Location Of Myomas Research Articles

Patients’ Age, Myoma Size, Myoma Location, and Interval Between Myomectomy and Pregnancy May Influence the Pregnancy Rate and Live Birth Rate After Myomectomy

Abstract Objective: To investigate which clinical characteristics will influence the pregnancy rate and live birth rate after myomectomy. Subjects and Methods: Data of clinical characteristics and reproductive outcome from 471 patients who wished to conceive and who underwent abdominal or laparoscopic myomectomy in the Obstetrics and Gynecology Hospital of Fudan University from January 2008 to June 2012 were retrospectively analyzed. Results: Average age in the pregnancy group (30.0±3.7 years) and the nonpregnancy group (31.2±4.1 years) was statistically different (P=.000). The diameter of the biggest myoma had a positive relationship with the pregnancy rate when it was .05). The location of the myoma may influence the live birth rate after myomectomy (rs=0.198, P=.002). Anterior and posterior my...

Magnetic resonance imaging of uterovaginal lesions associated with female infertility

Abstract Objective To study the mandatory indications and accuracy of magnetic resonance (MR) imaging for the diagnosis of uterovaginal lesions associated with female infertility. Design Prospective cross sectional study. Main outcome measures Indications and accuracy of MR imaging for the diagnosis of uterovaginal lesions. Materials and methods 423 infertile women were investigated by hysterosalpingography (HSG) and transvaginal ultrasonography (TVUS). In 54 women having uterovaginal lesions and 76 women with tubo-ovarian lesions, the diagnosis was not conclusive by HSG and TVUS and consequently they were examined by MR imaging. The present study was devoted for infertile women suffering from uterovaginal lesions. Results MR imaging confirmed the diagnosis of agenesis of the uterus and the vagina (1 case), unicornuate uterus (2 cases, functioning rudimentary horn connected to the dominant horn in 1 case), uterus didelphys (1 case), bicornuate uterus (5 cases), septate and subseptate uteri (10 cases). Eighteen patients had multiple corporeal leiomyomas, 8 subserous and 10 intramural, diffuse adenomyosis, 14 cases and localized adenomyoma, 3 cases. Intramural leiomyomas showed enhancement on T2-weighted imaging suggesting a good response to uterine artery embolization (UAE). The size, number and location of myomas were precisely demonstrated on MR imaging, information necessary for myomectomy and UAE. The findings of MR imaging were compared with the final diagnosis after laparoscopy or surgical intervention and histopathological study. The accuracy, sensitivity, specificity, and positive and negative predictive values of MR imaging for diagnosing uterovaginal lesions associated with infertility were 100%. Conclusion The present study proved that MR imaging was the method of choice for precise diagnosis of uterovaginal lesions associated with infertility, when the diagnosis was not conclusive on HSG and TVUS. MR imaging was mandatory for conclusive diagnosis of mullerian duct anomalies, adenomyosis uteri and multiple uterine leiomyomas destined to myomectomy or uterine artery embolization. The accuracy, sensitivity, specificity and positive and negative predictive values of MR imaging for diagnosis of these lesions were 100%.

Co-Existence of Uterine Myomas and Endometriosis in Women Undergoing Laparoscopic Myomectomy: Risk Factors and Surgical Implications

Study ObjectiveTo investigate the prevalence of and explore risk factors for the coexistence of uterine myomas and endometriosis and to assess operative outcomes during laparoscopic myomectomy. DesignRetrospective cohort study (Canadian Task Force classification II-2). SettingTertiary referral center in London, England. PatientsTwo hundred twelve women undergoing laparoscopic myomectomy to treat symptomatic uterine myomas. InterventionLaparoscopic myomectomy. Measurements and Main ResultsCoexisting myomas and endometriosis were identified in 21.2% of patients. Endometriosis was more common in those with subfertility (44% vs 25.7%; p = .02) and less common in those with bleeding disorders (20% vs 45%; p = .003). Parity, location of myoma, and race/ethnicity affected risk of endometriosis, whereas size and number of myomas did not. Of patients with endometriosis, 42% underwent surgical treatment of endometriosis during myomectomy. Significantly more patients with endometriosis also underwent ovarian cystectomy than did those without endometriosis (15.6% vs 3%; p = .004). Operative time was similar in both groups (109.6 minutes vs 116.4 minutes; p = .83), as was estimated blood loss (271 mL vs 327 mL; p = .16). ConclusionsA diagnosis of concomitant endometriosis should be considered, in particular in patients with subfertility and pain. This enables optimal preoperative counseling and consent for potential additional procedures such as treatment of endometriosis or ovarian cystectomy.

Laparoscopic myomectomy: a 6-year follow-up single-center cohort analysis of fertility and obstetric outcome measures

To evaluate fertility, pregnancy and delivery outcomes after laparoscopic myomectomy (LM) during long-term follow-up. In this single-center retrospective observational study, data were analyzed from 59 women aged 23-42 years with the desire to have children and who underwent LM for symptomatic uterine leiomyoma between January 2001 and December 2006 and subsequently delivered at our hospital. During a mean follow-up period of 73.55 months, the post-LM conception rate was 68 %. The proportion of miscarriages (n = 16) among all pregnancies (n = 55) was lower after (24 %) than before (43 %) LM. Thirty-nine (46 %) deliveries were primary cesarean sections (CSs). CS was performed due to patients' preference, placental complications, and uterine rupture (UR). Labor was successful in 62 % of all vaginal delivery trials. UR and placental complications occurred in 10 and 13 % of all pregnancies, respectively. LM reduced the abortion rate and increased the CS rate in our cohort. UR risk may have been affected by suturing technique, the size and location of myomas removed.

Laparoendoscopic single-site (LESS) myomectomy: characteristics of the appropriate myoma

ObjectiveTo describe the characteristics of 35 myomas in 28 patients who underwent laparoendoscopic single-site myomectomy (LESS-M). Study designRetrospective analysis of 28 patients who underwent LESS-M at Samsung Medical Center from January 2009 to January 2013. ResultsThe median age of 28 patients was 34 years (range: 27–61) and median body mass index was 21.9 (range: 17.3–28.5). The median number of extracted myomas was one (range: 1–4) and the largest myoma diameter was 6cm (range: 2–15). The total number of extracted myomas was 35 and the types of extracted myoma were subserosal (16 myomas, 45.7%), intramural (nine myomas, 25.7%) and intraligamentary (seven myomas, 20%). In subserosal and intramural myoma, 21 myomas were located at the anterior wall and four myomas were located at the posterior wall of the uterus. Median operation time was 131min (range: 35–232). Estimated intraoperative blood loss was 65mL (range: 20–300), hemoglobin change was 2g/dL (range: 0.5–2.9) and hospital stay was 3 days (range: 1–4). There was no conversion to laparotomy but in one patient (3.6%), LESS-M converted to two-port laparoscopic myomectomy. There was no blood transfusion during and after operation. Intraoperative and postoperative complications did not occur. ConclusionCareful selection of patients considering the type and location of myomas is important for successful LESS-M. Myomas located in the anterior wall, subserosal or intraligamentary myomas are appropriate for LESS-M.

Patients' Age, Myoma Size, Myoma Location, and Interval Between Myomectomy and Pregnancy May Influence the Pregnancy Rate and Live Birth Rate After Myomectomy

To investigate which clinical characteristics will influence the pregnancy rate and live birth rate after myomectomy. Data of clinical characteristics and reproductive outcome from 471 patients who wished to conceive and who underwent abdominal or laparoscopic myomectomy in the Obstetrics and Gynecology Hospital of Fudan University from January 2008 to June 2012 were retrospectively analyzed. Average age in the pregnancy group (30.0±3.7 years) and the nonpregnancy group (31.2±4.1 years) was statistically different (P=.000). The diameter of the biggest myoma had a positive relationship with the pregnancy rate when it was <10 cm (rs=0.095, P=.039). Abortions before myomectomy, operation type, number, location, and classification of myomas, uterine cavity penetration, and uterine volume seemed not to influence the pregnancy rate (P>.05). The location of the myoma may influence the live birth rate after myomectomy (rs=0.198, P=.002). Anterior and posterior myomas were associated with higher live birth rates than other locations (P=.001). The average interval between myomectomy and pregnancy was 16.0±8.7 months, and there was no difference between the abdominal (17.2±8.6 months) and laparoscopic (15.2±8.8 months) groups (P=.102). The interval in the live birth group was 15.0±8.4 months, and that in the non-live birth group was 18.9±9.3 months; the difference was significant (P=.005). Patients' age, myoma size and location, and interval between myomectomy and pregnancy may influence the pregnancy rate and live birth rate after myomectomy.

Pregnancy Outcomes after Laparoscopic Myomectomy with Barbed Suture

Pregnancy Outcomes after Laparoscopic Myomectomy with Barbed Suture

Comparison of robotic-assisted laparoscopic myomectomy outcomes with laparoscopic myomectomy

This study aimed at comparing short-term outcomes of patients who underwent robotic-assisted laparoscopic myomectomy and laparoscopic myomectomy. From January 2008 to August 2010, prospective data including 15 consecutive patients who underwent robotic-assisted myomectomy (RALM) with the da Vinci surgical system were recorded. These cases were compared with a retrospective cohort of 23 patients who underwent laparoscopic myomectomy (LM). Patient demographics, fibroid characteristics and peri-operative data (operative time, anesthesia time, set-up time, console time for robotic cohort, Estimated blood loss (EBL), length of hospital stay, conversion to laparotomy and operative complications were collected in both groups. Mean operative time for the robotic group was 138.73 ± 39.51 min compared with 140.57 ± 38.17 min for the laparoscopy group (p = 0.887). No significant differences were noted between RALM versus LM for hospital stay (1.67 ± 0.58 vs. 1.87 ± 0.67 days, p = 0.369) and EBL (101.33 ± 39.84 vs. 119.78 ± 43.70 ml, p = 0.549). The numbers, size and location of myomas removed for two groups were similar. None of the cases in both groups required conversion to laparotomy. There were no significant intra-operative and post-operative complications in either group. RALM appears to provide the same surgical outcomes when compared with traditional laparoscopic myomectomy.

Robotic-assisted, laparoscopic and open myomectomy: a comparison of surgical outcomes

OBJECTIVE: To compare the surgical outcomes of robotic-assisted laparoscopic myomectomy (RM), standard laparoscopic myomectomy (LM) and open myomectomy (OM). DESIGN: Retrospective,case-matched analysis. MATERIALS AND METHODS: All patients who underwent RM between 2008 and 2009,LM and OM between 1995 and 2009 at Cleveland Clinic were included.The 3 groups were compared regarding the baseline demographics,operative and immediate postoperative outcomes associated with each type of surgery.Data analysis was performed using analysis of variance, Wilcoxon's rank sum test,Chi-square and Fisher exact tests where appropriate. RESULTS: From a total of 575 myomectomies,393(68.3%) were OM,93(16.2%) were LM,and 89(15.5%) were RM.The median (IQR) BMI of patients was 26.7 (22.9, 31.3) kg/m2.The three groups were comparable regarding size,number,and location of myomas after adjusting for age and BMI. Significantly heavier myomas were removed in the RM group 223.00(85.25,391.50)gm compared to the LM group 96.65 (49.50,227.25)gm (p<0.001)and was lower than the OM group 263.00 (90.43,448.25)gm (p=0.002).The RM group has significantly lower (P<0.001)blood loss compared to the OM and the LM groups with mean ± SD of blood loss in ml is 100.00(50.00, 212.50),200.00(100.00, 437.50)and 150.00 (100.00, 200.00)respectively.Total surgical time in minutes was 176.50(138.00, 225.00) in the OM, 222.00(147.00,268.00) in the LM and 200.00(167.75,261.00) in the RM (P<0.001).Patients in the OM had significantly higher median length of hospital stay of 3(2,3) days; compared to 1(0,1) in the LM and 1(1,1) days in the RM (p<0.001). CONCLUSION: Robotic assisted myomectomy is associated with decreased estimated blood loss,and length of hospital stay compared to traditional laparoscopy and to open myomectomy.Despite the robotic use is associated with longer OR time compared to open procedures it is shorter than the laparoscopic approach.It appears that robotic technology is able to convert more laparotomy cases to laparoscopic cases than traditional laparoscopy alone.

Perioperative complications in conventional and microsurgical abdominal myomectomy

It has become evident that laparoscopic myomectomy is limited by size, number and location of fibroids. Myomectomy performed by laparotomy can be technically challenging and the surgical benefits have to be weighed against associated risks and impairing fertile potential, especially in multiple and large fibroids that may be positioned close to the cavity. Our aim was to evaluate the effect of microsurgical myomectomy technique on perioperative morbidity in premenopausal women. This retrospective study included 228 patients with symptomatic uterine fibroids and/or infertility undergoing myomectomy by laparotomy. As much as 156 patients were treated by standardized microsurgical technique and 72 patients by conventional myomectomy. The following data were recorded and analysed: postoperative haemoglobin, haemoglobin decrease, rate of blood transfusion, and number, size and location of myomas. In 228 patients, seven complications occurred (abdominal wall haematoma, bowel and colon injury, transient ileus). The transfusion rate was 1.3%. Microsurgical technique was associated with a smaller haemoglobin decrease compared to conventional myomectomy (1.77 vs. 2.38 g/dl; P = 0.007). Microsurgical technique correlated inversely with haemoglobin decrease (P < 0.001). Haemoglobin decrease correlated positively with myoma number (P < 0.001), size of myoma (P < 0.001) and the opening of the cavum uteri (P = 0.014). In this large series of abdominal myomectomies, procedure-related morbidity, mainly perioperative blood loss, was amongst the lowest reported when microsurgical techniques were used. In patients with multiple, large or deep intramural fibroids who desire future pregnancies, the use of microsurgical techniques may decrease intraoperative blood loss and perioperative morbidity.

RETRACTED: Submucous myomas and their implications in the pregnancy rates of patients with otherwise unexplained primary infertility undergoing hysteroscopic myomectomy: a randomized matched control study

To determine whether hysteroscopic myomectomy for submucous fibroids in women with unexplained primary infertility achieved better pregnancy rates than no intervention. Prospective randomized matched control trial. Tertiary university fertility care unit. From January 1999 to February 2006, a total of 215 women with unexplained primary infertility and with ultrasonographically diagnosed submucous myomas as the sole cause for fertility failure were recruited. Women were randomly allocated to one of two pretreatment groups matched by age. Hysteroscopic myomectomy was performed in the study group (n = 101). Diagnostic hysteroscopy and myoma biopsy was performed in the control group (n = 103). No fertility therapy was given for either group. Clinical pregnancy rates according to patient and myoma characteristics. The baseline characteristics of both patients and submucous myomas were comparable. Among patients with complete follow-up, a total of 93 (45.6%) pregnancies occured-64 (63.4%) in the study group and 29 (28.2%) in the control group. Women in the study group had a better possibility of becoming pregnant after hysteroscopic myomectomy with a relative risk of 2.1 (95% confidence interval, 1.5-2.9). No difference in pregnancy rates was observed according to size, number, and location of myomas in both groups. However, fertility rates appeared to increase after hysteroscopic myomectomy of type 0 and type I myomas (P < 0.05). In contrast, for the subgroup of patients with type II myomas, no difference in fertility rates were noted. Hysteroscopic myomectomy for submucous fibroids in women with unexplained primary infertility is effective in achieving a better pregnancy rate. We think that a multicenter study should be conducted before evaluating the impact of submucous myoma characteristics on fertility outcome.

Laparoscopy vs laparoscopically assisted myomectomy in the management of uterine myomas: a prospective study

This study was undertaken to compare the intraoperative and short-term outcomes between the 2 modalities of minimally invasive surgery for the management of uterine fibroids. A total of 116 patients with inclusion criteria were prospectively collected in a study period from March 1997 through 2007. Laparoscopic (n = 40) vs laparoscopically assisted myomectomy (n = 76) were compared for the management of no more than 3 intramural or subserous uterine myomas, of a maximum diameter of 90 mm. The patients' characteristics by age, parity, body mass index, number and location of myomas were well balanced between the 2 study groups. The mean diameter of the myomas was the only characteristic significantly higher in the laparoscopically assisted myomectomy group. The operative time in the laparoscopically assisted myomectomy was significantly shorter compared with the laparoscopic myomectomy (mean +/- standard deviation: 66 +/- 19 minutes vs 94 +/- 18 minutes, P < .0001). A shorter uterine incision was found in the laparoscopically assisted myomectomy technique compared with the laparoscopic myomectomy (2.9 +/- 0.6 vs 4.3 +/- 1.2, P < .0001). Estimated blood loss was significantly higher in the laparoscopically assisted myomectomy group (P = .002). Intraoperative, early postoperative complications, hospitalization days, and fully returned activity were similar between the 2 study groups. The present data suggest that the laparoscopically assisted myomectomy is a valid alternative to laparoscopy in a setting of minimally invasive surgery for the management of uterine fibroids.

Laparoscopic Myomectomy: Do Size, Number, and Location of the Myomas Form Limiting Factors for Laparoscopic Myomectomy?

Study Objective To assess whether it is possible for an experienced laparoscopic surgeon to perform efficient laparoscopic myomectomy regardless of the size, number, and location of the myomas. Design Prospective observational study (Canadian Task Force classification II-1). Setting Tertiary endoscopy center. Patients A total of 505 healthy nonpregnant women with symptomatic myomas underwent laparoscopic myomectomy at our center. No exclusion criteria were based on the size, number, or location of myomas. Interventions Laparoscopic myomectomy and modifications of the technique: enucleation of the myoma by morcellation while it is still attached to the uterus with and without earlier devascularization. Measurements and Main Results In all, 912 myomas were removed in these 505 patients laparoscopically. The mean number of myomas removed was 1.85 ± 5.706 (95% CI 1.72–1.98). In all, 184 (36.4%) patients had multiple myomectomy. The mean size of the myomas removed was 5.86 ± 3.300 cm in largest diameter (95% CI 5.56–6.16 cm). The mean weight of the myomas removed was 227.74 ± 325.801 g (95% CI 198.03–257.45 g) and median was 100 g. The median operating time was 60 minutes (range 30–270 minutes). The median blood loss was 90 mL (range 40–2000 mL). Three comparisons were performed on the basis of size of the myomas (<10 cm and ≥10 cm in largest diameter), number of myomas removed (≤4 and ≥5 myomas), and the technique (enucleation of the myomas by morcellation while the myoma is still attached to the uterus and the conventional technique). In all these comparisons, although the mean blood loss, duration of surgery, and hospital stay were greater in the groups in which larger myomas or more myomas were removed or the modified technique was performed as compared with their corresponding study group, the weight and size of removed myomas were also proportionately larger in these groups. Two patients were given the diagnosis of leiomyosarcoma in their histopathology and 1 patient developed a diaphragmatic parasitic myoma followed by a leiomyoma of the sigmoid colon. Six patients underwent laparoscopic hysterectomy 4 to 6 years after the surgery for recurrent myomas. One conversion to laparotomy occurred and 1 patient underwent open subtotal hysterectomy for dilutional coagulopathy. Conclusion Laparoscopic myomectomy can be performed by experienced surgeons regardless of the size, number, or location of the myomas.

Robotic-assisted laparoscopic myomectomy compared with standard laparoscopic myomectomy—a retrospective matched control study

Compare robotic-assisted laparoscopic myomectomy (RALM) to a matched control standard laparoscopic myomectomy (LM). A retrospective matched control study. Private practice setting. Premenopausal and postmenopausal women who underwent either robotic-assisted or standard laparoscopic myomectomy. None. Retrospective chart review was performed. Cases of laparoscopic robotic-assisted myomectomies were compared with a matched control group of standard LM. Comparisons were based on Fisher's exact, Mann-Whitney, and exact chi-square tests. Between January 2006 and August 2007, 15 consecutive RALMs were performed at our institution, compared with 35 matched control standard LMs. The two groups were matched by age, body mass index, parity, previous abdominopelvic surgery, size, number, and location of myomas. Mean surgical time for the RALM was 234 minutes (range 140-445) compared with 203 minutes (range 95-330) for standard LMs. Blood loss, hospitalization time, and postoperative complications were not significantly different. The RALM required a significant prolonged surgical time over LM. It appears that in the hands of a skilled laparoscopic surgeon, the RALM does not offer any major advantage. This technology, however, offers exciting potential applications while learning endoscopic surgery. Further studies are warranted to asses the utility of RALM for general gynecologic surgeons.

Percutaneous Sonographically Guided Radiofrequency Ablation of Medium-Sized Fibroids: Feasibility Study

The purpose of this study was to assess the feasibility and safety of percutaneous radiofrequency ablation under sonographic guidance as a unique procedure in the management of symptomatic uterine myomas. Six premenopausal women with symptomatic submucosal or intramural uterine myomas underwent percutaneous radiofrequency ablation under suprapubic sonographic guidance. Relief of symptoms and reduction in the diameter and volume of the myomas were measured every 3 months. The location of myomas was anterior and submucosal in one of the six patients and intramural in the other five (one posterior, one anterior, two fundal, and one on the left side). Five of the patients had pelvic pain, and four had menorrhagia. The median baseline diameter was 4.8 cm (range, 4.4-5.2 cm), and the mean volume was 58.57 cm3 (range, 44.58-73.58 cm3). The mean follow-up time was 9 months (range, 3-12 months). At follow-up, the median diameter was 2.3 cm (range, 1.20-3.2 cm), and the median volume was 8.97 cm3 (range, 0.90-18.81 cm3). The median preoperative symptom score was 47.2 (31.8-67.30), and the median health-related quality of life (QOL) score was 63.92 (37.20-86.00). The median symptom score during follow-up was 5.15 (range, 0-26), and the mean QOL score was 96.2 (range, 86.30-100). Four of six patients were symptom-free at the last follow-up visit. Percutaneous sonographically guided radiofrequency ablation alone is a feasible and efficient procedure in the management of medium-sized uterine myomas.

Italian multicenter study on complications of laparoscopic myomectomy

Study objective To study intraoperative and postoperative complications of laparoscopic myomectomy and patients’ characteristics influencing this risk. Design Prospective study, with a review of the patient records by the first author (Canadian Task Force classification II-2). Setting Four Italian referral centers. Patients The incidence and type of complications occurring in 2050 laparoscopic myomectomies undertaken from January 1998 through December 2004 were recorded. Interventions The surgical technique, as well as the expertise of the operators, was the same for the 4 centers. Injection of vasoconstrictive agents was used in 37%. The serosa was always incised in a vertical fashion; mechanical enucleation of the myoma was completed whenever possible; suture was performed in 1 or 2 layers with deep and large stitches swaged to 1 or 0 polyglactin sutures that were tied intracorporeally or extracorporeally. Measurements and main results Single or multiple myomectomies (n = 2050) for symptomatic myomas measuring at least 4 cm in diameter were performed. Most patients (48%) had more than 1 myoma, with a maximum of 15 per patient (myomas removed for patients: 2.26 ± 1.8, mean ± SD). Myoma size ranged from 1 to 20 cm (mean 6.40 ± 2.6 SD). Myomas smaller than 4 cm were removed during myomectomy for larger ones. Total complication rate was 11.1% (225/2050 cases). Minor complications accounted for 9.1% (187/2050 cases) and major complications for 2.02% (38/2050 cases). The most serious events were hemorrhages (14 cases, 0.68%) requiring blood transfusions in 3 cases (0.14%); 10 postoperative hematomas (0.48%, one in the broad ligament and 9 in the myomectomy scar); 1 bowel injury (0.04%); 1 postoperative acute kidney failure (0.04%); and 2 unexpected sarcomas (0.09%). Failure to complete planned surgery occurred in 7 cases (0.34%). Two patients were readmitted for surgery (0.09%): 1 had a laparoscopic hysterectomy because of a severe blood loss, and the other had drainage of a hematoma in the broad ligament. After a follow-up period of 41.70 ± 23.03 months (mean ± SD), 386 (22.9%) patients conceived, with a pregnancy rate in patients wishing pregnancy of 69.8%; among them, 1 (0.26%) recorded spontaneous uterine rupture at 33 weeks gestation. Odds ratio computed to estimate the risk of complications in relation to the patient characteristics showed that the probability of complications significantly rises with an increase in the number (more than 3 myomas OR: 4.46, p <.001) and with the intramural (OR: 1.48, p <.05) or the intraligamentous location of myomas (OR: 2.36, p <.01) whereas the myoma size seems to influence particularly the risk of major complications (OR: 6.88, p <.001). Conclusions This is one of the largest series reported of laparoscopic myomectomy and the first focused on complications. The complication rate appears to be better than acceptable in comparison with complication rates reported after laparotomic myomectomies. Laparoscopic myomectomy, when performed by an experienced surgeon, can be considered a safe technique with an extremely low failure rate and good results in terms of pregnancy outcome.

Myomectomy during Cesarean Section

A patient's frequent request is the simultaneous surgical removal of a previously diagnosed myoma during cesarean section. The aim of this study was to evaluate the safety and efficacy of myomectomy during cesarean section. From January 1995 until December 2004, 47 pregnant women with coexisting uterine myomas underwent cesarean section and simultaneous myomectomy. All cesarean sections were performed by residents while myomectomies were conducted by the senior staff. Intraoperative and postoperative complications such as blood loss were estimated and compared with 94 women with uterine myomas who underwent surgical delivery without removal of the fibroids. Furthermore, the length of hospitalization was compared between the two groups. Myomectomy added a mean time of 15 min to the operative time of cesarean section. No hysterectomy was performed at the time of the cesarean section. No complications were developed during the puerperium. The difference between the preoperative and postoperative hemoglobin mean value was statistically significant (P=0.001) but did not differ between isolated cesarean and myomectomy-combined cesarean groups. None of the patients received blood transfusion. The length of hospitalization was comparable between the two groups. Despite controversial literature data, we suggest that myomectomy during cesarean section could be generally recommended. Depending on size and location of myomas, the associated risks are similar to those of isolated cesarean section.

Leiomyoma characteristics and risk of subsequent surgery after myomectomy

Objective: Evaluate the association between leiomyoma characteristics at myomectomy with subsequent surgery risk. Methods: A population-based nested case control study from a cohort of women at a large HMO, identified as having had a myomectomy was performed; 82 cases had subsequent uterine surgery; 82 controls, frequency matched for age and date of first surgery, did not. Medical records were abstracted; follow-up was 18–128 months. Adjusted odds ratios (aOR) and 95% confidence intervals (CI) were calculated. Results: Women without subserosal myomas were more likely to have a second surgery as compared to women with at least one subserosal myoma, aOR = 4.1(95% CI 1.5–10.9). Size of myomas did not predict subsequent surgery in subanalyses by type of surgery. Number of leiomyomas was not predictive of a subsequent uterine surgery overall or in subgroup analyses. Conclusion: Myoma location, but not number or size, impacts the risk for subsequent leiomyoma uterine surgery.

Uterine Myomas and Infertility: Any Relationship?

The relationship between uterine myomas and infertility is unclear, and numerous studies have attempted to better define this association. This review article explores the available data about the impact of submucosal, intramural and subserosal myomas, and small and large myomas, on reproductive outcomes in natural conception and assisted reproduction. Overall myoma location, followed by size, is the most important factor determining the impact of myomas on fertility. Distortion of the uterine cavity can also be detrimental to fertility. The importance of proper evaluation of a myomatous uterus and its endometrial cavity is discussed. For patients with myomas and infertility, or for those with symptomatic myomas who desire future fertility, current medical and surgical management options are reviewed. However, myomectomy remains the standard of care for patients with problematic myomas and fertility concerns. Keywords: Myomectomy, endometrial cavities, hysterosalpingogram, intracytoplasmic sperm injection, implantation, conservative management, Mifepristone

Impact of sonohysterography on the management of women with uterine myomas

Purpose: Assess the importance of sonohysterography findings in women with suspected/known myomas particularly with regard to location within/near the endometrial cavity and its impact on treatment.Methods: Review of 240 sonohysterograms identified 109 women (age 24–76, mean 42.4; 84.4% pre‐menopausal, 15.6% post‐menopausal) with suspected/known myomas. Images, reports, pathology/surgery results, and clinical/imaging follow up were reviewed. Myoma location with respect to the cavity was described and feasibility of hysteroscopic resection assessed.Results: Indications for sonohysterography abnormal bleeding (74.3%), infertility (8.3%), other (17.4%). Five groups were defined (1) normal cavity (19/109 patients, 17.4%); (2) normal but displaced cavity (7/109, 6.4%); (3) myoma with endoluminal component (50/109, 45.9%); (4) other endoluminal findings, mostly polyps (25/109, 22.9%); (5) myoma plus other (8/109, 7.3%). An intracavitary myoma(s) (ICM), a submucous myoma &gt;50% within the cavity, was found in 45 patients; submucous – 20; mural – 71; and subserosal – 37 (57 patients had myomas in more than one location). SHG indicated that myomas were amenable to hysteroscopic resection (HR) in 45 women; in 39 others SHG revealed that myoma(s) were not amenable to HR. There was a significant difference in the use of hysteroscopic resection between these two groups; HR was performed in 21/45 (46.7%) of the former but only in 2/39 (5.1%) of the latter (P &lt; 0.01). Other treatments were not significantly different between the two groups: hysterectomy in 7/45(15.6%) and 5/39(12.8%); abdominal myomectomy in 1/45 (2.2%) and 3/39 (7.7%); uterine artery embolization, curettage or endometrial ablation in 4/45 (8.9%) and 3/39 (7.7%), respectively. Sonohysterography findings were proved by pathology, hysteroscopy, laparoscopy or imaging in 64/109 (63.3%) patients; however, in the ICM group, 41/45 (91.1%) were proved.Conclusions: SHG is useful for assessing the relationship of myomas to the cavity and for identifying or excluding concomitant endometrial abnormalities. Although other factors also influence treatment choices, SHG provides information that assists in determining therapeutic approach, particularly the appropriate use of hysteroscopic resection.