Multiple Myomas Research Articles

Clinical comparison of laparoscopic and open surgical approaches for uterus-preserving myomectomy: a retrospective analysis on patient-reported outcome, postoperative morbidity and pregnancy outcomes.

Uterine fibroids pose clinical challenges due to varied symptoms and impact on fertility. Aim of this research is to compare open and laparoscopic myomectomy, with focus on evaluating their effects on patients' quality of life and analyzing their implications for pregnancy outcomes. This retrospective study compares open and laparoscopic myomectomy outcomes in 168 patients treated October 2017 and July 2023. Preoperative characteristics and postoperative outcomes in terms of symptoms and pregnancy outcomes were examined. The patient cohort comprised patients with a high symptom burden. Only 51.2% expressing a desire for future pregnancies, highlighting diverse motivations for uterus-preservation. No significant differences were observed in preoperative symptoms. Larger and multiple myomas were associated with a higher likelihood of laparotomy. Recurrence rates were lower after laparoscopy (10.2% vs. 23.8%, p = 0.02). Cesarean section recommendations were more frequent post-laparotomy group (36.6% vs. 86.6%, p = 0.000). Morbidities and satisfaction showed no significant differences between approaches, with slightly better bleeding improvement after laparotomy. Despite similar pregnancy outcomes, a high proportion of patients did not conceive postoperatively (75.4%). Among patients who became pregnant postoperatively (n = 31), most patients conceived after one year or more, with no dependence on the surgical approach (p = 0.227). Both open and laparoscopic myomectomy surgeries showed high patient satisfaction, symptom alleviation, and comparable pregnancy results. A preference emerged for laparoscopy in terms of cesarean section recommendations and recurrence risk. Laparoscopic procedures tended to offer higher operative satisfaction and fewer complications. The study emphasized the complexity of therapeutic decision-making.

A retrospective analysis of single-port laparoscopy in myoma management

ObjectiveThis study assesses the effectiveness and safety of single-port laparoscopic myomectomy (SPLM) versus conventional laparoscopic myomectomy (CLM). MethodsWe conducted a retrospective case-control study at a university tertiary hospital, involving 262 patients treated from July 2020 to December 2022. Participants were divided into two groups: 132 underwent SPLM and 130 underwent CLM. ResultsThe two groups were comparable in terms of age, body mass index, parity, delivery history, preoperative anemia, number of myomas, and size of the largest myoma. The SPLM group showed a significant reduction in operation time (average 93 min) and estimated blood loss (average 50 ml) compared to the CLM group (average 118.5 min and 100 ml, respectively). Subgroup analysis based on the size, location, and number of myomas further highlighted the advantages of SPLM, particularly for patients with large (diameter ≥8 cm) or multiple myomas (number ≥4). Patient satisfaction was also notably higher in the SPLM group. ConclusionsSingle-port laparoscopic myomectomy offers a highly effective, safer, and patient-preferred option for the surgical management of fibroids, especially in cases of large or multiple myomas. These findings suggest that SPLM could become the preferred surgical approach for complex fibroid cases, promising less trauma and quicker recovery for patients.

Impact of CYP2D6 polymorphisms on adverse events in patients with breast cancer treated with tamoxifen: Insights from an early dose escalation trial in CYP2D6 poor metabolizers.

547 Background: Tamoxifen is widely used in treating hormone receptor-positive breast cancer. It is primarily metabolized by the CYP2D6 enzyme to yield active metabolites. However, CYP2D6 polymorphisms have been associated with a differential response to tamoxifen. In a clinical trial involving an early dose escalation of tamoxifen in poor metabolizers, we found endoxifen concentration levels similar to those of patients with extensive phenotype, and no long-term survival differences among CYP2D6 phenotypes. However, the impact of that dose escalation on side effect incidence was not addressed. Methods: In this study, we analyzed the incidence of specific side effects - osteoarticular pain, hot flashes, asthenia, and uterine alterations - in 86 breast cancer patients, differentiated by their CYP2D6 phenotype estimated according to the Clinical Pharmacogenetics Implementation Consortium. In poor metabolizers, the tamoxifen standard dose of 20 mg/day was escalated to 40 mg/day and 60 mg/day for 4 months each, and then treated with 20 mg/day until completing the treatment. Kaplan-Meier analysis and Cox proportional hazards regression model were employed to assess the relationship between the CYP2D6 phenotype and the incidence of these side effects. Results: The median follow-up time was 139.5 months. The analyses revealed that only uterine changes showed significant differences between CYP2D6 phenotypes, with a lower incidence in extensive metabolizers (P-value < 0.001 in Kaplan-Meier; HR in Cox of 0.195, 95% CI 0.073 - 0.521, P = 0.001). This finding persisted after adjustment for the covariates tumor grade, size, nodal status, chemotherapy, and radiotherapy in multivariate Cox regression (HR 0.098, 95% CI 0.020 - 0.466, P = 0.004). Selection of a subgroup through Propensity Score Matching (21 vs 21) corroborated these results. The spectrum of uterine changes and pathologies included endometrial hyperplasia, polyps, adenocarcinoma, myometrial or endometrial thickening, and the presence of multiple myomas. Conclusions: Our study indicates that an early increase in tamoxifen dose in poor metabolizer patients according to CYP2D6 polymorphisms may significantly affect the incidence of uterine changes, but not the incidence of osteoarticular pain, hot flashes, or asthenia. Clinical trial information: 2007-002942-40/ES .

A Novel Approach of Intralesional Vasopressin using an Ovum Pick up Needle in Hysteroscopic Myomectomy

The aim was to evaluate the efficacy of vasopressin injected into the center of submucosal myomas using an ovum pick up needle during hysteroscopic myomectomy. Design: Canadian task force II-2 clinical study Setting: Urban clinical research center,38 patients were enrolled in the study Materials and Methods: A retrospective Canadian Task Force II-2 clinical study design conducted on women aged 22-55 years in an urban clinical research center. 38 symptomatic patients underwent hysteroscopic myomectomy after injection of dilute vasopressin (10U in 100mL Normal Saline). Around 5-8 mL was injected into the center of myomas using an ovum pick up needle, and the study was carried out between 2018-2021. Measured parameters were surgical operative time, and the secondary outcomes were related to fluid volume, visual clarity, and pregnancy outcome in patients with infertility. Results: The Wamsteker Grading System adopted by the European Society for Gynecological Endoscopy was used to classify the myomas. The mean time of myomectomy was 22 minutes (normal range: 15-40 minutes), with a median fluid deficit of 700 mL (normal range: 500- 900mL); one patient had more than 1000 mL fluid deficit which was detected immediately and managed efficiently. This patient had the longest surgical operative time of 40 minutes with 10 multiple myomas between 1 and 4 cm in size. The diagnosis of the size, number, and grade of submucosal myomas was made by transvaginal ultrasound. In our study it was observed that the use of vasopressin injection during hysteroscopic myomectomy resulted in significantly reduced surgical operative time, minimal fluid deficit, lesser bleeding with a clear surgical field, and improved pregnancy outcome in infertility patients. Conclusion: Injection of vasopressin during hysteroscopic myomectomy was found to be effective in decreasing surgical operative time, improvement of visual clarity, thereby improving pregnancy outcomes in patients presenting with infertility.

#306 : Enhancing Myoma Detection in Robot-Assisted Myomectomy: Evaluating the Efficacy of Intracorporeal Ultrasonography

Background and Aims: Robot-assisted myomectomy is being widely implemented in gynecologic surgery, with strength in cases with multiple myomas. To maximize myoma detection during surgery, intracorporeal ultrasonography (USG) has been introduced. The study aims to evaluate the efficacy of intracorporeal USG in robot-assisted myomectomy. Method: This was a retrospective study of patients who underwent robot-assisted myomectomy from January 2022 to February 2023. The cases with preoperative pelvis magnetic resonance imaging (MRI) and which utilized intracorporeal USG during surgery were identified. Demographic and operative variables were analyzed, along with myoma extraction rates, which were determined as the proportion of surgically removed myomas compared to the number identified in preoperative MRI, and the number of additional myomas removed during the operation. Results: In all patients, the number of myomas removed was greater than the number of myomas in preoperative MRI (12.4 ± 8.6 vs. 7.9 ± 5.0, [Formula: see text]<0.001). An average of 4.5 additional myomas were found, and the extraction rate was 167%. For subgroup analysis, patients were stratified according to preoperative myoma counts: 1-5(n=22), 6-9(n=17), and 10 or more(n=17). For all three groups, more myomas were detected in surgery with the use of intracorporeal USG (Median 4 vs 5, [Formula: see text]=0.001, 7 vs 12, [Formula: see text]<0.001, 12 vs 18, [Formula: see text]=0.005, respectively) and the number of additional myomas removed increased in proportion to the preoperative myoma count. There was a positive correlation between the number of myomas identified in preoperative MRI and the number of additional myomas removed (Pearson’s correlation coefficient: 0.292, p=0.029). Conclusion: Intracorporeal ultrasound improves myoma detection, as significantly more myomas are removed during surgery than anticipated based on preoperative MRI. Moreover, this study demonstrates a positive correlation between the number of myomas identified in preoperative MRI and the additional myomas removed during surgery. Intracorporeal ultrasound may be particularly advantageous for patients with multiple myomas detected on preoperative MRI.

#334 : Tackling Complex Infertility Patient: A Case Report

Background: Infertility is a common problem presented in women with endometriosis especially as it is often associated with poor quality of life. Therefore, surgical Intervention has been considered as the first-line treatment of choice. On the other hand, surgery itself has detrimental effects on ovarian reserve and is associated with ovarian failure. Case Report: We present a case of a 39-year-old woman para 1 with multiple myoma uteri, bilateral endometriosis cyst, left hydrosalpinx, deep infiltrating endometriosis (DIE), and adhesion (Figure 1). She comes with a history of heavy abnormal uterine bleeding, lower abdominal pain, and unable to conceive 11 years after their first child despite adequate unprotected intercourse. The patient was anemic (Hemoglobin 7.30 g/dL) with low Anti Mullerian Hormone (AMH; 0.26 mg/ml). We decided to perform laparoscopic uterine myoma with multiple bilateral endometrial cysts, left salpingectomy, and adhesiolysis (Figure 2). Patient then underwent an ultra-long protocol with three cycles of leuprolide acetate 3.75 mg. Ovum pick-up was performed and we retrieved five M-II oocytes and from embryo culture, two embryos with good and moderate quality were collected for vitrification procedure. Prior frozen embryo transfer, extra acetylsalicylic acid 80 mg once a day and estradiol valerate 4 mg thrice a day were given for 18 days. The patient soon became pregnant after a few weeks of embryo transfer with βHCG of 185 mIU/m. Conclusion: Individualized treatment plans based on the patient’s symptoms and respective reproductive goals are important points to be discussed in endometriosis-associated infertility patients. Surgical intervention before IVF/ICSI is deemed as necessary to preserve ovarian reserve and to restore normal anatomy to increase the success rate of embryo implantation.

Intraoperative Fluorescent Ureter Visualization in Complex Laparoscopic or Robotic-Assisted Gynecologic Surgery.

This study aimed to demonstrate the feasibility of ureteral navigation using intraoperative indocyanine green (ICG) and near-infrared fluorescence (NIRF) imaging during complex laparoscopic or robot-assisted gynecologic surgery (LRAGS). Twenty-six patients at high risk of ureteral injury with complex pelvic pathology (CPP) due to pelvic organ prolapse (POP), multiple myomas, large intraligamentary or cervical myoma, severe pelvic adhesions, or cervical atresia underwent LRAGS. All patients underwent cystoscopic intraureteral ICG instillation before LRAGS and ureteral navigation under NIRF imaging intraoperatively. Both ureteral pathways were identified from the pelvic brim downwards through NIRF imaging in all patients, even though some were not visualized under the white light mode. The fluorescent ureters were visualized immediately after the beginning of surgery and typically lasted for >5 h during surgery. There were no cases of iatrogenic ureteral injury. The hemoglobin decrement was 1.47 ± 1.13 g/dL, and no transfusion was required. In our study, both ureters in all patients were identified with ICG-NIRF imaging during LRAGS, and these techniques made surgeries easier and safer. Despite the CPP, there was no ureteral injury or transfusion following surgery. Further prospective studies are needed to introduce intraoperative ureteral guidelines for ICG-NIRF imaging during LRAGS with CPP.

Clinical features at the time of non-hysteroscopic myomectomy before pregnancy, which affect adverse pregnancy outcomes: a retrospective cohort study

BackgroundTo investigate the association of clinical characteristics at the time of non-hysteroscopic myomectomy before pregnancy and adverse obstetric outcomes in the next pregnancy.MethodsIn this retrospective cohort study, we identified 248 women who underwent abdominal or laparoscopic myomectomy for intramural (IM) and/or subserosal (SS) uterine myomas in Bundang CHA Medical Center before pregnancy and delivered at the same hospital between 2010 and 2020. The association between clinical characteristics at the time of myomectomy and subsequent obstetric outcomes was analyzed using the Chi-square test, the Student t-test or one-way ANOVA, and multivariable analysis.ResultsThere was one case of uterine rupture. The gestational age at delivery was 37.7 ± 2.4 weeks. There were 2 (0.8%) cases of fetal loss before 23 weeks, but there were no cases of perinatal death. The risk of transfusion during or after delivery was higher in the group in which multiple myomas were removed compared to the group in which only one was removed (aOR = 2.41, 95% CI [1.20–4.86], p = 0.014). The risk of neonatal composite morbidity was higher in the group in which myomas including the IM type were removed, than in the group in which only SS myomas were removed (aOR = 14.29, 95% CI [1.82–99.57], p = 0.012). Although not statistically significant, the group in which the sum of the diameters of the three largest myomas was greater than 15 cm showed a higher frequency of preterm birth (19.3% vs. 10.1%, p = 0.001) and lower birth weight (2901 ± 625 g vs. 3063 ± 576 g, p = 0.001) compared to the group with diameters less than 15 cm. Placenta accreta/increta (7.9% vs. 3.8%, p = 0.043) and lower placental weight (646 ± 170 g vs. 750 ± 232 g, p = 0.034) were more common in patients with an interval between myomectomy and pregnancy of less than 12 months compared to more than 12 months.ConclusionsTo our knowledge, this is the first study to investigate the association between clinical features at the time of myomectomy before pregnancy and various adverse obstetric and perinatal outcomes. If the removed myomas are multiple, IM, large, or the interval between myomectomy and pregnancy is short, the risk of obstetric and neonatal complications may increase.

Prevalence of Asymptomatic Uterine Leiomyoma in Western Turkey and Factors Affecting Myoma Presence

Objective: To reveal the prevalence of asymptomatic uterine leiomyomas among gynecologic patients and to evaluate risk factors associated with the presence of leiomyomas. Study Design:Two thousand five hundred eighty-three patients aged between 18 and 66 years who presented to the gynecology outpatient clinic of our hospital in January and February 2021 who had an intact uterus and underwent transvaginal ultrasound were included in the study. Patients withsymptoms due to fibroids were defined as symptomatic, and those without symptomswere defined as asymptomatic; then two groups were compared in terms of certain variables.The independent risk factors associated with the presence of fibroids were determined using univariate and multivariate logistic regression analysis. Results: Leiomyomas were detected in a total of 437 patients with an overall prevalence of 17.2%. Leiomyomas were detected in 12.2% of asymptomatic patients and 27.8% of symptomatic patients (p<0.001). The prevalence of fibroids tended to increase with advancing age and decreased after age 50 years. It was observed that myoma diameter was significantly large (29.5 (6-123) mm and 18 (7-74) mm; p<0.001) and the frequency of multiple myomas was significantly high in symptomatic patients (46.5% vs. 33.6%; p<0.001). In the multivariate logistic regression analysis, high body mass index, younger age at menarche, and not using oral contraceptives were associated with the presence of fibroids. Conclusion: Approximately half of all leiomyomas, one of the important gynecological health problems of women, are asymptomatic.

Postsurgical Intrauterine Adhesions after Hysteroscopic Myomectomy Using the Myoma Pseudocapsule Preservation Technique Evaluated bv Second-look Hysteroscopy: A Retrospective Comparative Study

To analyze the frequency and risk factors of postsurgical intrauterine adhesions (IUAs) using second-look hysteroscopy (SLH) in patients undergoing hysteroscopic myomectomy performed using the myoma pseudocapsule preservation technique for submucosal myoma. Retrospective cohort study. University hospital from January 2017 to December 2019. A total of 124 patients underwent hysteroscopic myomectomy and SLH. None. Surgical duration, intraoperative blood loss, number of enucleated myomas, volume of specimen, and postsurgical IUA evaluated by SLH. Postsurgical IUA were found in 5 of 124 cases (4.0%) at SLH. There were no cases of IUA formation in cases in which a single myomas was resected (0 of 83 cases, 0%); all cases were multiple myomas (5 of 41 cases, 12.2%), and IUA significantly occurred more frequently in cases of multiple myoma (p=.003). Univariate analyses showed that the IUA group contained a significantly larger number of enucleated uterine myoma (p <.001), required a longer operation (p=.003), and displayed an increased volume of intraoperative bleeding (p=.007), and the heavier the specimen, the greater the number of patients that had inserted an intrauterine device than the group that did not display postsurgical IUA. Multivariate logistic regression analysis of the risk factors of postsurgical IUA showed that the number of enucleated myomas was strongly associated with IUA (odds ratio, 1.45; 95% confidence interval, 1.06-1.97). The frequency of postsurgical IUA after hysteroscopic myomectomy was high in cases of multiple myoma and may be a risk factor. SLH should be actively pursued in cases where the patient desires to bear children, and an informed consent should be attained before performing surgery.

Incorporating 3D reconstruction in preoperative surgical planning of Multiple Myomectomy.

Medical 3D imaging is a promising emerging technology that allows recreating the details of human anatomy. The use of this innovative technology has resulted in improved surgical efficiency and better clinical outcomes. However, its incorporation in gynaecologic surgery has not been widely adopted. To demonstrate the use of Hyper Accuracy 3D reconstruction in a patient with infertility who underwent multiple myomectomy. A stepwise approach describing the incorporation of Hyper Accuracy 3D imaging technology into the preoperative surgical planning and intraoperative guidance of a patient with multiple myomas undergoing multiple myomectomy. Preoperative evaluation of a patient with multiple myoma and infertility who presented to our department seeking surgical management. Hyper Accuracy 3D image was obtained, and a 3D digital image reconstruction of the uterus delineating the exact number, volume, and location of the fibroids was created. The 3D digital image was available during the surgical procedure which helped to plan the surgical steps allowing a systematic surgical approach resulting in an effective surgery with minimal blood loss. The benefits of intraoperative guidance using Hyper Accuracy 3D in a patient with multiple myomas and infertility are demonstrated. The adoption of this promising imaging technology into gynaecologic surgery is feasible and should be further investigated. Additional studies evaluating the clinical impact of using Hyper Accuracy 3D imaging in the preoperative planning of patients with gynaecologic surgical pathology are needed.

Enzyme immunoassay of interleukin content in tumor supernatants in patients with multiple uterine myoma

Introduction. Uterine leiomyoma is the most common benign tumor in women, which is accompanied by the life quality decrease and infertility. Despite numerous studies, the etiology of uterine myoma is still unknown.The aim of the study was to determine the effects of a mixture of polyclonal activators on the interleukin production by dominant myomatous and myometrial tissue samples under treating by ulipristal acetate (UA), a selective modulator of progesterone receptors.Materials and methods. Surgical material of 35 reproductiveaged women with multiple uterine myoma (1st group – without hormone therapy, 2nd group – after UA) was studied using enzyme immunoassay analysis. After determining of cytokine production, being spontaneous and stimulated by polyclonal activators phytohemagglutinin, concanavalin A, and lipopolysaccharide, the cytokine production stimulation index (SIPA) was calculated, followed by statistical analysis.Results. In patients of the 1st group the SIPA of IL-1β, IL-6 and IL-10 in the myomatous nodes and myometrium did not differ; at the same time, SIPA of IL-18 and 17-OH-progesterone were statistically higher in the myometrium samples than in the nodes (p &lt; 0.05). In patients of the 2nd group, who have been treated by UA before myomectomy, there was a significantly higher SIPA of the IL-6 (p &lt; 0.001) and IL-10 (p = 0.002) in the myometrium samples, compared with the dominant nodes. When comparing the nodes and myometrium between two groups, it was revealed that, compared with the 1st group, in patients using UA in the supernatants of myomatous nodes, out of 5 studied markers, the SIPA of the pro-inflammatory cytokine Il-6 was down-regulated (p = 0.013). In the myometrial supernatants in the 2nd group, there were a higher SIPA of anti-inflammatory IL-10 (p &lt; 0.001), as well as the lower levels of pro-inflammatory IL-18 (p &lt; 0.001).Discussion. The results of study demonstrate the anti-inflammatory effect of UA on the cellular elements of the dominant myomatous nodes and perifocal myometrium, and also confirm the role of inflammation in the pathogenesis of uterine fibroids.Conclusion. Polyclonal activators during in vitro incubation, had multidirectional effects on the production of some interleukins and the content of the progesterone metabolite in the tissue of the dominant myomatous node and perifocal myometrium.

Single-Site Robotic Myomectomy without Accessory Instrument Compared with Two-Port Laparoscopic Myomectomy: A Propensity Score Matching Analysis

Objectives: Despite the advantages of robotic technology, single-site robotic myomectomy (SSRM) without an accessory instrument is limited by a restricted range of motion, weaker suturing of a thick myometrium, and non-articulating instruments. We present our novel gradual turning out method (GTOM) of SSRM and our assessment of its feasibility and safety by comparing its perioperative outcomes with those of two-port laparoscopic myomectomy (LM). Design: A retrospective cohort case-control study was carried out. Methods: This study included consecutive 46 patients who underwent SSRM for intramural myomas larger than 7 cm, from 2016 to 2019. Subsequently, 46 patients who underwent LM were selected by 1:1 propensity score matching by controlling for age, body mass index, myoma number, myoma diameter, and the presence of sexual intercourse. The perioperative outcomes of the two groups were compared using a Mann-Whitney U test and Fisher’s exact test. The effect of covariates on operation time was analyzed using univariable and multivariable linear regression. Results: SSRM was performed successfully with GTOM for myomas of up to 14 cm in the longest diameter, without conversion to laparotomy and intraoperative injuries. No differences between the groups were found in length of hospital stay, estimated blood loss, hemoglobin level decrease, transfusion rate, and postoperative pain, but operative time was significantly longer in the SSRM group than in the LM group (p < 0.001). Larger myomas, location of the lower segment, and the operation method of SSRM were significantly associated with a longer operation time. Whereas operation time for myomas located at the anterior wall, singleton myomas, and myomas <10 cm was significantly longer in the SSRM group than in the LM group, that for myomas at the posterior or lateral side of the uterus, multiple myomas, and myomas ≥10 cm did not differ significantly between the groups, indicating the advantage of SSRM for difficult myomectomy. Limitations: Retrospective nature of the study and limitation to a single-center study are the limitations of the study. Conclusions: Despite the lack of an accessory instrument, SSRM using the GOTM was feasible and safe as it yielded similar perioperative outcomes to those of LM.

3D Printing—Presurgical Precision Planning for Complex Robotic Myomectomy

Three-dimensional (3D) printing in medicine is increasingly being incorporated [1]. We report the first case from India using a 3D model for presurgical planning of robotic myomectomy in a 31-year-old woman with heavy menstrual bleeding, dysmenorrhea, urinary frequency, and anemia for 6 months. Irregular, firm abdominal mass of 32 weeks size with multiple myomas was noted. She requested uterine conservation. Identification and removal of all myomas during myomectomy was challenging because of multiple, oddly located myomas.

Leiomyomas in pregnancy

Uterine fibroids are the most common benign tumors affecting female genital tract, responsible for a high morbidity across fertile age women, with a prevalence of 0,1-11% among pregnant women. Although generally asymptomatic, they can lead to a series of symptoms and complications such as pain, infertility, miscarriages, antenatal bleeding, postpartum hemorrhage, preterm labor, fetal malpresentation, placental abruptio and high cesarean section rates. The purpose of review is to update information regarding fibroids specifications and their correlation with pregnancy outcomes as well as fibroids management during pregnancy. Because of uterine fibroids heterogeneity and lack of large, randomized trials there are encountered discrepancies among studies, but it was observed that uterine fibroids increase the risks of negative obstetrical outcomes, especially when it goes to large, multiple, submucous and retroplacental myomas. Conservative management during pregnancy is advised, but in special situations myomectomy could be recommended and possible. Trial of labor should be offered to pregnant women even if they have large uterine fibroids, or previous myomectomy excepting fibroids obstructing the birth canal or patients who underwent extensive surgery for fibroids removal.

Parasitic myoma developing at the port site after laparoscopic myomectomy; a case report

Parasitic myomas occur especially after laparoscopic myomectomy and its incidence increases due to the use of morcellators. Parasitic myomas can rarely occur at the port entry site, being more commonly seen on the intestines, the omentum, the ureter, the bladder, and the diaphragm in different periods after surgery, the average duration being 24 months. In this article, we present the case of parasitic myoma developing secondary to the port site in a 45-year-old nulliparous woman after the use of laparoscopic myomectomy and morcellation 8 years ago. The patient presented with complaints of pelvic pain and a palpable mass in the left trocar incision line, and an appearance compatible with multiple myomas in the subcutaneous tissue of the left trocar incision line. Besides, myomas were also observed in the mesentery of the rectosigmoid colon and at the uterus in the present study. Numerous and large myomas were observed in the uterus, in the mesentery of the rectosigmoid colon, on the left pelvic peritoneum, and under the skin corresponding to the port entrance. The pathological examination of the myomas excised was reported as leiomyoma. In this article, the diagnosis, the treatment, the possible risk factors, and the complications of myomas were discussed in the light of the literature.

The True Fibroid Map: Correlating Preoperative MRI and Intraoperative Findings

Study Objective To evaluate and compare the accuracy of Magnetic Resonance Imaging (MRI) in myoma diagnosis and mapping and its correlation with intraoperative findings. Design All patients with symptomatic leiomyoma attending the centre of study (Centre for minimally invasive Gynaecology, Obstetrics and ART, Paras Hospital, India) from August 2018-June 2020 underwent MRI and were subsequently operated at the same centre were considered for inclusion. The MRI was reviewed for number of fibroids, size, location, type and FIGO class of the largest fibroid and the same was correlated with intraoperative findings. Setting N/A. Patients or Participants 42 women with a diagnosis of symptomatic leiomyoma and meeting the inclusion criteria were enrolled. Interventions Laparoscopic myomectomy, Hysteroscopic myomectomy, Total laparoscopic hysterectomy, Abdominal myomectomy. Measurements and Main Results Of 42 patients enrolled, the number of fibroids predicted by MRI corroborated with intraoperative findings in 26 patients, 15 patients had greater number of fibroids during surgery and 1 had less than that predicted (median fibroid on MRI=2.0, median number in surgery=2.0, p=0.001). Location of largest fibroid predicted by MRI correlated with intraoperative findings in 77.8% anterior wall, 90% posterior wall, 83.3% left lateral wall and in 81.8% of fundal fibroids (k=0.757, p<0.001). MRI could accurately predict the type of fibroid in 80% submucosal, 87.5% intramural and 66.7% subserosal variants (k=0.642, p<0.001). FIGO class of largest fibroid denoted by MRI showed good correlation with intraoperative findings (k=0.670, p<0.001). Size of largest fibroid predicted by MRI (median=58.5cm2) correlated well with size measured during surgery (median= 60cm2, k=0.819). Conclusion MRI is an efficient tool for mapping of fibroid location, type and FIGO class but falls short in identifying the exact number of fibroids that can be encountered during surgery particulary in patients with larger uteri (> 12-week size) or multiple myomas (>5 in number). To evaluate and compare the accuracy of Magnetic Resonance Imaging (MRI) in myoma diagnosis and mapping and its correlation with intraoperative findings. All patients with symptomatic leiomyoma attending the centre of study (Centre for minimally invasive Gynaecology, Obstetrics and ART, Paras Hospital, India) from August 2018-June 2020 underwent MRI and were subsequently operated at the same centre were considered for inclusion. The MRI was reviewed for number of fibroids, size, location, type and FIGO class of the largest fibroid and the same was correlated with intraoperative findings. N/A. 42 women with a diagnosis of symptomatic leiomyoma and meeting the inclusion criteria were enrolled. Laparoscopic myomectomy, Hysteroscopic myomectomy, Total laparoscopic hysterectomy, Abdominal myomectomy. Of 42 patients enrolled, the number of fibroids predicted by MRI corroborated with intraoperative findings in 26 patients, 15 patients had greater number of fibroids during surgery and 1 had less than that predicted (median fibroid on MRI=2.0, median number in surgery=2.0, p=0.001). Location of largest fibroid predicted by MRI correlated with intraoperative findings in 77.8% anterior wall, 90% posterior wall, 83.3% left lateral wall and in 81.8% of fundal fibroids (k=0.757, p<0.001). MRI could accurately predict the type of fibroid in 80% submucosal, 87.5% intramural and 66.7% subserosal variants (k=0.642, p<0.001). FIGO class of largest fibroid denoted by MRI showed good correlation with intraoperative findings (k=0.670, p<0.001). Size of largest fibroid predicted by MRI (median=58.5cm2) correlated well with size measured during surgery (median= 60cm2, k=0.819). MRI is an efficient tool for mapping of fibroid location, type and FIGO class but falls short in identifying the exact number of fibroids that can be encountered during surgery particulary in patients with larger uteri (> 12-week size) or multiple myomas (>5 in number).

Complex myomectomy: A case report and literature review

Background: Myomectomy is the surgical removal of fibroids with the preservation of the uterus for future childbirth. It may be complex when adhesions, multiple myomas of different sizes are present in various sites, and a repeat myomectomy.Case presentation: A 40-year-old nulliparous presented with primary infertility. She reported having heavy and prolonged menstrual bleeding that led to multiple blood transfusions due to symptomatic anemia. Physical examination revealed a palpable mass that was irregular, mobile, non-tender. Her fundal height was 16 weeks. Pelvic ultrasound demonstrated multiple uterine fibroids of varying sizes and locations. The patient desired fertility and was therefore scheduled for myomectomy. A total of 80 fibroids were excised. Tourniquet and vasopressin were used to reduce hemorrhage. Bilateral uterine artery ligation was done to achieve hemostasis.Conclusion: Myomectomy complicated by multiple myomas up to 80 in number is possible. However, a meticulous surgical technique of myomectomy by an experienced surgeon is required. The use of tourniquet and vasopressin is vital to reduce hemorrhage during the operation.

Reducing the risk of bleeding after myomectomy: is preemptive embolization a valuable tool?

PurposeAbdominal myomectomy can be a challenging procedure, with elevated intraoperative blood loss and post-operative complications such as the need for blood transfusion and hemostasis with sometimes hysterectomy. Previous studies suggested that preemptive uterine artery embolization (PUAE) might reduce intraoperative blood loss.Materials and methodsWe reviewed all cases of abdominal myomectomy in our institution between January 2016 and June 2018. Out of 119 cases, 16 patients had PUAE and 103 did not. The objective of our study was to determine whereas PUAE reduced blood loss and post-operative complication rate.ResultsIn our study, there was no difference between the two groups in regard to average blood loss (128 vs 192 mL, OR 1,00 [0.99;1,01], p = 0,73), difference between pre- and post-operative hemoglobin level (− 1,15 g/dL vs − 1,32 g/dL, OR 0,91 [0.47;1,73], p = 0,79), and post-operative complications (need for transfusion, surgical revision, post-operative embolization, hysterectomy).ConclusionOur findings could not conclude that PUAE is effective in reducing intraoperative blood loss during abdominal myomectomy, but it should still be considered an option for patients with large or multiple myomas, with a specific situation or previously operated, who wish to preserve their uterus.

Comparison of Laparoscopic Myomectomy with and without Uterine Artery Occlusion in Treatment of Symptomatic Multiple Myomas

ObjectiveUterine artery occlusion (UAO) is a minimally invasive approach often used to treat symptomatic uterine myomas. This study aimed to compare the clinical effects of laparoscopic UAO (LUAO) in combination with laparoscopic myomectomy (LM) with LM alone to treat symptomatic multiple uterine myomas.MethodsThis was a prospective observational study. In total, 122 patients with symptomatic multiple uterine myomas underwent LUAO + LM or LM alone between April 2015 and October 2017. The surgical procedure time, blood loss, highest postoperative temperature, hospital length of stay, number of removed myomas, surgical complications, and recurrence rate of the two groups were compared.ResultsMean blood loss was significantly lower in the LUAO + LM group compared with the LM group (177.97 ± 104.09 mL vs 258.10 ± 119.55 mL, p < 0.05). No significant difference in surgical procedure time, hospital length of stay, highest postoperative temperature, and surgical complications was found between the LUAO + LM group and LM group. The number of removed myomas was considerably higher in the LUAO + LM group than in the LM group (4[4–7] vs 3[3–5], p < 0.05). The recurrence rate in the LUAO + LM group was considerably lower than that in the LM group (6.2% vs 25.9%).ConclusionLUAO in combination with LM was associated with higher surgical quality and lower recurrence of myomas compared with LM alone. LUAO in combination with LM is recommended for women with symptomatic multiple uterine myomas who wish to retain their uteruses.