Removal Of Myomas Research Articles

Retroperitoneal Müllerian Cyst Found Incidentally During Total Laparoscopic Hysterectomy: Is There a Role for MRI in Pre-Operative Evaluation?

Retroperitoneal cysts of Müllerian origin are rare and often discovered incidentally during surgical procedures or imaging studies. We present a case of a retroperitoneal cyst found during a total laparoscopic hysterectomy performed for myoma removal. A 40-year-old female presented with symptomatic myomas and underwent pre-operative evaluation, including pelvic ultrasound, which revealed no abnormalities apart from the myomas. A cyst was incidentally discovered in the retroperitoneal space during a total laparoscopic hysterectomy procedure. The cyst was excised and sent for histological examination, which confirmed its Müllerian origin. Retroperitoneal cysts of Müllerian origin are rare findings during TLH. This case report highlights the importance of thorough pre-operative evaluation and imaging studies and the significance of intraoperative awareness in identifying incidental findings. Further research is warranted to determine the optimal diagnostic imaging strategies for such cysts.

Comparison of Prone With Lithotomy Position in Removal of Posterior Myoma in Transvaginal Natural Orifice Endoscopic Surgery: A Prospective Cohort Study

ObjectiveVaginal natural orifice transluminal endoscopic surgery (vNOTES) is considered to have the advantages of completely scarless, less postoperative pain, earlier flatus, and faster postoperative recovery. However, posterior myoma are relatively difficult to operate through vNOTES in the conventional lithotomy position. Thus, we innovated the application of prone position in the removal of posterior myoma in vNOTES. The aim of this study is the comparison of myomectomy outcomes of patient for single posterior myoma in prone and lithotomy position. DesignA single-center, prospective study. SettingA university teaching hospital. PatientsA total of 81 patients with posterior myoma who underwent myomectomy in vNOTES from January 2021 to December 2022. InterventionsThe patients underwent myomectomy in vNOTES in prone or lithotomy position. Measurements and Main ResultsAmong the patients who underwent vNOTES myomectomy, 29 (35.8%) were in the lithotomy position group, and 52 (64.2%) in the prone position group. Of note, 4 (4.9%) patients underwent a conversion to LESS during the operation—3 in the lithotomy and 1 in the prone position group. And a patient in the lithotomy position group underwent resurgery for hemostasis due to postoperative pelvic bleeding. Compared with the lithotomy position, prone position significantly shortens the operation time (12.3, 95% CI: 6.811, 17.761. p = .009) without increasing the complications and postoperative discomfort of patients. ConclusionCompared to the lithotomy position, the prone position provides greater convenience for operation and exhibits a lower rate of surgical conversion during the removal of single posterior myomas via vNOTES. Further, for patients selecting vNOTES, surgeons need to conduct sufficient preoperative evaluation, timely hemostasis during surgery, and timely surgical conversion if necessary to ensure patient safety.

Ultrasonographic Characters of Uterine Myoma as Predictors for Successful Laparoscopic Myomectomy at Mansoura University Hospital

Background: Myomectomy is the surgical procedure of choice for symptomatic myoma in the reproductive age, especially if future fertility is desired. LM is the surgical removal of uterine myoma through small incisions in the abdomen. It is an appropriate, if not preferred, alternative to abdominal myomectomy in well-selected patients since it offers shorter hospitalization, short recovery period and resumption of activities within 1–2 weeks, reduced risk of blood transfusion, and intraoperative adhesions. Aim: The aim of the current study was to determine the diagnostic accuracy of different ultrasonographic characters of uterine myoma in predicting success of laparoscopic myomectomy. Methods: The present study was prospective interventional study that was carried out on 35 cases with Chronic pelvic pain. All patients had radiological evaluation by TVS and TAS. All Laparoscopic myomectomies done under general anaesthesia. Outcomes included determining ultra-sonographic predictors for successful laparoscopic myomectomy as regards site, size, and character of Myoma, presence of capsule and line of separation around myoma. Results: The most common complain among the studied cases was bleeding followed by pain and lastly infertility. Regarding location, the most common site was posterior followed by fundal, then anterior and lastly at the cornu. Operative times, blood loss amount, method of extraction, need laparoscopic suturing, complications during surgery recovery and hospital stay after operation demonstrated significant relation with outcomes. Myoma characters, numbers and type demonstrated insignificant relation with outcomes. Conclusion: The current study concluded that, myoma characters, numbers and type could not be used as predictors for successful LM; outcomes. However, operative times, blood loss amount, complications during surgery recovery and hospital stay after operation were less in successful LM than in LAM; and laparoscopic suturing and morcellation have less time consumption and better results than LAM.

Comparation of two methods of surgery for myoma bleeding rate in open myomectomy cases: Ligation and using tourniquet

BackgroundMyomectomy is a surgical procedure that is associated with the removal of non-cancerous masses inside the uterus. Among the methods of myomectomy, we can mention the use of tourniquet and ligation. This study was designed to compare 2 surgery methods for bleeding management in myomectomy. MethodsThis prospective randomized control trial study was conducted on 60 patients who were divided into two groups and underwent myomectomy by 2 surgery methods: ligation and using tourniquet, in Emam Sajad hospital in 2020–2022. Informed consent was obtained from all participants. All the patients underwent ultra-sonography. Patient's vital signs and Hemoglobin was recorded after surgery. Further, after discharge, the patient's condition was followed up for 2 weeks. ResultsThe average age of the patients in the tourniquet and ligation group was about 38 and 39 years, respectively. In this study, out of a total of 60 patients, 30 were in the tourniquet group and 30 were in the ligation group. According to the results, there was a significant difference between the average volume of bleeding and the duration from surgery onset to myoma removal in the 2 groups (p<0.05). But there was no significant difference between average blood pressure (p = 0.45), heart rate (p = 0.64), respiration rate (p = 0.03), hemoglobin (p = 0.88) and platelets 6 h after surgery (p = 0.31) between 2 studied groups. ConclusionOur findings showed that, the amount of bleeding and duration of surgery in the ligation method was less than applying tourniquet. So, ligation method can be a safe method in open myomectomy surgeries.

Hysteroscopic myomectomy with the IBS® Intrauterine Bigatti Shaver: A Retrospective Comparative Analysis of the impact of rotational speed and aspiration flow rate

Myoma removal remains a challenge hysteroscopically including for the "IBS®" Intrauterine Bigatti Shaver technique. To evaluate whether the Intrauterine IBS® instrument settings and the myoma size and type are prognostic factors for the complete removal of submucous myomas using this technology. This study was conducted at the San Giuseppe University Teaching Hospital Milan, Italy; Ospedale Centrale di Bolzano - Azienda Ospedaliera del Sud Tirolo Bolzano, Italy (Group A) and the Sino European Life Expert Centre-Shanghai Jiao Tong University School of Medicine Affiliated Renji Hospital, Shanghai, China (Group B). In Group A: surgeries were performed between June 2009 and January 2018 on 107 women using an IBS device set to a rotational speed of 2,500 rpm and an aspiration flow rate of 250ml/min. In Group B: surgeries were performed between July 2019 and March 2021 on 84 women with the instrument setting to a rotational speed of 1,500 rpm and aspiration flow rate of 500 ml/min. Further subgroup analysis was performed based on fibroid size:<3 cm and 3-5 cm. Both Groups A and B were similar in terms of patient age, parity, symptoms, myoma type and size. Submucous myomas were classified according to the European Society for Gynaecological Endoscopy classification. All patients underwent a myomectomy with the IBS® under general anaesthesia. The conventional 22 Fr. Bipolar Resectoscope was used in cases requiring conversion to the resection technique. All surgeries were planned, performed and followed by the same surgeon in both institutions. Complete resection rates, total operation time, resection time and used fluid volume. Complete resection with the IBS® Shaver was seen in 93/107 (86.91%) in Group A versus 83/84 (98.8 %) in Group B (P=0.0021). Five patients (5.8%) in Subgroup A1 (<3 cm) and nine patients (42.9%) in Subgroup A2 (3cm~5cm) could not be finished with the IBS (P<0.001, RR=2.439), while in Group B only one case (8.3%) in Subgroup B2 (3cm~5cm) underwent a conversion to bipolar resectoscope (Group A: 14/107=13.08% vs. Group B: 1/84=1.19%, P=0.0024). For <3cm myomas (subgroup A1 versus B1) there was a statistically significant difference in terms of resection time (7.75±6.363 vs. 17.28±12.19, P<0.001), operation time (17.81 ± 8.18 vs. 28.19 ±17.614, P<0.001) and total amount of fluid used (3365.63 ± 2212.319 ml vs. 5800.00 ± 8422.878 ml, P<0.05) in favour of Subgroup B1. For larger myomas, a statistical difference was only observed for the total operative time (51.00±14.298 min vs. 30.50±12.122 min, P=0.003). For hysteroscopic myomectomy using the IBS®, 1,500rpm rotational speed and 500ml/min aspiration flow rate are recommended as these settings result in more complete resections compared to the conventional settings. In addition, these settings are associated with a reduction in total operating time. Reducing the rotational speed rate from 2500 rpm to 1500 rpm and increasing the aspiration flow rate from 250 ml/min to 500 ml/min improve complete resection rates and reduce operating times.

Clinical outcome analysis of intramural myoma greater than 8 cm in diameter removed during caesarean section: a retrospective study

ObjectiveTo explore the safety and efficiency of endometrial myomectomy (EM) and Serosal myomectomy (SM) for the removal of intramural myoma greater than 8 cm in diameter during cesarean section.MethodsRetrospective analysis and follow-up were used, and 190 cases of pregnancy complicated with uterine myoma from Jan. 2017 to May 2022 in Ningbo Women’s and Children’s Hospital were collected, 130 cases of caesarean myomectomy as study group, 64 cases of EM as study group A, 66 cases of SM as study group B, 33 cases with uterine fibroids removed before suturing the uterine incision as study group B1, 33 cases with uterine incision sutured followed by removal of fibroids as study group B2, 60 cases of Caesarean section alone as control group. To compare perioperative conditions between and within groups.Results① Operation time, postoperative exhaust time, pre- and post-operative haemoglobin drop, intraoperative blood loss were all more than those of the control group in the study group (68.65 ± 11.87 vs 56.17 ± 9.18 min, 21.04 ± 4.98 vs 17.03 ± 1.3 h, 1.27 ± 0.59 vs 1.09 ± 0.43 g/dl, 613 ± 221 vs 532 ± 156 ml, P < 0.001, P < 0.001, P = 0.025, P = 0.011). ② For type III and V fibroids, the time of myoma removal, postoperative exhaust and pre- and post-operative haemoglobin drop and intraoperative blood loss in study group A were less than those in study group B (18.02 ± 3.89 vs 20.19 ± 5.32 min, 18.83 ± 2.57 vs 23.93 ± 6.84 h, 600 ± 194 vs 730 ± 277 ml, 1.20 ± 0.57 vs 1.59 ± 0.70 g/dl, P = 0.036, P < 0.001, P = 0.014, P = 0.008); For type IV uterine fibroids, only postoperative exhaust time was less in Study Group A than in Study Group B (19.27 ± 2.2 vs 21.35 ± 3.23 h, P = 0.016). ③ Time of myoma removed was less in study group B1 than in study group B2 (18.24 ± 4.53 vs 20.7 ± 4.59 min, P = 0.033).ConclusionIt is safe and feasible to remove interstitial myomas larger than 8 cm in diameter during caesarean section. EM has the advantage of shorter operation time and less intraoperative bleeding, SM, in a way that the myoma is removed before suturing the uterine incision, can shorten the myomectomy time. It can benefit the patients more.

In Low- and Middle-Income Countries the Uterine Tourniquet during Open Myomectomy is a Simple and Efficient Method of Reducing Blood Loss

Background: Uterine fibroids are the most common form of benign uterine tumors. African women of reproductive age usually present late with large and numerous uterine fibroids. Conservative surgical treatment requires ways to reduce intraoperative bleeding. This study attempts to describe innovative methods in the efficient management of fibroids in low-and middle incomes countries. We demonstrate the efficiency of the uterine tourniquet during abdominal polymyomectomy in intraoperative bleeding reduction despite removal of numerous myomas. Methods: A prospective, descriptive and analytical review was conducted on 92 patients who underwent open myomectomy in the gynecology department of the university hospital of Cocody (Côte d’Ivoire) over 3 years (2019 to 2020). Intraoperative surgical steps include placing a uterine tourniquet before removal of the myomas. The variations in mean hemoglobin levels before and after myomectomies were compared. The significance level was set at 5% (p &lt; 0.05). Results: The patients’ mean age was 38.5 years old, and 39% were nulliparous. Abnormal vaginal bleeding was the main symptom (67.4%). On physical exam the uterine size varied significantly from 20 to 30 cm. The average number of uterine fibroids enucleated was ten. The mean duration of the procedure was 155 minutes with an estimated average blood loss of 250 mL. The mean difference between preoperative and postoperative hemoglobin levels was not significant (p &lt; 0.061). Only four patients (4.3%) received a blood transfusion. Conclusions: Placing a uterine tourniquet allowed enucleation of several uterine fibroids with relatively reduced blood loss in abdominal myomectomies. This technique can be an alternative to embolization in countries with limited resources.

Microwave Thermal Ablation of Uterine Fibroids during Laparoscopic Surgery for Endometriosis

Endometriosis is defined as the presence of endometrial glands or stroma outside the uterus, commonly diagnosed in women of childbearing age frequently with subfertility. Endometriosis is associated with the presence of uterine fibroids, which are benign tumors of the smooth muscle cells of the uterus, in 20-25% of cases. It is unclear whether fibroids interfere with fertility and pregnancy. The association of the two pathologies makes us ask the question of which is the best therapy to use. Sometimes medical therapy is not effective or has contraindications, surgery can be burdened with secondary effects that can impair fertility. In recent years, new techniques have been introduced to integrate conventional therapies, which involve the use of different forms of energy. Among these energies, an important place is occupied by microwaves (MW). MW creates an electromagnetic field that transforms kinetic energy into heat that induces cell death by coagulation necrosis. We have chosen to use MW thermal ablation to treat fibroids during laparoscopic surgery for endometriosis due to the fact that laparoscopic removal of myomas significantly lengthens the surgical time and increases possible complications.

O-257 The effect of the presence of intramural myomas smaller than 6 cm on reproductive outcome in IVF treatment: a systematic review and meta-analysis

Abstract Study question What is the effect of small intramural myomas on the reproductive outcome of in vitro fertilization (IVF) treatment? Summary answer Non-cavity-distorting intramural myomas with the size of &amp;lt; 6 cm have a significant adverse effect on reproductive outcomes in IVF treatment. What is known already There is a consensus that submucous myomas have a significant unfavorable impact on reproductive outcomes, whereas subserosal myomas do not seem to have any adverse effects. Women with large (≥6 cm) non-cavity-distorting intramural myomas should be evaluated individually, considering their reproductive history. However, there is scarce data on the effect of relatively smaller intramural myomas (&amp;lt;6 cm) on reproductive outcomes and how to manage them before IVF treatment. Study design, size, duration This study is a systematic review and meta-analysis according to PRISMA guidelines. We performed a comprehensive search of PubMed, Web of Science, and Cochrane Library databases to identify relevant studies from inception until 31 November 2021. Search terms were used as “intramural fibroid*” [tw] OR “intramural leiomyom*” [tw] OR “intramural myom*” [tw]. English language and human subjects were applied to search filters. Participants/materials, setting, methods The target population was infertile women undergoing IVF treatment with non-cavity-distorting intramural myomas &amp;lt;6 cm in diameter. History of myomectomy and the presence of predominant subserous myomas, submucous myomas, or other cavity distorting pathologies were exclusion criteria. The primary outcome measures were live birth rate (LBR) and miscarriage rate (MR). Newcastle-Ottawa Scale (NOS) was used to assess the methodological quality of included studies. All statistical analyses were performed using RevMan 5.4.1. Main results and the role of chance The initial search strategy yielded 378 studies. After adopting exclusion criteria, eight studies were included in the final analysis. Six of these studies had a NOS score of 8 out of 10, and the remaining two studies had 9 out of 10. Three studies had a prospective design, and five studies had a retrospective design. Two of eight studies did not report LBR as an outcome. In pooling data analysis of six studies including 2058 cycles (1980 women), 41% relative reduction in LBR was observed in women with non-cavity-distorting intramural myomas with the size of &amp;lt; 6 cm compared to women without myomas (RR = 0.59, 95%CI: 0.49–0.71, I2=0%, p&amp;lt;0.00001). A sub-group analysis for smaller intramural myomas (&amp;lt;3 cm) was also performed and concordantly 27% decrease in the LBR (RR = 0.73, 95% CI: 0.57–0.93, I2=0%, p=0.01) was found. Regarding the MR, for women with non-cavity-distorting intramural myomas with the size of &amp;lt; 6 cm, 50% relative increase in MR was found when compared with women without myomas (RR = 1.50, 95%CI: 1.11–2.04, I2=0%, 8 studies, p=0.009). Limitations, reasons for caution Lack of information regarding the distance of myomas from endometrium and the number of myomas in most of the included studies is a limitation. Differences in IVF treatment and uterine cavity evaluation methods among studies may limit generalizability of the findings. Future RCTs are warranted to confirm our findings. Wider implications of the findings This study is the first meta-analysis with overall moderate-quality evidence from observational studies to demonstrate the adverse effect of the presence of small (&amp;lt;6 cm) intramural myomas on reproductive outcomes in IVF treatment. Surgical removal of such small myomas should be considered before IVF treatment. Trial registration number not applicable

Successful Application of Manual Hand Morcellation Technique in Giant Leiomyoma: A Case Report

Introduction: Uterine leiomyoma is the most common benign neoplasm of the female reproductive tract. However, he use of the laparoscopy approach for giant myomas is still controversial and rarely performed. Only few cases have been published in the literature. Retrieval of giant myoma in laparoscopy is difficult and still challenging even by a power morcellator.&#x0D; Case presentation: A 39 years old para 3 woman was referred to the gynaecology department with abdominal swelling during the previous 3 years. No family history, past medical and gynaecology history disease was reported. A physical examination revealed a firm huge palpable abdominal mass with identifiable borders. The mass extended to her umbilicus. The abdominal ultrasound revealed a markedly enlarged and lobular uterus containing intramural uterine leiomyoma measuring 15 x14 cm without ascites. No additional pathology was noted. The results of the laboratory examination were within normal limit. She was offered laparoscopy removal of myoma.&#x0D; Conclusion: The case concludes the efficiency, reliability, and safety of laparoscopy surgery to treat huge leiomyoma and try to consider manual hand morcellation to remove the entire myoma to reduce spreading malignancy through electrical morcellation. Although a laparoscopic approach for a huge myoma has several challenges, it does represent an option for minimally invasive removal of giant myoma.&#x0D; Keywords: Giant leiomyoma, Laparoscopy, Leiomyoma, Morcellation, Manual morcellation

Critical Steps to Performing a Successful Single-site Laparoscopic Myomectomy for Large Pedunculated Myoma during Pregnancy

To demonstrate tips and tricks for the successful use of single-site laparoscopic surgery for pedunculated myomectomy during pregnancy. Stepwise demonstration with narrated video footage. An academic tertiary care hospital affiliated with Baylor College of Medicine. Our patient is a 39-year-old pregnant G1P0010 with a symptomatic 12-cm degenerating pedunculated myoma refractory to conservative pain management. Recent literature has indicated that most laparotomic myomectomies performed during pregnancy showed overall positive pregnancy outcomes and low complications. This indicates that myomectomy in pregnancy is safe and can be used in cases unresponsive to conservative management [1]. However, cases in literature discussing the single-site techniques for laparoscopic myomectomy during pregnancy have been sparse [2]. Four case series were reviewed; a total of 62 pregnant patients underwent laparoendoscopic single-site surgery without any complications [3-6]. Using laparoscopy in myomectomy compared with laparotomy during pregnancy permits decreased postoperative pain, quicker recovery, and lowered risk of postoperative complications [5,7,8]. Single-site laparoscopic surgery also aids in improved patient cosmesis and can be used for the myoma removal. Literature has demonstrated that single-site laparoscopy is safe and feasible during all stages of pregnancy [3,4]. Nevertheless, this approach may be challenging for inexperienced surgeons owing to the lack of triangulation and crowding of instruments in single-site laparoscopy [5]. At 21 weeks and 3 days pregnancy, our patient underwent single-incision laparoscopic surgery myomectomy. A 2.5-cm skin incision was made at the umbilicus to the abdominal cavity, and a GelPOINT Mini was inserted. Through the laparoscope, we can observe that a 12-cm pedunculated myoma was protruding from the right uterine fundus on a 4-cm stalk. A 0-Vicryl suture was tied around the base of the stalk. The stalk was then cauterized with bipolar energy and transected with the harmonic scalpel, completely detaching the myoma. Subsequently, an Endo Catch bag was placed around the myoma and brought up to the umbilical incision. Using a scalpel, bag-contained morcellation was completed within 22 minutes and the contents removed. As a result, the estimated blood loss was 50 cc and the total operative time was 123 minutes. The extended operating time was caused by slow movements to avoid disrupting the fetus. She had an unremarkable postoperative course, no medications were needed for pain management, and she was discharged home on postoperative day 2. At 38 weeks, she successfully delivered with elective cesarean delivery with no complications. Histopathology showed fragments of leiomyoma with diffuse necrosis. Tips and tricks: 1. Single-site entry technique uses the open Hasson technique, which reduces the risk of injury to the pregnant uterus and dilated surrounding vessels. 2. Through a 2.5-cm incision, the surgeon placed a suture in the myoma stalk because other hemostasis agents such as vasopressin are contraindicated in pregnancy. 3. Owing to difficulties related to single-site surgery, the surgeon should possess extensive expertise in single-site surgery. 4. Manipulation of the uterus should be minimized to reduce the disturbance of the pregnant uterus. 5. V-loc suture allows for faster and simplified uterine incision closure. 6. If the surgeon encounters excessive difficulty during the surgery, a 5-mm accessory port can be placed. 7. During tissue extraction, gentle traction should be used to reduce provoking the pregnant uterus. 8. When transecting the myoma stalk, it is important to leave a stump of more than 1 cm to increase suturing ease and prevent accidental suturing of the uterus. Single-incision laparoscopic surgery myomectomy for pedunculated myoma may be a practical technique in women refractive to conservative management. When performed by an experienced surgeon, the patient may benefit from faster specimen removal and recovery.

Preoperative Uterine Artery Embolization in Women Undergoing Uterus-Preserving Myomectomy for Extensive Fibroid Disease: A Retrospective Analysis

Objectives: The aim of this study was to determine if a long versus short interval between preoperative uterine artery embolization (PUAE) and subsequent myomectomy impact perioperative blood loss and the complication rate in cases of enlarged multi-fibroid uterus. Design: In cases of an enlarged multi-fibroid uterus, operative myomectomy can lead to heavy blood loss and consequently increases the risk for transfusion and hysterectomy. PUAE can possibly contribute to a reduction of these risks. Our study was designed to determine if a long versus short interval between PUAE and subsequent surgery impacts perioperative blood loss and complication rate. Participants and Methods: PUAE was performed 24 h before the planned myoma enucleation in 21 patients between January 2011 and March 2016 (group 1) or 19 days before the operation in 23 patients from March 2016 to May 2018 (group 2). A comparison was made to a historical sample of 57 patients with large myomas (>10 cm) without PUAE (group 3). Perioperative blood loss, need for postoperative blood transfusion, and postoperative complications were recorded. Subjective improvement of myoma-related symptoms was assessed for each group by a questionnaire. Results: PUAE was carried out successfully without complications in all patients. Conversion to hysterectomy was not needed in any of the PUAE patients but was necessary in one of the control patients. In the three groups’ comparison, there was a significant lower risk for high blood loss (≥500 mL) in group 1 and a lower but not significant lower risk in group 2 compared to group 3 without an embolization preoperatively. Also, a significant lower risk for postoperative blood transfusion for group 1 (OR 0.02; 0.001–0.328; p = 0.01) and 2 (OR 0.02; 0.001–0.277; p = 0.01) compared to group 3 was observed. The postoperative complication risk was lower in group 2 (model 1: OR 0.12; 0.016–0.848; p = 0.03; model 2 OR 0.07; 0.009–0.588; p = 0.01) compared to group 3. In the context of the postoperative questionnaire, 10 of 11 patients in group 1, 12 of 12 patients in group 2, and 31 of 36 patients from the control group reported an improvement of their complaints. Conclusion: PUAE is beneficial for uterus-preserving removal of myomas from patients with a substantially enlarged uterus. There is a significant reduction of high blood loss (≥500 mL), need for postoperative blood transfusion, and postoperative complications in patients with extensive fibroid disease after PUAE compared to no intervention before myoma enucleation.

Dermoid cyst and parasitic myoma removal without iatrogenic spillage using the needle laparoscopic surgery system: A case report

Dermoid cyst and parasitic myoma removal without iatrogenic spillage using the needle laparoscopic surgery system: A case report

Hysteroscopic Myomectomy for Submucosal Myoma: Literature Review

Uterine myomas are usually asymptomatic, although, most women with submucous myoma have severe symptom including abnormal uterine bleeding and infertility. Hysteroscopic myomectomy is a minimally invasive surgery and is a key benefit to patient care. Patient with submucous myoma no longer requires hysterotomy. Hysteroscopic myomectomy became the gold standard treatment in women who desire to preserve fertility. Complete removal of myoma in one-step procedure should be considered. Pre-operative optimization with cervical ripening agents including osmotic dilators such as laminaria tents and prostaglandin such as misoprostol and dinoprostone is important and decrease the risk of cervical trauma as well as uterine perforation. During the procedure, low viscosity isotonic conductive media such as normal saline are recommended to use with bipolar resectoscope and mechanical morcellator, and fluid deficit should be closely monitored at a minimum of 10-minute intervals. Resectoscope is usually used with slicing technique for resection of myoma. Morcellator can be used as it is easy to use, reduces risk of perforation, and reduces non-electrical currents. However, there is a limited utility in type 2 myoma. In addition, hyaluronic acid and polyethylene oxidesodium carboxymethylcellulose gel may reduce intrauterine adhesion after hysteroscopic myomectomy. Keywords: Hysteroscopy; Morcellation; Myoma; Uterine myomectomy

Evaluation of Biomarkers in Myoma Patients: A Prospective Study Investigating the Role of LDH, CA 125, and IGF-1 after Uterus-Preserving Surgical Therapy

Objective: Myomas are one of the most common tumors of the lower abdomen in women. At present, sonography and clinical examination are the prevalent diagnostic standards for these tumors, and no biomarkers have been established yet. The primary aim of this study was to determine if the surgical removal of myomas leads to a drop of lactate dehydrogenase (LDH), CA 125, and/or insulin-like growth factor (IGF-1) and therefore if these parameters are suitable as potential biomarkers for the presence or recurrence of a myoma. Study Design: The blood levels of LDH, CA 125, and IGF-1 were determined in 83 patients (age 18–50) with a verified diagnosis of myomas and surgical therapy at 3 different timepoints: preoperative (T0), 2 days postoperative (T1), and 6 months postoperative (T2). Vaginal sonography was performed preoperatively and once again at 6 months postoperatively. Results: The median (Q1–Q3) LDH values dropped significantly postoperatively: 239 (217–266) U/L at T0 versus 217 (190–255) U/L at T1, p < 0.001. The median (Q1–Q3) IGF-1 values also dropped: 140.4 (118.6–179.0) ng/mL versus 112.4 (99.5–143.0), p < 0.001. By contrast, the CA 125 values rose slightly but not significantly. At 6 months (n = 34), the LDH values were not significantly different from either the preoperative or the immediate postoperative values. This was observed both in patients with and without a recurrence of myoma. In contrast, the median (Q1–Q3) IGF-1 level at T2 was significantly elevated both in patients with sonographic evidence of new myomas (129.0 [116.0–163.1] ng/mL, p = 0.023) and in patients with sonographic proof of no new myomas (161.0 [130.2–198.5] ng/mL, p < 0.001). Conclusion: Both LDH and IGF-1 dropped significantly in the immediate postoperative days in women with myomas after uterus-preserving surgeries were performed. The postoperative concentration of IGF-1 was correlated with the evidence of new myomas and can be potentially used for further monitoring. Future studies should be able to confirm these results. This study concludes that myomas do influence LDH and IGF-1 and could possibly be suitable as biomarkers.

Comparison of operative time between robotic and laparoscopic myomectomy for removal of numerous myomas.

We hypothesized that the total operative time of robot myomectomy (RM) is shorter than that of laparoscopic myomectomy (LM) in cases where numerous myomas are removed, due to the faster suturing time of the robotic system. To verify this, we compared the surgical outcomes of RM vs LM for the number of myomas removed. The medical records of 144 women underwent LM and 121 women underwent RM by a single surgeon were reviewed. The operative time did not statistically differ between the groups, even when the number of removed myomas was more than 12 (200.6 ± 48.2 vs 196.0 ± 48.4 minutes, P = .791). Note that in our logistic regression analysis, the operation type was excluded from the independent risk factors prolonging operative time. RM showed a similar operative time relative to LM regardless of the number of myomas removed (numerous or not).

One-Step Resection via Hysteroscopic Myomectomy and Prostaglandin F2α for Large Submucosal Myoma

To assess the efficacy of prostaglandin F2α (PGF2α) in hysteroscopic myomectomy of submucous myomas. Single-blind, randomized clinical trial study. Teaching hospital, affiliate of Iran University of Medical Sciences, Tehran, Iran. Forty-four patients with symptomatic submucous myomas were randomly assigned to the intervention group (n = 21; 1 excluded owing to myoma not identified on pathologic examination) and the control group (n = 22). In the intervention group, PGF2α was injected into the cervix twice: before the beginning of the surgery and after the resection of the intrauterine portion of the submucous myoma. TIn the control group, the myomas were resected without the PGF2α injection. The same procedure was performed in the control group without the PGF2α injection. There were no differences in the demographics, size, or type of myomas among the groups at baseline. Although the proportion of complete removal of the submucous myomas in the intervention group (PGF2α) was higher (20/23 myomas or 87%) than that in the control group (15/23 myomas or 65.2%), the difference was not significant (p = .1). The number of 1-step complete removal of large submucous myomas (>5 cm) in the PGF2α group was significantly higher than that in the control group (8/10 myomas [80%] vs 2/8 myomas [25%], p = .03). The mean duration of operative time was significantly longer in the intervention group than in the control group (p = .01). The intervention group experienced more days of postoperative bleeding than the control group (p = .001). There were no differences regarding the length of stay at the hospital or hemoglobin levels between the groups (p = .07). In the current study, injection of PGF2α was beneficial for 1-step complete resection of large (>5 cm) submucous myomas via hysteroscopic myomectomy.

Culdotomy in laparoscopic myomectomy and its limits

ObjectiveTo examine the results and limits of culdotomy method for removal of myoma from the abdomen while preserving its integrity in laparoscopic myomectomy. To determine if this is a good option for tissue extraction. DesignRetrospective analysis of data collected prospectively. SettingA gynecology and obstetrics training and research hospital. PatientsA total of 102 patients who underwent laparoscopic myomectomy with culdotomy for tissue extraction. ResultsA total of 102 patients underwent laparoscopic myomectomy between September 2017 and April 2019, and tissues were taken from the abdomen by culdotomy. The mean myoma diameter was 7.7 ± 2.4 cm (4−15 cm) and the mean weight was 161 ± 120 g (20–602 g). The mean duration of surgery was 95 ± 41 min (36–214 min). All myomas were extracted with preservation of their integrity, except in 2 patients.In 87 patients, the myoma was less than 10 cm, and all myomas in this group could be easily extracted from the vagina.The myoma was between 11 and 13 cm in 13 patients. Of these, 8 were extracted without difficulty, 5 could barely be extracted, and superficial vaginal lacerations occurred in 4 of these patients.Due to the inability to extract myomas intact in 2 patients (14 and 15 cm), vaginal mechanical morcellation was performed.In terms of vaginal births, 34 patients (33.3 %) had never had vaginal births, and 68 patients (66.7 %) had a history of vaginal birth. The largest myoma extracted from a woman who had not given birth was 12 cm (345 g). The largest myoma extracted from a woman who had given birth was 13 cm (490 g).None had major complications. No signs of infection were detected on the 7th and 30th postoperative days, and no operative dyspareunia was detected at 6-month follow-up. ConclusionIn the present study, it was seen that myomas up to 13 cm (490 g) in multiparous and 12 cm (350 g) in nulliparous could be removed from the culdotomy while maintaining their integrity. Culdotomy is a safe, inexpensive and effective method for myoma extraction.

Laparoscopic In-Bag Morcellation Compared with Conventional Morcellation of Myomas and Uterus with Myomas.

To evaluate contained bag electromechanical morcellation for removal of myomas and uterus with myomas, laparoscopically (Study group B), and compare it with uncontained laparoscopic morcellation (Control group A) in patients with similar parameters done earlier. Retrospective Cohort Comparative Study (Canadian Task Force 2-1). Advanced Gynaecologic MAS, university recognized tertiary centre, Mumbai, India. 720 women had laparoscopic removal of myomas or large uterus with myomas during a study period of 6years (from 13 May 2012 to 14 August 2018) with contained bag electromechanical or conventional morcellation. Laparoscopic hysterectomy, laparoscopic myomectomy, conventional uncontained morcellation, contained in-bag morcellation. Laparoscopic contained in-bag morcellation was compared with conventional morcellation of myomas and uterus with large myomas during a study period of 6years. Parameters assessed were operating time, time for insertion of bag, morcellation of tissues and removal of bag, blood loss, complications, conversion to open surgery and histopathologic findings of tissues. In Group A, in the first 3years, 355 women underwent uncontained morcellation. Myoma size and weight varied from 5 cm to 26 cm and 200 g to 3740 g respectively. The myoma number ranged from 1 to 18. No case of leiomyosarcoma was reported. In Group B, in the next 3years, 365 women underwent contained bag morcellation in 196 myomectomy cases and 169 hysterectomy cases. Myoma size and weight varied from 4 cm to 20 cm and 200 g to 2100 g respectively. The number of myomas varied from 1 to 17. Laparoscopic contained bag morcellation for myomas and uterus with large myomas were evaluated. In myomectomy group both conventional and in bag laparoscopic morcellation were comparable in terms of duration of the surgery and blood loss. When all cases ( hysterectomy and myomectomy combined together) and cases of hysterectomy with large fibroid were studied, laparoscopic in bag morcellation took less operative time and there was statistically significant difference in operative time . No case of leiomyosarcoma was found in our study of 720 cases of myomas or uterus with large myomas.

The importance of pseudocapsule preservation during hysteroscopic myomectomy

Minimally invasive techniques for myomectomy are based on the rationale of preserving the myometrial integrity, in order to spare muscular and fibro-neurovascular myometrial fibers and ensure complete and bloodless myoma removal. Post-operative myometrial vascularization is crucial in injured muscle regeneration. The post-surgical myometrial healing is needful for uterine reproductive function. Neurotransmitters and neurofibers were analyzed in the myoma pseudocapsule surrounding fibroid. They activate signaling molecule synthesis and release which, in turn, promote cell activation and induce muscle regeneration and growth. Pseudocapsule damage during myomectomy may lead to a reduction of neuropeptides and neurofibers at the hysterotomic site, to a poor physiological myometrial healing, with more fibrosis due to hypoxia, ischemia and necrosis.These pathophysiological events cause deficit in myometrial neurotransmission, muscular impulse and contractility, with ultimately impaired uterine muscle function during pregnancy, labor and delivery. Hence, during myomectomy, all manipulations should be performed as precisely and bloodlessly as possible, avoiding extensive, high wattage diathermocoagulation or excessive tissue manipulation or muscular trauma. Any iatrogenic pseudocapsule damage may alter neurotransmitter function during successive myometrial healing, impacting negatively on uterine repair and on eventual pregnancies. Hence the reasoned myomectomy on a biological basis, the “intracapsular myomectomy”, satisfied these surgical and physiological requirements. It was described precisely and firstly by the hysteroscopy, with the image magnification of the preservation of the myoma pseudocapsule. The “intracapsular hysteroscopic myomectomy” demonstrated the safe and effective removal of submucous myomas with intramural development. It allowed to completely remove the myoma in one or two surgical steps, saving the pseudocapsule and the surrounding healthy myometrium. The respect of the myometrium and the reduced thermal injury, a part the excellent outcomes in terms of surgical complications prevention, post-surgical fibrosis and intrauterine synechiae reduction, highlighted the physiological development of a successive pregnancy, without any myometrial complications during pregnancy, labor and delivery.