Myoma Enucleation Research Articles

Therapiemöglichkeiten beim Uterus myomatosus - Neue Aspekte 2008

Due to the high incidence of uterine leiomyomas, various aspects involved in the treatment of the condition are extremely important. Many treatment methods are already long established, but there are important new findings that are of relevance for everyday practice - particularly with regard to myoma embolization, various hysterectomy procedures, and the issue of myoma enucleation in patients wishing to have children. Prospective and randomized studies have shown that 1 year after hysterectomy, patients have fewer symptoms compared to women who undergo myoma embolization, and that after 2 years there are no differences between the two methods. Two years after embolization, 20 - 25 % of the women having received this form of treatment had also undergone a hysterectomy. After myoma embolization, fertility was found to be reduced compared to a control group undergoing organ-preserving surgery, and the rate of miscarriages was markedly increased. It has been shown in randomized studies that supracervical hysterectomy offers no advantages over total hysterectomy with regard to sexuality, incontinence, or bowel function. Laparoscopic hysterectomy techniques are associated with an increased risk of injury to the urinary tract, but reduce the postoperative morbidity for patients.

278: Role of Laparoscopic Management of the Benign Pelvic Masses

Elective interventions for gynecological bening pelvic masses include: enucleation of ovarian cysts, endometriomas, myoma enucleation, septum resection, polips and myomas of the cavity, salpingoneostomy, adhesiolysis, tubal oclussion and sterilisation.

Ursachen und Therapie von uterinen Blutungsstörungen

Bleeding disorders are one of the most frequent gynecological problems. The causes of bleeding disorders, and their frequency in particular, vary depending on the age of the woman affected. In premenopause and perimenopause, the most frequent causes are hormonal, in up to 90 % of cases, as well as organic changes in the uterus such as myomas, adenomyosis uteri, or endometrial polyps, in up to 70 % of cases. Coagulation defects cause increased bleeding, particularly in girls and young women, with no other recognizable cause. The treatment of bleeding disorders is causally based, although if the woman does not wish to have children, the therapeutic algorithm in many cases leads to similar symptomatic measures. The following therapeutic approaches, listed in order of increasing efficacy, are mainly used in the treatment of increased bleeding: gestagen, estrogen-gestagen combination, levonorgestrel (Mirena) and endometrial ablation or myoma enucleation, with comparable success rates, and finally hysterectomy. Embolization of the uterine artery in myomas or adenomyosis uteri, nonsteroidal anti-inflammatory drugs, and antifibrinolytic agents represent alternatives that may be useful in individual cases. The paper provides an overview of the various causes, useful diagnostic measures, and treatment options in uterine bleeding disorders.

Myoma enucleation during cesarean section: elective procedure or incalculable risk?

Background Myomas are often located in the area of the lower uterine segment. During cesarean section they can lead to problems in delivering the baby and can make it difficult or impossible to close the uterine incision. The goal of the study was to determine the relative risk of a myoma enucleation in combination with a cesarean section.

Comparison of the effects of the ligation of ascending branches of bilateral arteria uterina with tourniquet method on the intra-operative and post-operative hemorrhage in abdominal myomectomy cases

Objective: To compare the effects of ligation of the ascending branches of the uterine artery and tourniquet methods intra-operative and post-operative hemorrhage during abdominal myomectomy. Methods: Fifty-one cases with symptomatic myoma uteri were prospectively, randomly assigned to two single blind groups. Myomectomy was performed in Group 1 ( n=26) by bilateral ligation of the ascending branches of the uterine artery and in Group 2 ( n=25) by the intra-operative tourniquet method. Mann–Whitney U, Wilcoxon Rank and χ 2 tests were used in the comparison of the data. Spearman correlation analysis was used to determine the correlation between myoma enucleation, operation duration and blood loss ( r s, P, n). Results: Operation time, number of removed myoma nuclei, ( P>0.05, Mann–Whitney U test), and febrile morbidity were similar in the two groups ( P>0.05, χ 2 test). Intra-operative blood loss was lower in Group 1 ( P<0.05, Mann–Whitney U test). In three cases from Group 2 post-operative hemorrhage occurred, and the laparotomy and bilateral ligation of the internal iliac arteries were performed in these cases. There was a positive correlation among myoma enucleation, operation duration and blood loss ( r s=0.7, P=0.001, n=51). Conclusions: Intra-operative blood loss is lower with bilateral ligation of the ascending branches of the uterine artery during myomectomy. The effect of ligation on hemorrhage continues in the post-operative period.

A New Technique of Hysteroscopic Myomectomy with Enucleation in Toto

Study Objective To determine the safety and effectiveness of a new technique for hysteroscopic resection of uterine submucous myomas with high intramural involvement (G2 type, European Society of Hysteroscopy classification). Design Prospective study (Canadian Task Force classification II-1). Setting University hospital. Patients Forty-four women. Intervention Hysteroscopic myoma enucleation in toto. Measurements and Main Results With a hysteroresectoscope and Collins electrode, an elliptic incision of endometrial mucosa that covers the myoma is made at the level of its reflection on the uterine wall until the cleavage zone of the myoma is reached. Connecting bridges between myoma and surrounding muscle fibers are resected. This allows nearly complete protrusion of the myoma into the uterine cavity, facilitating complete myomectomy by slicing. The procedure was performed in 41 (93.1%) of 44 women. Of these, 38 (92.6%) had myomas between 2 and 4 cm in diameter and 3 (7.4%) had myomas exceeding 4 cm. Mean operating time was 27 minutes (range 10–45 min). Conclusion This technique is efficient and allows complete resection of submucous myomas with large intramural component by favoring intracavitary protrusion of that part.

A Single, Continuous Spiraling Suture for Uterine Wall Reconstruction after Laparoscopic Enucleation of Intramural Myomas

After laparoscopic enucleation of intramural myomas in eight women, the uterine wall defect was reconstructed with a single continuous spiraling suture. The procedure contained cost and reduced operating time. No patients had postoperative intramural hematoma. Although this is a reproducible method of laparoscopic uterine wall reconstruction, long-term results must be obtained to determine safety in pregnancy and extent of postoperative adhesions.

GnRH agonist decreases endothelial nitric oxide synthase (eNOS) expression in leiomyoma

Objective: To define the effect of GnRH agonist (GnRHa) treatment on endothelial nitric oxide synthase (eNOS) expression in leiomyoma. As eNOS expression is more pronounced in leiomyoma compared to parental myometrium, we hypothesized that the mechanism(s) of tumor shrinkage by GnRHa may be due to decreased nitric oxide (NO) production in leiomyoma. Methods: Eleven patients with leiomyoma were operated for myoma enucleation by laparatomy. Six of them were treated with GnRHa every 28 days, three times before the operation. The remaining five patients who had no treatment prior to operation formed the control group. Blood was drawn from the patients before treatment and on the day of operation for the assay of serum estradiol (E 2). Immunohistochemical localization of eNOS expression in leiomyoma and myometrium in treated patients, and in leiomyoma in the control group, was performed using monoclonal antibodies specific to eNOS. Results: All treated subjects showed a significant reduction of fibroid volume at the end of therapy. eNOS-positive cells were localized primarily within the vascular endothelium and smooth muscle cells, but had weak expression in fibroid and myometrial muscle cells in the treated group. The immunoreactivity was similar for both the leiomyoma and myometrium ( P>0.05). In contrast to this, the control group had shown strong expression in leiomyoma muscle cells ( P<0.005) in addition to the vascular endothelium and smooth muscle cells. Conclusion: GnRHa-induced tumor shrinkage should be due to diminished eNOS expression, most probably by lowering estrogen secretion.

Endothelial Nitric Oxide Synthase Expression in Leiomyoma and Parental Myometrium

The aim of this study was to determine the expression of endothelial nitric oxide synthase (eNOS) in leiomyomatous tissue as a possible mediator of the growth process. Nine patients had myoma enucleation during the follicular phase. The myomata and adjacent myometrial tissues were fixed in formol until study. Immunohistochemical localization of leiomyomatous and myometrial tissue eNOS expression was performed using specific monoclonal antibodies to eNOS. Statistical comparisons were made using the Mann-Whitney Wilcoxon rank-sum test for the expression of eNOS. The test was considered significant when p values were <0.05. Immunostaining for eNOS was seen in the cytoplasm of myometrial endothelial and smooth muscle cells in both tissue sections. eNOS expression was significantly higher in the smooth muscle cells of leiomyomata, compared to parental myometrium (p < 0.0005). The expression of eNOS in vascular endothelial cells was not different in the leiomyoma and myometrium (p > 0.05). To our knowledge, this is the first study to document marked expression of eNOS in leiomyomatous tissue, compared to parental myometrium. We also conclude that the mechanism(s) of the growth-promoting effect of estrogen on leiomyomata is mediated by more synthesis of NO.

Dilute ornitin vasopressin and a myoma drill for laparoscopic myomectomy

To improve enucleation of uterine myomas, we designed a reusable 5-mm laparoscopic drill with a distal forked pin and locking system. Because the device is jointed, it can apply traction not only along its own axis, but also along planes, depending on its bending radius. We compared enucleation time for myomas 5 to 8 cm in size before and after introduction of the drill. The last 23 procedures performed with this instrument were easier, with a reduction in operating time of about 28.5% for the enucleation part of the procedure (p<0.001).

腹腔鏡下手術においてレーザーは必要か

Laparoscopic surgery demands flexibility in that it requires selection of the method most suited to the patient, technician, and circumstances. The instruments used are also an important factor in determining the safety and ease with which laparoscopic surgery is conducted. Here we introduce procedures for the enucleation of uterine myoma and the laparoscopic, techniques we use, and compare the electric scalpel, laser scalpel, and ultrasound scalpel (harmonic scalpel). While the laser scalpel is an important tool in laparoscopic surgery, we did not find it to have any clear advantages over the electric scalpel. As for the harmonic scalpel, although it transiently produces a smoke-like vapor, the field of vision remains clear. The harmonic scalpel was equal to the laser scalpel in terms of incision and coagulation ability, and is expected to become an important tool in the futere.Ultimately, the advisability of surgery and the type of operations that are possible will depend not only on the instruments used, but also on the views of the surgeon regarding a particular procedure and the surgen's level of technical skill.

Pelviscopic myoma enucleation: technique, limits, complications

Between 1992 and 1993 surgery conserving the organ was undertaken in 215 patients with uterine myomas. Only myomas of more than 2 cm in diameter were included. It was possible to conserve the organ in 207 cases (90%). Myomectomy by pelviscopy was performed in 131 cases. The procedure was successful in 117 cases (89%), secondary laparotomy had to be done in 14 of these patients. On average the myomas removed by pelviscopy measured 5.2 cm in diameter. The S.E.M.M. (Serrated Edged Macro Morcellator) was used in the procedure. It did not take long to morecellate even larger myomas (the largest one removed by pelviscopy weighed 418 g) and to remove them by means of a 15 mm-trocar. An average of 2 myomas were removed per patient (r: 1-5). The mean Hb drop amounted to 1.5 g%. Repeat pelviscopy had to be done in one patient because of a secondary haemorrhage, a laparotomy and hysterectomy for subilius had to be performed in one case on the 3rd postoperative day. An intestinal loop has adhered to the uterine wound dehiscence. No other complications were observed after pelviscopic myomectomy. A 41-year-old patient wanting children suffered a late complication, namely a ruptured uterus in the 28 w of pregnancy. It is therefore imperative to inform patients who are still in the reproductive phase about the possibility of an uterus rupture after pelviscopic myomectomy.

Pelviscopic Surgery: A Key for Conserving Fertility

As a result of experience with more than 16,000 pelviscopic operative procedures performed at the Kiel University Women's Clinic from 1971 to 1988 which in this time had been adapted and used around the world, it may be said that the pelviscopic operative techniques, based completely on the laparotomy techniques which employ the microscissors, needles and suture material, is superior for many of the classical gynecological indications to operation. Minimally invasive surgery reduces hospitalization for even the most difficult cases to approximately 3 days. Convalescence is also reduced to approximately 1 week. Postoperative complaints are few, particularly when the primary exudate is removed through an abdominal drain. Late complications are practically unknown. It must be said that even the most minimal of operative procedures can produce late postoperative complaints or can be ascribed as the source of late postoperative complaints. Experiences gathered from around the world with endoscopically guided intraabdominal surgery have shown that for some gynecological procedures laparotomy is now indicated only in the rare case. The leading example of this switch can be seen in the operative treatment of the ectopic pregnancy. Following closely are operations to correct sterility such as salpingolysis, ovariolysis, fimbrioplasty, and salpingostomy. Finally pelviscopic treatment is increasing for all benign ovarian tumors, and the enucleation of myomas of up to 400 grams in weight. Endoscopically guided intraabdominal surgery also has a place in the field of general abdominal surgery--that of treatment of chronic abdominal adhesions. These procedures in the future should basically commence with endoscopic adhesiolysis, the patient having had the proper preoperative bowel preparation. Because of this minimally invasive technique the surgeon will only rarely be forced to perform laparotomy. In the case of abdominal adhesions a prerequisite for pelviscopic treatment is the visually controlled perforation of the peritoneum. Endoscopic surgery, in contrast to open laparoscopy, has a large periumbilical radius of action and produces no postoperative scars. In Kiel operative pelviscopy has replaced 80% of the classic gynecological laparotomies. The recurrence rate of adhesions is 84% with laparotomy compared with a recurrence rate of less than 40% with postendoscopic adhesiolysis. Forty to sixty percent of the patients who underwent pelviscopic adhesiolysis are complaint-free; this is a result not attained with classical abdominal surgery. Adhesiolysis per laparotomy is now limited to the emergency situation, as in the cases of ileus, for example. Endoscopically guided intraabdominal surgery has now improved the quality of life for surgical patients.

Local infiltration of ornithine 8-vasopressin (POR 8) as a vasoconstrictive agent in surgical pelviscopy (applied to myoma enucleation, salpingotomy in cases of tubal pregnancy and peripheral salpingostomy).

For better hemostasis in cases of operative pelviscopy in 60 patients Ornithine-8 Pitressin (POR 8) was applied locally as a vasoconstrictive agent in quantities of up to 50 ml at a concentration of 0.05 IU/ml. From the broad spectrum of indications for operative pelviscopy, the following procedures employing local application of a 5% POR 8 solution to produce intraoperative ischemia are described: Myoma enucleation, longitudinal salpingotomy with conception product extraction in the conservative treatment of a tubal pregnancy, ovarian cystectomy and salpingostomy. The tolerance was optimal no side effects were observed.

Pelvi-trainer, a training device in operative pelviscopy for teaching endoscopic ligation and suture technics

Unlike in laparotomy, the art of pelviscopic surgery cannot be learned through assisting. For this reason, a training dummy, called a Pelvi-Trainer, has been developed. With this device, all surgical measures occurring in abdominal surgery can be simulated, such as adhesiolysis, internal ligature, internal sutures, resection, adnexectomy, enucleation of myomas, etc. The Pelvi-Trainer, designed for a three-stage plan, allows one to become gradually acquainted with the field of endoscopic surgery, and to make the transition from binocular vision to perfect three-dimensional control over intra-abdominal surgery under monocular endoscopic vision.

ESOPHAGEAL LEIOMYOMAS

LEIOMYOMA of the esophagus is a rare benign tumor. Rose 1 reviewed the literature in 1936 and found but 49 cases of myoma of the esophagus, all of them noted at autopsy. From a series of 7,459 postmortem examinations at the Mayo Clinic, 2 44 benign tumors including 32 leiomyomas were reported. With the increased interest in the differential diagnosis of esophageal tumors, more leiomyomas have been discovered during life. Recent literature reports 14 cases of surgically removed leiomyomas of the esophagus, including those of the esophagocardiac junction. The progress of surgical treatment of this lesion is illustrated by a brief review of these cases. In 1933 Ohsawa 3 performed what was probably the first enucleation of an esophageal myoma in a 43 year old woman. It was found during an esophagocardioplasty undertaken for idiopathic esophageal dilatation. Through a thoracoabdominal incision, Brock 4 in 1942 performed a successful resection of

Enucleation of Uterine Myomas; Why and When Performed

Enucleation of Uterine Myomas; Why and When Performed