TXA vs TXA, 405.4mL vs 205.6mL, p=0.006 and 408.3mL vs 229.2mL, p=0.01, respectively). No patients required a blood transfusion. Average operating time was 238 minutes and was also not statistically different between the two groups (p=0.95). There were no cases of anaphylaxis in either group. There was one case of thromboembolism which occurred in the non-TXA group. Rates of nausea/vomiting and headaches did not differ between the two groups (p=1.0 and p=0.41, respectively). <h3>Conclusion</h3> There was a statistically significant reduction in blood loss at the time of myomectomy in patients with a large fibroid burden treated with TXA. Furthermore, TXA is demonstrated as a safe hemostatic agent associated with extremely low rates of adverse events. TXA is a safe and effective hemostatic agent that may reduce intraoperative blood loss during myomectomy.

Laparoscopic Intracapsular Myomectomy in Women 40 Years Old and Over with Symptomatic Uterine Fibroids. A Pilot Study.

Authors evaluated the impact of laparoscopic intracapsular myomectomy (LIM) in women 40 years of age and over with desire of future fertility compared with medical management of symptomatic fibroids, by a prospective cohort study in University affiliated Hospitals. This study includes a cohort of women 40 years of age and older with symptomatic intramural fibroids with desire of future fertility. Women with symptomatic fibroid uterus were offered to undergo LIM or medical management. They were encouraged to attempt conception either spontaneously or by assisted reproductive technology (ART) according to their individual preference. All women were followed for 2 years. Fibroid characteristics, pre- and post-surgical variables, including surgical complications, days of hospitalization, pregnancy rate, and obstetrical outcomes were collected. A total of 100 patient were included in the analysis. Fifty patients were assigned to the LIM group and 50 to the medical treatment group (MT). Groups were similar regarding age (43.5 ± 2.4 and 43.5 ± 2.4, p = 0.99), body mass index (23.8 ± 3.1 and 24.2 ± 3.1, p = 0.54), parity (0.46 ± 0.09 and 0.58 ± 0.09, p = 0.37), fibroid number (1.38 ± 0.6 and 1.46 ± 0.6, p = 0.53), and fibroid size (5.92 ± 1.62 cm vs. 5.94 ± 1.49 cm, p = 0.949). Of the patients who underwent LIM, 62% conceived within the study period compared with 56% in the control group ( p = 0.54). Pregnancy was achieved by ART in 44% of the patients of the LIM group and 30% in control group. There was no significant difference in pregnancy rates among the two groups regarding spontaneous pregnancy rate ( p = 0.332), nor in pregnancies obtained by ART with own eggs ( p = 0.146) and oocyte or embryo donation ( p = 0.821). The take home baby rate was 65% (20/31) in the LIM group and 61% (17/28) in the control group ( p = 0.7851). Both groups had similar rate of miscarriage ( p = 0.748). Patients 40 years old and over with symptomatic fibroid uterus who undergo LIM have similar subsequent fertility and obstetrical outcomes than women treated with medical management. LIM has no detrimental impact on future fertility in women 40 years old and over.

Placenta accreta spectrum in subsequent pregnancy following myomectomy

Purpose To compare the prevalence of placental abnormalities in pregnancy following different modes of operative myomectomy. Methods A retrospective cohort study, including all women after myomectomy that gave birth in a single tertiary care center from February 2011 to January 2019. Data was collected from the patients' medical files and completed by telephone questionnaire. Patients were stratified to 3 groups, according to the mode of operative myomectomy (laparotomy, laparoscopy, hysteroscopy). Groups were compared for women demographics, fibroid's characteristics, operative management, post-operative placental evaluation and delivery characteristics. Primary outcome was defined as the need for any intervention for placental separation during the third phase of the delivery. Results Two hundred forty one women met inclusion criteria. Complete follow-up was achieved in 199 (82.57%) women, of whom 82, 89, and 28 underwent laparoscopic, laparotomy and hysteroscopic myomectomy, respectively. There were no in-between groups differences in women's age, BMI, and gravidity. Disruption of the endometrial cavity during laparoscopy and laparotomy was reported in 3 (3.6%) and 7 (7.8%) cases, respectively (p = .21). During the subsequent pregnancy following myomectomy, placenta accreta spectrum disorder was suspected in only one woman in each of the study groups (p = .63). Placenta previa was low and comparable between groups. Vaginal delivery rate was significantly higher in the hysteroscopy group, as compared to the laparoscopy or the laparotomy groups [11 (36.3%) vs. 5 (6.1%) vs. 4 (4.5%); p = .001], with significantly lower need for manual lysis of the placenta [11(39.0%) vs. 51 (62.1%) vs. 62 (69.7%); p = .01] and further interventions for blood loss control. Conclusions Subsequent pregnancy following surgical myomectomy was not found to be associated with higher prevalence placental abnormality. Furthermore, other than manual lysis, the different modes of myomectomy did not necessitate any further intervention for complications associated with abnormal placentation requiring intervention. Key Message Subsequent pregnancy following surgical myomectomy is not associated with higher prevalence of placental abnormality

Uterine artery embolization versus surgical treatment in patients with symptomatic uterine fibroids: Protocol for a systematic review and meta-analysis of individual participant data

ObjectiveUterine fibroids are the most common benign tumours in women of the reproductive age. Symptoms of heavy menstrual bleeding, abdominal discomfort and infertility may seriously affect a woman’s quality of life. Uterine artery embolization is a safe and effective alternative treatment to hysterectomy or myomectomy for symptomatic uterine fibroids. Which treatment provides the highest quality of life, least complications, symptom reduction and least chance intervention, has not been established and might depend on strict patient selection. This study aims to identify which specific subgroups benefit most of each treatment by analyzing individual participant data derived from randomized controlled trials of women undergoing embolization or surgical treatment. This study will primarily assess the effectiveness of both treatment groups by evaluating the effect on quality of life of embolization in comparison to surgery on specific patient and fibroid characteristics and the possible need for re-intervention for fibroid-related symptoms. Data sourcesPubMed/MEDLINE, Embase and The Cochrane Library were searched up to August 2020. Study eligibility criteriaWe will collect individual participant data from randomized controlled trials that studied clinical and procedural outcomes of premenopausal women with symptomatic uterine fibroids, who were randomized between uterine artery embolization and surgery. Study appraisal and synthesis methodsIndividual participant data from all eligible trials will be sought and analysed according to intention-to-treat principle. Risk of Bias will be done by using version 2 of the Cochrane tool for Risk of Bias in randomized trials. Subgroup analyses to explore the effect of e.g. age, fibroid characteristics and fibroid complaints will be performed, if data is available. This individual patient data meta-analysis will be analysed according to a one-stage model.

Clinical, Imaging and Procedural Risk Factors for Intrauterine Infective Complications After Uterine Fibroid Embolisation: A Retrospective Case Control Study

IntroductionThis was a retrospective case–control study at a single tertiary centre investigating all UFE procedures between January 2013 and December 2018 for symptomatic fibroids. The aim was to determine the clinical, imaging and procedural risk factors which impact upon the risk of post-uterine fibroid embolisation (UFE) intrauterine infection. Cases were patients which developed intrauterine infection post-procedure, and controls were the background UFE population without infection.MethodsClinical demographics, presenting symptoms, uterine and fibroid characteristics on imaging and procedural variants were analysed. A p value of less than 0.05 was considered statistically significant. The main outcome measures were presence of infection and requirement of emergency hysterectomy.Results333 technically successful UFE procedures were performed in 330 patients. Infection occurred after 25 procedures (7.5%). 3 of these patients progressed to overwhelming sepsis and required emergency hysterectomy. Clinical obesity (BMI > 30) (OR 1.53 [1.18–1.99]) and uterine volume > 1000cm3 (2.94 [1.15–7.54]) were found to increase the risk of infectionConclusionsUFE is generally safe in patients with symptomatic fibroids. Obese patients (BMI > 30) and those with large volume uteri (> 1000cm3) are at slight increased risk of developing infection and require appropriate pre-procedural counselling, as well as careful post-UFE follow-up. BMI and uterine volume may be useful to assess before the procedure to help to determine post-UFE infection risk.

Evaluation of the Effect of Routine Antibiotic Administration after Uterine Artery Embolization on Infection Rates

PurposeTo evaluate the effect of routine administration of post-procedural antibiotics following elective uterine artery embolization (UAE) on infectious complication rates. Materials and MethodsThe charts of patients who underwent UAE between January 2013 and September 2019 were retrospectively reviewed. Prior to January 15, 2016, all patients received post-procedural antibiotics with 500 mg of ciprofloxacin twice a day orally for 5 days. After January 15, 2016, none of the patients received post-procedural antibiotics. All patients in both groups received pre-procedural intravenous antibiotics. The post-procedural antibiotics group included 217 patients (age, 44.7 ± 6 years); the no-antibiotics group included 158 patients (age, 45.4 ± 5.6 years). Patients in the no-antibiotics group had a significantly higher rate of diabetes mellitus (P = .03) but fewer cases of adenomyosis (P = .048). Otherwise, demographic and fibroid characteristics were similar between the groups. ResultsSix infectious complications (6/375, 1.6%) were recorded. No statistically significant difference (P = .66) was observed in the number of infections between the post-procedural antibiotics group (4/217, 1.8%) and the no-antibiotics group (2/158, 1.3%). Three of the 6 infectious complications presented with malodorous vaginal discharge (3/375, 0.8%) and received nominal therapy. The 3 remaining complications (0.8%) were considered major and included 2 patients (0.5%) who underwent hysterectomy and 1 patient (0.3%) who underwent myomectomy. The major infection rate was 0.9% (2/217) in the post-procedural antibiotics group and 0.7% (1/158) in the no-antibiotics group (P = 1). There were no 90-day post-procedural mortalities. ConclusionsDiscontinuation of routine post-procedural antibiotics with ciprofloxacin after elective UAE did not result in increased rates of infectious complications within the first 90 days post procedure.