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

OBJECTIVE: To explore the safety and efficiency of endometrial myomectomy (EM) and Serosal myomectomy (SM) for the removal of intramural myoma greater than 8 cm in diameter during cesarean section. METHODS: Retrospective analysis and follow-up were used, and 190 cases of pregnancy complicated with uterine myoma from Jan. 2017 to May 2022 in Ningbo Women's and Children's Hospital were collected, 130 cases of caesarean myomectomy as study group, 64 cases of EM as study group A, 66 cases of SM as study group B, 33 cases with uterine fibroids removed before suturing the uterine incision as study group B1, 33 cases with uterine incision sutured followed by removal of fibroids as study group B2, 60 cases of Caesarean section alone as control group. To compare perioperative conditions between and within groups. RESULTS: ① Operation time, postoperative exhaust time, pre- and post-operative haemoglobin drop, intraoperative blood loss were all more than those of the control group in the study group (68.65 ± 11.87 vs 56.17 ± 9.18 min, 21.04 ± 4.98 vs 17.03 ± 1.3 h, 1.27 ± 0.59 vs 1.09 ± 0.43 g/dl, 613 ± 221 vs 532 ± 156 ml, P < 0.001, P < 0.001, P = 0.025, P = 0.011). ② For type III and V fibroids, the time of myoma removal, postoperative exhaust and pre- and post-operative haemoglobin drop and intraoperative blood loss in study group A were less than those in study group B (18.02 ± 3.89 vs 20.19 ± 5.32 min, 18.83 ± 2.57 vs 23.93 ± 6.84 h, 600 ± 194 vs 730 ± 277 ml, 1.20 ± 0.57 vs 1.59 ± 0.70 g/dl, P = 0.036, P < 0.001, P = 0.014, P = 0.008); For type IV uterine fibroids, only postoperative exhaust time was less in Study Group A than in Study Group B (19.27 ± 2.2 vs 21.35 ± 3.23 h, P = 0.016). ③ Time of myoma removed was less in study group B1 than in study group B2 (18.24 ± 4.53 vs 20.7 ± 4.59 min, P = 0.033). CONCLUSION: It is safe and feasible to remove interstitial myomas larger than 8 cm in diameter during caesarean section. EM has the advantage of shorter operation time and less intraoperative bleeding, SM, in a way that the myoma is removed before suturing the uterine incision, can shorten the myomectomy time. It can benefit the patients more.

Parasitic myoma after transabdominal hysterectomy for fibroids: a case report.

BACKGROUND: Parasitic myomas typically occur after a pedunculated subserosal fibroid loses its uterine blood supply and parasitizes other organs or after a surgery involving morcellation techniques. Parasitic myomas that occur after transabdominal surgery are extremely rare and may not be sufficiently documented. Here, we present a case of parasitic myoma in the anterior abdominal wall following a transabdominal hysterectomy for fibroids. CASE PRESENTATION: The patient was a 46-year-old Chinese woman who had undergone surgery for uterine myomas at our hospital 1 year prior. The patient later revisited our department with a palpable mass in her abdomen, and imaging revealed a mass in the iliac fossa. The possibility of a broad ligament myoma or solid ovarian tumor was considered before surgery, and laparoscopic exploration was performed under general anesthesia. A tumor measuring approximately 4.5 × 4.0 cm was found in the right anterior abdominal wall, and a parasitic myoma was considered. The tumor was completely resected. Pathological analysis of the surgical specimens suggested leiomyoma. The patient recovered well and was discharged on postoperative day 3. CONCLUSION: This case suggests that parasitic myoma should be considered in the differential diagnosis of patients presenting with abdominal or pelvic solid tumors with a history of surgery for uterine leiomyomas, even without a history of laparoscopic surgery using a power morcellator. Thorough inspection and washing of the abdominopelvic cavity at the end of surgery is vital.

Preoperative Hematocrit Level and Associated Risk of Transfusion for Myomectomy Based on Myoma Burden and Surgical Route.

STUDY OBJECTIVE: To determine the association between preoperative hematocrit level and risk of blood transfusion for laparotomic and laparoscopic myomectomy based on myoma burden and surgical route. DESIGN: A cohort study of prospectively collected data. SETTING: American College of Surgeons National Surgical Quality Improvement Program participating institutions. PATIENTS: A total of 26 229 women who underwent a laparotomic or laparoscopic myomectomy from 2010 to 2020. INTERVENTIONS: The primary outcome assessed was the risk of transfusion based on preoperative hematocrit level. This was evaluated with respect to myoma burden and surgical route. MEASUREMENTS AND MAIN RESULTS: There were 26 229 women who underwent a myomectomy during the study interval, 2345 women (9%) of whom required a blood transfusion. Compared with patients who did not require transfusion, those who did had lower median preoperative hematocrit levels (34.7 vs 38.2). Patients were stratified by surgical approach (laparotomic vs laparoscopic) and myoma burden (1-4 myomas/weight ≤250 g or ≥5 myomas/weight >250 g) using Current Procedural Terminology codes (58140, 58146, 58545, 58546). In all categories, there was an inverse relationship between blood transfusion and preoperative hematocrit level with increasing risk depending on preoperative hematocrit range. The odds ratios comparing hematocrit level of 29% with 39% were 6.16 (95% confidence interval [CI], 5.15-7.36), 4.92 (95% CI, 4.19-5.78), 4.85 (95% CI, 3.72-6.33), and 5.2 (95% CI, 3.63-7.43) for patients with laparotomic (1-4 myomas/≤250 g, ≥5 myomas/>250 g) and laparoscopic myomectomy (1-4 myomas/≤250 g, 5 myomas/>250 g), respectively. CONCLUSION: Incremental increases in hematocrit result in a significantly decreased risk of blood transfusion at the time of myomectomy.

Laparoscopic Management of Disseminated Peritoneal Leiomyomatosis.

STUDY OBJECTIVE: To show laparoscopic management of disseminated peritoneal leiomyomatosis (DPL). DESIGN: Stepwise demonstration of the technique with narrated video footage. SETTING: DPL is characterized by dissemination and proliferation of peritoneal and subperitoneal lesions primarily originating from smooth muscle cells [1]. Generally considered benign, cases of malignant transformation to leiomyosarcoma have been reported [2,3]. Iatrogenic DPL occurs because of unconfined morcellation resulting in small fragments of myoma that may implant on any organ and start deriving blood supply from it or may be pulled into port site while withdrawing laparoscopic cannulas [4]. It is estimated that the overall incidence of DPL after laparoscopic uncontained morcellation was 0.12% to 0.95% [5]. Mainstay of treatment is surgical resection of myomas and regular follow-up with imaging. A 28-year-old unmarried girl presented with complain of lump abdomen increasing in size for 1 year. She also complained of a 15 kg weight loss in the last 1 year; 4 years ago, patient had undergone laparoscopic myomectomy with unconfined morcellation for a 10 × 8 cm cervical myoma. Presently her menses were regular with a 28-day cycle and 3 to 4 days' average flow. Magnetic resonance imaging showed multiple nodular lesions of varying sizes in relation to small bowel, colon, uterus, and anterior abdominal wall  suggestive of DPL. Bilateral ovaries were normal. Tumor markers were as follows: CA 125 23.2 (<35) U/mL Carcinoembryonic antigen 1.67 (<8) ng/mL CA 19-9 47 (<37) U/mL Lactate dehydrogenase 809 (180-360) IU/L Alpha-fetoprotein 2.03 (<10) ng/mL Beta human chorionic gonadotropin 1.2(<2) mIU/mL Tru-cut biopsy was done elsewhere to rule out peritoneal carcinomatosis in view of raised CA 19-9 and lactate dehydrogenase, history of weight loss, and imaging showing multiple abdominal masses. Histopathological examination showed leiomyomatosis and immunohistochemistry for smooth muscle actin, desmin, and vimentin were positive. INTERVENTIONS: On laparoscopy the abdominal cavity was found studded with multiple leiomyomas of varying sizes deriving blood supply from ilium, transverse, descending and sigmoid colon, rectum, left tube, left ovary, pouch of Douglas, bilateral uterosacrals, uterovesical fold, and anterior abdominal wall. Large blood vessels were seen traversing between the descending and sigmoid colon and the myomas. Principles of surgery were as follows: 1. Complete removal of myomas 2. Cauterization of blood vessels feeding the parasitic myomas to minimize blood loss 3. Disscetion abutting the myoma to prevent injury to adjacent viscera. A total of 26 myomas were removed. All the myomas were retrieved by morcellation in a bag. Histopathology confirmed the diagnosis of diffuse peritoneal leiomyomatosis. Follow-up ultrasound at 6 months showed no recurrence of leiomyomatosis. CONCLUSION: Proper mapping of lesions and surgery for complete removal of all masses is the mainstay of treatment. Contained morcellation in bag should be the norm to prevent iatrogenic DPL. Regular follow-up with imaging is required to rule out recurrence.

The Effect of a Myomectomy on Myoma-related Symptoms and Quality of Life: A Retrospective Cohort Study.

STUDY OBJECTIVE: Although it is assumed that myomectomy improves uterine myoma-related symptoms such as pelvic pain and heavy menstrual bleeding (HMB), validated measures are rarely reported. This study aimed to verify the effect of myomectomy on myoma-related symptoms. DESIGN: A retrospective cohort study. SETTING: A university-affiliated hospital. PATIENTS: Our study included 241 patients with a myoma diagnosis and received a myomectomy between 2004 and 2018. Data were collected from the patient medical file and patients responded in 1 questionnaire. INTERVENTIONS: Transcervical resection of myoma (TCRM) and laparoscopic or abdominal myomectomy (LAM). MEASUREMENTS AND MAIN RESULTS: One year after TCRM, a significant number of women experienced symptom improvement for pelvic pain (79% [19/24, p = .01]) and HMB (89% [46/52, p <.001]). For other myoma-related symptoms, abdominal pressure (43%, 10/23), sexual complaints (67%, 2/3), infertility (56%, 10/18), and other complaints (83%, 5/6), improvements were not statistically significant. One year after LAM, a significant number of women experienced symptom improvement for pelvic pain (80%, 74/93), HMB (83%, 94/113), abdominal pressure (85%, 79/93), sexual complaints (77%, 36/47), and other complaints (91%, 40/44). One year after myomectomy, 47% (30/64) (TCRM) and 44% of women (78/177) (LAM) described no myoma-related symptoms. Most women (82% [172/217]) were satisfied with the postoperative result after 1 year and 53% (114/217) would have liked to receive the myomectomy earlier in life. Average quality of life (measured on a 10-point Likert scale) increased from 6.3 at baseline to 8.0 at 1 year after TCRM and from 6.2 to 8.0 1 year after LAM, resulting in a difference of 1.7 points (p <.001; 95% confidence interval, 1.1-2.3) and 1.9 points (p <.001; 95% confidence interval, 1.4-2.3), respectively. CONCLUSION: One year after myomectomy, most women have benefited from myomectomy, concluded by a significant number of women who experienced myoma-related symptom improvement, positive patient satisfaction, and a significant improvement in reported quality of life. Validation of results after conventional treatment such as myomectomy is essential in counseling patients for surgical treatment in today's evidence based practice. In addition, it is necessary to make an adequate comparison with new treatment options for myomas. To provide this, further research should preferably be conducted prospectively or by randomization.

Safety of Same-Day Discharge Versus Hospital Admission in Minimally Invasive Myomectomy.

STUDY OBJECTIVE: To compare postoperative complication rates between same-day discharge patients and patients admitted to hospital after minimally invasive myomectomy, stratified by patient demographics and perioperative variables including myoma burden. DESIGN: Retrospective cohort study. Setting Hospitals participating in the National Surgical Quality Improvement Program database from January 2015 to December 2019. PATIENTS: Female patients aged ≥18 years undergoing minimally invasive myomectomy. INTERVENTIONS: Patients were categorized into either the same-day discharge or admitted patient cohort. Univariate comparisons of demographics, perioperative variables, and 30-day postoperative complications were performed. Multivariate logistic regression was used to 1) identify demographic and perioperative factors associated with admission, and 2) compare postoperative complication rates of same-day discharge patients with those of admitted patients while adjusting for demographic and perioperative factors. MEASUREMENTS AND MAIN RESULTS: Eight thousand one hundred patients were recruited during the study period. The overall rate of same-day discharge was 57.2% in 2015 and 65.0% in 2019. The same-day discharge rate was 64.6% for patients with a smaller myoma burden (1-4 fibroids and ≤250 grams, Current Procedural Terminology 58545) and 56.8% for larger myoma burden (≥5 fibroids or >250 grams, Current Procedural Terminology 58546). Age, race, American Society of Anesthesiologists classification III or IV, preoperative hematocrit <36%, hypertension, diabetes, bleeding disorder, and increasing operative time were associated with admission to hospital. After adjusting for these variables, composite postoperative complication rates were similar between admitted patients and patients who were discharged the same day regardless of myoma burden (adjusted OR [aOR], 0.66; 95% confidence interval [CI] 0.18-2.47 for low myoma burden and aOR, 0.91; 95% CI 0.18-4.63 for high myoma burden). Admitted patients with both low (aOR, 9.1; 95% CI 2.27-37.04) and high (aOR, 8.24; 95% CI 1.59-42.49) myoma burdens were significantly more likely to receive a blood transfusion compared to same-day discharge patients. CONCLUSION: Same-day discharge after minimally invasive myomectomy, regardless of myoma burden, is associated with low complication rates. Our findings may aid in shared decision making on discharge planning.

Nascent myoma as a cause of urinary retention.

We present the case of a 47-year-old woman with a bulky, nascent necrotic myoma, which at first glance appeared to be a malignant process in the cervix. It caused significant retention of urine due to compression of the bladder and ureters, hydronephrosis and deterioration of renal function. A fully developed picture of the "bulge syndrome" dominated - lymphedema of the lower limbs and lower abdomen, pain in the lower abdomen, constipation, secondary secondary urinary infection, and paradoxical ischuria. During a gynecological examination in a specula, a strong-smelling, necrotic tumour was visualized reaching half of the vagina, which was causing a bloody discharge, which brought the patient to the examination. A biopsy was taken from the tumour. A permanent urinary catheter was inserted into the urinary bladder with gradual adjustment of renal functions. Due to the difficulties and the benign histological findings from the biopsy, a simple abdominal hysterectomy with bilateral salpingectomy from a lower midline incision was indicated. The operation was complicated by an extensive adhesive process and blood loss of 1,200 mL, with a decrease in hemoglobin in the blood count from 128 g/L to 79 g/L and the need for three blood transfusions. In the postoperative period, there is a prompt recovery of spontaneous micturition with normalization of bladder function, subsidence of lymphedema and subjective complaints of the patient.

Ultrasound features of highly vascularized uterine myomas (uterine smooth muscle tumors) and correlation with histopathology.

OBJECTIVE: To correlate the ultrasound appearance of highly vascularized uterine myomas with their histopathological diagnosis. METHODS: This was a prospective observational study of patients with a preoperative ultrasound diagnosis of a highly vascularized uterine myoma (color score of 3 or 4, according to the Morphological Uterus Sonographic Assessment (MUSA) criteria), characterized by circumferential and intralesional vascular pattern, who underwent myomectomy or hysterectomy. For each patient, ultrasound characteristics were recorded at baseline, including the number of lesions, the size, echogenicity and border regularity of the lesion, presence of cystic areas and shadowing within the myoma, and visualization of the endometrium. Ultrasound features were correlated with the definitive histological diagnosis. Ultrasound features were then compared between malignant and benign lesions. RESULTS: We included 70 patients with highly vascularized uterine myomas on power/color Doppler. Their mean age was 46.5 ± 11.4 years and 13 (18.6%) were postmenopausal. At histological examination, 65 (92.9%) uterine myomas were benign lesions, comprising 32 typical leiomyomas, 29 leiomyoma variants and four adenomyomas. The remaining five (7.1%) uterine myomas were malignant masses, comprising two uterine sarcomas, one leiomyosarcoma, one neuroendocrine tumor and one uterine smooth muscle tumor of uncertain malignant potential (STUMP). The mean age of patients with a malignant lesion was significantly higher than the age of those with a benign lesion (64.8 ± 16.0 vs 42.4 ± 5.1; P < 0.001). Four out of five patients with a malignant lesion were over 45 years old. Ultrasound demonstrated cystic areas within the lesion in 10/32 (31.3%) typical leiomyomas, 16/29 (55.2%) leiomyoma variants, all four adenomyomas and in the cases of STUMP and leiomyosarcoma. Lesion borders were regular in 64/65 (98.5%) benign lesions and 2/5 (40%) malignant lesions (P < 0.05). No significant differences were observed between benign and malignant lesions with respect to echogenicity, presence of shadowing and size. The endometrium was visible in 55/65 women with benign lesions and in 2/5 with malignant lesions (P = 0.03). CONCLUSIONS: Our results showed that ultrasound features of uterine myomas, such as circumferential and intralesional vascularity, cystic areas and lesion borders, are important parameters for differential diagnosis, especially when combined with the patient's age. Such features could be useful to differentiate typical myomas from benign variants and malignant lesions in a preoperative setting and to select patients that may benefit from conservative management rather than surgery. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

The Impact of Race and Ethnicity on Use of Minimally Invasive Surgery for Myomas.

STUDY OBJECTIVE: To determine whether minimally invasive surgery (MIS) for uterine myomas is used differentially based on race and ethnicity. DESIGN: Retrospective cohort study. SETTING: Quaternary care academic hospital in the United States. PATIENTS: Patients undergoing hysterectomy or myomectomy for uterine myomas between March 15, 2015, and March 14, 2020 (N = 1311). Cases involving correction of pelvic organ prolapse, malignancy, peripartum hysterectomy, or combined procedures with nongynecologic specialties were excluded. Racial/ethnic composition of the study population was 40.0% non-Hispanic white (white), 27.9% non-Hispanic black (black), 14.0% Hispanic, 13.7% non-Hispanic Asian (Asian), and 4.3% non-Hispanic American Indian/Alaska Native/Pacific Islander/Other. INTERVENTIONS: Hysterectomy, myomectomy. MEASUREMENTS AND MAIN RESULTS: Of the 1311 cases, 35.9% were minimally invasive hysterectomy, 16.4% abdominal hysterectomy, 35.6% minimally invasive myomectomy, and 12.1% abdominal myomectomy. MIS rates were 94.7% among fellowship-trained minimally invasive gynecologic surgery subspecialists, 44.2% among obstetrics and gynecology specialists, and 46.8% among gynecologic oncologists. There were disparities in surgeon type based on race/ethnicity, with 59.8% of white patients having undergone surgery with a minimally invasive gynecologic surgery subspecialist vs 44.0% of black patients and 45.7% of Hispanic patients. Black and Hispanic patients were less likely to undergo MIS overall vs white patients (adjusted odds ratio [aOR] 0.33, 95% confidence interval [CI] 0.22-0.48 and aOR 0.44, 95% CI 0.28-0.72, respectively). Black and Hispanic patients undergoing hysterectomy were less likely than white patients to undergo MIS (aOR 0.33, 95% CI 0.21-0.51 and aOR 0.35, 95% CI 0.20-0.60, respectively). There were no significant differences in rates of MIS based on race/ethnicity for myomectomies nor differences in major or minor complications by race/ethnicity overall. CONCLUSION: At a quaternary care institution, black and Hispanic patients were significantly less likely than white patients to undergo MIS for uterine myomas, particularly for hysterectomy.

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

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

Radiofrequency Ablation of Uterine Myomas and Pregnancy Outcomes: An Updated Review of the Literature.

OBJECTIVE: To provide a systematic review of pregnancy outcomes after radiofrequency ablation (RFA) of uterine myomas. DATA SOURCES: A literature search was conducted using PubMed, Cochrane Library, Scopus, Web of Science, and Embase, from database inception to October 2021. METHODS OF STUDY SELECTION: Two reviewers conducted independent literature searches. Studies that met the criteria based on title and abstract underwent full-text review. Publications were included if they reported pregnancies and obstetric outcomes after laparoscopic or transcervical RFA of myomas. TABULATION, INTEGRATION, AND RESULTS: A total of 405 publications were initially identified and screened, 39 underwent full-text review, and 10 publications were ultimately included. There were 50 pregnancies reported among 923 RFA patients: 40 pregnancies after 559 laparoscopic RFAs and 10 pregnancies after 364 transcervical RFAs. The number of patients from these studies actively trying to conceive after RFA is unknown. Among the RFA patients who conceived, the average age at ablation was 37 years old (range, 27-46 years). Most patients had between 1 and 3 myomas ablated, and myomas size ranged from <2 cm to 12.5 cm. There were 6 spontaneous abortions (12%) and 44 full-term pregnancies (88%), of which 24 were vaginal deliveries and 20 were cesarean deliveries. There were only 2 complications among 44 deliveries: one placenta previa that underwent an uncomplicated cesarean delivery and 1 delayed postpartum hemorrhage with expulsion of a degenerated myoma, with no long-term sequelae. There were no cases of uterine rupture, uterine window, or invasive placentation and no fetal complications. The spontaneous abortion rate was comparable with the general obstetric population. CONCLUSION: Almost all pregnancies after RFA of myomas were full-term deliveries with no maternal or neonatal complications. These findings add to the literature that radiofrequency myoma ablation may offer a safe and effective alternative to existing treatments for women who desire future fertility.

Rates of Complications and Reoperation after Myomectomy-the Impact of Surgical Approach: A Statewide Population-based Cohort Study from 2005-2018.

STUDY OBJECTIVE: To assess rates of and factors associated with complications and reoperation after myomectomy. DESIGN: Population-based cohort study. SETTING: All non-Veterans Affairs facilities in the state of California from January 1, 2005, to December 31, 2018. PARTICIPANTS: Women undergoing abdominal or laparoscopic myomectomy for myoma disease were identified from the Office of Statewide Health Planning and Development datasets using appropriate International Classification of Diseases, Ninth and Tenth Revision and Current Procedural Terminology codes. INTERVENTIONS: Demographics, surgery facility type, facility surgical volume, and surgical approach were identified. Primary outcomes included complications occurring within 60 days of surgery and reoperations for myomas. Patients were followed up for over an average of 7.3 years. Univariate and multivariable associations were explored between the above factors and rates of complications and reoperation. All odds ratios (ORs) are adjusted ORs. MEASUREMENTS AND MAIN RESULTS: Of the 66 012 patients undergoing myomectomy, 5265 had at least one complication (8.0%). Advanced age, black, Asian race, MediCal and Medicare payor status, academic facility, and medical comorbidities were associated with increased odds of a complication. Minimally invasive myomectomy (MIM) was associated with decreased complications compared with abdominal myomectomy (AM) (OR, 0.29; 95% confidence interval [CI], 0.25-0.33; p <.001). Overall, 17 377 patients (26.3%) underwent reoperation. Medicare and MediCal payor status and medical comorbidities were associated with increased odds of a repeat surgery. Reoperation rates were higher in the MIM group over the entire study period (OR, 2.33; 95% CI, 1.95-2.79; p <.001). However, the odds of reoperation after MIM decreased each year (OR, 0.93; 95% CI 0.92-0.95; p <.001), with the odds of reoperation after AM surpassing MIM in 2015. CONCLUSION: This study identifies outcome disparities in the surgical management of myomas and describes important differences in the rates of complications and reoperations, which can be used to counsel patients on surgical approach. These findings suggest that MIM can be considered a lasting and safe approach in properly selected patients.

Laparoscopic Triple-tourniquet Constriction: A Convenient Way for Minimizing Blood Loss during Myomectomy.

STUDY OBJECTIVE: Although a pericervical tourniquet helped reduce blood loss in myomectomy [1], a technique of triple tourniquets was more influential in occluding the uterine vessel networks [2,3]. This video demonstrates the procedures of laparoscopic triple-tourniquet constriction with the number 1 suture around the uterine isthmic portion and bilateral infundibulopelvic ligaments [4] in a case of robotic myomectomy. DESIGN: A step-by-step, narrated video demonstration. SETTING: A university hospital. INTERVENTIONS: Robotic myomectomy was scheduled for a patient with menorrhagia. Magnetic resonance imaging revealed 8 uterine myomas; the maximal one was 9.1 × 8.4 × 8.6 cm in dimension. Our robotic settings included 3 ports: fenestrated bipolar in the left lower quadrant, spatula or mega needle holder in the right lower quadrant, and an umbilical glove port accessible for lens and assisted instruments. A number 1 Monocryl (Ethicon, Bridgewater, NJ) was introduced from the suprapubic area extracorporeally; then, the needle penetrated through bilateral avascular zones of broad ligaments at the isthmic level and with a sliding tie made anteriorly to the uterus. The isthmic tourniquet-we also named it as the hangman's tourniquet-was tightened by manually tensioning the suture extracorporeally and pushing down the knot intracorporeally. Bilateral infundibulopelvic tourniquets were placed by using sliding ties of 1-0 Monocryl as well. With the total occlusion of uterine vessel networks, the uterus should retain only minimal blood flow. During the enucleation of uterine myomas, the tourniquet may loosen because of newly developed, unoccupied space with increasing bleeding; therefore, the tourniquet should be tightened up regularly throughout the surgery. After the repair of all the uterine wounds, we removed the 3 tourniquets. CONCLUSION: The convenient and adjustable triple-tourniquet constriction is a safe and feasible laparoscopic technique to block the vessel networks temporally in uterine-preserving surgery.

Single-Site Robotic Myomectomy without Accessory Instrument Compared with Two-Port Laparoscopic Myomectomy: A Propensity Score Matching Analysis.

OBJECTIVES: Despite the advantages of robotic technology, single-site robotic myomectomy (SSRM) without an accessory instrument is limited by a restricted range of motion, weaker suturing of a thick myometrium, and non-articulating instruments. We present our novel gradual turning out method (GTOM) of SSRM and our assessment of its feasibility and safety by comparing its perioperative outcomes with those of two-port laparoscopic myomectomy (LM). DESIGN: A retrospective cohort case-control study was carried out. METHODS: This study included consecutive 46 patients who underwent SSRM for intramural myomas larger than 7 cm, from 2016 to 2019. Subsequently, 46 patients who underwent LM were selected by 1:1 propensity score matching by controlling for age, body mass index, myoma number, myoma diameter, and the presence of sexual intercourse. The perioperative outcomes of the two groups were compared using a Mann-Whitney U test and Fisher's exact test. The effect of covariates on operation time was analyzed using univariable and multivariable linear regression. RESULTS: SSRM was performed successfully with GTOM for myomas of up to 14 cm in the longest diameter, without conversion to laparotomy and intraoperative injuries. No differences between the groups were found in length of hospital stay, estimated blood loss, hemoglobin level decrease, transfusion rate, and postoperative pain, but operative time was significantly longer in the SSRM group than in the LM group (p < 0.001). Larger myomas, location of the lower segment, and the operation method of SSRM were significantly associated with a longer operation time. Whereas operation time for myomas located at the anterior wall, singleton myomas, and myomas <10 cm was significantly longer in the SSRM group than in the LM group, that for myomas at the posterior or lateral side of the uterus, multiple myomas, and myomas ≥10 cm did not differ significantly between the groups, indicating the advantage of SSRM for difficult myomectomy. LIMITATIONS: Retrospective nature of the study and limitation to a single-center study are the limitations of the study. CONCLUSIONS: Despite the lack of an accessory instrument, SSRM using the GOTM was feasible and safe as it yielded similar perioperative outcomes to those of LM.

Short-term administration of oral relugolix before single-port laparoscopic-assisted vaginal hysterectomy for symptomatic uterine myomas: A retrospective comparative study with leuprorelin injection.

AIM: To investigate the efficacy of short-term administration of relugolix, a novel orally active gonadotropin-releasing hormone (GnRH) antagonist, before single-port laparoscopic-assisted vaginal hysterectomy (LAVH) for symptomatic uterine myomas, retrospectively compared with injection of leuprorelin, a GnRH agonist. METHODS: A retrospective comparative study of each 35 women with symptomatic myomas in the relugolix and leuprorelin groups. RESULTS: Before administration of relugolix and leuprorelin, the median uterine volume did not differ significantly between the two groups (p = 0.53). Median uterine volume change from baseline after short-term administration of relugolix and leuprorelin did not differ significantly (p = 0.17). Surgical duration (p = 0.84) and estimated blood loss (p = 0.48) were not different between the two groups. According to a patient questionnaire, the side effects of the drugs were not different between the two groups (p = 0.27). When patients were was asked if they wanted to have either of these drugs again, some relugolix users preferred leuprorelin due to concern about forgetting daily medication, while some leuprorelin users preferred relugolix to avoid pain at injection. CONCLUSION: Oral relugolix medication or leuprorelin injection administered before single-port LAVH for uterine myomas yielded an equivalent reduction of uterine volume and perioperative outcomes with no significant adverse events. Patient preference for either oral daily relugolix or a monthly injection of leuprorelin could be considered when preoperative management is determined.

Laparoendoscopic two-site myomectomy (LETS-M) using conventional laparoscopic instruments and the glove-port technique.

PURPOSE: To evaluate the perioperative outcome of laparoendoscopic two-site myomectomy (LETS-M). METHODS: The medical records of 204 women receiving LETS-M in a tertiary referral center, including 183 surgeries performed by the experienced surgeon and 21 surgeries performed by 3 well-supervised trainees were retrospectively reviewed. RESULTS: The age of the participants was 39.3 ± 6.4 years. The mean diameter of the largest myoma and the mean number of myomas were 8.5 ± 2.2 cm and 1.7 ± 1.1, respectively. Thirty-one (15%) operations removed more than 2 myomas larger than 5 cm in diameter. The mean weight of the myomas was 281.1 ± 183.1 g. The operation time was 97.6 ± 40.2 min, and the intraoperative blood loss was 99.3 ± 115.2 mL. There were 3 (1%) cases of excessive blood loss (more than 500 mL) and 2 (1%) of postoperative hematoma. The only significant difference between the experienced surgeon and trainees was the operation time (92.3 ± 32.2 min vs. 141.2 ± 54 min, p < .001), while the myoma number, myoma diameter, myoma weight, and intraoperative blood loss were not significantly different. The operation time did not differ among different myoma locations. In multivariate analysis, virginity, myoma number, more than 2 large myomas, and myoma size were independent variables for longer operation times. No patient experienced any major complications. CONCLUSION: LETS-M using conventional laparoscopic equipment is a minimally invasive surgical method that is safe, effective, and easy to learn for managing uterine myoma. It is useful to achieve a favorable perioperative outcome with acceptable operation time.

Resectoscopic Surgery Part III: Advanced Resectoscopic Surgery.

In this final section of our three-part series, we will apply the basic and intermediate skills described in the first two parts to advance the gynecologist's skills to accomplish the most demanding of resectoscopic surgical challenges. In Part I of this series, we reviewed the benefits of the continuous flow gynecologic resectoscope (CFGR) and how the motivated gynecologist can assemble an operative team and overcome the impediments to learning the use of this versatile and minimally invasive instrument. In this first section, we outlined and analyzed basic resectoscopic surgery-endometrial ablation, the resection of small submucous myomas and endometrial polyps, as well as the treatment of mild Asherman's syndrome and the removal of retained products of conception. In Part II-intermediate level resectoscopic surgery-we introduced procedures such as endomyometrial resection, the resection of intermediate-size submucous leiomyomas, hysteroscopic metroplasty, and endocervical resection. Though it is not considered an absolute requirement to accomplish procedures at this level, sonographic guidance was introduced in preparation for more challenging cases. In Part III, the author reviews advanced resectoscopic procedures in which sonographic guidance is a requirement for the management of severe intrauterine adhesions and late-onset endometrial ablation failures, the management of FIGO Type 3 and 4 intramural myomas, as well as large submucous myomas.

Hysterectomy Provides Benefit in Health-Related Quality of Life: A 10-Year Follow-up Study.

STUDY OBJECTIVE: This study aims to evaluate short- and long-term effects of hysterectomy on health-related quality of life (HRQoL) and compare that with a representative age-standardized sample from the general population. DESIGN: A prospective survey as a part of FINHYST study. SETTING: Four Helsinki area hospitals. PATIENTS: Eight hundred thirty-six women with hysterectomy because of benign indications during 2006. INTERVENTIONS: A change in HRQoL assessed by the 15D instrument at baseline, and after 6 months and 10 years. The HRQoL of women was also compared with that of the age-standardized sample from the general female population. MEASUREMENTS AND MAIN RESULTS: Most hysterectomies were performed laparoscopically (41.8%), followed by vaginal (38.2%) and abdominal (20%) approaches. Indications were classified into 6 subgroups; myoma, abnormal uterine bleeding (AUB), endometriosis, pelvic organ prolapse (POP), adnexal mass, and precancerous lesions. The preoperative mean HRQoL in the patients was lower than that of the general population. In the whole study population, hysterectomy provided the greatest improvement in the dimensions of distress, vitality, discomfort and symptoms, and sexual activity, both short- and long-term. Those operated on for myoma, AUB, endometriosis, and POP showed an improved mean HRQoL after 6 months, whereas after 10 years in those operated on for myoma, AUB, and endometriosis, the HRQoL was still better than at baseline. Women with endometriosis never reached HRQoL of the general population. This is right, but the HRQoL of the general population remained lower than that of all other groups. CONCLUSION: Hysterectomy provided long-term improvement in HRQoL, especially in women with myoma, AUB, and endometriosis.

Incidence of Leiomyosarcoma at Surgery for Presumed Uterine Myomas in Different Age Groups.

STUDY OBJECTIVE: To evaluate the incidence of leiomyosarcoma (LMS) at surgery for presumed uterine myomas according to different age groups. DESIGN: A retrospective cohort study. SETTING: A tertiary referral hospital. PATIENTS: All women undergoing surgery for presumed uterine myomas between January 1, 2006, and December 31, 2016. INTERVENTIONS: Laparoscopic myomectomy, laparotomic myomectomy, total hysterectomy, or hysteroscopic myomectomy. MEASUREMENTS AND MAIN RESULTS: A total of 1398 patients underwent surgery for presumed uterine myomas. The incidence of LMS was 2.15 per 1000 surgeries (n = 3, 1/466, 0.2%). In women under 40 years old, the incidence of occult LMS was 0 (0/561). In women between 40 and 49 years old, 190 myomectomies were performed (28% of the surgeries), and the rate of LMS was 1.49 per 1000 (n = 1, 1/673, 0.15%). In women over 49 years old, a total hysterectomy was performed in 82.3% of the cases, and the incidence of LMS was 12.2 per 1000 surgeries (n = 2, 1/82, 1.2%). CONCLUSION: The incidence of occult LMS in patients under 40 years old undergoing surgery for presumed uterine myomas was 0. These findings are suggestive that the use of power morcellation in this population may be safe.

Augmented Reality with Diffusion Tensor Imaging and Tractography during Laparoscopic Myomectomies.

Augmented reality is a technology that allows a surgeon to see key hidden subsurface structures in an endoscopic video in real-time. This works by overlaying information obtained from preoperative imaging and fusing it in real-time with the endoscopic image. Magnetic resonance diffusion tensor imaging (DTI) and fiber tractography are known to provide additional information to that obtained from standard structural magnetic resonance imaging (MRI). Here, we report the first 2 cases of the use of real-time augmented reality during laparoscopic myomectomies with visualization of uterine muscle fibers after DTI tractography-MRI to help the surgeon decide the starting point incision. In the first case, a 31-year-old patient was undergoing laparoscopic surgery for a 6-cm FIGO type V myoma. In the second case, a 38-year-old patient was undergoing a laparoscopic myomectomy for a unique 6-cm FIGO type VI myoma. Signed consent forms were obtained from both patients, which included clauses of no modification of the surgery. Before surgery, MRI was performed. The external surface of the uterus, the uterine cavity, and the surface of the myomas were delimited on the basis of the findings of preoperative MRI. A fiber tracking algorithm was used to extrapolate the uterine muscle fibers' architecture. The aligned models were blended with each video frame to give the impression that the uterus is almost transparent, enabling the surgeon to localize the myomas and uterine cavity exactly. The uterine muscle fibers were also displayed, and their visualization helped us decide the starting incision point for the myomectomies. Then, myomectomies were performed using a classic laparoscopic technique. These case reports show that augmented reality and DTI fiber tracking in a uterus with myomas are possible, providing fiber direction and helping the surgeon visualize and decide the starting incision point for laparoscopic myomectomy. Respecting the fibers' orientation could improve the quality of the scar and decrease the architectural disorganization of the uterus.