The Value of Using Patient-Specific 3D-Printed Anatomical Models in Surgical Planning for Patients With Complex Multifibroid Uteri.

OBJECTIVES: To compare surgeon responses regarding their surgical plan before and after receiving a patient-specific three-dimensional (3D)-printed model of a patient's multifibroid uterus created from their magnetic resonance imaging. METHODS: 3D-printed models were derived from standard-of-care pelvic magnetic resonance images of patients scheduled for surgical intervention for multifibroid uterus. Relevant anatomical structures were printed using a combination of transparent and opaque resin types. 3D models were used for 7 surgical cases (5 myomectomies, 2 hysterectomies). A staff surgeon and 1 or 2 surgical fellow(s) were present for each case. Surgeons completed a questionnaire before and after receiving the model documenting surgical approach, perceived difficulty, and confidence in surgical plan. A postoperative questionnaire was used to assess surgeon experience using 3D models. RESULTS: Two staff surgeons and 3 clinical fellows participated in this study. A total of 15 surgeon responses were collected across the 7 cases. After viewing the models, an increase in perceived surgical difficulty and confidence in surgical plan was reported in 12/15 and 7/15 responses, respectively. Anticipated surgical time had a mean ± SD absolute change of 44.0 ± 47.9 minutes and anticipated blood loss had an absolute change of 100 ± 103.5 cc. 2 of 15 responses report a change in pre-surgical approach. Intra-operative model reference was reported to change the dissection route in 8/15 surgeon responses. On average, surgeons rated their experience using 3D models 8.6/10 for pre-surgical planning and 8.1/10 for intra-operative reference. CONCLUSIONS: Patient-specific 3D anatomical models may be a useful tool to increase a surgeon's understanding of complex gynaecologic anatomy and to improve their surgical plan. Future work is needed to evaluate the impact of 3D models on surgical outcomes in gynaecology.

Management of Uterine Fibroids and Sarcomas: The Palermo Position Paper.

BACKGROUND: Uterine fibroids are benign monoclonal tumors originating from the smooth muscle cells of the myometrium, constituting the most prevalent pathology within the female genital tract. Uterine sarcomas, although rare, still represent a diagnostic challenge and should be managed in centers with adequate expertise in gynecological oncology. OBJECTIVES: This article is aimed to summarize and discuss cutting-edge elements about the diagnosis and management of uterine fibroids and sarcomas. METHODS: This paper is a report of the lectures presented in an expert meeting about uterine fibroids and sarcomas held in Palermo in February 2023. OUTCOME: Overall, the combination of novel molecular pathways may help combine biomarkers and expert ultrasound for the differential diagnosis of uterine fibroids and sarcomas. On the one hand, molecular and cellular maps of uterine fibroids and matched myometrium may enhance our understanding of tumor development compared to histologic analysis and whole tissue transcriptomics, and support the development of minimally invasive treatment strategies; on the other hand, ultrasound imaging allows in most of the cases a proper mapping the fibroids and to differentiate between benign and malignant lesions, which need appropriate management. CONCLUSIONS AND OUTLOOK: The choice of uterine fibroid management, including pharmacological approaches, surgical treatment, or other strategies, such as high-intensity focused ultrasound (HIFU), should be carefully considered, taking into account the characteristics of the patient and reproductive prognosis.

Anesthetic Management of a Patient With Hemoglobin M Disease Undergoing Laparoscopic Uterine Myomectomy: A Case Report.

Hemoglobin M (Hb M) is a group of abnormal Hb variants that form methemoglobin, which leads to cyanosis. Patients with Hb M appear cyanotic but are usually asymptomatic. Cyanosis with low peripheral oxygen saturation is unresponsive to oxygen therapy despite normal partial pressure of oxygen. As such, close attention should be paid during anesthesia. We report the first case of a Hb M patient undergoing laparoscopic uterine myomectomy under general anesthesia.

Predictors of Infused Distending Fluid Volume in Hysteroscopic Myomectomy.

Background and Objectives: The use of a bipolar resectoscope has become popular due to the lower risk of hyponatremia. However, gynecologists might overlook the risk of water intoxication. Water intoxication is associated with the infusion of distending fluid. We were interested in the prediction of the infused distending fluid volume in the era of bipolar hysteroscopy. Thus, the aim of this study was to identify the predictors of the infused distending fluid volume for hysteroscopic myomectomy. Materials and Methods: All consecutive women who underwent monopolar (n = 45) or bipolar (n = 137) hysteroscopic myomectomy were reviewed. Results: Myoma diameter (cm, coefficient = 680 mL, 95% confidence interval (CI) = 334-1025 mL, p <0.001) and bipolar hysteroscopy (coefficient = 1629 mL, 95% CI = 507-2752 mL, p = 0.005) were independent predictors of infused distending fluid volume. A myoma diameter ≥4.0 cm was the optimal cutoff value to predict the presence of >5000 mL of infused distending fluid. One woman in the bipolar group developed life-threatening water intoxication. Conclusions: Myoma diameter is associated with an increase in infused distending fluid volume, especially for myomas ≥4 cm. Meticulous monitoring of the infused distension fluid volume is still crucial to avoid fluid overload during bipolar hysteroscopic myomectomy.

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 and effectiveness of uterine fibroid embolization in patients with scarred uterus.

AIM: To evaluate the safety and effectiveness of uterine fibroid embolization (UFE) in patients with a scarred uterus caused by a previous myomectomy or cesarean section. METHODS: A total of 140 patients who underwent embolization for symptomatic fibroids were included in this retrospective study. The patients were divided into two groups, those with a history of myomectomy and/or cesarean section (scarred uterus group, n = 56), and those without surgical history involving the uterus (no-scar group, n = 84). Demographics, embolization details, outcomes, and complications were analyzed. RESULTS: The overall clinical success rate was 89.28% in the scarred uterus group and 95.24% in the no-scar group. There was no statistical difference in infarction rate or change in fibroid volume in follow-up magnetic resonance imaging between the groups. There was one major complication in the no-scar group, but there was no statistical difference in complications between the groups. The mean follow-up period was 25.9 months. The mean symptom-free time was 27.2 months in the scarred uterus group and 21.9 months in the no-scar group without a significant difference. There were no statistically significant differences in symptom changes, recurrence, and complication rates between the groups. Recurrence seen on imaging or regrowth was more common in the group with myomectomy history. However, there was no significant difference in symptom recurrence rates. CONCLUSION: No statistically significant difference in technical and clinical outcomes was observed between the two groups. There was no significant increase in complication rates of UFE in scarred uterus group.

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.

Study on the method of enucleation of anterior uterine fibroids by transverse incision of the lower uterine segment during cesarean section.

INTRODUCTION: A retrospective study was conducted to investigate the effectiveness and feasibility of fibroid enucleation in the anterior wall of the uterus by transverse uterine incision during cesarean section. METHODS: The medical history, surgical data, preoperative and postoperative changes in the blood system, and complications of 90 pregnant women who underwent myomectomy of the anterior uterine wall during cesarean section at the second Department of Maternal and Child Health Hospital of Fujian Province were analyzed retrospectively. RESULTS: No significant differences were noted in the leiomyoma number, pathological type, preoperative and postoperative hemoglobin level, perioperative bleeding incidence, blood transfusion frequency, postoperative fever incidence, and duration of lochia between the study and control groups. The proportion of large fibroids was slightly higher in the study group than in the control group (p < 0.05), and the operation time and average hospitalization time were slightly longer in the study group than in the control group (p < 0.05). The distribution of type III-V fibroids was slightly more in the study group than in the control group (p < 0.05), and the distribution of type VI fibroids in the study group was less than that in the control group (p < 0.05). CONCLUSION: Fibroid enucleation is safe and effective in the anterior wall of the uterus through the lower uterine transverse incision in cesarean section. It has the potential to reduce the risk of pelvic and intrauterine adhesions in the future.

Spontaneous Intestinal Perforation in Pregnancy from a Pre-Existing Postoperative Adhesion: A Case Report.

BACKGROUND: Spontaneous intestinal perforation is rare in pregnancy. Previously described cases have been associated with endometriosis, Crohn's disease, and intestinal tuberculosis. CASE: We describe a case of spontaneous intestinal perforation in pregnancy from a postoperative adhesion. The patient presented with multiple episodes of abdominal pain and vomiting starting at 255 weeks. The diagnosis was made at 28 weeks when she presented with severe pain and abnormal fetal heart rate requiring emergency cesarean section with bowel resection. CONCLUSION: This case demonstrates that adhesions between the bowel and uterus from prior surgery may lead to spontaneous intestinal perforation as the uterus enlarges during pregnancy. As this diagnosis can be difficult because of imaging limitations and physiologic changes of pregnancy, it should be considered in cases of unremitting abdominal pain and vomiting.

One-Step Resection via Hysteroscopic Myomectomy and Prostaglandin F2α for Large Submucosal Myoma.

STUDY OBJECTIVE: To assess the efficacy of prostaglandin F2α (PGF2α) in hysteroscopic myomectomy of submucous myomas. DESIGN: Single-blind, randomized clinical trial study. SETTING: Teaching hospital, affiliate of Iran University of Medical Sciences, Tehran, Iran. PATIENTS: Forty-four patients with symptomatic submucous myomas were randomly assigned to the intervention group (n = 21; 1 excluded owing to myoma not identified on pathologic examination) and the control group (n = 22). INTERVENTIONS: In the intervention group, PGF2α was injected into the cervix twice: before the beginning of the surgery and after the resection of the intrauterine portion of the submucous myoma. TIn the control group, the myomas were resected without the PGF2α injection. The same procedure was performed in the control group without the PGF2α injection. MEASUREMENTS AND MAIN RESULTS: There were no differences in the demographics, size, or type of myomas among the groups at baseline. Although the proportion of complete removal of the submucous myomas in the intervention group (PGF2α) was higher (20/23 myomas or 87%) than that in the control group (15/23 myomas or 65.2%), the difference was not significant (p = .1). The number of 1-step complete removal of large submucous myomas (>5 cm) in the PGF2α group was significantly higher than that in the control group (8/10 myomas [80%] vs 2/8 myomas [25%], p = .03). The mean duration of operative time was significantly longer in the intervention group than in the control group (p = .01). The intervention group experienced more days of postoperative bleeding than the control group (p = .001). There were no differences regarding the length of stay at the hospital or hemoglobin levels between the groups (p = .07). CONCLUSION: In the current study, injection of PGF2α was beneficial for 1-step complete resection of large (>5 cm) submucous myomas via hysteroscopic myomectomy.

Measures to Reduce Perioperative and Intraoperative Blood Loss at Myomectomy: A Survey of Obstetrician-Gynaecologists.

OBJECTIVE: This study sought to determine current techniques used by Canadian obstetrician-gynaecologists (OB/GYNs) to medically optimize patients undergoing myomectomy during the perioperative and intraoperative periods and to identify gaps in knowledge or barriers to access of blood conservation methods. METHODS: From September to December 2016, a self-administered electronic questionnaire was distributed to 120 Canadian OB/GYNs who perform myomectomies and who practise in either academic, community, or community academic-affiliated hospitals. RESULTS: A total of 68 of 120 (57%) completed responses were analyzed. Most respondents were general OB/GYNs (72.1%; n = 49) who worked in the community (70.6%; n = 48) and had practised >10 years (67.7%; n = 46); 79.4% (n = 54) delayed surgery to correct anemia. The most common preoperative medical agents used included tranexamic acid (94.1%), ulipristal acetate (92.6%), gonadotropin-releasing hormone agonist (79.4%), and combined hormonal contraception (58.8%). The majority had access to hematology (83.8%; n = 57) and intravenous iron (82.4%; n = 56). However, respondents had variable knowledge of oral and intravenous iron dosing and administration. The most common intraoperative agents used included vasopressin (94.1%; n = 64 [subserosal, 59.4% vs. intramyometrial, 40.6%]), vasopressin with epinephrine (26.6%; n = 17 [subserosal, 58.8% vs. intramyometrial, 41.2%]), intravenous tranexamic acid (73.5%; n = 50), mechanical tourniquet (66.2%; n = 45), misoprostol (33.8%; n = 23), uterine artery ligation (22.1%; n = 15), topical sealant (17.6%; n = 12), and intraoperative blood salvage (11.8%; n = 8). CONCLUSION: Most OB/GYNs delay surgery to correct anemia, but they are uncertain of personal and institutional transfusion rates, iron dosing and administration, and optimal multimodal approaches to minimize intraoperative blood loss during myomectomy. Education and creation of a clinical pathway to address blood conservation may decrease perioperative morbidity for patients undergoing myomectomy.

Uterine Isthmus Tourniquet during Abdominal Myomectomy: Support or Hazard? A Randomized Double-Blind Trial.

BACKGROUND AND OBJECTIVES: A tourniquet has been suggested as a useful means of reducing massive hemorrhage during myomectomy. However, it is not clear whether the restricted perfusion affects the ovaries. In the present study, we examined the effect of a tourniquet on ovarian reserve and blood loss during myomectomy. MATERIALS AND METHODS: In a randomized double-blind clinical trial, fertile nonobese patients scheduled for abdominal myomectomy at Rasool-e-Akram Hospital from February 2018 to June 2019 were randomized to a tourniquet (n = 46) or a non-tourniquet group (n = 35). Serum levels of anti-Müllerian hormone (AMH) and follicle-stimulating hormone (FSH) were measured before and 3 months after surgery, blood loss was recorded during surgery, and serum levels of hemoglobin (Hb) were recorded before surgery, 6 h and 3 days after surgery. SPSS version 21 was used for statistical analysis. RESULTS: Demographic, obstetric, and myoma characteristics were similar in the 2 groups (p > 0.05). The mean baseline values of AMH and FSH did not differ between groups (p > 0.05). After surgery, only FSH was higher in the control group (p = 0.043). Despite the time taken to fasten and open the tourniquet, the mean operating time was shorter in the tourniquet group (p < 0.001). Blood loss was higher in the control group (p = 0.005). The drop in Hb levels at 6 h after surgery was higher in the non-tourniquet group (p = 0.002). Blood loss was significantly associated with the duration of surgery (r = 0.523, p < 0.001). CONCLUSION: The use of a tourniquet during abdominal myomectomy significantly reduced the mean volume of blood loss compared to the non-tourniquet group, while it did not prolong the duration of surgery, nor reduced the ovarian reserve. A tourniquet is a safe and efficient measure during abdominal myomectomy.

Safety of Laparoscopic Surgery for Benign Diseases during Pregnancy: A Nationwide Retrospective Cohort Study.

STUDY OBJECTIVE: To compare fetal, maternal, and operative outcomes of laparoscopic surgery versus laparotomy for major benign diseases including appendicitis, cholecystitis, adnexal masses, and uterine myoma during pregnancy. DESIGN: Retrospective cohort study (Canadian Task Force classification II-2). SETTING: The Diagnosis Procedure Combination database, a national inpatient database for acute care inpatients in Japan. PATIENTS: Eligible patients (n = 6018) underwent abdominal surgery (4047 laparotomy and 1971 laparoscopy patients) from July 2010 through March 2016. INTERVENTIONS: The 2 groups were compared using propensity score matching analysis. MEASUREMENTS AND MAIN RESULTS: The primary outcome was fetal adverse events, including abortion or stillbirth within 7 days after surgery and premature delivery during hospitalization. Secondary outcomes were operative time, blood transfusion, and length of hospital stay after surgery. Propensity score matching created 740 pairs. Significant difference was observed in the primary outcome between propensity score-matched patients in the laparotomy versus laparoscopy group (1.8% vs .41%, respectively; risk difference, -1.4%; 95% confidence interval, -2.4 to -.30; p = .01). Compared with the laparotomy group, the laparoscopy group had a significantly lower incidence of blood transfusion (2.3% vs .41%, p = .002), shorter operative time (115 vs 95 minutes, p <.001), and shorter hospital stay (9.2 vs 5.9 days, p <.001). CONCLUSION: Our current study using propensity score matching suggests the advantages of laparoscopic surgery for benign diseases compared with laparotomy because laparoscopic surgery had advantages in short-term fetal adverse events, incidence of blood transfusion, operative time, and hospital stay.

Myomectomy scar ectopic pregnancy following a cryopreserved embryo transfer.

CASE: A 40 year old woman with a history of a myomectomy visited the Department of Obstetrics and Gynecology, Niigata University Medical and Dental Hospital, Niigata, Japan, following 2 years of infertility. Magnetic resonance imaging detected an abnormal endometrial-like pseudo-cavity. A hysterosalpingography also revealed an abnormal accumulation of contrast medium at the myometrial scar site. A transvaginal ultrasound showed a thin myometrium at the lower uterine body. The patient conceived via in vitro fertilization under a luteal phase down-regulation protocol (long protocol) for controlled ovarian stimulation, followed by a cryopreserved embryo transfer during her natural ovulation cycle. After the embryo transfer, the gestational sac was located at the subserosal site of the myomectomy scar. OUTCOME: An emergent laparoscopic operation was performed and the embryo was removed successfully via laparoscopy under transvaginal ultrasonography. CONCLUSION: A subserosal uterine pregnancy is a rare form of intramural pregnancy, which is a rare subtype of an ectopic pregnancy, which could occur at the myomectomy site, especially after an embryo transfer. It is believed that this rare ectopic pregnancy resulted from embryo implantation under the serosa through a micro-sinus tract that was a site of suture failure of the myomectomy scar and was partially affected by the embryo transfer. Clinicians should consider the possibility of an ectopic pregnancy after uterine surgery, including a myomectomy.

Age-stratified risk of unexpected uterine sarcoma following surgery for presumed benign leiomyoma.

BACKGROUND: Estimates of unexpected uterine sarcoma following surgery for presumed benign leiomyoma that use age-stratification are lacking. PATIENTS AND METHODS: A retrospective cohort of 2,075 patients that had undergone myomectomy was evaluated to determine the case incidence of unexpected uterine sarcoma. An aggregate risk estimate was generated using a meta-analysis of similar studies plus our data. Database-derived age distributions of the incidence rates of uterine sarcoma and uterine leiomyoma surgery were used to stratify risk by age. RESULTS: Of 2,075 patients in our retrospective cohort, 6 were diagnosed with uterine sarcoma. Our meta-analysis revealed 8 studies from 1980 to 2014. Combined with our study, 18 cases of leiomyosarcoma are reported in 10,120 patients, for an aggregate risk of 1.78 per 1,000 (95% confidence interval [CI]: 1.1-2.8) or 1 in 562. Eight cases of other uterine sarcomas were reported in 6,889 patients, for an aggregate risk of 1.16 per 1,000 (95% CI: 0.5-4.9) or 1 in 861. The summation of these risks gives an overall risk of uterine sarcoma of 2.94 per 1,000 (95% CI: 1.8-4.1) or 1 in 340. After stratification by age, we predict the risk of uterine sarcoma to range from a peak of 10.1 cases per 1,000, or 1 in 98, for patients aged 75-79 years to <1 case per 500 for patients aged <30 years. CONCLUSION: The risk of unexpected uterine sarcoma varies significantly across age groups. Our age-stratified predictive model should be incorporated to more accurately counsel patients and to assist in providing guidelines for the surgical technique for leiomyoma.

Perspectives of obstetricians on labour and delivery after abdominal or laparoscopic myomectomy.

OBJECTIVE: Because of concerns about uterine rupture, many obstetricians recommend elective Caesarean section for women with a prior myomectomy. This practice has led to an increased rate of elective CS and subsequently of repeat Caesarean sections. The purpose of this study was to evaluate the perspectives of obstetricians on labour and delivery after abdominal or laparoscopic myomectomy. METHODS: We conducted a survey of 49 practising obstetricians from July 2012 to January 2013, using a standard questionnaire. This included questions on labour and delivery after myomectomy by laparotomy or laparoscopy. RESULTS: Overall, the inter-respondent agreement was fair (kappa 0.3; P < 0.001). There was no significant difference in the likelihood that respondents would allow vaginal delivery after myomectomy by laparotomy and by laparoscopy (27% and 14% if the uterine cavity was entered and 76% and 71% if the uterine cavity was not entered, respectively). However, the likelihood that respondents would allow vaginal delivery was significantly reduced if the uterine cavity was entered, regardless of the surgical approach (P < 0.001). Entry into the uterine cavity during myomectomy also significantly increased the likelihood that obstetricians would recommend elective CS rather than induction of labour. There was no significant difference in practice regarding the use of oxytocin with amniotomy, oxytocin infusion, or prostaglandins. CONCLUSION: Despite a lack of evidence, obstetricians consider entry into the uterine cavity at myomectomy to be an important factor in determining the method of delivery, the use of oxytocin, and delivery by elective Caesarean section. This was independent of the myomectomy approach.

Objectif : En raison de préoccupations au sujet de la rupture utérine, de nombreux obstétriciens recommandent la tenue d'une césarienne planifiée pour ce qui est des femmes ayant déjà subi une myomectomie. Cette pratique a mené à la hausse du taux de césarienne planifiée et, subséquemment, à celle du taux de césarienne itérative. Cette étude avait pour objectif d'évaluer les points de vue des obstétriciens en ce qui concerne le travail et l'accouchement à la suite d'une myomectomie abdominale ou laparoscopique. Méthodes : Nous avons mené un sondage auprès de 49 obstétriciens praticiens, entre juillet 2012 et janvier 2013, au moyen d'un questionnaire standard. Ce dernier comptait des questions sur le travail et l'accouchement à la suite d'une myomectomie menée par laparotomie ou par laparoscopie. Résultats : De façon globale, le consensus inter-répondants était assez bon (kappa 0,3; P < 0,001). Aucune différence significative n'a été constatée en ce qui concerne la probabilité que les répondants permettent la tenue d'un accouchement vaginal à la suite d'une myomectomie menée par laparotomie ou par laparoscopie (27 % et 14 %, si la cavité utérine avait été pénétrée, et 76 % et 71 %, si la cavité utérine n'avait pas été pénétrée, respectivement). Cependant, la probabilité que les répondants permettent la tenue d'un accouchement vaginal était considérablement atténuée lorsque la cavité utérine avait été pénétrée, peu importe l'approche chirurgicale utilisée (P < 0,001). La probabilité que les obstétriciens recommandent la tenue d'une césarienne planifiée, plutôt que celle d'un déclenchement du travail, connaissait également une hausse significative lorsque la cavité utérine avait été pénétrée au cours de la myomectomie. Aucune différence significative n'a été constatée au niveau de la pratique en ce qui concerne l'utilisation d'oxytocine conjointement avec une amniotomie, d'oxytocine en perfusion ou de prostaglandines. Conclusion : Malgré le manque de données sur le sujet, les obstétriciens considèrent que la pénétration de la cavité utérine pendant la myomectomie (et ce, peu importe l'approche chirurgicale utilisée dans le cadre de cette dernière) constitue un facteur important au moment de prendre des décisions quant au mode d'accouchement, à l'utilisation d'oxytocine et au recours à une césarienne planifiée.

A case of parasitic myoma 4 years after laparoscopic myomectomy.

We present a case of parasitic myoma complaining of abdominal pain, constipation, dyspareunia and dysmenorrhea 4 years after laparoscopic myomectomy. We performed laparoscopic myomectomy for multiple parasitic myomas. Three myomas were very firmly attached to bowel and mesentery. Parasitic myoma after laparoscopic surgery is very rare condition there are almost 35 cases in the literature. It is related with variable symptoms or can be asymptomatic. Laparoscopic surgeons should be aware of this situation, and further investigation should be made in case of suspicion. Surgery for parasitic myomas can be difficult in case of bowel and mesentery involvement and patient should be informed about the extensive surgery.

The great debate: Surgical outcomes of laparoscopic versus laparotomic myomectomy. A meta-analysis to critically evaluate current evidence and look over the horizon.

Myomectomy is one of the most common surgical procedure in the field of gynecology. However, the role of laparoscopic myomectomy is still debated for many factors, including surgical considerations, safety and fertility concerns, long-term outcomes, and cost-related issues. The aim of this study is to evaluate the surgical peri- and post-operative outcomes of laparoscopic and abdominal myomectomy. A systematic search for studies was performed up to June 2023 through MEDLINE, Pubmed, Embase. Studies reporting the comparison of surgical and obstetrical outcomes in laparoscopic versus laparotomic myomectomy were included for the following outcomes: time of surgery, estimated blood loss, decrease of postoperative hemoglobin, hospital stay, intra-operative complication rates, postoperative complications rates, postoperative analgesic use, postoperative pain at 24 h and pregnancy rate. The meta-analysis was performed using the Cochrane Review software. Fifty-six relevant articles were retrieved through the process of evidence acquisition. Eleven articles met inclusion criteria, for a total of 2,133 patients undergoing laparoscopic or laparotomic myomectomy. The estimated blood loss [standard mean differences (SMD) 0.72, IC 95 % 0.22 to 1.22], the hospital stays [SMD 3.12, IC 95 % 0.57 to 4.28], were significantly lower in laparoscopic than in open group. No statistically significant difference in intra-operative and post-operative complication rates, in pregnancy rate and others obstetrical outcomes between two surgical approaches were found. The findings of present metanalysis suggest that laparoscopic myomectomy offers multiple benefits, including reduced blood loss, shorter hospital stays, and less postoperative analgesic need, without a significant increase in complication rates and similar results in obstetrical outcomes when compared to abdominal myomectomy. However, the presence of few randomized studies on selected population may limit the generalizability of the findings to the entire population. Therefore, more well-designed studies or large population programdata to draw definitive conclusions are therefore warranted.

Myomectomy with ArtiSential fully articulating laparoscopic instruments: A prospective multicenter study.

BACKGROUND: ArtiSential, a class of innovative laparoscopic instrument, has been developed to overcome the limitations of conventional laparoscopic surgery by enabling free, 360°-unrestricted movement of the wrist joint, as in robotic surgery. OBJECTIVE: The aim of the present study was to describe the initial experiences with these devices in myomectomy and to report the surgical outcomes. METHODS: A total of 77 women undergoing laparoscopic or robotic myomectomy between January 2021 and June 2022 were included in this multicenter prospective study. The ArtiSential instruments used by the surgeons were those chosen according to their respective preferences. The baseline characteristics, surgical outcomes, trocar placement options, and operator survey results were scrutinized. RESULTS: The mean age of the patients was 39.9 ± 6.3, and the mean body mass index (BMI, calculated as weight in kilograms divided by the square of height in meters) was 22.4 ± 3.4 kg/m2; 46.8% of the patients underwent robotic surgery, while 53.2% underwent laparoscopic surgery. The number of removed myomas was 3.3 ± 3.0, the size of the largest myoma was 7.1 ± 2.3 cm, and the operative time was 130.0 ± 54.0 min. No transfusions or laparotomy conversions were required. Other than one case of ileus, there were no postoperative complications. In most cases, the instruments were inserted through the umbilicus trocar, and the fenestrated forceps, needle holder, and bipolar fenestrated forceps, in that order, were frequently employed. According to a surgeon survey, 29.9% moderately or strongly agreed that the ArtiSential devices utilized were more convenient than conventional laparoscopic instruments, while only 9.7% moderately or strongly agreed that they were more convenient than robotic instruments. CONCLUSIONS: Myomectomy as performed with an ArtiSential instrument seems to be feasible and safe. Further studies are necessary in order to comparatively assess the outcomes and potential benefits of ArtiSential, robotic, and conventional laparoscopic myomectomy.

Enhancing surgical performance: the role of robotic surgery in myomectomies, a systematic review and metanalysis.

Examine the role, benefits, and limitations of robotic surgery in myomectomies compared to laparoscopic and open surgical approaches. This review sourced data from CENTRAL, Pubmed, Medline, and Embase up until May 1, 2023. Full articles comparing clinical outcomes of robotic myomectomy with open or laparoscopic procedures were included without language restriction. Initially, 2150 records were found. 24 studies were finally included for both qualitative and quantitative analyses. Two investigators independently assessed all reports following PRISMA guidelines. Meta-analysis was conducted using the software "Review Manager Version 5.4". Risk-of-bias was assessed using the Newcastle-Ottawa scale. Sensitivity analysis was conducted, when feasible. In a comparison between robotic and laparoscopic myomectomies, no significant difference was observed in fibroid weights and the size of the largest fibroid. Robotic myomectomy resulted in less blood loss, but transfusion rates were comparable. Both methods had similar complication rates and operative times, although some robotic studies showed longer durations. Conversion rates favored robotics. Hospital stays varied widely, with no overall significant difference, and pregnancy rates were similar between the two methods. When comparing robotic to open myomectomies, open procedures treated heavier and larger fibroids. They also had greater blood loss, but the robotic approach required fewer transfusions. The complication rate was slightly higher in open procedures. Open surgeries were generally faster, postoperative pain scores were similar, but hospital stays were longer for open procedures. Pregnancy rates were comparable for both robotic and open methods. Robotic surgery offers advancement in myomectomy procedures by offering enhanced exposure and dexterity, leading to reduced blood loss and improved patient outcomes. PROSPERO registration: CRD42023462348.