Uterine Reconstruction Research Articles

Successful Pregnancy After Fertility-Sparing Local Resection and Uterine Reconstruction for Low-Grade Endometrial Stromal Sarcoma

Fertility-sparing management of endometrial stromal sarcoma has been demonstrated, but reports of pregnancy after such management are rare in our current body of literature. A 16-year-old nulligravid adolescent girl presented with symptoms of menometrorrhagia and was found to have a 17-cm uterine mass. The patient underwent local resection of the mass with uterine reconstruction. Pathology revealed a low-grade endometrial stromal sarcoma. She was placed on high-dose daily megestrol acetate therapy and remained disease-free for 8 years before achieving pregnancy spontaneously. The patient underwent an uncomplicated pregnancy until 34 weeks of gestation, when she presented in preterm labor and underwent cesarean delivery of a liveborn male neonate, with no evidence of disease recurrence. Fertility-sparing management and close follow-up of low-grade endometrial stromal sarcoma may be a viable option for those desiring future fertility.

Laparoscopic Resection of a Non-Communicating Rudimentary Horn from a Unicornuate Uterus and Uterine Reconstruction

Laparoscopic Resection of a Non-Communicating Rudimentary Horn from a Unicornuate Uterus and Uterine Reconstruction

Criteria for Choosing the Optimal Myometrial Incision During Laparoscopic Myomectomy

During laparoscopic myomectomy, the orientation and location of the myometrial incision have implications for operative blood loss, ease of uterine reconstruction, and future adhesion risk. Poorly chosen incisions may increase the risk of excessive blood loss, surgical inefficiency, technical difficulty with incisional closure, and postoperative adhesions adversely affecting fertility. This video uses computer generated animation and surgical footage to review criteria that should be used when planning the location and orientation of the myometrial incision during laparoscopic myomectomy.

Conservative management of a myxoid endometrial stromal sarcoma in a 16-year-old nulliparous woman

Background. Sarcomas comprise less than 1% of all gynecological cancers and 2% to 5% of all uterine malignancies, of which endometrial stromal sarcoma accounts for approximately 15%. Surgery is fundamental in sarcoma management and a total hysterectomy is performed in the majority of cases. Case. Presented is a case of low-grade myxoid endometrial stromal sarcoma in a nulliparous adolescent female managed by local resection and uterine reconstruction. Conclusion. In selected cases, the initial management of a localized and well defined low-grade endometrial stromal sarcoma could potentially be conservative (uterine-sparing) surgical resection.

Figure-of-eight suture for uterine wall reconstruction in laparoscopic myomectomy

Figure-of-eight suture for uterine wall reconstruction in laparoscopic myomectomy

A 7.5-MHz finger-grip ultrasound probe for real-time intraoperative guidance during complex reproductive surgical procedures

Objective: A 7.5-MHz finger-grip probe was used to monitor intra-abdominal reproductive surgery in two groups of patients. Study Design: The first group of patients underwent transabdominal myomectomy for multiple uterine leiomyomas (n = 3) and the second group underwent uterine reconstruction and excision of obstructive uterine horn (n = 3). Intraoperative real-time imaging was accomplished by direct application of the finger-grip probe to the uterine serosa by using saline solution as a transmission media. Ultrasound imaging and surgical dissection were carried out both sequentially and simultaneously. Results: In the first group of patients, the finger-grip probe provided precise location of the leiomyomas and intraoperative guidance for dissection during the myomectomy. In the second group of patients, the finger probe provided images of intrauterine anatomy in one patient who had a normal-sized and normal-shaped uterus with an obstructed intracavitary horn and hematometrium. In two other patients, the obstructed uterine horn extended deep into the pelvis lateral to the vagina. Real-time imaging provided intraoperative monitoring of depth of dissection into the paravaginal space. Conclusion: The finger-grip probe demonstrated intrauterine anatomy and enabled a more directed surgical approach, both in placement of uterine incisions for surgical reconstruction and excision of obstructed horns for mullerian abnormalities and in identification and dissection for leiomyomas. (Am J Obstet Gynecol 2002;187:1588-90.)

Uterine Reconstruction for Complete Septate Uterus.

In the period between 1990-1995, six women with complete septate uterus presented to our clinic and underwent uterine reconstruction using our own unique procedure, a method we independently developed using the Jones & Jones procedure and the Thompkins procedure for reference. Five of these 6 cases later became pregnant, and to date, they have given birth to 7 newborns. Because of a very high rate of successful postoperative pregnancy, we were convinced that uterine reconstruction is useful for complete septate uterus.

Laparoscopic myomectomy with uterine reconstruction is a safe surgical procedure

Laparoscopic myomectomy with uterine reconstruction is a safe surgical procedure

Uterine myomata and outcome of assisted reproduction.

The aim of this work was to study the effect of uterine myomata on the implantation rate and outcome in in-vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI). Among 406 patients, 51 (12.6%) were found to have uterine corporeal myomata. Twelve patients were excluded from the study as they had large myomata, submucous myomata or intramural myomata encroaching on the cavity. These patients were advised to have myomectomy before being enrolled in the IVF/ICSI programme. The remaining patients (n = 39) were sorted according to the number, site and size of the myomata as assessed by transvaginal sonography. Three patients had more than one myoma. Most of the myomata were subserous (72.7%) and the mean diameter of the myomata was 3.5 +/- 0.9 cm. A control group (n = 367) was chosen with normal uteri and no history of uterine reconstruction surgery. The mean age of myoma patients was 34.7 +/- 3.6 years as compared to 34.0 +/- 4.4 years in the control group. The age, period of infertility, body mass index, duration and number of human menopausal gonadotrophin ampoules needed for stimulation, oestradiol levels, number of oocytes retrieved and the fertilization rate were not significantly different in the myoma patients compared to the control group. Fifteen myoma patients (38.5%) subsequently showed one or more pregnancy sacs on ultrasonography of which three (20%) spontaneously aborted during the first trimester and two (13.3%) had preterm labour, as compared to 123 (33.5%), 19 (15.5%) and nine (7.3%) respectively, among the control group (P = 0.27, 0.33 and 0.21). In conclusion, uterine corporeal myomata, not encroaching on the cavity and <7 cm in mean diameter, do not affect the implantation or miscarriage rates in IVF or ICSI.

Laparoscopic-assisted transvaginal myomectomy

We conducted a retrospective review of 21 combined laparovaginal myomectomies to treat extensive and deeply infiltrating fundal and posterior wall leiomyomata. Laparoscopy confirmed the size, and position of leiomyomata, permitted intramyometrial vasopressin infiltration, and allowed partial enucleation of large and deep myomata. Posterior colpotomy permitted delivery of myomata and uteri, and uterine reconstruction by conventional suturing performed transvaginally. The uteri were then placed in their anatomic position, the colpotomies were repaired, and a final laparoscopic survey and lavage were performed. All surgeries were successfully completed without intraoperative or postoperative complications. This approach allows a layered traditional uterine reconstruction of deep myometrial defects and may enhance the ability to repair extensive uterine defects in a minimally invasive fashion.

Treatment of placental site trophoblastic tumor with hysterotomy and uterine reconstruction

Placental site trophoblastic tumor is an unusual variant of gestational trophoblastic neoplasia that is usually confined to the uterus, although 10% of patients have metastases. Because this tumor occurs in women of reproductive age, preservation of fertility may be relevant. Therefore, local excision of placental site trophoblastic tumor by hysterotomy may have a place in management. A 25-year-old woman, gravida 1, para 1, presented with irregular bleeding. Uterine curettage revealed intermediate trophoblasts that on immunostaining were positive for hCG and human placental lactogen, consistent with placental site trophoblastic tumor. Endovaginal ultrasonography and magnetic resonance imaging demonstrated tumor localized to the anterior fundal myometrium. The patient underwent local excision of the tumor by hysterotomy followed by uterine reconstruction. Pathologic examination confirmed that the surgical margins were free of tumor. The patient has had no recurrence. Two subsequent pregnancies resulted in two spontaneous abortions. A third pregnancy was carried to term. The patient was delivered by cesarean because of the hysterotomy. The hysterotomy scar was intact at cesarean. Hysterectomy has been recommended by most authors for treatment for placental site trophoblastic tumor. In some patients with localized placental site trophoblastic tumor who desire preservation of fertility, more conservative surgical therapy may be considered.