The importance of the 'uterine factor' in recurrent pregnancy loss: a retrospective cohort study on women screened through 3D transvaginal ultrasound.

STUDY QUESTION: What is the prevalence of congenital and acquired anomalies of the uterus in women with recurrent pregnancy loss (RPL) of unknown etiology examined using 3D transvaginal ultrasound (US)? SUMMARY ANSWER: Depending on the adopted diagnostic criteria, the prevalence of partial septate uterus varies between 7% and 14% and a T-shaped uterus is 3% or 4%, while adenomyosis is 23%, at least one of type 0, type 1 or type 2 myoma is 4%, and at least one endometrial polyp is 4%. WHAT IS KNOWN ALREADY: ESHRE and the Royal College of Obstetricians and Gynaecologists guidelines on RPL recommend the adoption of the 3D transvaginal US to evaluate the 'uterine factor'. Nevertheless, there are no published studies reporting the prevalence of both congenital and acquired uterine anomalies as assessed by 3D transvaginal US and diagnosed according to the criteria proposed by the most authoritative panels of experts in a cohort of women with RPL. STUDY DESIGN, SIZE, DURATION: This was a retrospective cohort study including 442 women with at least two previous first-trimester spontaneous pregnancy losses (i.e. non-viable intrauterine pregnancies), who referred to the obstetrics and gynecology unit of two university hospitals between July 2020 and July 2023. PARTICIPANTS/MATERIALS, SETTING, METHODS: Records of eligible women were reviewed. Women could be included in the study if: they were between 25 and 42 years old; they had no relevant comorbidities; they were not affected by infertility, and they had never undergone ART; they and their partner tested negative to a comprehensive RPL diagnostic work-up; and they had never undergone metroplasty, myomectomy, minimally invasive treatments for uterine fibroids or adenomyomectomy. Expert sonographers independently re-analyzed the stored 2- and 3D transvaginal US images of all included patients. Congenital uterine anomalies (CUAs) were reported according to the American Society for Reproductive Medicine (ASRM) 2021, the ESHRE/European Society for Gynaecological Endoscopy (ESGE) and the Congenital Uterine Malformation by Experts (CUME) criteria. Acquired uterine anomalies were reported according to the International Federation of Gynecology and Obstetrics (FIGO) and the Morphological Uterus Sonographic Assessment (MUSA) criteria. MAIN RESULTS AND THE ROLE OF CHANCE: The partial septate uterus was diagnosed in 60 (14%; 95% CI: 11-17%), 29 (7%; 95% CI: 5-9%), and 47 (11%; 95% CI: 8-14%) subjects, according to the ESHRE/ESGE, the ASRM 2021, and the CUME criteria, respectively. The T-shaped uterus was diagnosed in 19 women (4%; 95% CI: 3-7%) according to the ESHRE/ESGE criteria and in 13 women (3%; 95% CI: 2-5%) according to the CUME criteria. The borderline T-shaped uterus (diagnosed when two out of three CUME criteria for T-shaped uterus were met) was observed in 16 women (4%; 95% CI: 2-6%). At least one of FIGO type 0, type 1, or type 2 myoma was detected in 4% of included subjects (95% CI: 3-6%). Adenomyosis was detected in 100 women (23%; 95% CI: 19-27%) and was significantly more prevalent in women with primary RPL and in those with three or more pregnancy losses. At least one endometrial polyp was detected in 4% of enrolled women (95% CI: 3-7%). LIMITATIONS, REASONS FOR CAUTION: The absence of a control group prevented us from investigating the presence of an association between both congenital and acquired uterine anomalies and RPL. Second, the presence as well as the absence of both congenital and acquired uterine anomalies detected by 3D US was not confirmed by hysteroscopy. Finally, the results of the present study inevitably suffer from the intrinsic limitations of the adopted classification systems. WIDER IMPLICATIONS OF THE FINDINGS: The prevalence of CUAs in women with RPL varies depending on the classification system used. For reasons of clarity, the US reports should always state the name of the uterine anomaly as well as the adopted classification and diagnostic criteria. Adenomyosis seems to be associated with more severe forms of RPL. The prevalence rates estimated by our study as well as the replicability of the adopted diagnostic criteria provide a basis for the design and sample size calculation of prospective studies. STUDY FUNDING/COMPETING INTEREST(S): No specific funding was used. The authors have no conflicts of interest to declare. TRIAL REGISTRATION NUMBER: N/A.

[Reducing the Time Before the Console in Robotic-Assisted Laparoscopic Hysterectomy].

Robotic-assisted surgery enables precise manipulations with magnified vision, stereoscopic vision, and forceps with multi-joint functions. It requires unique procedures such as position setting, port placement, roll-in, and docking, which lead to prolonged operation and anesthesia time. Five conditions described below were established at our institution to reduce the time to the initiation of console: (1) changing the patients' position from the flat lithotomy position to the spread legs position; (2) attaching a Hasson cone to hold the umbilical cannula stable; (3) changing the cannula's obturator (inner tube) from blunt to bladeless; (4) fixing the team, and (5) conducting regular docking training. These outcomes were examined in this study. The study included 77 patients who underwent robotic-assisted total hysterectomy for benign uterine disease and stage IA uterine cancer at our individual institution between April 2019 and July 2022. We compared the median time from anesthesia to console initiation between the first half group (cases 1-40) and the second half group (cases 41-77). The former required 91.5 (53-131) minutes, whereas the latter required 59 (37-126) minutes. Appropriate equipment selection and team education can reduce the time to console initiation.

Cesarean Myomectomy: Reflections on Clinical and Surgical Controversies between a New Trans-Decidual Technique vs. Traditional Method.

Up to 70-80% of women of reproductive age may be affected with the most common uterine tumors, known as fibroids or myomas. These benign tumors are the second most prevalent cause of surgery among premenopausal women. Predictions show that the occurrence of myomas in pregnancy will increase, and that the risk of having myomas during pregnancy increases with advanced maternal age. Although most women with fibroids do not experience any symptoms during pregnancy, up to 30% of women experience problems during pregnancy, childbirth, and the puerperium. The viability of myoma excision during cesarean surgery (CS) is a contentious issue raised by the rising incidence of myomas in pregnancy and CS rates. A new surgical procedure for removing fibroids using a trans-endometrial approach, which involves making an incision through the decidua itself, has put into doubt the long-standing practice of cesarean myomectomy (CM) with a trans-serosal approach. Some authors have recently advocated for this last approach, highlighting its advantages and potential uses in real-world situations. The purpose of this paper is to critique the present approach to cesarean myomectomy by analyzing the clinical and surgical distinctions between the two approaches and providing illustrations of the CM methods.

Killer Function of Circulating Neutrophils in Relation to Cytokines in Uterine Myoma and Endometrial Cancer.

The study presents the killer functions of circulating neutrophils: myeloperoxidase activity, the ability to generate ROS, phagocytic activity, receptor status, NETosis, as well as the level of cytokines IL-2, IL-4, IL-6, IL-17A, and IL-18, granulocyte CSF, monocyte chemotactic protein 1, and neutrophil elastase in the serum of patients with uterine myoma and endometrial cancer (FIGO stages I-III). The phagocytic ability of neutrophils in uterine myoma was influenced by serum levels of granulocyte CSF and IL-2 in 54% of the total variance. The degranulation ability of neutrophils in endometrial cancer was determined by circulating IL-18 in 50% of the total variance. In uterine myoma, 66% of the total variance in neutrophil myeloperoxidase activity was explained by a model dependent on blood levels of IL-17A, IL-6, and IL-4. The risk of endometrial cancer increases when elevated levels of monocyte chemotactic protein 1 in circulating neutrophils are associated with reduced ability to capture particles via extracellular traps (96% probability).

Combined transabdominal and transvaginal ultrasound-guided percutaneous microwave ablation of uterine myomas: an effective monitoring technique.

OBJECTIVE: This study compared the feasibility and efficacy of transabdominal ultrasound (TAU) and combined transabdominal and transvaginal ultrasound (TA/TV US)-guided percutaneous microwave ablation (PMWA) for uterine myoma (UM). METHOD: This study enrolled 73 patients with UM who underwent PMWA via the transabdominal ultrasound-guided (TA group) or the combined transabdominal and transvaginal ultrasound-guided (TA/TV group) approaches. The intraoperative supplementary ablation rates, postoperative immediate ablation rates, lesion reduction rates and other indicators three months postoperatively were compared between the groups. The display of the needle tip, endometrium, uterine serosa, rectum and myoma feeding vessels under the guidance of TAU, transvaginal ultrasound (TVU) and TA/TV US were evaluated in the TA/TV group. RESULTS: In the TA/TV group, the real-time position of the needle tip and the endometrium complete display rate of the same lesions with TVU guidance were significantly higher than those using TAU. TA/TV US guidance significantly improved the complete display rate of each indicator. The intraoperative supplementary ablation rate in the TA/TV group was lower than that in the TA group. Similarly, the postoperative immediate ablation and volume reduction rates of the lesions three months postoperatively were higher than those in the TA group, especially for lesions with a maximum diameter ≥6 cm. CONCLUSION: TA/TV US is an effective monitoring method that can be used to improve imaging display. Its use is recommended in patients with obesity, poor transabdominal ultrasound image quality and large myoma volumes.

Venous Thromboembolism After Abdominal and Minimally Invasive Large Specimen Hysterectomy.

STUDY OBJECTIVE: To investigate the incidence of venous thromboembolism (VTE) in patients undergoing large specimen hysterectomy for benign indications. To evaluate the impact of route of surgery and operative time in the development of VTE in this population. DESIGN: Retrospective cohort study (Canadian Task Force Classification II2) of targeted hysterectomy data prospectively collected from the American College of Surgeons National Surgical Quality Improvement Program involving over 500 hospitals across the United States. SETTING: National Surgical Quality Improvement Program Database. PATIENTS: Women aged 18 years or older undergoing hysterectomy for benign indications between 2014 and 2019. Patients were further classified into 4 groups according to uterine weight: <100 g, 100-249 g, 250 g-499 g, and specimens ≥500 g. INTERVENTIONS: Current Procedural Terminology codes were used to identify cases. Variables including age, ethnicity, body mass index, smoking status, diabetes, hypertension, blood transfusion, and American Society of Anesthesiologists classification system scores were collected. Cases were stratified by route of surgery, operative time, and uterine weight. MEASUREMENTS AND MAIN RESULTS: A total of 122,418 hysterectomies occurring between 2014 and 2019 were included in our study, of which 28,407 (23.2%) patients underwent abdominal, 75,490 (61.7%) laparoscopic, and 18,521 (15.1%) vaginal hysterectomy. The overall rate of VTE in patients with large specimen hysterectomies (≥500 g) was 0.64%. After multivariable adjustment, there was no significant difference in the odds of VTE between uterine weight groups. Only 30% of the surgeries with uterine weight above 500 g were performed with minimally invasive surgical routes. Patients who underwent minimally invasive hysterectomy had lower odds of VTE via laparoscopic (adjusted odds ratio [aOR] 0.62; confidence interval [CI]: 0.48-0.81) and vaginal (aOR 0.46; CI: 0.31-0.69) routes compared to laparotomy. Prolonged operative time (>120 min) was associated with increased odds of VTE (aOR 1.86; CI:1.51-2.29). CONCLUSION: The occurrence of VTE after a benign large specimen hysterectomy is rare. The odds of VTE is higher with longer operative times and lower with minimally invasive approaches, even for markedly enlarged uteri.

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.

Prediction using T2-weighted magnetic resonance imaging-based radiomics of residual uterine myoma regrowth after high-intensity focused ultrasound ablation.

OBJECTIVES: To develop and evaluate magnetic resonance imaging (MRI)-based radiomics models for predicting residual myoma regrowth within 1 year after high-intensity focused ultrasound (HIFU) ablation of uterine myomas. METHODS: A retrospective analysis of residual myoma regrowth within 1 year was performed on 428 myomas in 339 patients who were diagnosed with uterine myoma and treated with HIFU ablation in two hospital centers. In total, 851 radiomics features were extracted from T2-weighted images (T2WI) obtained 1 day after HIFU ablation, and the least absolute shrinkage and selection operator in the training cohort (n = 243) was employed to select radiomics features. Support vector machines were adopted to develop radiomics, clinicoradiological and combined radiomics-clinical models to predict residual myoma regrowth, defined as an increase in residual myoma volume of > 10% between that at day 1 post HIFU and that at follow-up MRI within 1 year. These models were validated in both internal (n = 81) and external (n = 104) test cohorts. The predictive performance and clinical application of these models were assessed using receiver-operating-characteristics-curve analysis, the area under the curve (AUC) and decision-curve analysis. RESULTS: The AUCs of the T2WI-based radiomics prediction model in the internal and external test cohorts were 0.834 (95% CI, 0.747-0.920) and 0.801 (95% CI, 0.712-0.889), respectively, and those of the clinicoradiological model were 0.888 (95% CI, 0.816-0.960) and 0.912 (95% CI, 0.851-0.973), respectively. The combined model had better predictive performance than either the radiomics or the clinicoradiological model, with AUC values of 0.922 (95% CI, 0.857-0.987) and 0.930 (95% CI, 0.880-0.980) in the internal and external test cohorts, respectively. Decision-curve analysis also indicated that application of the combined model has clinical value, this model achieving more net benefits than the other two models. CONCLUSION: T2WI-based radiomics features can predict effectively the occurrence of residual myoma regrowth within 1 year after HIFU ablation of uterine myomas, which serves as an accurate and convenient reference for clinical decision-making. © 2022 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Clinical features at the time of non-hysteroscopic myomectomy before pregnancy, which affect adverse pregnancy outcomes: a retrospective cohort study.

BACKGROUND: To investigate the association of clinical characteristics at the time of non-hysteroscopic myomectomy before pregnancy and adverse obstetric outcomes in the next pregnancy. METHODS: In this retrospective cohort study, we identified 248 women who underwent abdominal or laparoscopic myomectomy for intramural (IM) and/or subserosal (SS) uterine myomas in Bundang CHA Medical Center before pregnancy and delivered at the same hospital between 2010 and 2020. The association between clinical characteristics at the time of myomectomy and subsequent obstetric outcomes was analyzed using the Chi-square test, the Student t-test or one-way ANOVA, and multivariable analysis. RESULTS: There was one case of uterine rupture. The gestational age at delivery was 37.7 ± 2.4 weeks. There were 2 (0.8%) cases of fetal loss before 23 weeks, but there were no cases of perinatal death. The risk of transfusion during or after delivery was higher in the group in which multiple myomas were removed compared to the group in which only one was removed (aOR = 2.41, 95% CI [1.20-4.86], p = 0.014). The risk of neonatal composite morbidity was higher in the group in which myomas including the IM type were removed, than in the group in which only SS myomas were removed (aOR = 14.29, 95% CI [1.82-99.57], p = 0.012). Although not statistically significant, the group in which the sum of the diameters of the three largest myomas was greater than 15 cm showed a higher frequency of preterm birth (19.3% vs. 10.1%, p = 0.001) and lower birth weight (2901 ± 625 g vs. 3063 ± 576 g, p = 0.001) compared to the group with diameters less than 15 cm. Placenta accreta/increta (7.9% vs. 3.8%, p = 0.043) and lower placental weight (646 ± 170 g vs. 750 ± 232 g, p = 0.034) were more common in patients with an interval between myomectomy and pregnancy of less than 12 months compared to more than 12 months. CONCLUSIONS: To our knowledge, this is the first study to investigate the association between clinical features at the time of myomectomy before pregnancy and various adverse obstetric and perinatal outcomes. If the removed myomas are multiple, IM, large, or the interval between myomectomy and pregnancy is short, the risk of obstetric and neonatal complications may increase.

Oral Gonadotropin-Releasing Hormone Antagonists in the Treatment of Uterine Myomas: A Systematic Review and Network Meta-analysis of Efficacy Parameters and Adverse Effects.

OBJECTIVE: The aim of this systematic review is to gather and synthesize evidence regarding the use of oral gonadotrophin-releasing hormone (GnRH) antagonist for the treatment of bleeding associated with uterine myomas. DATA SOURCES: Web of Science, and MEDLINE databases were searched electronically on March 5, 2021, using combinations of the relevant Medical Subject Headings terms and keywords. The search was restricted to the English language and to human studies. METHODS OF STUDY SELECTION: Only randomized controlled trials involving patients with heavy menstrual bleeding associated with uterine myomas treated with different doses of oral nonpeptide GnRH antagonists with or without add-back therapy were included. Studies comparing oral nonpeptide GnRH antagonists with treatments other than placebo were also excluded. TABULATION, INTEGRATION, AND RESULTS: A total of 5 randomized trials including 2463 women were included in the analyses. Included studies were found to be at low risk of bias. When treatments were compared against placebo, the top 3 treatments for bleeding suppression were elagolix 600 mg, 400 mg, and 200 mg without add-back. Elagolix 600 mg without add-back therapy had a significantly higher risk of amenorrhea than lower doses of elagolix with and without add-back and relugolix as well. Uterine volume changes were more pronounced in therapies without add-back. All treatments were associated with significantly improved quality of life scores, both for myoma symptom-related and overall health-related scores. With the exception of relugolix with high-dose add-back, all treatments significantly increased low-density lipoprotein (LDL) levels. Again, all treatment modalities except for elagolix 200 mg without add-back significantly increased LDL-to-HDL ratio. The increase was highest for treatment without add-back therapy. CONCLUSION: Oral GnRH antagonists seem to be effective for myoma-associated bleeding and for improving quality of life. The safety profile is acceptable for short-term use, but lipid metabolism is affected.

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.

Oviductal Oxygen Homeostasis in Patients with Uterine Myoma: Correlation between Hypoxia and Telocytes.

Oxygen balance is crucial for angiogenesis, immunity, and tissue repair. The human oviduct is essential for reproductive function, and any imbalance in homeostasis leads to fertility disturbances and might be a reason for ectopic pregnancy development. Uterine myoma is a widespread benign tumour, which is often accompanied by infertility. Telocytes have been discussed in the contexts of motility, fibrosis development, and angiogenesis. We observed the oviducts from patients with and without uterine myoma, comparing the expression of HIF-1, HO, VEGF and its receptor, NOS, oestrogen, and progesterone receptors by immunolabeling. The myometrial and oviductal telocytes were also compared in both groups. Biochemical analyses were conducted for FSH, LH, AMH, sFlt, oestrogen, and progesterone in blood samples. Patients with uterine myoma have different expressions of sex steroid receptors and an increased number of telocytes. The decreasing VEFG expression was compensated by the rise in the HIF-1 and NOS expression. Blood biochemical analyses revealed a higher progesterone level and lower AMH in patients with uterine myoma. No differences in sFlt, FSH, and LF were observed. Uterine myoma impacts oviduct oxygen homeostasis and might cause fertility disturbances (uterine and oviductal infertility factors).

Simultaneously Occurring Ischemic Stroke, Leg Artery Occlusion, and Pulmonary Embolism Induced by a Uterine Myoma.

OBJECTIVES: Paradoxical embolism from venous thrombosis through the patent foramen ovale is a rare but well-known cause of stroke in young adults. Here, we report a case of simultaneous middle cerebral artery infarction, multiple occlusions of the leg arteries, and pulmonary thromboembolism from the venous thrombus, all due to compression of the external iliac vein by a uterine leiomyoma. MATERIALS AND METHODS (CASE PRESENTATION): A 44-year-old woman presented with left hemiparesis and central-type left facial palsy. She denied a history of hypertension, diabetes mellitus, previous cerebral infarction, myocardial infarction, smoking, or oral contraceptive use. The patient recovered completely after injection of tissue plasminogen activator. Brain diffusion-weighted imaging showed an acute right middle cerebral artery infarction. Transcranial Doppler with saline agitation test revealed a right-to-left shunt, suggesting a patent foramen ovale. Chest computed tomography revealed multiple pulmonary thromboembolisms. Lower extremity sonography and lower extremity computed tomography revealed a multifocal thrombus in the major veins and arteries of the left leg. Moreover, a large uterine myoma compressing the left external iliac vein was noted on lower extremity computed tomography. RESULTS: After the treatment of pulmonary thromboembolism and venous thrombosis with rivaroxaban, surgical thrombectomy of the left popliteal artery, patent foramen ovale closure, and total hysterectomy were performed. Subsequently, she had no recurrent paradoxical embolism or pulmonary thromboembolism. CONCLUSION: Structural abnormalities in the pelvic cavity are not commonly suspected as stroke etiology. However, examination of the pelvic cavity is advisable in young female stroke patients with pulmonary thromboembolism or other paradoxical embolisms.

Clinicopathological features and prognostic factors for uterine myoma.

Objectives: To investigate the clinicopathological features of patients with uterine myoma and to analyze and summarize factors affecting patient prognosis. Methods: This study retrospectively investigated records of uterine myoma patients treated at Huzhou Central Hospital between June 2018 and May 2020. A total of 149 patients were included in this study, including 121 patients with good prognosis and 28 patients with poor prognosis. Clinical and pathological characteristics, including age, average body mass index (BMI), menopausal status, average lesion diameter, presence of hypertension or diabetes mellitus, operation method, myoma type, location, and quantity, number of fibroids, and presence of pelvic adhesion were analyzed via multivariate analysis. Results: Among the 149 patients with uterine uterine myoma, 92 had anterior wall uterine myoma, 36 had posterior wall uterine myoma, and 21 had uterine fundus uterine myoma. In terms of location, 94 cases were intramural and 55 cases were subserosal. Quantity-wise, 107 had 1-3 myomas while 42 had four or more. Moderate or more severe pelvic adhesions were present in 33 cases. Univariate analysis showed significant differences in age, operation method, myoma type, myoma location, myoma number, and pelvic adhesion severity between patients with good and poor prognosis. Multivariate analysis showed that age, surgical method, uterine myoma type, uterine myoma location, uterine myoma quantity, and pelvic adhesion severity were risk factors affecting the prognosis. Conclusion: Many prognostic factors, including age, operation method, myoma type, myoma location, myoma number, and pelvic adhesion severity are linked to uterine myoma patient prognosis.

A Simple Technique for the Placement of Seprafilm, a Sodium Hyaluronate or Carboxymethylcellulose Absorbable Barrier, during Laparoscopic Myomectomy.

This report describes a simple technique using conventional instrumentation for the placement of Seprafilm, a sodium hyaluronate or carboxymethylcellulose absorbable barrier for adhesion prevention. A total of 378 women with uterine myomas undergoing laparoscopic myomectomies had 737 Seprafilm pieces placed. Seprafilm sheet was softened through exposure to room air for 5 minutes, cut into 4 pieces (length, 5-10 mm), rolled up alongside a plastic sheet cut from a camera drape cover, and gently placed at the right paracolic gutter. The Seprafilm pieces unfolded semiautomatically on release and were then placed on the uterus. The median time to apply per Seprafilm piece was 1 (range: 0.8-3.5) minute. We failed to place 16 pieces (16 of 737, 2.2%) in 11 patients. Virginal status, myoma weight, and the number of removed myomas were the risk factors of failed placement. Our technique for Seprafilm placement during laparoscopic myomectomy is simple and safe.

Ultrasonographic Features of Uterine Scar after Laparoscopic and Laparoscopy-Assisted Minilaparotomy Myomectomy: A Comparative Study.

STUDY OBJECTIVE: To evaluate uterine scar features after laparoscopic myomectomy (LM) compared with myomectomy performed by laparoscopy initially and then completed with minilaparotomy (LAM). DESIGN: Prospective cohort study. SETTING: An academic center for advanced endoscopic gynecologic surgery. PATIENTS: Sixty-nine symptomatic women who underwent myomectomy between July and December 2018. INTERVENTION: Patients underwent LM or LAM and 3-month follow-up ultrasonography. MEASUREMENTS AND MAIN RESULTS: Forty-four patients underwent LM and 25 underwent LAM. Demographic data, intraoperative parameters, and postoperative outcomes were collected. Two-dimensional color Doppler ultrasound was done at a 3-month follow-up to evaluate myomectomy scar features, myometrial thickness, and the presence of and vascularity of a heterogeneous mass. These features were compared with those of the intact myometrium on the opposite wall of the patient's uterus. The 2 groups had similar demographic characteristics, and there were no significant between-group differences in the number, maximum diameter, type, or location of myomas. The mean myometrial thickness at the scar site was 18.9 ± 3.22 mm in the LM group and 19.7 ± 3.50 mm in the LAM group, with no significant difference between the 2 groups. There was no meaningful difference in vascularity between the scar and normal myometrium. Heterogeneous masses were detected in 23% of patients in the LM group and in 24% of those in the LAM group. Other than mean operative time (207 minutes for LM vs 150 minutes for LAM; p < .001) and mean postoperative reduction in hemoglobin (1.77 mg/dL for LM vs 2.35 mg/dL for LAM; p = .023), there were no other statistical differences between the 2 groups. One patient in the LM group experienced a bowel injury resulting from morcellation. CONCLUSION: There were no differences in myometrial scar features after LM compared with after LAM, implying effective suturing via both approaches.

Preoperative Treatment with Ulipristal Acetate before Outpatient Hysteroscopic Myomectomy.

INTRODUCTION: Nowadays, the resection of submucosal myomas is usually performed by hysteroscopy. No previous study has investigated the use of preoperative hormonal therapy before outpatient hysteroscopic myomectomy. OBJECTIVE: To compare the usefulness of 3-month preoperative treatment with ulipristal acetate (UPA) before outpatient hysteroscopic myomectomy in patients with FIGO (International Federation of Gynecology and Obstetrics) type 0-1 myomas. STUDY DESIGN: This prospective patient preference study included women requiring hysteroscopic resection of single FIGO type 0-1 myoma with the largest diameter <2 cm. Patients underwent either preoperative treatment with UPA (5 mg/day) for 3 months or direct surgery. Outpatient myomectomy was performed using the bipolar electrosurgical Versapoint system (Ethicon Gynecare, USA). The primary objective of the study was to compare the rate of complete resections in the 2 study groups. The secondary objective of the study was to compare the operative time and the volume of fluid infused/absorbed. The tertiary objective of the study was to assess the surgical appearance of the myomas in patients treated with UPA. RESULTS: The study included 38 women treated with UPA and 45 women who underwent direct surgery. UPA treatment significantly decreased the volume of uterine myomas (p < 0.001). The percentage of complete resection was higher in patients treated with UPA (89.5%) than in those who underwent direct surgery (68.9%; p = 0.046). Preoperative UPA treatment decreased the operative time (p < 0.001) and the volume of fluid infused (p = 0.016), but it did not significantly affect the volume of fluid absorbed (p = 0.874). The texture of the myoma was not significantly affected by UPA treatment (p = 0.142). CONCLUSIONS: Three-month UPA treatment improves the chance of single-step complete outpatient hysteroscopic resection of single FIGO type 0-1 myoma. Future randomized studies with a larger sample size should confirm these preliminary findings.

Total Laparoscopic Hysterectomy and Bilateral Salpingo-Oophorectomy for a 6095-g Myomatous Uterus in a Patient of the Jehovah's Witness Faith.

STUDY OBJECTIVE: To demonstrate techniques for addressing the unique challenges for a minimally invasive approach to hysterectomy presented by a massive myomatous uterus. DESIGN: Technical video of an operation demonstrating the methods used to perform hysterectomy in this setting, highlighting such aspects as port placement (Fig. 1), uterine manipulation (Fig. 2), exposure, and vascular control (Figs. 3 and 4) (Canadian Task Force classification III). SETTING: Academic tertiary care hospital. INTERVENTION: A 49-year-old woman elected to proceed with laparoscopic hysterectomy after years of suffering from bleeding and bulk symptoms from a massively enlarged myomatous uterus. A computed tomography scan estimated uterine dimensions of 32 × 27 × 24 cm, for a volume of >7000 mL (Fig. 5). Her surgical history included a ventral herniorrhaphy with mesh, and her body mass index was 43 kg/m2. She was a Jehovah's Witness, and thus blood transfusion was not an acceptable option for her due to a religious prohibition. Intraoperatively, the uterus extended deep into the pararectal and paravesical spaces on the right, from the caudad below the cervix (Fig. 6) to superiorly near the liver edge (Fig. 7). MEASUREMENTS AND MAIN RESULTS: Laparoscopic hysterectomy was successfully completed (Table), and the patient was discharged on the day after surgery. Final pathology revealed a 6095-g uterus with benign leiomyomata. She presented 9 days after surgery with nausea and vomiting, suspicious for an incarcerated hernia at the tissue extraction site. Her symptoms were ultimately determined to be due to either ileus or small bowel obstruction, which likely could have been managed nonoperatively with bowel rest and fluids. She stayed an additional 2 days after readmission and was then discharged, with no further complications. CONCLUSIONS: The size of the uterus was once considered a barrier to the use of laparoscopy for hysterectomy, but experience has shown that the benefits of minimally invasive surgery are particularly relevant for large myomas [1-4], given that a vaginal approach is not feasible and that other risks, such as wound complications and venous thromboembolism, would be greater with the large incision required to perform the procedure by laparotomy. This video uses a particularly challenging case to demonstrate a roadmap for addressing myomas in laparoscopic hysterectomy through exposure and vascular control. Although the presentation focused on the initial steps of the procedure and not on uterine extraction, this patient's readmission highlights potential complications associated with various methods of tissue removal for very large specimens.

Ultrasound-Guided Percutaneous Microwave Ablation for Subserosal Uterine Myomas.

STUDY OBJECTIVE: To prospectively evaluate the clinical effectiveness and safety of ultrasound-guided percutaneous microwave ablation for symptomatic subserosal uterine myomas. DESIGN: Prospective observational study (Canadian Task Force classification II-1). SETTING: A teaching hospital (Department of Interventional Ultrasound, General Hospital of Chinese PLA, Beijing, China). PATIENTS: Sixty-nine patients with symptomatic subserosal uterine myomas treated with ultrasound-guided percutaneous microwave ablation. INTERVENTIONS: All 69 patients underwent ultrasound-guided percutaneous microwave ablation. The number of patients lost to follow-up at was 21 at 3 months, 34 at 6 months, and 35 at 12 months. MEASUREMENTS AND MAIN RESULTS: The efficacy of treatment was evaluated based the mean myoma volume shrinkage rate and changes in Uterine Fibroid Symptom and Quality of Life Questionnaire scores at 3, 6, and 12 months after therapy. Treatment safety was evaluated based on the Society of Interventional Radiology practice guidelines. The mean patient age was 40.3 ± 4.9 years (range, 26-49 years). The mean myoma volume was 221.74 ± 153.18 cm3 before ablation, decreasing to 87.24 ± 45.93 cm3 at 3 months after ablation (p < .001), 46.68 ± 24.7 cm3 at 6 months after ablation (p < .001), and 38.05 ± 24.93 cm3 at 12 months after ablation (p <.001), respectively. Between pretreatment and 3-month follow-up, the mean symptom severity score decreased from 34.53 ± 3.83 to 12.74 ± 3.07 (p < .001), and the mean health-related quality of life score increased from 45.25 ± 10.97 to 78.48 ± 11.39 (p < .001). Both scores remained stable at the 6- and 12-month follow-up time points. No permanent injury or fatal complications were seen in this series. CONCLUSION: Ultrasound-guided percutaneous microwave ablation of subserosal uterine myomas is a promising treatment method. Further studies with larger sample sizes and a control group are needed.