Long-Term Risk of Reintervention After Surgical Leiomyoma Treatment in an Integrated Health Care System.

OBJECTIVE: To compare long-term risk of reintervention across four uterus-preserving surgical treatments for leiomyomas and to assess effect modification by sociodemographic factors in a prospective cohort study in an integrated health care delivery system. METHODS: We studied a cohort of 10,324 patients aged 18-50 (19.9% Asian, 21.2% Black, 21.3% Hispanic, 32.5% White, 5.2% additional races and ethnicities) who had a first uterus-preserving procedure (abdominal, laparoscopic, or vaginal myomectomy [referred to as myomectomy]; hysteroscopic myomectomy; endometrial ablation; uterine artery embolization) after leiomyoma diagnosis in the 2009-2021 electronic health records of Kaiser Permanente Northern California. We followed up patients until reintervention (second uterus-preserving procedure or hysterectomy) or censoring. We used a Kaplan-Meier estimator to calculate the cumulative incidence of reintervention and Cox regression models to estimate hazard ratios and 95% CIs comparing rates of reintervention across procedures, adjusting for age, parity, race and ethnicity, body mass index (BMI), Neighborhood Deprivation Index, and year. We also assessed effect modification by demographic characteristics. RESULTS: Median follow-up was 3.8 years (interquartile range 1.8-7.4 years). Index procedures were 18.0% (1,857) hysteroscopic myomectomies, 16.2% (1,669) uterine artery embolizations, 21.4% (2,211) endometrial ablations, and 44.4% (4,587) myomectomies. Accounting for censoring, the 7-year reintervention risk was 20.6% for myomectomy, 26.0% for uterine artery embolization, 35.5% for endometrial ablation, and 37.0% for hysteroscopic myomectomy; 63.2% of reinterventions were hysterectomies. Within each procedure type, reintervention rates did not vary by BMI, race and ethnicity, or Neighborhood Deprivation Index. However, rates of reintervention after uterine artery embolization, endometrial ablation, and hysteroscopic myomectomy decreased with age, and reintervention rates for hysteroscopic myomectomy were higher for parous than nulliparous patients. CONCLUSION: Long-term reintervention risks for uterine artery embolization, endometrial ablation, and hysteroscopic myomectomy are greater than for myomectomy, with potential variation by patient age and parity but not BMI, race and ethnicity, or Neighborhood Deprivation Index.

Contemporary approaches in the management of uterine leiomyomas.

BACKGROUND: Leiomyomas (fibroids), the most common benign solid tumours in females, originate from the myometrium and are associated with poor quality of life for patients. The current management of uterine leiomyomas mainly includes surgical interventions such as hysterectomy and myomectomy, either by laparoscopy or laparotomy, which have several complications and are not ideal for preserving fertility. Therefore, there is a need to develop or repurpose medical treatments that do not require surgical intervention. OBJECTIVE: Many drugs are used to treat the symptoms associated with uterine fibroids. The main objective of this systematic review is to give an up-to-date account of potential pharmacological agents (non-surgical methods) for the management of uterine leiomyomas. SEARCH STRATEGY: PubMed was searched for scientific and clinical literature using the keyword 'uterine fibroids' along with the drug names described in each section. For example, 'uterine fibroids' and 'ulipristal acetate' were the keywords used to search for literature on ulipristal acetate (UPA). RESULTS: Various preclinical and clinical studies have shown that some drugs and herbal formulations exhibit activity in the management of uterine leiomyomas. Recent studies found that drugs such as UPA, elagolix, EC313, asoprisnol, nutritional supplements and herbal preparations were helpful in treating the symptoms associated with uterine leiomyomas. CONCLUSION: Many drugs show efficacy in patients with symptomatic uterine fibroids. UPA is one of the most studied and prescribed medicines for uterine fibroids; however, its usage has been restricted due to a few recent incidences of hepatic toxicity. Herbal drugs and natural supplements have also shown promising effects on uterine fibroids. The synergistic effects of nutritional and herbal supplements have been reported in certain cases, and should be studied in detail. Further research is warranted to identify the mode of action of the drugs, and to determine the precise conditions that would explain the causes of toxicity in some patients.

Minimally invasive myomectomy: practice trends and differences between Black and non-Black women within a large integrated healthcare system.

BACKGROUND: Although multiple professional organizations encourage minimally invasive surgical approaches whenever feasible, nationally, fewer than half of myomectomies are performed via minimally invasive routes. Black women are less likely than their non-Black counterparts to have minimally invasive surgery. OBJECTIVE: This study aimed to assess the trends in surgical approach among women who underwent minimally invasive myomectomies for uterine leiomyomas within a large integrated healthcare system as initiatives were implemented to encourage minimally invasive surgery, particularly evaluating differences in the proportion of minimally invasive surgery performed in Black vs non-Black women. STUDY DESIGN: We conducted a retrospective cohort study of women, aged ≥18 years, who underwent a myomectomy for a uterine leiomyoma within Kaiser Permanente Northern California between 2009 and 2019. Generalized estimating equations and Cochran-Armitage testing were used to assess myomectomy incidence and linear trend in the proportions of myomectomy by surgical route-abdominal myomectomy and minimally invasive myomectomy. Multivariable logistic regression analyses were used to assess the associations between surgical route and (1) race and ethnicity and (2) complications, controlling for patient demographic, clinical, and surgical characteristics. RESULTS: A total of 4033 adult women underwent a myomectomy during the study period. Myomectomy incidence doubled from 0.12 (95% confidence interval, 0.12-0.13) per 1000 women in 2009 to 0.25 (95% confidence interval, 0.24-0.25) per 1000 women in 2019 (P<.001). During the 11-year study period, the proportion of minimally invasive myomectomy increased from 6.0% to 89.5% (a 15-fold increase). The proportion of minimally invasive myomectomy in Black women remained lower than in non-Black women (54.5% vs 64.7%; P<.001). Black women undergoing myomectomy were younger (36.4±5.6 vs 37.4±5.8 years; P<.001), had a higher mean fibroid weight (436.0±505.0 vs 324.7±346.1 g; P<.001), and had a higher mean body mass index (30.8±7.3 vs 26.6±5.9 kg/m2; P<.001) than their non-Black counterparts. In addition to patient race, surgery performed between 2016 and 2019 compared with surgery performed between 2009 and 2012 and higher surgeon volume compared with low surgeon volume were associated with an increased proportion of minimally invasive myomectomy (adjusted relative risks, 12.58 [95% confidence interval, 9.96-15.90] and 6.63 [95% confidence interval, 5.35-8.21], respectively). Black race and fibroid weight of >500 g each independently conferred lower rates of minimally invasive myomectomy. In addition, there was an interaction between race and fibroid weight such that Black women with a fibroid weight of ≤500 g or >500 g were both less likely to have minimally invasive myomectomy than non-Black women with a fibroid weight of ≤500 g (adjusted relative risks, 0.74 [95% confidence interval, 0.58-0.95] and 0.26 [95% confidence interval, 0.18-0.36], respectively). Operative, perioperative, and medical complications were low during the 11-year study period. In regression analyses, after controlling for race, age, fibroid weight, parity, low-income residence, body mass index, surgeon volume, and year of myomectomy, the risk of complications was not markedly different comparing abdominal myomectomy with minimally invasive myomectomy. Similar results were found comparing laparoscopic minimally invasive myomectomy with robotic-assisted minimally invasive myomectomy except for women who underwent laparoscopic minimally invasive myomectomy had a lower risk of experiencing any medical complications than those who underwent robotic-assisted minimally invasive myomectomy (adjusted relative risk, 0.27; 95% confidence interval, 0.09-0.83; P=.02). CONCLUSION: Within an integrated healthcare delivery system, although initiatives to encourage minimally invasive surgery were associated with a marked increase in the proportion of minimally invasive myomectomy, Black women continued to be less likely to undergo minimally invasive myomectomy than their non-Black counterparts. Race and fibroid weight alone did not explain the disparities in minimally invasive myomectomy.

The Median Effective Dose of One Intravenous Bolus of Oxycodone for Postoperative Analgesia After Myomectomy and Hysterectomy With Local Ropivacaine Wound Infiltration: An Up-Down Dose-Finding Study.

BACKGROUND: Oxycodone has been shown to be an effective analgesic for early postoperative analgesia, especially for abdominal operations associated with severe visceral pain. However, the dose needed varies depending on the operation and application of multimodal analgesia, such as local ropivacaine wound infiltration. Therefore, we conducted this study to estimate the median effective dose (ED50) of oxycodone that provides analgesia for hysterectomy and myomectomy with local ropivacaine wound infiltration. METHODS: In this dose-finding study, the ED50 of oxycodone for postoperative analgesia was estimated separately for laparoscopic hysterectomy, transabdominal hysterectomy, laparoscopic myomectomy, and transabdominal myomectomy. We used the sequential allocation designed by Dixon. Trials were conducted simultaneously in the 4 surgical type groups. A predefined dose of oxycodone was injected 30 minutes before the end of the operation with an initial dose of 0.1 mg/kg. A series of trials were performed following the rule of a relative 10% increase in dose after inadequate analgesia and a relative 10% decrease in dose after adequate analgesia. The study was conducted until the collection of 7 crossover points was achieved. Local ropivacaine wound infiltration was administered during abdominal stitching. The mean blood pressure (MBP) and heart rate (HR) were analyzed to assess the hemodynamic changes associated with oxycodone administration. RESULTS: A total of 113 patients were included in the estimation of ED50: 28 each in the laparoscopic hysterectomy group and transabdominal myomectomy group, 27 in the transabdominal hysterectomy group, and 30 in the laparoscopic myomectomy group. The estimated oxycodone ED50 (95% confidence interval [CI]) after laparoscopic hysterectomy, transabdominal hysterectomy, laparoscopic myomectomy, and transabdominal myomectomy was 0.060 mg/kg (0.053-0.068), 0.079 mg/kg (0.072-0.086), 0.060 mg/kg (0.051-0.071), and 0.092 mg/kg (0.086-0.098), respectively, for postoperative analgesia with local ropivacaine wound infiltration. The ED50 of oxycodone was different between laparoscopic surgeries and transabdominal surgeries (P < .001). The MBP and HR before and after oxycodone injection were different, regardless of surgical type. CONCLUSIONS: The oxycodone ED50 for postoperative analgesia was lower for laparoscopic hysterectomy (0.060 mg/kg) and laparoscopic myomectomy (0.060 mg/kg) than for transabdominal hysterectomy (0.079 mg/kg) and transabdominal myomectomy (0.092 mg/kg) when combined with local ropivacaine wound infiltration. A single intravenous injection of oxycodone is associated with an acceptable decrease in MBP and HR within a short time.

Alternative Treatment Utilization Before Hysterectomy for Benign Gynecologic Conditions at a Large Integrated Health System.

STUDY OBJECTIVE: To investigate rates of utilization of alternative treatments before hysterectomy for benign gynecologic indications within a large integrated health care system. DESIGN: Retrospective cohort study of patients who underwent hysterectomies for benign gynecologic conditions between 2012 and 2014 (Canadian Task Force classification II-2). SETTING: Kaiser Permanente Northern California, a community-based integrated health system. PATIENTS: Women who underwent hysterectomy for a benign gynecologic condition between 2012 and 2014. INTERVENTIONS: From an eligible cohort of 6892 patients who underwent hysterectomy, a stratified random sample of 1050 patients were selected for chart review. Stratification was based on the proportion of indications for hysterectomy. MEASUREMENTS AND MAIN RESULTS: The primary outcome was the use of alternative treatments before hysterectomy. Alternative treatments included oral hormone treatment, leuprolide, medroxyprogesterone intramuscular injections, a levonorgestrel intrauterine device, hormonal subdermal implants, endometrial ablation, uterine artery embolization, hysteroscopy, and myomectomy. Of the 1050 charts reviewed, 979 (93.2%) met the criteria for inclusion in this study. The predominant indication for hysterectomy was symptomatic myomas (54.4%), followed by abnormal uterine bleeding (29.0%), endometriosis (5.8%), pelvic pain (3.1%), dysmenorrhea (3.4%), and other (4.3%). The major routes of hysterectomy were laparoscopy (68.7%) and vaginal hysterectomy (13.4%). Before hysterectomy, 81.2% of patients tried at least 1 type of alternative treatment (33.8% with 1 treatment and 47.4% with at least 2 treatments), and 99.3% of patients were counseled regarding alternative treatments. Compared with younger women age <40 years, women age 45 to 49 years were less likely to use alternative treatments before hysterectomy (adjusted odds ratio, 0.41; 95% confidence interval, 0.21-0.76). There were no variations in treatment rates by socioeconomic status or between major racial and ethnic groups. The final pathological analysis identified myomas as the most common pathology (n = 637; 65.1%); 96 patients (9.8%) had normal uterine pathology. CONCLUSION: More than 80% of patients received alternative treatments before undergoing hysterectomy for a benign gynecologic condition. Additional investigation is warranted to assess alternative treatment use as it relates to preventing unnecessary hysterectomies.

High-intensity focused ultrasound and laparoscopic myomectomy in the treatment of uterine fibroids: a comparative study.

OBJECTIVE: To compare the clinical efficacies of high-intensity focused ultrasound (HIFU) and laparoscopic myomectomy (LM) in the treatment of uterine fibroids and their effects on patients' quality of life. DESIGN: A non-randomised control study. SETTING: Gynaecological department in a university teaching hospital. POPULATION: Patients with uterine fibroids. METHODS: From November 2014 to November 2015, 166 patients with uterine fibroids were enrolled and underwent HIFU (n = 99) and LM (n = 67) surgeries, respectively. Clinical efficacy, postoperative complications and quality of life after treatment were evaluated using the SF-36 Scale to compare the differences in each variable at the 1-year follow up. MAIN OUTCOMES MEASURES: Differences in efficacy, safety and quality of life between the patients treated with HIFU and LM. RESULTS: The 12-month follow-up results showed that the HIFU group had a total effective rate of 99%; only one patient underwent alternative treatment due to non-apparent tumour shrinkage. All patients in the LM group showed complete tumour disappearance. Of these patients, 52 showed significant clinical improvement, 15 with partial clinical improvement, a total effective rate of 98%. There was no significant difference in effectivity rate between the two groups (P > 0.05). Both treatments effectively improved patients' quality of life. Compared with the LM group, patients in the HIFU group experienced no blood loss, a shorter hospital stay and fewer adverse effects and complications, the difference being statistically significant (P < 0.05). CONCLUSIONS: High-intensity focused ultrasound can be as efficacious as LM therapy and effectively improve patients' quality of life in the treatment of uterine fibroids, with fewer adverse effects and complications, shorter hospital stays, and quicker postoperative recovery compared with LM therapy. TWEETABLE ABSTRACT: Patients with uterine fibroids can be effectively treated with both HIFU and myomectomy.

Radiofrequency Thermal Ablation for Uterine Myomas: Long-term Clinical Outcomes and Reinterventions.

STUDY OBJECTIVE: To assess the long-term efficacy and rate of reintervention after ultrasound-guided radiofrequency thermal ablation (RFA) for uterine myomas. DESIGN: A retrospective follow-up, cohort study (Canadian Task Force classification II-2). SETTING: University hospitals and private clinics. PATIENTS: Between November 1, 2007, and February 26, 2010, 66 consecutive women underwent ultrasound-guided RFA. INTERVENTIONS: Patients underwent abdominal or vaginal ultrasound-guided RFA and were contacted for a long-term follow-up to complete the Uterine Fibroid Symptom and Quality of Life Score (UFS-QOL) questionnaire and optional ultrasound and examination. MEASUREMENTS AND MAIN RESULTS: Sixty-six consecutive patients (mean age 45 ± 7 years) with type 2 to 5 symptomatic myomas per the International Federation of Gynecology and Obstetrics (median size = 122.5 cm3 [range, 24-675]) were included. Forty of 62 patients recruited for follow-up underwent no/minor hysteroscopic reinterventions; 35 patients from this group completed the UFS-QOL questionnaire and showed sustained and improved symptom severity scores (100-point scale) from baseline (57.2 ± 16.6) to long-term follow-up (23.8 ± 20.8, p < .001). Twenty-two patients (35%) had major reinterventions (15 hysterectomies and 7 myomectomies). Six of the 22 patients underwent major reinterventions for reasons other than myoma-related complaints. The estimated major reintervention rate because of myoma-related symptoms determined by the Kaplan-Meier method was 13.5% (95% confidence interval [CI], 7%-25%) after 2 years and 29.1% (95% CI, 19%-43%) after 5 years. Women ≥45 years of age had a major reintervention rate of 12% (95% CI, 5%-26%) after 2 years and 19% (95% CI, 10%-35%) after 5 years, and women <45 years had a major reintervention rate of 35.0% (95% CI, 19%-60%) and 73.8% (95% CI, 52%-92%) after 2 and 5 years, respectively. Fewer major reinterventions occurred in women with only 1 RFA-treated myoma (volume ≤180 cm3, diameter <7 cm) than women with more than 1 RFA-treated myoma (>180 cm3, p < .01). The Kaplan-Meier estimates for reintervention in women with only 1 RFA-treated myoma with a volume ≤180 cm3 were 13% (95% CI, 6-28%) and 26% (95% CI, 14%-45%) after 2 and 5 years, respectively. No patients with morphologic myoma characteristics underwent reinterventions. CONCLUSION: Ultrasound-guided RFA for uterine myomas is an alternative treatment option especially for women ≥45 years of age with only 1 myoma (volume ≤180 cm3) and warrants further evaluation.

Minilaparotomy Versus Laparoscopic Myomectomy After Cessation of Power Morcellation: Rate of Wound Complications.

STUDY OBJECTIVE: After the US Food and Drug Administration statement warning against electronic morcellation devices, gynecologic surgeons are performing laparoscopic and robotic myomectomies with minilaparotomy incisions for tissue morcellation and removal. No data exist that focus on the superficial wound complications as a result of these larger incisions. The objective of this study is to compare the rate of wound complications for myomectomy via minilaparotomy versus laparoscopic or robotic myomectomy. DESIGN: Retrospective cohort study (Canadian Task Force classification II-2). SETTING: Kaiser Permanente Northern California, a large integrated healthcare delivery system. PATIENTS: Women > 18 years of age who underwent a myomectomy from either complete laparoscopic or robotic approach (LR) were compared with minilaparotomy myomectomy (MM), comprising complete minilaparotomy (ML) and laparoscopic or robotic assisted by a minilaparotomy for morcellation purposes only (LRM) from January 2011 through December 2014. INTERVENTION: Myomectomy via LR, complete ML, and LRM. MEASUREMENTS AND MAIN RESULTS: Medical records were reviewed for outcomes of interest, including superficial wound complications and surgical and demographic data. After exclusion criteria were met, 405 cases were included in the study; 270 cases were classified as MM, which included ML (n = 224), or LRM (n = 46). One hundred thirty-five cases were classified as LR. Parametric and nonparametric analyses were used to compare the 2 groups. There was no significant difference between the groups insofar as patient morbidity, including the primary outcome of wound complications and other postoperative complications; emergency visits; or readmissions. There were 2 (1.5%) wound complications in the LR group and 7 (2.6%) in the MM group (p = .72). Similarly, there were no significant differences in the subcategories of wound complications, including cellulitis, seroma, hematoma, skin separation, wound infection, or postprocedure wound complication. The distribution of estimated blood loss was significantly different between LR and MM groups with an interquartile range of 50 to 150 mL in the LR group versus 50 to 300 mL in the MM group (p < .01). The MM group experienced a shorter procedure time with a median procedure time of 125 minutes compared with 169.5 minutes in LR surgeries (p < .01). The LR group demonstrated a significantly shorter median length of hospital stay (LR 5.0 hours vs MM 23 hours; p < .01). CONCLUSION: Compared with MM, LR is associated with a shorter length of hospital stay and longer operating time but no reduction in wound complication or other patient morbidity.

An open-label, randomized, parallel-group comparative study of the efficacy of sorghum bicolor extract in preoperative anemia.

OBJECTIVE: Anemia in patients presenting for elective surgery is associated with increased morbidity, allogeneic blood transfusion, and delay of surgery. Extract of sorghum bicolor has been shown to have hemopoietic, immune-stimulating, and antioxidant effects in rats and in patients with HIV. The aim of this study was to determine the effect of the extract in patients with preoperative anemia booked for myomectomy. METHODS: Consenting patients (N = 66) were randomly assigned to two groups. The test group (n = 34) was given folic acid 5 mg/d, 200 mg iron tablet three times daily, and 500 mg/d of the extract. The control group (n = 32) was given the same doses of folic acid and iron for a period of 3 wk. Blood samples were taken at baseline and weekly for full blood cell count and liver and kidney function tests. Participants were screened for tuberculosis, HIV, hepatitis, and sickle cell anemia. RESULTS: Increases in red blood cell count, hematocrit, and hemoglobin concentration in participants in the test group were highly significant (P < 0.0002, P < 0.0001, and P < 0.0001, respectively). Participants in the control group had a significant increase in the hemoglobin concentration (P > 0.04). The changes in liver enzymes, urea, and creatinine for participants in the test group were within the normal ranges. CONCLUSION: The addition of the extract of sorghum bicolor to routine hematinics is superior to the use of routine hematinics alone. Although the difference is not statistically significant, the extract will correct preoperative anemia in an additional 15% of the patients.

An Evidence-based Approach to the Medical Management of Fibroids: A Systematic Review.

Fibroids are the most common tumor of the female reproductive tract, but approved medical treatments are limited. Patients demand uterine-sparing treatments which preserve fertility and avoid surgery. We systematically reviewed PubMed and Cochrane databases from January 1985 to November 2015 for evidence-based medical therapies for fibroids in the context of disease prevention, treatment of early disease, treatment of symptomatic disease, and preoperative management. We identified 2182 studies, of which 52 studies met inclusion and exclusion criteria. Published data affirm the efficacy of multiple agents, which are promising avenues for the development of medical alternatives to surgery.

Hysteroscopic Myomectomy of FIGO Type 2 Leiomyomas Under Local Anesthesia: Bipolar Radiofrequency Needle-Based Release Followed By Electromechanical Morcellation.

OBJECTIVE: To demonstrate a technique designed to expand the capabilities of hysteroscopic intrauterine morcellators to deep type 1 and type 2 lesions. The technique comprises "release" of the tumor using a bipolar radiofrequency needle, followed by dissection and extraction with an electromechanical morcellator, all under local anesthesia. DESIGN: Description of technique using images and video (Canadian Task Force classification Class III). SETTING: Office uterine procedure and imaging center; academic medical center. INTERVENTION: Following the administration of local anesthesia and access to the endometrial cavity with a 5.5-mm-o.d. hysteroscopic sheath with a 5 Fr operative channel, a 5 Fr bipolar needle electrode system is used to circumscribe the leiomyoma and enter the pseudocapsule, thereby "releasing" the lesion. Blunt dissection is performed as appropriate and then the system is switched to a hysteroscopic morcellating system (MyoSure; Hologic, Bedford, MA), which is then used to further dissect and remove the target lesion with electromechanical morcellation. CONCLUSION: The development of intrauterine morcellators has facilitated the performance of hysteroscopic myomectomy, especially under local anesthesia, but the side aperture-based design of the systems limits their use in International Federation of Gynecology and Obstetrics (FIGO) type 1 and 2 tumors, particularly those located at the uterine fundus. This technique, based in part on a previously published technique of leiomyoma release, improves access of the electromechanical morcellator to leiomyomas that previously were inaccessible, and minimizes myometrial trauma by dissecting the tumor via the relatively avascular pseudocapsule.

Occult Uterine Sarcoma and Leiomyosarcoma: Incidence of and Survival Associated With Morcellation.

OBJECTIVE: To estimate the incidence of occult uterine sarcoma and leiomyosarcoma in hysterectomies for leiomyomas and the risk associated with their morcellation. METHODS: We conducted a population-based cohort study. All uterine sarcomas from 2006-2013 in an integrated health care system were identified. Age- and race-specific incidences of occult uterine sarcoma were calculated. Kaplan-Meier survival analysis was performed. Crude and adjusted risk ratios of recurrence and death associated with morcellation at 1, 2, and 3 years were estimated using Poisson regression with inverse probability weighting. RESULTS: There were 125 hysterectomies with occult uterine sarcomas identified among 34,728 hysterectomies performed for leiomyomas. The incidence of occult uterine sarcoma and leiomyosarcoma was 1 of 278 or 3.60 (95% confidence interval [CI] 2.97-4.23) and 1 of 429 or 2.33 (95% CI 1.83-2.84) per 1,000 hysterectomies. For stage I leiomyosarcoma (n=111), eight (7.2%) were power and 27 (24.3%) nonpower-morcellated. The unadjusted 3-year probability of disease-free survival for no morcellation, power and nonpower morcellation was 0.54, 0.19, and 0.51, respectively (P=.15); overall survival was 0.64, 0.75, and 0.68, respectively (P=.97). None of the adjusted risk ratios for recurrence or death were significant except for death at 1 year for power and nonpower morcellation groups combined (6/33) compared with no morcellation (4/76) (5.12, 95% CI 1.33-19.76, P=.02). We had inadequate power to infer differences for all other comparisons including 3-year survival and power morcellation. CONCLUSION: Morcellation is associated with decreased early survival of women with occult leiomyosarcomas. We could not accurately assess associations between power morcellation and 3-year survival as a result of small numbers.

Use of medical, surgical and complementary treatments among women with fibroids.

OBJECTIVE: To examine the use of medical management, uterus-preserving surgery (UPS), and complementary treatments among women with uterine fibroids. STUDY DESIGN: Prospective cohort study of 933 premenopausal women ages 31-54 years with symptomatic fibroids who participated in the Study of Pelvic Problems, Hysterectomy, and Intervention Alternatives (SOPHIA) for an average of 4.3 years (SD 2.5 years). Incident use of fibroid treatments was determined through annual interviews. Linear regression models were used to compare changes in fibroid-related symptoms among women who underwent UPS versus those who did not undergo surgery. RESULTS: Participants were racially and ethnically diverse, with a mean age of 43 years. During study follow-up, 531 participants (57%) did not undergo UPS or hysterectomy, 250 (27%) had at least one UPS, and 152 (16%) underwent hysterectomy. Complementary and alternative treatments were commonly used, including exercise (45%), diet (34%), herbs (37%), and acupuncture (16%): participants reported significant symptom improvement and few side effects with these interventions. In multivariable linear regression models, women who did not undergo surgery during the study reported improvement in dyspareunia (p<.001), pelvic pain (p<.001), and menstrual cramps (p<.001). However, women who underwent UPS reported greater overall resolution of "pelvic problems" compared with women who did not have surgical treatment (difference in change score 1.18 on a four-point Likert scale, p<.001). CONCLUSION: UPS are effective treatments for women with fibroids, but many women use hormonal or complementary treatments and report significant symptom improvement without surgical intervention.

Recovery from endometrial thinning and successful pregnancy following vitamin E and C supplementation in infertile woman undergoing myomectomy for diffuse leiomyomatosis of the uterus: a case report.

The authors here report a case of an infertile woman with diffuse leiomyomatosis of the uterus, which is a rare benign pathological condition in which the myometrium is occupied by innumerable small fibroid nodules. Due to the progressive abdominal distension of the patient and the desire for pregnancy of the couple, myomectomy was performed as a primary treatment. Urgent relaparotomy was required for hematoma debridement on the following day. Despite the evidence of the follicular growth and cyclic ovarian steroid secretion, the patient had postoperative endometrial thinning that was unresponsive to hormone replacement therapy. Supplementation of oral tocopherol nicotinate/vitamin E and ascorbic acid/vitamin C was effective for immediate recovery of withdrawal bleeding and gradual gain of endometrial thickness. The patient had a successful pregnancy in an in vitro fertilization-embryo transfer program and gave a birth to a healthy baby.

Bleeding associated with uterine leiomyomas. Tailor treatment to the individual patient.

Uterine leiomyomas are benign, often asymptomatic, tumours of the uterus. When they are symptomatic, the most frequent symptom is heavy, prolonged menstrual bleeding, which stops at menopause. When this blood loss causes iron-deficiency anaemia, iron supplementation is justified. Various treatments aimed at reducing uterine blood loss are proposed for women with leiomyoma-related bleeding. As of late 2013, what is the harm-benefit balance of these treatments? To answer this question, we reviewed the available data using the standard Prescrire methodology. Hysterectomy (removal of the uterus) is the most radical treatment for the clinical manifestations of uterine leiomyomas. Serious complications sometimes occur. Nine randomised trials including a total of 1553 patients found no advantage in leaving the cervix intact. Randomised trials in about 4500 patients showed that the vaginal approach is preferable to an open abdominal or laparoscopic approach: in particular, it resulted in fewer infections and less bleeding. Myomectomy (selective removal of uterine leiomyomas) is another surgical option, especially when the patient wishes to preserve her fertility. Its evaluation is mainly based on noncomparative case series. As with hysterectomy, it exposes patients to the risk of serious complications. Symptoms recur in 4% to 27% of cases.The reintervention rate is 4% to 20%. Injections of the gonadorelin agonists leuprorelin or triptorelin reduce bleeding associated with leiomyomas, according to several randomised trials. They have not been demonstrated to reduce the need for transfusion or to facilitate subsequent surgery for leiomyomas.The harm-benefit balance of prolonged use of these drugs is unfavourable, due to their numerous adverse effects. The oral progesterone receptor antagonist ulipristal reduces excessive bleeding, but has not been demonstrated to facilitate subsequent surgery.The effects on the endometrium of taking ulipristal for more than 3 months are unknown. The progesterone antagonist mifepristone reduced bleeding in small randomised trials, but increased the incidence of endometrial hyperplasia. The levonorgestrel-releasing intrauterine device has mainly been evaluated in non-comparative studies, which suggest that it reduces menstrual bleeding in women with leiomyomas. The risk of expulsion of the device in women with leiomyomas appears to be about 20%. Its main adverse effects are rare cases of acne, depression, headache, weight gain and breast tenderness. Very little evaluation data is available on oral progestins in this situation. A progestin, such as norethisterone, taken from the 5th to the 26th day of the menstrual cycle seems to reduce menstrual blood loss and has a contraceptive effect. Oral progestins expose women to an increased risk of venous thromboembolism and possibly increase the risk of breast cancer. Their harm-benefit balance seems less favourable than that of the levonorgestrel-releasing intrauterine device. The thrombotic risk associated with tranexamic acid is unclear, but deserves serious consideration given the drug's uncertain efficacy. In practice, the treatment should be chosen with the patient, based on various factors, including severity of symptoms, age, desire to preserve fertility or the uterus, characteristics of the leiomyomas, and patient preference. As of late 2013, when drug treatment is considered useful in postponing surgery or while awaiting menopause, the levonorgestrel-releasing intrauterine device is the first choice. Oral progestins are another alternative, although their adverse effects are unclear when taken for several months. It is better to avoid exposing patients to the other available drugs, and to choose iron supplementation for women who develop anaemia.

Utility of cell salvage in women undergoing abdominal myomectomy.

OBJECTIVE: We examined the use and cost of autologous blood cell salvage in women who undergo abdominal myomectomy. STUDY DESIGN: Patients who underwent abdominal myomectomy from 2007-2011 were identified. Use of the cell salvage system and reinfusion of autologous blood in women who had the system set-up were analyzed. Cost was examined by directly reported data. RESULTS: We identified 607 patients who underwent abdominal myomectomy. Four hundred twenty-five women (70%) had the set-up of the cell salvage system. Cell-salvaged blood was processed and reinfused into 85 of these subjects (20%). In a multivariable model, performance of myomectomy by a gynecologic-specific surgeon (odds ratio [OR], 2.14; 95% confidence interval [CI], 1.28-3.59), >5 myomas (OR, 2.49; 95% CI, 1.27-4.89), and larger uterine size statistically were associated significantly with cell-salvage device set-up. Conversely, having a reproductive-endocrinology-infertility specialist as the surgeon was associated with a significant reduction in cell-salvage system set-up (OR, 0.37; 95% CI, 0.21-0.66). For the women who had cell-salvage system set-up, uterine size of >15-19 weeks of gestation (OR, 3.22; 95% CI, 1.56-8.95) or ≥20 weeks of gestation (OR, 4.62; 95% CI, 1.45-14.73), operating time of >120 minutes (OR, 3.98; 95% CI, 1.70-9.29), and intraoperative blood loss of >1000 mL (OR, 26.31; 95% CI, 10.49-65.99) were associated significantly with a higher incidence of reinfusion of cell-salvaged blood. CONCLUSION: The routine use of cell salvage in women who undergo abdominal myomectomy does not appear to be warranted. Cell-salvage set-up appears to be cost-effective only when reinfused, but clinical characteristics cannot predict accurately which women will require reinfusion of cell-salvaged blood.

Magnetic resonance-guided focused ultrasound myomectomy: safety, efficacy, subsequent fertility and quality-of-life improvements, a systematic review.

We performed a systematic review about studies reporting data of myomectomy performed by magnetic resonance-guided focused ultrasound (MRgFUS) technique in order to define its safety, feasibility, indications, complications, and impact on uterine fibroid symptom and health-related quality of life (UFS-QOL) and fertility. Outcomes were considered according to fibroids shrinkage, nonperfused volume (NPV), NPV ratio, and uterine fibroid symptoms assessed with UFS-QOL questionnaire (baseline 3, 4, 6, and 12 months). We analyzed 38 eligible studies reporting outcomes about 2500 patients (mean age 43.67 years). The MRgFUS results a safe, efficient, and cost-effective minimal invasive technique for treatment of uterine fibroids. Increasing experience, device improvements, and availability for a larger number of patients are enhancing the outcomes, while the obstetrical ones should be more extensively explored. The MRgFUS could be considered as a minimal invasive alternative to traditional surgical or radiological procedures for the treatment of symptomatic uterine myomas improving both QOL and subsequent fertility.