Uterine Preservation Research Articles

Transvaginal hysteropexy to levator myorrhaphy: A novel technique for uterine preservation.

Levator myorrhaphy may provide an alternative surgical option for hysteropexy without the use of mesh materials.

Laparoscopic Mesh Sacrohysteropexy: A Uterine Conserving Technique for Uterovaginal Prolapse

Video Objective The purpose of the video is to describe the surgical technique involved in performing laparoscopic mesh sacrohysteropexy. A brief review of the outcomes from a 10 year retrospective single centre cohort study will be discussed. Setting Laparoscopic mesh sacrohysteropexy is a uterine conserving surgical technique for the management of apical vaginal prolapse. Interventions Laparoscopic mesh sacrohysteropexy involves fixing non-absorbable mesh from the posterior cervix to the sacral promontory. This is then covered with peritoneum from the para-rectal space. Conclusion A ten year retrospective cohort study has demonstrated success in 86% of patients with no further vaginal surgery required during the follow up period. This technique is useful for women wishing uterine preservation or for women who would be unable to tolerate a longer procedure such as a laparoscopic hysterectomy and sacrocolpopexy.

1538 Incidence of Gynecologic Cancers in Women after Uterine Fibroid Embolization

Study Objective To estimate the likelihood that patients who have undergone uterine fibroid embolization (UFE) for leiomyomata will go on to develop subsequent gynecologic cancer that may have been prevented with hysterectomy. Design We identified women over 18 years old without prior diagnosis of cancer who had undergone UFE for treatment of leiomyomata in the MarketScan database between 2007 and 2016. Records were then electronically queried for any diagnostic or procedure codes (ICD9, ICD10, and CPT) related to uterine, cervical, tubal, or ovarian malignancies occurring after the UFE procedure date through the end of data available. All charts identified through electronic query had all codes manually reviewed by a minimum of three coders to confirm diagnosis of cancer, and discrepancies were resolved by consensus. Diagnosis of cancer was defined as having at least two codes for gynecological malignancy submitted at least one week apart and/or with malignancy codes linked to tissue pathology results. Descriptive statistics were generated for the final study sample. Setting N/A Patients or Participants Patient data was obtained from MarketScan, a database of diagnostic and treatment data for over 60 million commercially insured individuals in the US. Interventions N/A Measurements and Main Results Between 2007 and 2016, 20,575 women underwent UFE. Fifty-one women met criteria for exhibiting cancer after UFE (37/51, 73% uterine cancer; 13/51, 25% ovarian cancer; 1/51, 2% cervical cancer). One in 403 (95% CI: 1 in 354 to 1 in 469) women undergoing UFE developed a gynecologic malignancy. On average, women exhibited cancer within 2.3 years from the date of UFE with a standard deviation of ±2.14 years and a range of 17 days to 7.8 years. Conclusion A small fraction of women undergoing UFE develop subsequent gynecologic malignancies. Women choosing uterine preservation with UFE should be counseled about the risk of developing gynecologic malignancies in the future, some of which may be preventable with hysterectomy.

What Is New in Uterine Conservation in the Clinical Setting of Uterovaginal Prolapse?: Best Articles From the Past 5 Years.

This month we focus on current research in uterine conservation at the time of uterovaginal prolapse repair. Dr. Richter discusses four recent publications, which are concluded with a "bottom line" that is the take-home message. A complete reference for each can be found on on this page along with direct links to the abstracts.

Surgical Resection with Uterine Preservation in Uterine Arteriovenous Fistula: A Case Report and Literature Review

Abstract Background: Uterine arteriovenous fistula (UAVF), a rare condition, usually occurs in females of reproductive age and is commonly diagnosed in those with histories of myometrial traumas. U...

Effects of uterine preservation on long-term subjective outcomes of sacrospinous ligament fixation for the treatment of pelvic organ prolapse

ObjectiveTo evaluate the long-term subjective outcomes in women who underwent sacrospinous ligament fixation with and without uterine preservation for treatment of uterovaginal prolapse. Study designTwo hundred and ten women with POP-Q≧stage III uterovaginal prolapse, who underwent sacrospinous ligament fixation from January 1994 to December 2007 were included. Patient Global Impression of Improvement was used to assess the surgical outcome in July 2016. Primary outcome measures were subjective success rate and current satisfaction. Kaplan-Meier method and Cox proportional hazard model were used for analysis. ResultsThe mean follow-up was 13.3 years (range 8.5–22.6 years). One hundred and thirty-nine patients were successfully interviewed and analyzed. The cumulative subjective success rate was 88.5% and current satisfaction was 77.7%. The repeat surgery rate was 2.9%. There were no significant differences in subjective success (89% vs. 88%) or current satisfaction (78.1% vs. 77.3%) between uterine preservation (n = 64) and concomitant hysterectomy (n = 75). Kaplan-Meier analysis showed that sacrospinous ligament fixation with uterine preservation had a better subjective outcome at mid-term follow-up but was not significantly different compared with concomitant hysterectomy after long-term follow-up (P = 0.63). The adjusted HR of uterine preservation was 0.75 (95%CI: 0.22–2.12, P = 0.59). ConclusionSacrospinous ligament fixation with or without uterine preservation in the treatment of women with uterovaginal prolapse has no significant difference in long-term subjective outcomes and patient satisfaction.

Manchester Repair as A Uterine Preservation Surgery

Uterine preservation surgery in uterovaginal prolapse is beginning to be relooked at more vigorously now. The need for uterine preservation surgery is for the reasons of desire for future fertility, maintaining sexual function and sense of identity for the woman. Incontinence and pelvic organ prolapse (POP) have an impact on sexuality.

WITHDRAWN: Effects of Uterine Preservation on Long-term Subjective Outcomes of Sacrospinous Ligament Fixation for the treatment of Pelvic Organ Prolapse

This article has been withdrawn at the request of the author(s) and/or editor. The Publisher apologizes for any inconvenience this may cause. The full Elsevier Policy on Article Withdrawal can be found at https://www.elsevier.com/about/our-business/policies/article-withdrawal.

Fibroid Expulsion after Uterine Artery Embolization.

Uterine artery embolization (UAE) is a ubiquitous procedure, and a broadly recognized alternative to surgical interventions for symptomatic leiomyomata when uterine preservation is desired. Aside from postembolization syndrome (typically considered an expected feature of recovery), the most frequently described complications are temporary or permanent amenorrhea and lingering vaginal discharge. Less frequently described complications include fibroid expulsion (FE), protracted or refractory pain, infection, urinary retention, and access-related injuries. Reported rates of transcervical FE vary in the literature from 3 to 50% but are most often quoted to be around 5 to 15%. Certain features predispose a patient to FE, including size and location of the tumor, with pedunculated submucosal, submucosal, and transmural lesions considered to be "high risk." While the optimal management of FE has not been definitively determined, high rates of nonoperative management of FE are noted in the literature. This article describes a case in which a fibroid was expulsed following UAE, as well as the management of the complication. A literature review and recommendations for the management of FE is also given.

Self-reported physical, mental, and reproductive sequelae after treatment of abnormally invasive placenta: a single-center observational study.

To analyze the types of treatment of abnormally invasive placenta (AIP) and to investigate the self-reported physical and mental short- and long-term sequelae. This single-center observational study was performed between 2003 and 2017. Women with prenatal or intrapartum diagnosis of AIP were identified through the departmental database. Classification was performed according to the time of diagnosis establishment and the type of treatment. Medical complications overall and according to the type of treatment were analyzed. Data about women's perception of diagnosis, treatment, and short- and long-term sequelae were gathered by questionnaire. Cases were classified into four groups: prenatal diagnosis, cesarean hysterectomy (A, n = 10); prenatal diagnosis, expectant management (B, n = 19); intrapartum diagnosis, cesarean hysterectomy (C, n = 6); intrapartum diagnosis, conservative therapy (D, n = 20). Depth of invasion, total units of transfused red blood cells, and the need for reoperation differed between the treatment groups. Expectant management was successful in 94.7% of cases. Irrespective of the treatment group, 73.3% of women perceived the condition as serious or life-threatening; 30.0% utilized psychological support; and 36.7% reported persistent pain or problems. 37.5% of women after uterine preservation had another live birth, AIP recurred in 44.4% of cases. Conservative management of AIP is feasible in selected cases. The condition is perceived as life-threatening and has a lasting impact on the physical, mental, and reproductive health of those affected. This finding merits further investigation. AIP continues to be a condition with high morbidity.

Doit-on réaliser systématiquement une hystérectomie subtotale dans le cadre d’une promontofixation cœlioscopique ?

ObjectiveTo evaluate the place of subtotal hysterectomy during laparoscopic sacrocolpopexy. MethodsThis retrospective observational study includes patients undergoing laparoscopic sacrocolpopexy between November 2010 and March 2015 at the Centre Hospitalier Régional de la Citadelle, Liège, Belgium. Patient characteristics, medical and surgical history were collected. Clinical data, operative and intraoperative complications were analyzed. The postoperative results were collected at 6 weeks, 4 months and then every year with a clinical and anatomical evaluation by POP-Q (Pelvic Organ Prolapse - Quantification). ResultsNinety-four patients were included in the study. Sixty-four patients (68.1%) underwent sacrocolpopexy with subtotal hysterectomy, 12 patients (12.7%) had sacrocolpopexy with uterine preservation, 16 patients (17%) had a clinical history of hysterectomy and 2 patients (2.2%) have had sacrocolpopexy with total hysterectomy. The mean age of the patients was 61±20 years, parity 2±2 and BMI 25.2±7.32. The objective success rate, defined by a stage of POP-Q<2, was 93.75% in the sacrocolpopexy group with subtotal hysterectomy vs. 66.7% in the sacrocolpopexy group with uterine preservation (P=0.019). The subjective success rates were 98.4% and 83% respectively (P=0.063ns). ConclusionSacrocolpopexy offers good anatomical results, with better objective and subjective success rates when associated with a subtotal hysterectomy. The decision of hysterectomy should consider the risk/benefit balance and the patient's preferences.

Utero-ovarian preservation and overall survival of young women with early-stage borderline ovarian tumors.

To examine survival of women who had uterine and ovarian preservation during surgical treatment for early-stage borderline ovarian tumors (BOTs). The Surveillance, Epidemiology, and End Results Program was used to identify women aged < 50years with stage I BOTs who underwent ovarian conservation at surgical treatment between 1988 and 2003. Survival outcomes were examined based on the use of concurrent hysterectomy at surgery. Among 6379 cases of BOT, there were 1065 women who had utero-ovarian preservation at surgery, and there were 52 women who had hysterectomy with ovarian preservation alone. Women who had uterine preservation were more likely to be single and diagnosed in recent years (both, P < 0.05). On univariable analysis, women who had utero-ovarian preservation had cause-specific survival similar to those who had ovarian preservation alone without uterine preservation (10-year rates: 99.2% versus 98.1%, P = 0.42); however, overall survival was higher in the utero-ovarian preservation group compared to the hysterectomy group (95.8% versus 87.6%, P < 0.001). On multivariable analysis, utero-ovarian preservation remained an independent prognostic factor for improved overall survival (adjusted hazard ratio 0.35, 95% confidence interval 0.15-0.79, P = 0.012). Cardiovascular disease mortality was lower in the utero-ovarian preservation group compared to the hysterectomy group, but it did not reach statistical significance (20-year cumulative rate, 0.8% versus 3.0%, P = 0.29). Our study suggests that utero-ovarian preservation for young women with early-stage BOTs may be associated with improved overall survival compared to ovarian preservation alone without affecting BOT-related survival outcome.

New dedicated blunt straight needles and sutures for uterine compression sutures: a retrospective study and literature review

BackgroundWe developed a dedicated blunt straight needle with No. 2 polydioxanone sutures (2-Monodiox®) for uterine compression sutures (UCSs) and aimed to assess the outcomes and complication rates of UCSs for postpartum hemorrhage by comparing with commercially available needle and suture types.MethodsA retrospective analysis was performed between January 2010 and February 2018. During the study period, two types of commercially available sutures and 2-Monodiox® were used. PubMed, MEDLINE, and Scopus databases were searched for English articles published between January 1997 and May 2017 using search terms related to the suture and needle types for UCSs to discuss the dedicated needles and sutures for UCS.ResultsThe analysis included 47 cases of UCSs for the uterine body with three suture types (No. 0 polydioxanone, 7 cases; No. 1 poliglecaprone 25, 21 cases; and No. 2 polydioxanone, 19 cases). B-Lynch suture using No. 0 sutures was associated with a significantly lower uterine preservation rate than those with Nos. 1 and 2 sutures (42.9% vs. 95.2 and 89.5%, respectively; p < 0.01). A modified Hayman suture technique was performed using 2-Monodiox® sutures, which achieved a similar uterine preservation rate compared with B-Lynch suture using No. 1 poliglecaprone 25 sutures. No patients developed severe complications. The literature review showed that no dedicated sutures have developed for UCSs. Three dedicated needles for UCSs have been developed, and 2-Monodiox® is the first dedicated blunt straight needle for UCSs.ConclusionOur data showed that No. 0 sutures should not be used for B-Lynch suture. The uterine preservation rate is similar for 2-Monodiox® with modified Hayman suture and No. 1 poliglecaprone 25 sutures with B-Lynch suture, without the occurrence of severe complications.

Uterine preservation surgery in severe postpartum haemorrhage: What impact on reproductive function?

Introduction: Postpartum haemorrhage (PPH) remains one of the most risky situations in obstetrics and major cause of maternal morbidity and mortality worldwide. There can be major psychological sequelae also. Treatment options for PPH include conservative management with uterotonic drugs, selective devascularization by ligation or embolization of the uterine artery, external compression with uterine sutures, intrauterine balloon and hysterectomy. This last issue adds to the maternal drama of a situation with definitive infertility. The choice of treatment depends on several factors: delivery mode, the site of origin and volume of bleeding, the patient's hemodynamic tolerance, the technical possibility and the surgical skills.

Laparoscopic sacrohysteropexy for management of uterovaginal prolapse

Introduction: Increasingly there are interests in uterine conservation surgery using mesh suspension as traditional vaginal hysterectomy does not address poor connective tissue support issue.

Uterine-preserving surgeries for the repair of pelvic organ prolapse: a systematic review with meta-analysis and clinical practice guidelines.

We aimed to systematically review the literature on pelvic organ prolapse (POP) surgery with uterine preservation (hysteropexy). We hypothesized that different hysteropexy surgeries would have similar POP outcomes but varying adverse event (AE) rates. MEDLINE, Cochrane, and clinicaltrials.gov databases were reviewed from inception to January 2018 for comparative (any size) and single-arm studies (n ≥ 50) involving hysteropexy. Studies were extracted for participant characteristics, interventions, comparators, outcomes, and AEs and assessed for methodological quality. We identified 99 eligible studies: 53 comparing hysteropexy to POP surgery with hysterectomy, 42 single-arm studies on hysteropexy, and four studies comparing stage ≥2 hysteropexy types. Data on POP outcomes were heterogeneous and usually from <3years of follow-up. Repeat surgery prevalence for POP after hysteropexy varied widely (0-29%) but was similar among hysteropexy types. When comparing sacrohysteropexy routes, the laparoscopic approach had lower recurrent prolapse symptoms [odds ratio (OR) 0.18, 95% confidence interval (CI) 0.07-0.46), urinary retention (OR 0.05, 95% CI 0.003-0.83), and blood loss (difference -104ml, 95% CI -145 to -63ml) than open sacrohysteropexy. Laparoscopic sacrohysteropexy had longer operative times than vaginal mesh hysteropexy (difference 119min, 95% CI 102-136min). Most commonly reported AEs included mesh exposure (0-39%), urinary retention (0-80%), and sexual dysfunction (0-48%). Hysteropexies have a wide range of POP recurrence and AEs; little data exist directly comparing different hysteropexy types. Therefore, for women choosing uterine preservation, surgeons should counsel them on outcomes and risks particular to the specific hysteropexy type planned.

Methotrexate infusion followed by uterine artery embolisation for the management of placental adhesive disorders: a case series

To evaluate the efficacy and safety of the uterine artery embolisation (UAE) in combination with methotrexate (MTX) for conservative management of placental adhesive disorders. Patients with placental adhesive disorders (including accreta, increta, and percreta lesions) that were treated with UAE in combination with MTX were identified and were followed prospectively for outcomes including uterine preservation and complications. Twenty-six patients were identified who had the diagnosis of abnormal placenta implantation during this study. Fourteen patients were excluded because they were treated by a caesarean hysterectomy. Among remaining 12 patients, the successful uterine preservation observed in seven (58%) cases. Menstruation cycles returned in all successfully treated patients, although they did not have desire to get pregnant. Five (42%) patients underwent primary or delayed hysterectomy due to severe post-partum haemorrhage in three cases, and intestinal adhesion/peritonitis and secondary post-partum haemorrhage/sepsis in two patients, respectively. Although this interventional method is relatively successful in uterine preservation, the possibility of treatment failure cannot be ignored. Given that there are too few data regarding its efficacy and safety, this method should be reserved to patients who have a strong desire to maintain the uterus and their fertility, or if it is technically difficult to perform hysterectomy due to the extent of the invasion.

Impact of nonpneumatic antishock garment in the management of patients with hypoperfusion due to massive postpartum hemorrhage

Objective: The objective of this article was to compare hemodynamic and perfusion parameters as well as the clinical outcomes in critically ill patients with postpartum hemorrhage (PPH) who received treatment with a nonpneumatic antishock garment (NASG) as part of an intervention package, with a group of patients in similar conditions who did not receive an NASG. Methods: This observational study analyzed a historic cohort of 154 patients with PPH, secondary hypovolemic shock and signs of hypoperfusion who were admitted to this institution from 2012 to 2015. Group 1 (n= 77) was managed with NASG and Group 2 (n = 77) received interventions other than NASG. Hypoperfusion markers and maternal outcomes were compared in both groups. Results: Of 154 patients included in the analysis, 36.4% required a total abdominal hysterectomy (TAH) to achieve hemorrhage control, 98.2% of whom belonged to Group 2 and 1.8% to Group 1 (p = .001). The use of blood products was more common in Group 2 (p < .001), as was the administration of vasoactive agents. The mean number of days of hospitalization at the Obstetric High Dependency Unit (OHDU) was significantly lower in Group 1 and reached a statistically significant p value. Only two cases of maternal death occurred in Group 2. Discussion: The use of NASG in the management of PPH is a cost-effective strategy for patients with severe shock and signs of hypoperfusion and is optimal in a limited-resource scenario. In this study, the use of NASG was related to better outcomes in a statistically significant manner with better results regarding maternal outcomes such as uterine preservation and decreased transfusion requirements and hospital days. Conclusions: NASG, associated with the use of uterotonic agents and other strategies for PPH control, is a safe tool that helps reduce morbimortality in critically ill patients with PPH.

Two approaches for placenta accreta spectrum: B-lynch suture versus pelvic artery endovascular balloon

Purpose: Management of patients with placenta accreta spectrum (PAS) varies widely, and scarce data exist concerning its management. The current study compared two different surgical approaches in the management of PAS: the B-lynch approach (Group A) compared to the endovascular balloon catheters (Group B)Methods: A retrospective cohort study in two tertiary university-affiliated hospitals between the years 2004 and 2015. Elective cesarean section was planned at 35–37 weeks of gestation. One center utilized the B-lynch approach and the second utilized the endovascular balloon catheter approach.Results: The cesarean hysterectomy rate was significantly higher in the Group A approach compared to Group B (36.1 versus 29.2%, p = .00). The number of packed cells units administered during and postoperatively were higher in the Group A compared with Group B (p = .006 and .043, respectively). Overall, surgery length and hospitalization duration were shorter in patients who underwent cesarean hysterectomy compared with those who underwent uterine preservation (B-lynch or endovascular balloon catheters) (p = .000 and p = .004, respectively).Conclusions: The endovascular balloon technique seems to be a better option for uterine preservation due to less blood loss and higher postoperative hemoglobin level. Nevertheless, for those women who have completed their family planning, cesarean hysterectomy with the placenta left in situ is the safer and more suitable option.

Local resection for placenta accreta spectrum: a conservative uterus sparing technique for anterior placenta accreta

Objective: To evaluate and describe a surgical approach for uterine preservation and management of postpartum hemorrhage in placenta accreta spectrum (PAS). Methods: We analyzed the data of patients who were diagnosed with placenta previa companied with PAS prenatally and subsequently performed cesarean section with local resection technique to manage postpartum hemorrhage and uterine preservation at our tertiary care center between January 2016 and August 2017. The technique includes the local resection of placental invasion site and suturing the new uterine edges without internal iliac artery ligation. Results: The diagnosis of placenta accreta spectrum anterior in all 11 cases was confirmed intraoperatively. Only 1 case underwent hysterectomy in a second operation. Two of cases had bladder injury. The mean operative time was 99 ± 30 minutes. The mean received packed red blood cells was 2.3 ± 1.0 units. The mean length of postoperative hospital stay was 4.5 ± 1.4 days. There was no late complications regarding coagulopathy and infection. No maternal mortality was observed. Conclusion: Local resection is an effective, safe and fertility preserving approach in selected patients with PAS.