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OBJECTIVE: To study the effectiveness of a new intrauterine degradable polymer film (Womed Leaf) in the management of moderate to severe intrauterine adhesions (IUA). DESIGN: PREG-2 study was a multicenter, double-blind, randomized, controlled, stratified, two-arm superiority clinical trial conducted in 16 centers in seven countries. SETTING: Not applicable. PATIENT(S): Patients ≥18 years scheduled for hysteroscopic adhesiolysis because of symptomatic severe or moderate adhesions (according to American Fertility Society [AFS] IUA score) were considered eligible for the study. INTERVENTION(S): After adhesiolysis, patients were randomized at a 1:1 ratio to either have a Womed Leaf film inserted (intervention group) or not (control group). MAIN OUTCOME MEASURE(S): The primary effectiveness endpoint of the study was the change in AFS IUA score on second-look hysteroscopy (SLH), assessed by an independent evaluator, and compared with baseline. Information on the rate of no IUA and responder rate was collected as secondary effectiveness outcomes, while reported adverse events and patient-reported outcomes as safety and tolerability measures. RESULT(S): Between October 26, 2021, and September 28, 2023, a total of 160 women were randomized (Womed Leaf: n = 75 and controls: n = 85). The reduction in IUA AFS score on SLH was significantly higher in the intervention compared with the control group (mean 5.2 ± 2.8 vs. 4.2 ± 3.2). Similarly, the absence of adhesions on SLH was significantly higher in the intervention group (41% vs. 24%; odds ratio, 2.44; confidence interval, 1.161-5.116). None of the reported adverse events were serious or considered related to the device. CONCLUSION(S): Womed Leaf is effective and safe in the management of symptomatic severe or moderate IUAs. CLINICAL TRIAL REGISTRATION NUMBER: Clinicaltrials.gov identifier: NCT04963179.
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INTRODUCTION: This was a single-center pilot study that sought to describe an innovative use of 4DryField® PH (premix) for preventing the recurrence of intrauterine adhesions (IUAs) after hysteroscopic adhesiolysis in patients with Asherman's syndrome (AS). MATERIAL AND METHODS: Twenty-three patients with AS were enrolled and 20 were randomized (1:1 ratio) to intrauterine application of 4DryField® PH (n = 10) or Hyalobarrier® gel (n = 10) in a single-blind manner. We evaluated IUAs (American Fertility Society [AFS] score) during initial hysteroscopy and second-look hysteroscopy one month later. Patients completed a follow-up symptoms questionnaire three and reproductive outcomes questionnaire six months later. RESULTS: The demographic and clinical characteristics, as well as severity of IUAs, were comparable in both groups. The mean initial AFS score was 9 and 8.5 in the 4DryField® PH and Hyalobarrier® gel groups, respectively (p = .476). There were no between-group differences in AFS progress (5.9 vs. 5.6, p = .675), need for secondary adhesiolysis (7 vs. 7 patients, p = 1), and the follow-up outcomes. CONCLUSION: 4DryField® PH could be a promising antiadhesive agent for preventing the recurrence of IUAs, showing similar effectiveness and safety to Hyalobarrier® gel. Our findings warrant prospective validation in a larger clinical trial. CLINICAL TRIAL REGISTRY NUMBER: ISRCTN15630617.
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Three main uterine leiomyoma molecular subtypes include tumors with MED12 mutation, molecular aberrations leading to HMGA2 overexpression, and biallelic loss of FH. These aberrations are mutually exclusive and can be found in approximately 80-90% of uterine leiomyoma, in which they seem to be a driver event. Approximately 10% of uterine leiomyoma, however, does not belong to any of these categories. Uterine leiomyoma with HMGA2 overexpression is the most common subtype in cellular and second most common category of usual leiomyoma. In some of these tumors, rearrangement of HMGA2 gene is present. The most common fusion partner of HMGA2 gene is RAD51B. Limited data suggests that RAD51B fusions with other genes may be present in uterine leiomyoma. In our study, we described two cases of uterine leiomyoma with RAD51B::NUDT3 fusion, which occur in one case of usual and one case of highly cellular leiomyoma. In both cases, no other driver molecular aberrations were found. The results of our study showed that RAD51::NUDT3 fusion can occur in both usual and cellular leiomyoma. RAD51B may be a fusion partner of multiple genes other than HMGA2 and HMGA1. In these cases, RAD51B fusion seems to be mutually exclusive with other driver aberrations defining molecular leiomyoma subtypes. RAD51B::NUDT3 fusion should be added to the spectrum of fusions which may occur in uterine leiomyoma, which can be of value especially in cellular leiomyoma in the context of differential diagnosis against endometrial stromal tumors.
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OBJECTIVE: The aim of this study was to analyze the clinical and reproductive outcomes of patients treated with myomectomy who were histologically diagnosed with uterine smooth muscle tumor of uncertain malignant potential (STUMP). METHODS: Patients who were diagnosed with STUMP and underwent a myomectomy at our institution between October 2003 and October 2019 were identified. Variables of interest obtained from the institution's database included patient age, relevant medical history, pre-operative appearance of the tumor on ultrasound, parameters of the surgical procedure, histopathological analysis of the tumor, post-operative clinical course, and course of follow-up, including reinterventions and fertility outcomes. RESULTS: There were a total of 46 patients that fulfilled the criteria of STUMP. The median patient age was 36 years (range, 18-48 years) and the mean follow-up was 47.6 months (range, 7-149 months). Thirty-four patients underwent primary laparoscopic procedures. Power morcellation was used for specimen extraction in 19 cases (55.9% of laparoscopic procedures). Endobag retrieval was used in nine patients and six procedures were converted to an open approach due to the suspicious peri-operative appearance of the tumor. Five patients underwent elective laparotomy due to the size and/or number of tumors; three patients had vaginal myomectomy; two patients had the tumor removed during planned cesarean section; and two underwent hysteroscopic resection.There were 13 reinterventions (five myomectomies and eight hysterectomies) with benign histology in 11 cases and STUMP histology in two cases (4.3% of all patients). We did not observe any recurrence as leiomyosarcoma or other uterine malignancy. We did not observe any deaths related to the diagnosis. Twenty-two pregnancies were recorded among 17 women, which resulted in 18 uncomplicated deliveries (17 by cesarean section and one vaginal), two missed abortions, and two pregnancy terminations. CONCLUSIONS: Our study found that uterus-saving procedures and fertility-preservation strategies in women with STUMP are feasible, safe, and seem to be associated with a low risk of malignant recurrence, even while maintaining the mini-invasive laparoscopic approach.
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Laparoscopía , Tumor de Músculo Liso , Miomectomía Uterina , Neoplasias Uterinas , Humanos , Femenino , Embarazo , Lactante , Preescolar , Cesárea , Tumor de Músculo Liso/patología , Útero/patología , Neoplasias Uterinas/patología , Miomectomía Uterina/efectos adversos , Laparoscopía/métodos , Fertilidad , Estudios RetrospectivosRESUMEN
OBJECTIVE: Case report of a gynecologically polymorbid patient with enhanced myometrial vascularity, and review of current scientific literature on incidence, dia-gnostic method, and management of this phenomenon. CASE REPORT: A 38-year-old patient that has been treated long-term for secondary sterility with a medical history of laparotomic cytoreduction surgery for adenomyosis and subsequent development and treatment of postoperative intrauterine adhesions. Currently presenting with enhanced myometrial vascularity after spontaneous abortion. For symptomatic prolonged course of the observation period without tendency for spontaneous regression and risk of acute hemorrhage, she was initially indicated for selective embolization of uterine arteries and consecutive definitive treatment via hysteroscopic resection. CONCLUSION: Due to low incidence and tendency for spontaneous resorption, early recognition, and correct management of enhanced myometrial vascularity, it still represents a medical challenge.
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Adenomiosis , Enfermedades Uterinas , Adulto , Femenino , Humanos , Histeroscopía , Miometrio , Embarazo , Adherencias Tisulares , Enfermedades Uterinas/cirugíaRESUMEN
OBJECTIVE: The purpose of this study was to evaluate the appropriate surgical treatment of adenomyosis and its impact on reproductive outcomes. CONCLUSION: Patients with adenomyosis and fibroids may show a lower pregnancy rate and higher miscarriage rate than healthy individuals. However, there is no standard protocol for their optimal treatment, particularly in pregnancy-seeking or infertile women. Myomectomy is generally a commonly performed procedure that preserves fertility. On the other hand, the role of surgery in extensive uterine adenomyosis remains controversial, because adenomyosis often involves the whole uterus diffusely. It is almost impossible to remove all pathological tissue from the surrounding myometrium. Therefore, this procedure is called debulking/cytoreductive surgery. However, adenomyomectomy has also become a more common type of surgical intervention in recent years.
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Adenomiosis , Infertilidad Femenina , Leiomioma , Miomectomía Uterina , Adenomiosis/complicaciones , Adenomiosis/cirugía , Femenino , Humanos , Infertilidad Femenina/etiología , Infertilidad Femenina/cirugía , Embarazo , Miomectomía Uterina/efectos adversos , Miomectomía Uterina/métodos , Útero/patología , Útero/cirugíaRESUMEN
OBJECTIVE: To summarize recent data and knowledge of laparoscopic power morcellation. METHODS: Review of articles. RESULTS: Laparoscopic morcellation has been introduced to gynecologic surgery in 90s. In 2014, Food and Drug Administration announced negative statement about the morcellation use due to the risk of potential spreading of malignant tumor cells. This statement reduced utilization of morcellation, especially in the United States. Since that, many health institutions and organizations started new researches focused on the safety of this surgical technique. After a couple of years, the morcellation is considered as a useful tool if certain rules are followed. CONCLUSION: Morcellation has a place in laparoscopic operative procedures even in 2022, in condition of correct selection of patients and possible utilization of contained in-bag morcellation.
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Laparoscopía , Leiomioma , Morcelación , Miomectomía Uterina , Neoplasias Uterinas , Femenino , Humanos , Histerectomía/métodos , Laparoscopía/métodos , Leiomioma/cirugía , Morcelación/efectos adversos , Morcelación/métodos , Estados Unidos , Miomectomía Uterina/métodos , Neoplasias Uterinas/patología , Neoplasias Uterinas/cirugíaRESUMEN
INTRODUCTION: The aim of this study was to evaluate hysteroscopic findings after laparoscopic and laparotomic myomectomy with a focus on the presence of postoperative intrauterine adhesions in groups of patients with and without perioperative uterine cavity breach (UCB). MATERIAL AND METHODS: This is a historical cohort study. Our database was searched to identify patients with UCB during myomectomy and matched the same number of patients after myomectomy without UCB to create a control group. All relevant data were retrieved from our medical records. In both groups, the results of follow-up hysteroscopy were analyzed. RESULTS: Low prevalence of intrauterine adhesions after myomectomy was observed in only 3.5% of the 170 patients in our samples. No significant difference in the occurrence of synechiae between the patients with and without UCB was found (2 vs. 4, RR 0.5, 95% CI 0.1-2.7, p = .341), nor was the difference in other hysteroscopic findings. Follow-up hysteroscopy was performed with slender optics and expandable casing system without need of any anesthesia in 87.1% of cases. CONCLUSIONS: According to our findings, the prevalence of post-myomectomy intrauterine adhesions after myomectomy is low. Our study did not demonstrate that UCB during myomectomy is a risk factor for the formation of intrauterine synechiae.
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Laparoscopía , Leiomioma , Enfermedades Uterinas , Miomectomía Uterina , Neoplasias Uterinas , Estudios de Cohortes , Femenino , Humanos , Histeroscopía/efectos adversos , Histeroscopía/métodos , Laparoscopía/efectos adversos , Laparoscopía/métodos , Leiomioma/cirugía , Embarazo , Adherencias Tisulares/epidemiología , Adherencias Tisulares/etiología , Adherencias Tisulares/cirugía , Enfermedades Uterinas/cirugía , Miomectomía Uterina/efectos adversos , Miomectomía Uterina/métodos , Neoplasias Uterinas/cirugíaRESUMEN
STUDY OBJECTIVE: Women with adenomyosis may show a lower pregnancy rate and a higher miscarriage rate than healthy women. There is also a general agreement that leiomyomas, either submucosal or intramural, negatively affect fertility, when compared with women without myomas. Some of these women may benefit from adenomyomectomy, however this cytoreductive procedure is considered invasive and technically challenging especially in severe diffuse cases. The study aimed to compare the clinical and reproductive outcomes of patients who underwent adenomyomectomy with those of patients who underwent intramural myomectomy. DESIGN: A retrospective study. SETTING: Department of Obstetrics & Gynecology, Center of Gynecological Endoscopy and Minimally Invasive surgery, First Faculty of Medicine, General University Hospital in Prague. PATIENTS: A total of 55 women who underwent surgical resection of uterine adenomyosis and 55 patients who underwent myomectomy for intramural uterine myomas were included in this study. All study participants wished to retain and possibly improve their reproductive potential. INTERVENTIONS: Between 2004 and 2019, 110 women underwent laparoscopic or open uterus-sparing surgery for clinically significant uterine adenomyosis (group A) or myomas (group B), respectively. MEASUREMENTS AND MAIN RESULTS: Two groups of women who underwent different fertility-saving procedures were compared. Although all women entering the study had declared their wish to conceive, only 28 patients in group A (group A1) and 24 women in group B (group B1) finally aimed toward pregnancy. The mean age and follow-up period was 35.0 years and 76.81 months, respectively, in group A and 34.8 years and 72.5 months, respectively, in group B. The pregnancy and delivery rates were 75.0% and 46.4%, respectively, in group A1 vs 96.0% and 70.8%, respectively, in group B1, with no significant differences between the 2 groups. The open surgical approach was significantly more frequently employed in group A (47.3% vs 16.4%; p <.01). CONCLUSION: In this study, women who underwent surgery involving the uterine muscularity, including myomectomy or adenomyomectomy, had comparable reproductive outcomes, with no significant differences.
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Adenomiosis , Laparoscopía , Leiomioma , Miomectomía Uterina , Neoplasias Uterinas , Adenomiosis/cirugía , Femenino , Humanos , Laparoscopía/métodos , Leiomioma/cirugía , Embarazo , Estudios Retrospectivos , Resultado del Tratamiento , Miomectomía Uterina/métodos , Neoplasias Uterinas/cirugíaRESUMEN
Cellular leiomyoma (CL) represents an uncommon variant of uterine leiomyoma with limited data concerning its immunohistochemical and molecular profile. We performed a comprehensive analysis of 52 CL cases all of which were analyzed immunohistochemically. Molecular analysis was possible in 32 cases with sufficient DNA, and 38 cases with sufficient RNA. The immunohistochemical results showed a high expression of smooth muscle markers (calponin (100%), desmin (100%), smooth muscle actin (98.1%), caldesmon (96.1%), transgelin (96.1%), smooth muscle myosin heavy chain (86.5%), and smoothelin (61.5%)). Concerning markers of endometrial stromal differentiation, the expression of CD10 was observed in 65.4% cases (42.2% with H-score > 50), and IFITM1 in 36.5% cases (1.9% with H-score > 50). 36.5% showed HMGA2 overexpression at the IHC level, associated with increased mRNA expression in 14/14 cases. The rearrangement of the HMGA2 gene was detected in 13.2%. Chromosome 1p deletion was found in 19.3%, while 9.4% of tumors showed a pathogenic mutation in the MED12 gene. In conclusion, CL is immunohistochemically characterized by a high expression of "smooth muscle" markers commonly associated with a co-expression of "endometrial stromal" markers, where IFITM1 shows superior performance compared to CD10 regarding its specificity for differentiation from endometrial stromal tumors. The sensitivity of smoothelin in CL seems rather low, but no data is available to assess its specificity. On a molecular level, the most common mutually exclusive aberration in CL affects HMGA2, followed by chromosome 1p deletions and MED12 mutations.
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Neoplasias Endometriales , Leiomioma , Neoplasias Uterinas , Cromosomas/química , Cromosomas/metabolismo , Neoplasias Endometriales/genética , Femenino , Proteína HMGA2 , Humanos , Leiomioma/patología , Complejo Mediador/genética , Complejo Mediador/metabolismo , Mutación , Neprilisina/análisis , Neoplasias Uterinas/patologíaRESUMEN
INTRODUCTION: This study was designed to evaluate the feasibility and effectiveness of hysteroscopy in the management of symptoms related to endometrial polyps and submucous leiomyomas in women using a levonorgestrel-releasing intrauterine system (LNG-IUS). MATERIAL AND METHODS: Twenty-three LNG-IUS users presenting with endometrial polyps and/or submucous leiomyomas and irregular uterine bleeding were recruited for hysteroscopic examination and surgery. Intrauterine pathology was investigated and treated by hysteroscopic resection with the LNG-IUS in situ, and the effect of the procedure on symptoms was evaluated after three to six months. RESULTS: Intrauterine pathology was successfully resected by hysteroscopy in 23 (100.0%) out of 23 cases. Following hysteroscopy, 18 (78.3%) women reported amenorrhea, one (4.3%) regular spotting, three (13.0%) irregular spotting and one (4.3%) patient resumed normal menstrual cycle. We conclude that 19 (82.6%) patients were postoperatively asymptomatic. All procedures were uncomplicated and 4 (17.4%) were carried out without general anesthesia as office procedures. CONCLUSION: Endometrial polyps and submucous leiomyomas can develop in LNG-IUS users, and this can cause irregular uterine bleeding. Hysteroscopic resection of these pathologies is a feasible method in the clinical management of symptoms.
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Dispositivos Intrauterinos Medicados , Leiomioma , Pólipos , Neoplasias Uterinas , Femenino , Humanos , Leiomioma/tratamiento farmacológico , Leiomioma/cirugía , Levonorgestrel/uso terapéutico , Pólipos/tratamiento farmacológico , Pólipos/cirugía , Hemorragia Uterina , Neoplasias Uterinas/tratamiento farmacológico , Neoplasias Uterinas/cirugíaRESUMEN
This paper deals with the description, measurement, and use of electromagnetic properties of ferromagnetic fibres used as dispersed fibre reinforcement in composite mixtures. Firstly, the fibres' magnetic properties are shown, and a method of measuring the hysteresis loop of fibres is proposed. The results from the measurements are presented and a discussion of the influence of measured parameters on the fibres' orientation in a magnetic field is performed. Furthermore, methods of non-destructive estimation, of their amount and orientation in the composite specimens, are discussed. The main experimental goal of this paper is to show the relationship between this non-destructive method's results and the destructive flexural strength measurements. The method is sensitive enough to provide information related to fibre reinforcement.
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INTRODUCTION: The aim was to compare the surgical experience and the clinical results of laparoscopic myomectomy (LM) with or without pre-treatment with ulipristal acetate (UPA). MATERIAL AND METHODS: Fifty-four women who underwent LM for intramural myomas and were pre-treated with three months of UPA were matched with 54 patients with the same procedure but no hormonal pre-treatment. All operations were performed by one team. The technical features of the procedures were reviewed and evaluated by two other laparoscopists, unaware of the eventual use of UPA. The clinical, histological, and reproductive outcomes of each patient were assessed and the results of both groups were compared. RESULTS: The groups did not significantly differ in operation time, intra-operative blood loss, drop in hemoglobin concentration, number of complications, pregnancy rate, and delivery rate. Women pre-treated with UPA had significantly longer hospital stays, higher numbers of histologically abnormal leiomyomas, and higher rates of fibroids peri-procedurally assessed as soft and disintegrating. The other four technical parameters of LM were comparable in both groups. CONCLUSIONS: The surgeons performing LM in women pre-treated with UPA should be aware of the abnormal texture of enucleated myomas. Nevertheless, this does not negatively affect the other surgical and clinical outcomes of these patients.
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Laparoscopía , Norpregnadienos , Miomectomía Uterina , Neoplasias Uterinas , Femenino , Humanos , Embarazo , Neoplasias Uterinas/tratamiento farmacológico , Neoplasias Uterinas/cirugíaRESUMEN
OBJECTIVE: Uterine fibroids are the most common benign tumours in women of the reproductive age. Symptoms of heavy menstrual bleeding, abdominal discomfort and infertility may seriously affect a woman's quality of life. Uterine artery embolization is a safe and effective alternative treatment to hysterectomy or myomectomy for symptomatic uterine fibroids. Which treatment provides the highest quality of life, least complications, symptom reduction and least chance intervention, has not been established and might depend on strict patient selection. This study aims to identify which specific subgroups benefit most of each treatment by analyzing individual participant data derived from randomized controlled trials of women undergoing embolization or surgical treatment. This study will primarily assess the effectiveness of both treatment groups by evaluating the effect on quality of life of embolization in comparison to surgery on specific patient and fibroid characteristics and the possible need for re-intervention for fibroid-related symptoms. DATA SOURCES: PubMed/MEDLINE, Embase and The Cochrane Library were searched up to August 2020. STUDY ELIGIBILITY CRITERIA: We will collect individual participant data from randomized controlled trials that studied clinical and procedural outcomes of premenopausal women with symptomatic uterine fibroids, who were randomized between uterine artery embolization and surgery. STUDY APPRAISAL AND SYNTHESIS METHODS: Individual participant data from all eligible trials will be sought and analysed according to intention-to-treat principle. Risk of Bias will be done by using version 2 of the Cochrane tool for Risk of Bias in randomized trials. Subgroup analyses to explore the effect of e.g. age, fibroid characteristics and fibroid complaints will be performed, if data is available. This individual patient data meta-analysis will be analysed according to a one-stage model.
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Leiomioma , Embolización de la Arteria Uterina , Miomectomía Uterina , Neoplasias Uterinas , Femenino , Humanos , Leiomioma/cirugía , Metaanálisis como Asunto , Calidad de Vida , Ensayos Clínicos Controlados Aleatorios como Asunto , Neoplasias Uterinas/cirugíaRESUMEN
Leiomyoma with bizarre nuclei (LBN) is an uncommon variant of uterine smooth muscle neoplasm. Involvement of fumarate hydratase (FH) has been suggested in the pathogenesis of a subset of LBN. The goal of our study is to assess the clinicopathological, morphological, immunohistochemical and molecular findings focusing on FH in LBNs (n = 108) and compare it with the findings in usual leiomyomas (UL; n = 50) and leiomyosarcomas (LMS; n = 42). Immunohistochemically, loss of FH expression was found in 67/108 of LBN, 1/50 of UL and in no LMS. Class 4/5 FH mutations were detected in 15/53 LBN with sufficient DNA quality for molecular analysis. Pathogenic variants of the FH gene were detected in neither UL nor LMS. Local recurrence after surgery was present in 18/92 of LBN patients, 7 of which were histologically verified and 2 of which were found to be LBN. Our results confirmed that LBN behave in a benign fashion, although they may relapse. FH gene mutations were a common finding only in LBN, but not in UL and LMS. Immunohistochemistry with an antibody against FH seems to have a good sensitivity (87%) and moderate specificity (58%) with regard to predicting FH gene mutations and could be used as a screening method in tumors with features suggestive of FH alterations to identify patients who are at risk for the FH aberrations.
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Fumarato Hidratasa/genética , Leiomioma/genética , Leiomioma/patología , Neoplasias Uterinas/genética , Neoplasias Uterinas/patología , Adulto , Anciano , Biomarcadores de Tumor/genética , Núcleo Celular/patología , Femenino , Humanos , Persona de Mediana Edad , MutaciónRESUMEN
The levonorgestrel-releasing intrauterine system (LNG-IUS) is widely used and recommended as a reliable contraceptive. It also acts by opposing the effects of estrogen on the endometrium, thereby preventing development of endometrial hyperplasia and its possible malignant transformation. This case describes a 52-year-old multiparous amenorrhoeic patient who was seen in the gynecology outpatient department for a routine control 46 months after the insertion LNG-IUS as contraception. Hysteroscopy with a target biopsy following suspicious ultrasound scan confirmed well-differentiated endometrioid adenocarcinoma. Ultrasound scan prior to inserting LNG-IUS revealed normal 5 mm thin endometrium with the sharp edges. Uterine bleeding before the LNG-IUS insertion was regular and not excessive and the woman has remained amenorrhoeic after the LNG-IUS insertion. We present a case of the growth of a polyp-shaped endometrial carcinoma in a LNG-IUS asymptomatic user.
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Carcinoma Endometrioide/diagnóstico por imagen , Anticonceptivos Femeninos/uso terapéutico , Neoplasias Endometriales/diagnóstico por imagen , Dispositivos Intrauterinos Medicados , Levonorgestrel/uso terapéutico , Pólipos/diagnóstico por imagen , Enfermedades Asintomáticas , Biopsia , Carcinoma Endometrioide/patología , Neoplasias Endometriales/patología , Femenino , Humanos , Histeroscopía , Persona de Mediana Edad , Pólipos/patología , UltrasonografíaRESUMEN
PURPOSE: Risk factors for post-surgical adhesions following gynaecological surgery have been identified, but their relative importance has not been precisely determined. No practical tool exists to help gynaecological surgeons evaluate the risk of adhesions in their patients. The purpose of the study was to develop an Adhesion Risk Score to provide a simple tool that will enable gynaecological surgeons to routinely quantify the risk of post-surgical adhesions in individual patients. METHODS: A group of European gynaecological surgeons searched the literature to identify the risk factors and the surgical operations reported as carrying a risk of post-surgical adhesions. Through consensus process of meetings and communication, a four-point scale was then used by each surgeon to attribute a specific weight to each item and collective agreement reached on identified risk factors and their relative importance to allow construct of a useable risk score. RESULTS: Ten preoperative and 10 intraoperative risk factors were identified and weighed, leading to the creation of two sub-scores to identify women at risk prior to and during surgery. The Preoperative Risk Score can range from 0 to 36, and the Intraoperative Risk Score from 3 to 31. Several thresholds between these limits may be used to identify women with low, medium, and high risk of post-surgical adhesions. CONCLUSIONS: Gynaecological surgeons are encouraged to use this Adhesion Risk Score to identify the risk of adhesions in their patients. This will allow better informed use of available resources to target preventive measures in women at high risk of post-surgical adhesions.
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Procedimientos Quirúrgicos Ginecológicos/efectos adversos , Laparoscopía , Complicaciones Posoperatorias/prevención & control , Adherencias Tisulares/prevención & control , Adulto , Anciano , Femenino , Procedimientos Quirúrgicos Ginecológicos/métodos , Humanos , Persona de Mediana Edad , Complicaciones Posoperatorias/etiología , Valor Predictivo de las Pruebas , Factores de Riesgo , Adherencias Tisulares/etiologíaRESUMEN
Uterine artery embolization (UAE) is a minimally invasive procedure with large symptomatic potential in treatment of women with uterine leiomyomas. Due to specificities of this method and possible complications the appropriate indication is crucial. Patient' symptoms, age, plans for pregnancy, and surgical and reproductive history play a major role in decision-making regarding appropriate subjects for UAE. Close cooperation between the gynecologist and the interventional radiologist is necessary. UAE is usually offered as an alternative to surgical treatment. In patients with no fertility plans, it is a less invasive option than abdominal hysterectomy, with a comparable effect on fibroid-related symptoms and quality of life. The need for reintervention is markedly greater in patients after UAE (up to 35% within 5 years) than after hysterectomy. Women with large symptomatic fibroids wishing to retain the uterus and ineligible for minimally invasive (laparoscopic or vaginal) hysterectomy are good candidates for UAE. However, studies comparing UAE with minimally invasive hysterectomy are lacking. Use of UAE in younger women desiring pregnancy is more controversial, mainly because of the significant risk of miscarriage (as high as 64% in some studies) as well as the increased risk of other complications of pregnancy, such as preterm delivery, abnormal placentation, and post-partum hemorrhage. The risk of infertility or subfertility following UAE is unknown. Even poor candidates for myomectomy should be carefully selected for UAE after counseling about all possible adverse effects on fertility. Good prospective studies focused on fertility comparing UAE with no treatment or with myomectomy are needed but would be ethically questionable. This review summarizes the current knowledge regarding the benefits and potential risks of UAE from the point of view of the gynecologist, who should be responsible for proper indication of this treatment.
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The present survey was conducted among gynaecological surgeons from several European countries to assess the actual knowledge and practice related to post-surgical adhesions and measures for reduction. From September 1, 2012 to February 6, 2013, gynaecological surgeons were invited to answer an 18-item online questionnaire accessible through the ESGE website. This questionnaire contained eight questions on care settings and surgical practice and ten questions on adhesion formation and adhesion reduction. Four hundred fourteen surgeons participated; 70.8 % agreed that adhesions are a source of major morbidity. About half of them declared that adhesions represented an important part of their daily medical and surgical work. About two thirds informed their patients about the risk of adhesion. Most cited causes of adhesions were abdominal infections and extensive tissue trauma, and endometriosis and myomectomy surgery. Fewer surgeons expected adhesion formation after laparoscopy (18.9 %) than after laparotomy (40.8 %); 60 % knew the surgical techniques recommended to reduce adhesions; only 44.3 % used adhesion-reduction agents on a regular basis. This survey gives a broad picture of adhesion awareness amongst European gynaecological surgeons, mainly from Germany and the UK. The participants had a good knowledge of factors causing adhesions. Knowledge of surgical techniques recommended and use of anti-adhesion agents developed to reduce adhesions need to be improved.
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AIM: This study was designed to evaluate feasibility and effectiveness of hysteroscopic intervention in the management of symptoms related to the displaced levonorgestrel-releasing intrauterine system (LNG-IUS). MATERIAL AND METHODS: One hundred and thirteen patients with displaced LNG-IUS presenting with irregular uterine bleeding, pelvic pain or asymptomatic displacement were recruited for hysteroscopic examination. Displaced LNG-IUS was relocated by hysteroscopic intervention and the effect on symptoms and LNG-IUS position was followed. RESULTS: The displaced LNG-IUS was successfully relocated by hysteroscope in 112 (99.1%) of 113 cases. Following LNG-IUS relocation, 71 (79.8%) patients of 89 with preoperative irregular uterine bleeding had amenorrhea or vaginal spotting, and 14 of 15 (93.3%) patients with preoperative pelvic pain became asymptomatic. LNG-IUS expulsion was recorded in two patients 7 and 21 days after hysteroscopy. CONCLUSION: Displaced LNG-IUS can cause clinical symptoms (e.g. irregular bleeding, pain). Hysteroscopic relocation of displaced LNG-IUS is a feasible method in the management of these symptoms. Risk of spontaneous expulsion associated with hysteroscopy is low.