Uterine Artery Occlusion Research Articles

O-226 Effects of preventive uterine artery occlusion during laparoscopic myomectomy on ovarian reserve markers: a randomized controlled trial

Abstract Study question Does definitive occlusion of uterine arteries have a short or long term impact on anti-Müllerian hormone (AMH) levels in reproductive age women undergoing laparoscopic myomectomy? Summary answer Preventive uterine artery occlusion during laparoscopic myomectomy does not impact AMH levels in reproductive age women. What is known already Uterine leiomyoma are the most common benign tumours in women of reproductive age. For symptomatic women willing to retain their uterus, especially for a future pregnancy, the current gold standard is the myomectomy for subserous/intramural leiomyoma. Temporary or definitive occlusion of uterine arteries can be performed to control bleeding during surgery but its impact on ovarian reserve markers is still unknown. A single randomized trial with a one-year follow-up demonstrated that temporary bilateral uterine artery occlusion during laparoscopic myomectomy slightly decreased AMH levels at day-2 after surgery but has no impact thereafter 3, 6 and 12 months postoperatively. Study design, size, duration We conducted a randomized controlled trial with a two-year follow-up evaluating the effect of definitive occlusion of uterine arteries on ovarian reserve via sequential measures of anti-Müllerian hormone (AMH) levels. Fifty-eight women with symptomatic leiomyoma type FIGO 3-6 scheduled for laparoscopic myomectomy at were included between July 2015 and October 2021. Participants/materials, setting, methods Patients were randomized into: the intervention group (laparoscopic myomectomy with preventive occlusion of uterine arteries) and the control group (laparoscopic myomectomy without occlusion of uterine arteries) ). AMH evaluated at T0 and followed at 1 month (T1), 3 months (T3), 6 months (T6), 12 months (T12) and 24 months (T24) after surgery. Intraoperative blood loss, leiomyoma recurrence and adenomyosis occurrence were also evaluated comparing pre- and post-operative findings. Finally, pregnancies and live births were monitored. Main results and the role of chance Women in both groups did not differ in their baseline characteristics in terms of age, body mass index, ethnicity, parity, wish to become pregnant, hormonal treatment, leiomyoma number and size, baseline haemoglobin levels, bleeding symptoms baseline AMH levels and antral follicular count (AFC). The mean operative time was similar in between both groups. Mean blood loss during surgery was on average 138 (±104)ml in the intervention group versus 436 (±498)ml in controls (p < 0.001). The difference in haemoglobin between before and after surgery was significantly higher in the control group 21.8 (±12.7)g/l compared with the intervention group 14.8 (±8.9)g/l (p = 0.02). Regarding clinical symptoms, most patients had decreased menstrual flow at the last follow-up visit (24 months) compared to baseline in both group improvement of dysmenorrhea followed the same trend with a reduction in pain levels in both groups. Risk of leiomyoma recurrence was found similar between both groups. Most importantly, AMH levels were similar between groups at all times (T1, T3, T6, T12 and T24) and non-inferiority of preventive occlusion was demonstrated with a non-inferiority margin of -3.5pmol/L (0.5 ng/ml). The pregnancy rate was not different between groups. Limitations, reasons for caution Our sample size was calculated to detect a clinically relevant difference of at least two-third of the standard deviation in AMH levels, but we cannot exclude a smaller impact on AMH with a different sample size. Wider implications of the findings Preventive uterine artery occlusion during laparoscopic myomectomy does not impact ovarian reserve markers and can be safely used to control perioperative bleeding. Trial registration number NCT02563392

Efficacy of Human Recombinant Growth Hormone in Females of a Non-Obese Hyperglycemic Mouse Model after Birth with Low Birth Weight.

We examined whether the administration of growth hormone (GH) improves insulin resistance in females of a non-obese hyperglycemic mouse model after birth with low birth weight (LBW), given that GH is known to increase muscle mass. The intrauterine Ischemia group underwent uterine artery occlusion for 15 min on day 16.5 of gestation. At 4 weeks of age, female mice in the Ischemia group were divided into the GH-treated (Ischemia-GH) and non-GH-treated (Ischemia) groups. At 8 weeks of age, the glucose metabolism, muscle pathology, and metabolome of liver were assessed. The insulin resistance index improved in the Ischemia-GH group compared with the Ischemia group (p = 0.034). The percentage of type 1 muscle fibers was higher in the Ischemia-GH group than the Ischemia group (p < 0.001); the muscle fiber type was altered by GH. In the liver, oxidative stress factors were reduced, and ATP production was increased in the Ischemia-GH group compared to the Ischemia group (p = 0.014), indicating the improved mitochondrial function of liver. GH administration is effective in improving insulin resistance by increasing the content of type 1 muscle fibers and improving mitochondrial function of liver in our non-obese hyperglycemic mouse model after birth with LBW.

A combination of laparoscopy and bilateral uterine artery occlusion for the treatment of type II cesarean scar pregnancy: a retrospective analysis.

We investigated the efficacy of a combination of laparoscopy and bilateral uterine artery occlusion (BUAO) for the treatment of type II cesarean scar pregnancy (CSP). Patients with type II CSP underwent laparoscopy + bilateral uterine artery embolization (control group) or laparoscopy + BUAO (study group). Data regarding the duration of surgery, intraoperative hemorrhage, postoperative complications, the duration of the hospital stay, and the costs of hospitalization were retrospectively collected. One year later, the time to the return of the β-human chorionic gonadotropin (β-hCG) concentration to normal and to the return of menstruation were compared. The duration of surgery, time to the return of menstruation, and incidence of postoperative complications in the study group were significantly less than in the control group, but there was no significant difference in the time for β-hCG to return to normal or the volume of intraoperative hemorrhage. The duration of hospitalization and costs for the control group were higher than those for the study group. Laparoscopy in combination with BUAO is associated with minimal trauma, rapid recovery, a short duration of surgery, low cost of hospitalization, and a low postoperative complication rate. Thus, it represents a useful new surgical treatment for type II CSP.

Surgical impact of bilateral transient occlusion of uterine and utero-ovarian arteries during laparoscopic myomectomy

The objective of this article is to compare the amount of intraoperative blood loss during laparoscopic myomectomy when performing bilateral transient clamping of the uterine and utero-ovarian arteries versus no intervention. It´s a randomized controlled prospective study carried out in the Department of Obstetrics and Gynecology Ramón y Cajal University Hospital and HM Montepríncipe-Sanchinarro University Hospital, Madrid, Spain, in women with fibroid uterus undergoing laparoscopic myomectomy. Eighty women diagnosed with symptomatic fibroid uterus were randomly assigned to undergo laparoscopic myomectomy without additional intervention (Group A) or temporary clamping of bilateral uterine and utero-ovarian arteries prior to laparoscopic myomectomy (Group B). Estimated blood loss, operating time, length of hospital stay, and postoperative hemoglobin values were compared in both groups. The number of fibroids removed was similar in both groups (p = 0.77). Estimated blood loss was lower in the group of patients with prior occlusion of uterine arteries (p = 0.025) without increasing operating time (p = 0.17) nor length of stay (p = 0.17). No patient had either intra or postoperative complications. Only two patients (2.5%) required blood transfusion after surgery. We conclude that temporary clamping of bilateral uterine arteries prior to laparoscopic myomectomy is a safe intervention that reduces blood loss without increasing operative time.

Laparoscopic Correction of Cesarean Scar Defects by Temporary Bilateral Uterine Artery Occlusion

Laparoscopic Correction of Cesarean Scar Defects by Temporary Bilateral Uterine Artery Occlusion

VNOTES retroperitoneal transient uterine artery occlusion: a new approach to control bleeding during a high-risk evacuation of products of conception

To describe a retroperitoneal transient occlusion of the uterine or internal iliac artery in conjunction with a high-risk evacuation of products of conception. The procedure was performed vaginally, minimally invasively, via vaginal natural orifice transluminal endoscopic surgery. Description of the surgical technique using original video footage. This study was exempted from requiring hospital institutional review board approval. Teaching hospital. A 34-year-old woman (G8P3) with a medical history of 2 cesarean sections, 1 partial mole, and a missed abortion with 2.8 L of blood loss. The patient presented after 10 weeks of amenorrhea. Ultrasound revealed a large blood-filled niche in the cesarean section scar with a thin overlying myometrium. A partial mole was suspected as well as increased vascularization in the myometrium and enhanced myometrial vascularity with arterial flow velocities of 100 cm/s. A risk of heavy blood loss in conjunction with curettage was anticipated. The patient had a strong preference for a fertility-preserving treatment, and after informed consent, she opted for transient occlusion of the uterine arteries with subsequent suction evacuation of the molar pregnancy. The patient signed a consent form accepting the procedure. The patient included in this video provided consent for publication of the video and posting of the video online including social media, the journal website, and scientific literature websites. Institutional review board approval was not required in accordance with the IDEAL guidelines. A vaginal incision was made over the bladder, and the vaginal mucosa was dissected. The paravesical space was dissected over the arcus tendinous, and the pelvic retroperitoneal space was opened. A small (7 cm) GelPOINT V-Path (Applied Medical, Rancho Santa Margarita, California) was inserted into the obturator fossa and insufflated with 10 CO2 mm Hg. Standard laparoscopic instruments were used through the gel port. Under endoscopic view, dissection to the right obturator fossa and iliac vessels was made, and the internal iliac artery was identified. A removable clip was placed on the origin of the right uterine artery. The same procedure was performed on the left side where the internal iliac artery was clipped. Different vessels were clipped to demonstrate and investigate the feasibility of both approaches. Both vessels were equally accessible. Care should be taken not to injure the uterine vein at the time of clipping. Dilation and evacuation was performed under transanal ultrasound surveillance. When hemostatic control was assured, first, the right clip was removed from the iliac artery. Hemostatic control was ensured, and after 10 minutes, the second clip on the left iliac artery was removed. The GelPOINT was removed, and the vaginal incision was sutured. The patient bled in total 500 mL. Not applicable. The patient recovered swiftly without complications. Pathology confirmed a partial molar pregnancy. Uterine or internal iliac artery ligation can be lifesaving in situations with massive bleeding from the uterus. Current minimally invasive approaches are laparoscopic vessel ligation and, more commonly, uterine artery embolization, which has unclear impact on fertility and has shown an increased risk of intrauterine growth restriction, miscarriage, and prematurity. As the patient was undergoing a vaginal evacuation of pregnancy, a vaginal and retroperitoneal approach of artery ligation was deemed least invasive. In patients with fertility-preserving wishes, care should to be taken to avoid as much trauma as possible to the endometrium. Optimized blood control, and a shorter duration of using a curette, may potentially reduce the risk of endometrial damage. We present a novel minimally invasive approach via vaginal natural orifice transluminal endoscopic surgery-retroperitoneal transient occlusion of the internal iliac or uterine artery. The whole procedure can be performed by the operating gynecologist, and the occlusion is transient and can be reversed in a stepwise controlled manner.

Features of Angioarchitectonics of Uterus in Uterine Leiomyoma: a Series of Clinical Observations

INTRODUCTION: One of most important problems in the gynecological practice is the choice of the treatment method of uterine leiomyoma. Uterine artery embolization has been practiced in the Republic of Tatarstan (Kazan), since 2004. Individual peculiarities of blood supply to the uterus and ovaries become the cause of failure of the endovascular treatment of patients with uterine leiomyoma in 20%–25% of cases forcing the doctors to resort to traditional surgical methods. The article presents a series of clinical cases demonstrating variants of angioarchitectonics of uterus and the results of the analysis of uterine artery embolization (UAE, n = 1743) performed at the department of X-ray surgical methods of diagnostics and treatment in the Primary healthcare unit of Kazan (Privolzhsk) Federal University.&#x0D; CONCLUSION: Endovascular occlusion of uterine arteries in patients with uterine myoma is a fairly effective method of treatment of this disease, and an adequate assessment of the peculiarities of the angioarchitectonics of uterus in uterine myoma permits to considerably increase the effectiveness of treatment and reduce the frequency of complications. The presented series of clinical observations from the clinical archive of the authors’ team demonstrates the variants of angioarchitectonics of uterus.

Current Trends of Alternatives to Hysterectomy in Adenomyosis: A Review Article

Adenomyosis is a common gynecological problem characterized by the growth of endometrial glands and stroma within the myometrium. Previously, the definitive diagnosis of adenomyosis was made through histopathology after a hysterectomy. However, in the last two decades, several uterine-sparing treatment options have emerged, including High-Intensity Focused Ultrasound (HIFU), which has become a promising option. HIFU is a non-invasive local thermal ablation technique that can be performed via ultrasound or MRI guidance. Additionally, “Laparoscopic uterine artery occlusion with uterus sparing pelvic plexus block and partial adenectomy for adenomyosis” has become a popular option. While conventional adenomyomectomy carries a high risk of recurrence and uterine rupture, some novel surgical techniques have been described to mitigate these complications and preserve future fertility. There are also “new surgical techniques of laparoscopic resection of adenomyoma under real-time intraoperative ultrasound elastography guidance”. Diagnostic imaging techniques such as transvaginal ultrasound, MRI, and hysteroscopic evaluation have revolutionized the diagnosis of adenomyosis and opened up possibilities for conservative treatment options. Hysteroscopy can be used for direct visualization and biopsy collection, though it is not the first-line treatment option. With the increasing incidence of adenomyosis and the desire for fertility preservation among younger patients, there is a growing need for effective uterine-sparing treatments. Bangabandhu Sheikh Mujib Med. Coll. J. 2023;2(1): 55-58

Surgical Efficacy among Laparoscopic Ultrasonic Dissectors in Adenomyosis

Objectives: The present study aimed to investigate the efficacy of ultrasonic dissectors for adenomyomectomy using the double/multiple-flap method combined with temporary occlusion of the temporary bilateral uterine artery and the utero-ovarian vessels for the treatment of symptomatic adenomyosis. Design: This was a retrospective study. Participants: In total, 162 patients with symptomatic adenomyosis were included, and all of them had originally been scheduled to group A (n = 82) and group B (n = 80) with each group representing a different surgical application. All eligible women were informed of the potential complications, benefits, and alternatives of each approach before they were assigned to one of the two groups, and patients chose group A or group B by themselves. In group A, we performed laparoscopic ultrasonic dissectors in adenomyosis with the double/multiple-flap method combined with temporary occlusion of the bilateral uterine artery and utero-ovarian vessels, while in group B, we performed adenomyomectomy with scissors. During the period of treatment, we evaluated operative time, intraoperative blood loss, and the degree of fatigue of surgeons’ fingers. Results: The estimated blood loss, operative time, and the degree of fatigue of surgeons’ fingers in group A were significantly lower than that in group B (p < 0.001). No serious perioperative complications were observed in either group. Limitations: This was a retrospective study. Conclusion: The use of ultrasonic dissectors in laparoscopic adenomyomectomy with temporary occlusion of the bilateral uterine artery and the utero-ovarian vessels leads to improvements and releases the fatigue of surgeons’ fingers in laparoscopic adenomyomectomy.

Uterine Artery Occlusion Techniques: Tips and Tricks... and Some Pitfalls

<h3>Study Objective</h3> To demonstrate the benefits and challenges of various uterine artery occlusion techniques available to minimally invasive gynecologic surgeons. <h3>Design</h3> Educational Video Presentation. <h3>Setting</h3> Teaching hospital, Minimally Invasive Gynecology OR Team, patients in lithotomy position with various port configurations. <h3>Patients or Participants</h3> Patients at a Medical Teaching Facility. <h3>Interventions</h3> Uterine Artery Occlusion during Myomectomy and Hysterectomy. <h3>Measurements and Main Results</h3> Various research has shown that uterine artery occlusion is associated with decreased blood loss during laparoscopic and robotic hysterectomy and myomectomy. This video compares the benefits and challenges to each of the follow occlusions techniques: bipolar coagulation, bulldog clamps, polymer clips, laparoscopic clip appliers, and suture ligation. Comparisons are made between these options related to cost, technical difficulty, the extent of dissection needed, risk of thermal spread, port size requirements, and other notable differences. Intraoperative video demonstrates tips and tricks for successful application of each of these occlusion options. In addition, we also include intraoperative video of various pitfalls that surgeons can encounter with suboptimal applications of these various methods, so as to help surgeons prevent running into these foreseeable pitfalls. <h3>Conclusion</h3> Various uterine artery occlusion techniques are available to help reduce blood loss during minimally invasive gynecologic surgery. Knowing the benefits and challenges to each method can assist surgeons in choosing the best technique for each clinical circumstance.

An innovative approach in the treatment of nodular adenomyosis

Introduction. The necessity to improve methods of adenomyosis treatment is determined not only by its high prevalence, which reaches 40 % among women of reproductive age, but also by its association with infertility of unclear genesis. The disease significantly reduces the quality of life. Objective. To optimize reproductive outcomes after surgical treatment of nodular adenomyosis and to prevent the disease recurrence. Materials and Methods. A cohort prospective comparative study examined the efficacy of therapy with dienogestam after laparoscopic removal of adenomyosis nodules with temporary uterine artery occlusion and temporary balloon occlusion of the internal iliac arteries. The study included 25 women who underwent organ-preserving treatment for nodular adenomyosis from January 1, 2020 to January 1, 2022. Inclusion criteria: age 22–45 years, mean 32 ± 4.5; organ preserving treatment for nodular adenomyosis, no contraindications to hormone therapy, informed voluntary consent of the patient to participate in the study. Results. The use of Dientogest at a dose of 2 mg/day in a continuous regimen for 6 months after surgical treatment for nodular adenomyosis was shown to transform the intensity of pain syndrome to insignificant, the absence of recurrent disease for 24 months of follow-up. Conclusions. The comprehensive treatment of nodular adenomyosis, which included laparoscopic removal of the nodule and the drug therapy with dienogestam, permitted the achievement of reproductive function in 40% of the patients. The choice of the treatment method for nodular adenomyosis depends primarily on the reproductive plans of the patient, the size and location of the adenomyosis nodules, and its long-term results depend on the comprehensive antiretroviral therapy.

The effect of temporary uterine artery ligation on laparoscopic myomectomy to reduce intraoperative blood loss: A retrospective case-control study.

ObjectiveTo reduce intraoperative blood loss in laparoscopic myomectomy, uterine artery occlusion or temporary uterine artery clipping have been employed. Recently, in addition to these techniques, temporary uterine artery ligation has been reported as a new method that has less invasive effects on fertility and needs no special devices to be used. This study aimed to evaluate the effect of temporary uterine artery ligation to minimize intraoperative blood loss during laparoscopic myomectomy.Study DesignThis was a retrospective case-control study at the department of Obstetrics and Gynaecology, University Hospital Mizonokuchi, Teikyo University School of Medicine. A total of 264 patients with uterine leiomyoma who underwent laparoscopic myomectomy were enrolled in this study. We divided the patients into two groups, those who underwent temporary uterine artery ligation (52 patients) and those who did not (212 patients) and compared the operation time, blood loss volume, and other indexes. Second, to identify influential factors, we assessed the effects of 11 representative factors on massive blood loss or a prolonged operation time using multivariate analysis.ResultsThe intraoperative blood loss volume was decreased by approximately half with the addition of temporary uterine artery ligation (75.1 ± 73.6 ml vs. 158.5 ± 233.2 ml, p = 0.011), but the operation time was longer (200.5 ± 46.9 min vs. 160.1 ± 51.3 min, p < 0.001). Among the 264 patients, 25 patients (9/52 in the case group and 16/212 in the control group) had a prolonged operation time (≥ 240 min), and 24 patients (1/52 in the case group and 23/212 in the control group) experienced massive blood loss (≥ 400 ml). In the multivariate analysis, high body mass index, concomitant surgery and temporary uterine artery ligation showed a positive association with a prolonged operative time, and the presence of single leiomyoma showed a negative association. Concomitant surgery and the presence of large leiomyoma showed a positive association with massive blood loss, and temporary uterine artery ligation showed a negative association.ConclusionsBy performing temporary uterine artery ligation during laparoscopic myomectomy, the volume of intraoperative blood loss could be decreased, especially in patients with large leiomyomas. However, because this procedure prolongs the operation time, there is still room for improvement.

Can the application of a temporary uterine tourniquet during an abdominal myomectomy reduce bleeding?

Objective:Uterine fibroids are common, benign uterine tumours. The three most common surgical treatment approaches for uterine fibroids are laparoscopic, robotic and abdominal myomectomies. Bleeding is a risk with all three approaches. The present study compared post-operative and pregnancy outcomes in patients with bilateral uterine artery occlusion who underwent an abdominal myomectomy, with or without a temporary uterine tourniquet.Material and Methods:This retrospective study included patients with intra-mural fibroids (≥5 cm) who underwent an abdominal myomectomy. The patients were divided into two groups according to the use or non-use of a temporary uterine tourniquet. Post-operative and pregnancy outcomes in the tourniquet use and non-use groups were compared. The association of the number of uterine fibroids removed (≤3 vs >3) with laboratory parameters was also evaluated.Results:A total of 84 patients were included, divided into use (n=36) and non-use (n=48) of the temporary tourniquet. There was a statistically significant difference between the groups with >3 myomas removed and with a uterine tourniquet applied and not applied in terms of reduction in hemoglobin and hematocrit, transfusion amounts, operation times and lengths of hospitalization in favour of the uterine tourniquet use group (p=0.019, p=0.023, p=0.012, p=0.044 and p=0.036, respectively). Bilateral uterine arterial occlusion using a temporary uterine tourniquet had no negative effects on pregnancy outcomes.Conclusion:A temporary uterine tourniquet may be an effective method for reducing the amount of perioperative bleeding in patients with multiple, large-sized myomas located close to vascular structures.

Laparoscopic myomectomy of a lateral cervical fibroid with temporary uterine artery occlusion

Laparoscopic myomectomy of a lateral cervical fibroid with temporary uterine artery occlusion

Comparison of the Effects of Citicoline and Piracetam on Hypoxic-ischemic Brain Damage in Neonatal Rabbits.

Objectives Perinatal hypoxic-ischemic brain injuries have been a major cause of mortality and neurodevelopmental morbidities in newborns. Citicoline and Piracetam have been used as nootropic agents in a number of studies. In this investigation, we aimed to determine the effects of these agents solely and in combination in hypoxic-ischemic brain damage in rabbit neonates.Materials & Methods Hypoxic-ischemic brain damage was induced by the occlusion of both uterine arteries of dams for eight minutes. The subjects were randomly divided into five groups as follows (n=6 per group): control group without hypoxia (C1), control group with hypoxic-ischemic damage (C2), the third group (P) received Piracetam (100 mg/kg), the fourth group (T) administered with Citicoline (250 mg/kg), and the fifth (PT) received both. The preventive effects of the two drugs on hypoxic-ischemic brain damage were microscopically investigated by the rates of damage to the hippocampus.ResultsNeuronal destruction rates in C1, C2, P, T, and PT were 4%, 45%, 37.5%, 12.5% (P=0.01 vs. C2), and 20% (P=0.03 vs. C2), respectively. The total means of hypoxic-ischemic damage, cell edema, neuronal degeneration, and eosinophilic degeneration were lower in the T group compared to C2 (P<0.05). Conclusion According to our results and previous findings, Citicoline as a treatment for hypoxic-ischemic brain injuries could be beneficial, and it has priority over neuroprotective agents like Piracetam. Moreover, the combination of Citicoline and Piracetam showed no superior effect in contrast with Citicoline alone. However, experimental studies on larger populations and clinical trials are highly suggested.

A Video Article: The Laparoscopic Uterine Artery Occlusion in Combination with Myomectomy for Uterine Myoma.

A Video Article: The Laparoscopic Uterine Artery Occlusion in Combination with Myomectomy for Uterine Myoma.

Temporary Uterine Artery Occlusion and Surgical Techniques for Stage 4 Endometriosis

<h3>Study Objective</h3> To describe a surgical approach to minimize intraoperative blood loss and improve visualization for stage 4 endometriosis. <h3>Design</h3> Video presentation for surgical management of stage 4 endometriosis. <h3>Setting</h3> The procedure was performed with robot assisted laparoscopy in dorsal lithotomy position. <h3>Patients or Participants</h3> A 39-year-old patient G0 with stage 4 endometriosis and prior failed In Vitro Fertilization. <h3>Interventions</h3> In this Video we describe the surgical approach used for Stage 4 endometriosis after prior failed In Vitro Fertilization. Intraoperatively, Initial survey of the pelvis showed both small and large bowel adhesions to the posterior aspect of the uterus as well as obliteration of the cul-de-sac. We begin by opening the pelvic sidewall bilaterally, parallel and lateral to the infundibulopelvic ligament identifying the pararectal space. The ureters are identified bilaterally and are tagged with a vessel loop for easier identification and manipulation for ureterolysis. Further dissection into the pararectal space is performed to identify the uterine arteries at their origin and are temporarily ligated with vascular bulldog clamps. Ureterolysis is then performed followed by mobilization of the rectum using a lateral to medial approach towards the central pathology. The anatomy of the adnexa is then restored bilaterally and a bilateral salpingectomy was then performed due to hydrosalpinx to improve future attempts of In Vitro Fertilization. The vascular bulldog clamps are then removed at the end of the procedure. <h3>Measurements and Main Results</h3> Patient had significant improvement in pain post operatively and is pending In Vitro Fertilization. <h3>Conclusion</h3> Temporary uterine artery ligation during extensive endometriosis surgery could improve blood loss and visualization intraoperatively and can be utilized during pelvic side wall dissection and identification of critical anatomy.

Laparoscopic Management of Type 2 Cesarean Scar Pregnancies - Planning and Procedural Execution

<h3>Study Objective</h3> With increasing caesarean deliveries, Caesarean scar pregnancies CSP are also on the rise. We report our experience from successful laparoscopic management of type 2 exogenic CSPs which invades deep, projects into the vesicouterine fold and has the dangerous potential for rupture and massive hemorrhage. <h3>Design</h3> NA. <h3>Setting</h3> tertiary referral center. <h3>Patients or Participants</h3> four women confirmed to have type 2 cesarean scar pregnancy. <h3>Interventions</h3> MRI was done for preoperative planning to clearly define the sac, note dehiscence of scar and adherence of uterine corpus to anterior abdominal wall. This spatial resolution gave a good mental picture. At Laparoscopy, first adhesions are released and round ligaments divided temporarily, giving better access to lower uterine segment for surgery and suturing. Prior to making an incision on the uterus, the complete scar with sac inside is exposed till the anterior cervix. Careful controlled dissection avoids excessive bleeding and staining, which could result in loss of anatomic orientation and even panic. Bilateral uterine artery occlusion and Local injection of vasopressin are interventions used for decreasing bleeding from otherwise highly vascular gravid uterus. After complete resection and removal of the products, Full thickness, equidistant repair of LUS defect is aided by barbed suture. A Hegar's dilator placed in situ during the suturing phase prevents accidental approximation of uterine walls. Here we humbly acknowledge that we have managed laparoscopically one of the most advanced CSP reported so far at 16 weeks gestational age. <h3>Measurements and Main Results</h3> all four women had procedures accomplished laparoscopically, with complete resection of the type 2 CSPs and satisfactory reconstruction of defect, also received the benefits of the minimally invasive surgery such as less pain, less scar and rapid return to work. <h3>Conclusion</h3> Laparoscopy here is proven safe and effective, in view of excellent visualization, complete removal of pathology, good reconstruction of the defect, and should be the choice where facilities exist.

A Systematic Review of Minimally Invasive Treatments for Uterine Fibroid-Related Bleeding.

Newer minimally invasive techniques provide treatment options for symptomatic uterine fibroids while allowing uterus preservation. The objective of this review was to analyze the efficacy of uterine-preserving, minimally invasive treatment modalities in reducing fibroid-related bleeding. A comprehensive search was conducted of PubMed, Embase, PsycINFO, ClinicalTrials.gov, Scopus, and Cochrane Library databases from inception to July 2020. English-language publications that evaluated premenopausal women with fibroid-related bleeding symptoms before and after treatment were considered. Randomized controlled trials were assessed for bias with the established Cochrane Risk of Bias Tool 2.0 and observational studies were assessed for quality under the New Castle-Ottawa Scale guidelines. Eighty-four studies were included in the review, including 10 randomized controlled trials and 74 observational studies. Six studies on myomectomy demonstrated overall bleeding symptom improvement in up to 95.9% of patients, though there was no significant difference between mode of myomectomy. Forty-one studies on uterine artery embolization reported significant reduction of fibroid-related bleeding, with symptomatic improvement in 79 to 98.5% of patients. Three studies suggested that embolization may be superior to myomectomy in reducing fibroid-related bleeding. Six studies reported that laparoscopic uterine artery occlusion combined with myomectomy led to greater reduction of bleeding than myomectomy alone. Fifteen studies demonstrated significantly reduced bleeding severity after radiofrequency ablation (RFA). Additional research is needed to establish the superiority of these modalities over one another. Long-term evidence is limited in current literature for magnetic resonance-guided focused ultrasound surgery, cryomyolysis, microwave ablation, and laser ablation.

How to minimize bleeding in laparoscopic myomectomy.

Laparoscopic myomectomy is a common surgical procedure for symptomatic myomas. However, bleeding control during surgery may pose a challenge. Therefore, the aim of this study was to review recent evidence regarding interventions to control bleeding during laparoscopic myomectomy. The use of vasopressin resulted in less blood loss compared to placebo. Barbed sutures reduced blood loss compared to conventional sutures. Intravenous infusion of tranexamic acid (TXA) in the intraoperative period of large myomectomies showed no significant difference compared to placebo. Uterine artery occlusion (UAO) and emergency uterine artery embolization were reported to be feasible and may reduce and treat bleeding before conversion to laparotomy. Several methods can control bleeding during laparoscopic myomectomy. Vasopressin and barbed sutures resulted in decreased blood loss, and TXA did not have an impact on bleeding control. The use of UAO and emergency embolization techniques can contribute to the control of bleeding; however, further studies are needed to prove the efficacy of these and other agents.