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.

Deciphering endometrial dysfunction in patients with uterine myoma using endometrial organoids: a pilot study.

RESEARCH QUESTION: What influence does an intramural myoma have on the endometrium, and how is this mediated? DESIGN: Endometrium was collected from 13 patients with non-cavity-distorting intramural myomas (diameter ≤4 cm; International Federation of Gynecology and Obstetrics type 4) and 13 patients without myomas undergoing hysterectomy for benign cervical diseases with a similar clinical baseline. Endometrial organoids were established in vitro and induced to reach the secretory phase by oestrogen and progesterone. Transcriptome sequencing was conducted on endometrial organoids in both untreated and secretory stages from three individuals with myomas and three control participants. Immunofluorescence and real-time quantitative PCR (RT-qPCR) were performed on endometrial organoids from another 10 myoma patients and 10 control patients for validation. RESULTS: The data revealed abnormally increased hormone receptor (PGR) levels in the untreated endometrial organoids with myomas, resulting in potentially abnormal glandular and vascular development. The aberrant responses to oestrogen and progestogen prompted further investigation into the secretory phase. The secretory endometrial organoids with myomas exhibited greater changes in acetyl-α-tubulin, ODF2 and TPPP, demonstrating likely decreased cilia, and COL6A1, used as a marker for increased extracellular matrix (ECM) modelling. Both untreated and secretory endometrial organoids with myoma showed an up-regulation of genes and pathways related to ECM mechanotransduction. The expression pattern of receptivity-related genes was disturbed in endometrial organoids with myoma. CONCLUSIONS: This study is the first to reveal that intramural myomas create an abnormal hormonal and mechanical environment in the untreated and secretory endometrial organoids. The intramural myomas negatively impacted gene expression relating to endometrial glands, blood vessels, cilia and ECM, indicating that intramural myomas impair endometrial decidualization and receptivity.

Characteristics associated with blood transfusion among women undergoing laparoscopic myomectomy: a National Surgical Quality Improvement Program study.

BACKGROUND: Uterine fibroids are the most common benign tumors that affect females. A laparoscopic myomectomy is the standard surgical treatment for most women who wish to retain their uterus. The most common complication of a myomectomy is excessive bleeding. However, risk factors for hemorrhage during a laparoscopic myomectomy are not well studied and no risk stratification tool specific for identifying the need for a blood transfusion during a laparoscopic myomectomy currently exists in the literature. OBJECTIVE: This study aimed to identify risk factors for intraoperative and postoperative blood transfusion during laparoscopic myomectomies and to develop a risk stratification tool to determine the risk for requiring a blood transfusion. STUDY DESIGN: This was a retrospective cohort study of the American College of Surgeons National Surgical Quality Improvement Program database from 2012 to 2020. Women who underwent a laparoscopic (conventional or robotic) myomectomy were included. Women who received 1 or more blood transfusions within 72 hours after the start time of a laparoscopic myomectomy were compared with those who did not require a blood transfusion. A multivariable analysis was performed to identify risk factors independently associated with the risk for transfusion. Two risk stratification tools to determine the need for a blood transfusion were developed based on the multivariable results, namely (1) based on preoperative factors and (2) based on preoperative and intraoperative factors. RESULTS: During the study period, 11,498 women underwent a laparoscopic myomectomy. Of these, 331(2.9%) required a transfusion. In a multivariable regression analysis of the preoperative factors, Black or African American and Asian races, Hispanic ethnicity, bleeding disorders, American Society of Anesthesiologists class III or IV classification, and a preoperative hematocrit value ≤35.0% were independently associated with the risk for transfusion. Identified intraoperative factors included specimen weight >250 g or ≥5 intramural myomas and an operation time of ≥197 minutes. A risk stratification tool was developed in which points are assigned based on the identified risk factors. The mean probability of transfusion can be calculated based on the sum of the points. CONCLUSION: We identified preoperative and intraoperative independent risk factors for a blood transfusion among women who underwent a laparoscopic myomectomy. A risk stratification tool to determine the risk for requiring a blood transfusion was developed based on the identified risk factors. Further studies are needed to validate this tool.

Laparoscopic Multibipolar Radiofrequency Myolysis for Symptomatic Myomas in 10 Steps.

STUDY OBJECTIVE: To describe a minimal invasive 10-step technique of laparoscopic multibipolar radiofrequency myolysis for symptomatic myomas. DESIGN: A step-by-step video demonstration of the technique. SETTING: A woman with symptomatic FIGO 5 myoma of 60 mm of diameter, confirmed by magnetic resonance imaging. The patient included in this video gave consent for publication of the video and posting of the video online including social media, the journal website, scientific literature websites (such as PubMed, ScienceDirect, Scopus, etc.) and other applicable sites. INTERVENTIONS: Approximately 30% of women of child-bearing age with myomas will present with symptoms [1] that include chronic pelvic pain, abnormal uterine bleeding or infertility [2,3]. Data regarding fertility preservation and obstetric outcomes suggest that radiofrequency myoma ablation may offer an alternative to existing treatments for women who desire future fertility [4]. The local institutional review board stated that approval was not required because the video describes a technique and not a clinical case. In our center, all radiofrequency indications are discussed during a monthly multidisciplinary myomas meeting. This video presents the procedure divided into the following 10 steps: planning of the surgery; materials; installation; laparoscopic exploration; transvaginal ultrasound examination; visual and transvaginal ultrasound guided transparietal puncture of the myoma; control of the applicators' position; radiofrequency myolysis; end of myolysis, applicators removal; final check and additional procedures. CONCLUSION: Radiofrequency myolysis is a simple and reproductible procedure that can be offered as an alternative to myomectomy [5]. This video presents 10 steps to make the procedure easier to adopt and to reduce its learning curve.

3D Imaging reconstruction and laparoscopic robotic surgery approach to disseminated peritoneal leiomyomatosis.

OBJECTIVES: This video article explores the synergistic approach of 3D imaging reconstruction and laparoscopic robotic surgery for the management of a complex case of disseminated peritoneal leiomyomatosis (1). The primary focus lies in the capability of the reconstruction model to provide diagnostic support to identify fibroids during surgical procedures, potentially enhancing surgical precision, reducing operating times, minimizing uterine incisions, and limiting blood loss. 3D imaging reconstruction techniques were used to facilitate the identification of multiple parasitic and non-serosal myomas, which is particularly challenging when operating with a robotic surgical platform that lacks haptic feedback. SETTING: Tertiary referral center. PARTICIPANTS: A case report design was employed, focusing on a 43-year-old nulliparous infertile woman with multiple symptomatic uterine myomas. Our institution has made a further diagnosis of disseminated peritoneal leiomyomatosis(4-5). INTERVENTIONS: Due to the widespread nature of peritoneal leiomyomatosis and numerous uterine fibroids, robotic surgery was considered a preferable option based on our experience to operate within confined anatomical spaces. 3D imaging reconstruction technology was utilized for preoperative and intraoperative planning, enabling precise determination of the fibroids' location, size, and volume obtained through MRI imaging. Real-time 3D imaging guided rapid myoma localization and surgical strategy adjustment (2-3). The procedure resulted in the removal of 15 fibroids, with minimal blood loss (250 mL) and a total operative time of 120 minutes. Multilayer running hysterorraphy was performed using a barbed monofilament suture to ensure effective hemostasis, incorporating serosal introflection to reduce the risk of post-operative adhesion development. CONCLUSIONS: The combined approach of 3D imaging reconstruction and laparoscopic robotic surgery holds significant potential for the management of disseminated peritoneal leiomyomatosis. This approach can overcome some robotic surgery limitations, particularly the absence of haptic feedback, providing accurate preoperative planning and real-time intraoperative guidance, facilitating efficient fibroid localization, minimizing uterine incisions, and reducing blood loss. Further research is needed to fully evaluate the clinical impact of this promising technology.

Prostaglandin Injection for Myoma Expulsion (PRIME): Case Series of a Novel Approach to Hysteroscopic Resection of FIGO Type 2 Myomas.

STUDY OBJECTIVE: To evaluate the use of dilute carboprost tromethamine injection at the endometrium/myoma junction during hysteroscopy to facilitate myoma expulsion and removal in a single procedure. DESIGN: Case series. SETTING: Single high-volume academic medical center. PATIENTS: Seven patients aged 32 to 51 years old with FIGO type 2 uterine myomas and symptoms of abnormal uterine bleeding or infertility undergoing hysteroscopic resection with a morcellation device from November 2022 to July 2023. INTERVENTION: Dilute injection of carboprost tromethamine (10 µg/mL) at time of hysteroscopic myomectomy. MEASUREMENTS AND MAIN RESULTS: The main outcome measure was ability to complete the hysteroscopic myomectomy in a single procedure using a hysteroscopic morcellator. Secondary outcomes included total operative time, fluid deficit, and postoperative pharmacologic side effects and/or surgical complications. Among our 7 patients, all had successful single procedure complete resections of myomas ranging from 0.9 to 4.6 cm in maximal diameter. Average operative time was 30 minutes, and average fluid deficit was approximately 839 mL. The carboprost dosages used ranged from 30 to 180 µg. One patient experienced prolonged postoperative nausea and vomiting that resolved with antiemetics. One patient experienced postoperative endometritis that improved with antibiotics. CONCLUSION: In this pilot study, injection of dilute carboprost intraoperatively facilitated one-step hysteroscopic myomectomy of FIGO 2 myomas, via enhanced extrusion of the intramural portion of the fibroid into the uterine cavity, with both short operative times and acceptable fluid deficits.

The Association of Vitamin D with Uterine Fibroids in Premenopausal Patients: A Systematic Review and Meta-Analysis.

OBJECTIVE: This study aims to consolidate existing literature regarding the association between vitamin D and uterine fibroid presence and growth. DATA SOURCES: A comprehensive search across databases including Medline, Embase, CINAHL, Web of Science, ClinicalTrials.gov, and grey literature was conducted from inception to February 2023, using relevant keywords. Authors were contacted for unpublished data. STUDY SELECTION: From 9931 studies screened based on title and abstract, those evaluating serum vitamin D levels or vitamin D treatment effects, using ultrasonography for diagnosis, and involving at least 25 premenopausal participants were included. Case reports, case series, and reviews were excluded. DATA EXTRACTION AND SYNTHESIS: Data were extracted using a predefined form. Methodological quality was assessed through the Newcastle-Ottawa Scale and the Risk of Bias-2 tools. Evidence quality was evaluated using Grading of Recommendations Assessment, Development, and Evaluation. Data from 3 randomised controlled trials (n = 328) and 23 observational studies (n = 5650) were meta-analyzed via random-effects modelling. Patients receiving oral vitamin D supplementation had a significantly different change in fibroid size (standardized mean difference -5.7%; CI -10.63 to -0.76, P = 0.02, I2 = 99%), as measured by the percentage change in diameter or volume, compared to controls, over the span of 2-6 months. Those receiving supplementation had vitamin D insufficiency; regimens varied between 50 000 IU weekly for 12 weeks, 50 000 IU weekly for 8 weeks, and 50 000 IU biweekly for 10 weeks. Patients with fibroids exhibited lower serum vitamin D concentrations (mean difference -5.50 ng/mL; CI 6.99 to -4.01, P < 0.001, I2 = 87%) and higher odds of vitamin D deficiency (OR 3.71; CI 1.90-7.24, P < 0.001, I2 = 80%). CONCLUSION: This review underscores the potential of vitamin D in mitigating fibroid development and growth. While promising, further research is warranted to optimise dosage and treatment duration, potentially offering a non-invasive solution for at-risk patients. Continued exploration of vitamin D's role in fibroid treatment is encouraged.

Incidence and risk factors of parasitic myoma after laparoscopic myomectomy using uncontained power morcellation: Retrospective analysis of 87 patients who had a subsequent second laparoscopic surgery.

AIM: Studies on parasitic myomas after laparoscopic morcellation are mainly limited to case reports, and the incidence and risk factors have not yet been well-understood. We aimed to clarify the actual incidence and risk factors of parasitic myoma after laparoscopic myomectomy using uncontained power morcellation by reviewing cases with subsequent laparoscopic surgery. METHODS: This retrospective study included 87 patients who had laparoscopic myomectomy using uncontained power morcellation, followed by subsequent second laparoscopic surgery for gynecological disease between 2008 and 2021. First, the incidence and characteristics of parasitic myomas detected at the second laparoscopic surgery were reviewed. Second, patients were stratified according to the presence of parasitic myoma (PM+ and PM- groups), and risk factors were analyzed by comparing the background, intraoperative findings, and clinical course after laparoscopic myomectomy. RESULTS: Of the 87 patients, parasitic myomas were detected in 16 (18.4%). Twelve patients (75.0%) were asymptomatic and diagnosed incidentally during surgery. Two patients presented with acute abdomen requiring emergency surgery. Comparing the PM+ and PM- groups, the total weight of the enucleated myomas and the diameter of the largest myoma at the initial laparoscopic myomectomy were significantly greater in the PM+ group. Other factors, including age and number of enucleated myomas did not differ between the groups. CONCLUSIONS: The actual incidence of parasitic myoma after laparoscopic myomectomy using uncontained power morcellation is higher than that previously reported. In laparoscopic power morcellation, large myomas increase the risk of developing parasitic myoma, and a containment bag system is expected to minimize this complication.

The characteristics of a fibroid in pregnancy can influence the perinatal outcome.

The prevalence of fibroids during reproductive age is 20-25%. The presence of fibroids during pregnancy can impact perinatal outcomes. OBJECTIVE: To determine whether fibroids affect perinatal outcomes and whether women who undergo fibroid surgery before pregnancy have better perinatal outcomes than those who have fibroids during pregnancy. The study also analyzes the optimal time interval between myomectomy and pregnancy and the characteristics of fibroids during pregnancy that affect perinatal outcomes. In both groups, fibroids' size, number, and location were analyzed to determine their influence on perinatal outcomes. The perinatal outcome is determined by gestational age, birth weight, Apgar score, intrauterine growth retardation, placental complications, and delivery method. METHODS: A study was conducted on the perinatal outcomes of 338 women who had uterine fibroids during pregnancy and those who had undergone fibroid surgery before pregnancy. The medical records of women who gave birth at a tertiary university hospital were analyzed in this retrospective study. RESULTS: Women with submucosal fibroids have a lower gestational age of delivery (P = 0.0371), and those who operated on a higher number of fibroids before pregnancy had newborns with lower birth weights (P < 0.0001). Submucosal fibroids during pregnancy increase the chances of cesarean delivery (P = 0.0354). 14% of newborns have an Apgar score of less than seven within the first minute of birth in fibroids larger than 7 cm (P < 0.0001). CONCLUSION: There is a statistically significant difference in the perinatal outcome of newborns depending on the number, size and placement of uterine fibroids in both observed groups.

Elastographic and vascular findings of uterine myomas assessed by ultrasound.

OBJECTIVE: The objectives of this study were to evaluate the vascularization pattern of uterine myoma (UM) by ultrasonography using Superb Microvascular Imaging (SMI) and tissue stiffness elastography. METHOD: A prospective and cross-sectional study was carried out between March 2020 and December 2022 among women with clinical and ultrasound diagnosis of UM who would subsequently undergo radiofrequency ablation. Ultrasound examination was performed using both transvaginal and transabdominal routes. UM vascularization pattern was assessed by power Doppler (PD) and SMI, while elastographic pattern was assessed by shear wave (SWE) and strain (STE). FIGO classification, location, and measurement of the largest UM were also described. RESULTS: A total of 21 women diagnosed with UM were evaluated. There was a predominance of nulliparous women and 20 women (95.2%) reported desire for pregnancy. Of the 18 women with abnormal uterine bleeding, 15 (83.3%) had abdominal cramping. As far as previous treatment, 7 (33.3%) had undergone myomectomy for other UM. The mean uterine and UM volumes were 341.9 cm3 (90-730) and 126.52 cm3 (6.0-430), respectively. There was a predominance of hypoechogenic lesions (90.5%). There was also preponderance of UM in the FIGO 2-5 classification (n = 9; 42.9%). Vascularization patter was mostly moderate (score 2) in 9 cases (42.9%). The majority of UM were considered to have intermediate stiffness (n = 10; 47.6%). CONCLUSION: The majority of UM showed vascularization and moderate stiffness. A relationship was observed between the stiffness of the UM assessed by elastography and its FIGO classification.

Analysis of Expression of the ANG1, CaSR and FAK Proteins in Uterine Fibroids.

Understanding the molecular factors involved in the development of uterine myomas may result in the use of pharmacological drugs instead of aggressive surgical treatment. ANG1, CaSR, and FAK were examined in myoma and peripheral tissue samples taken from women after myoma surgery and in normal uterine muscle tissue samples taken from the control group. Tests were performed using tissue microarray immunohistochemistry. No statistically significant differences in ANG1 expression between the tissue of the myoma, the periphery, and the normal uterine muscle tissue of the control group were recorded. The CaSR value was reduced in the myoma and peripheral tissue and normal in the group of women without myomas. FAK expression was also lower in the myoma and periphery compared to the healthy uterine myometrium. Calcium supplementation could have an effect on stopping the growth of myomas.

Preoperative discrimination between uterine myomas and sarcomas.

The narrative review article is focused on the strengths and limitations of modern imaging methods in the preoperative differential diagnosis of uterine mesenchymal tumours. In order to tailor the surgical procedures, imaging methods, namely ultrasound and magnetic resonance imaging (MRI), should be taken into account as well as clinical symptoms, age, and fertility plans. On ultrasound scans, uterine sarcomas have the appearance of large, usually solitary tumours of non-homogenous structure with irregular cysts, ill-defined outline borders (interrupted capsule), absence of calcifications with acoustic shadowing, and moderate to rich internal vascularisation. Rapid growth between follow-ups or atypical growth in peri- or post-menopause is also a sign of malignancy. On MRI, uterine sarcomas are characterized by irregular borders, hyperintense areas on T1-weighted and T2- weighted images, and central non-enhancing necrotic areas. On diffusion-weighted imaging (DWI/MRI), sarcomas exhibit markedly restricted diffusion but there is a significant overlap with some variants of fibroids. Core-needle or hysteroscopic biopsy can be used preoperatively if suspicious features are detected on ultrasound or MRI scans, particularly before myomectomy if fertility preservation is required or when conservative management is considered in asymptomatic women. Other imaging methods, such as positron emission tomography fused with CT (PET-CT) or computed tomography (CT) have limited role to distinguish uterine sarcomas from myomas and are suitable only for staging purposes. The importance of tumour markers including lactate dehydrogenase in preoperative work-up have not been verified yet. Conclusion: Uterine sarcomas can be distinguished from much more common myomas based on a combination of malignant features on ultrasound or MR imaging. In these suspicious cases the type and extent of surgery should be adjusted, avoiding intraperitoneal morcellation, which could lead to iatrogenic tumour spread and worsening of the patient's prognosis.

[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.

Currently Available Treatment Modalities for Uterine Fibroids.

Uterine fibroids (leiomyomas and myomas) are the most common benign gynecological condition in patients presenting with abnormal uterine bleeding, pelvic masses causing pressure or pain, infertility and obstetric complications. Almost a third of women with fibroids need treatment due to symptoms. OBJECTIVES: In this review we present all currently available treatment modalities for uterine fibroids. METHODS: An extensive search for the available data regarding surgical, medical and other treatment options for uterine fibroids was conducted. REVIEW: Nowadays, treatment for fibroids is intended to control symptoms while preserving future fertility. The choice of treatment depends on the patient's age and fertility and the number, size and location of the fibroids. Current management strategies mainly involve surgical interventions (hysterectomy and myomectomy hysteroscopy, laparoscopy or laparotomy). Other surgical and non-surgical minimally invasive techniques include interventions performed under radiologic or ultrasound guidance (uterine artery embolization and occlusion, myolysis, magnetic resonance-guided focused ultrasound surgery, radiofrequency ablation of fibroids and endometrial ablation). Medical treatment options for fibroids are still restricted and available medications (progestogens, combined oral contraceptives andgonadotropin-releasing hormone agonists and antagonists) are generally used for short-term treatment of fibroid-induced bleeding. Recently, it was shown that SPRMs could be administered intermittently long-term with good results on bleeding and fibroid size reduction. Novel medical treatments are still under investigation but with promising results. CONCLUSIONS: Treatment of fibroids must be individualized based on the presence and severity of symptoms and the patient's desire for definitive treatment or fertility preservation.

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.

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.

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.

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.