Repair of a chronic myometrial defect with successful pregnancy outcome.

OBJECTIVE: To surgically demonstrate preconceptional laparoscopic repair of a chronic myometrial defect with mesh reinforcement, resulting in a successful pregnancy outcome. DESIGN: Video case report. The Institutional Ethical Committee was consulted, and the requirement for approval was waived because the video describes a modified surgical technique. The patient included in this video gave consent for publication of the video and posting of the video online, including on social media, the journal website, scientific literature websites (such as PubMed, ScienceDirect, Scopus, and others), and other applicable sites. SETTING: A referral advanced gynecological endoscopy center. PATIENT: A 27-year-old woman (P0A1) was diagnosed with myomas during pregnancy, resulting in miscarriage at 22 weeks. Laparotomy and myomectomy were performed 2 months later, and three 8-cm myomas were removed. The endometrial cavity opened posteriorly during surgery, and retained products of conceptions were removed. Periconceptional imaging done after two years showed few intramural myomas and a deficient myometrium in the posterior fundal region. Laparoscopy revealed a defect in the posterior fundal aspect of the uterus with leakage of dye, which was converted to laparotomy and myomectomy with the repair of the myometrial defect. After 1 year, follow-up magnetic resonance imaging showed thinned-out posterior myometrium with a focal area of absent myometrium in the midline and endometrial prolapse. The patient was advised on surrogacy, but she wanted to repair the defect again and try for pregnancy, so she was referred to our center. With the background of a few case reports using mesh to reinforce myometrial repair (1, 2), we counseled the patient about the myometrial repair with the additional use of mesh as an off-label use. INTERVENTION: The risk of uterine rupture after myomectomy is rare (<1%) (3), but it is a severe complication. High-risk cases, like significant myometrial defects or previous ruptures, may require surgical correction. Native repair may not achieve optimal results in all cases. Alternative approaches, like the additional use of mesh or biological materials, have been reported (4). In this case, we demonstrate the use of dual mesh for scar repair. Synthetic mesh over the uterus is used in laparoscopic procedures like sacrohysteropexy and cerclage. We used Parietex (Covidien, New Haven, CT, USA) mesh, a composite macroporous polyester mesh usually used for ventral hernia repair. It has an outer hydrophilic, absorbable collagen barrier that reduces adhesion formation. Laparoscopically, after adhesiolysis, a significant defect was demonstrated on the posterior wall of the uterus (Fig. 1). A complete resection of the fibrotic tissue along the edges of the scar defect was done to expose healthy myometrium. Myometrium was repaired in two layers, excluding the endometrium, with a V-Loc (Covidien, Dublin, Ireland) No. 1-0 suture. Parietex mesh was sutured over the repaired posterior myometrium to reinforce it (Fig. 2). MAIN OUTCOME MEASURES: The postoperative myometrial thickness on imaging and pregnancy outcome. RESULTS: Postoperative ultrasound scan after 6 weeks demonstrated restoration of posterior wall myometrial thickness of 14 mm. The patient was conceived through in vitro fertilization techniques 4 months after surgery. Antenatal follow-up was uneventful except for suspicion of posterior placenta accreta. She underwent an elective cesarean section with uterine artery embolization at 34 weeks and delivered a healthy infant weighing 1,950 g. Placental removal was uneventful. On inspection, the posterior surface of the uterus was intact without dehiscence, meshing in situ with minimal adhesions (Fig. 3). CONCLUSION: Myometrial scar defects can cause potential obstetric complications. Native repair of scar defects may not achieve optimal results, as in our case. Mesh repair of myomectomy scar defects can be used as an alternative approach, as exemplified in this case. However, further studies are required to establish the safety and efficacy of this approach.

Clinical results of uterine artery ligation in myomectomy.

AIM: To compare intraoperative and postoperative clinical results of laparoscopic and laparotomic myomectomy operations in patients with and without bilateral uterine artery ligation. MATERIALS AND METHODS: A retrospective analysis of 217 patients with intramural ≥ 5 cm myoma who underwent laparoscopic (n = 100) or laparatomic (n = 117) myomectomy was conducted. The patients were grouped according to the number of uterine myomas removed (≤2 or > 2). Clinical results of both laparoscopic and laparotomic myomectomy methods and the presence of uterine artery ligation were compared. The recurrence of myomas and pregnancy outcomes were also reported. RESULTS: For patients with > 2 myomas removed without uterine artery ligation, the amount of bleeding, operation time, and hospital stay were significantly lower in patients who underwent laparotomic myomectomy but no significant difference in patients with <2 myomas removed. The rate of hemorrhage was lower in both the laparoscopy and laparotomy uterine artery ligation groups. The recurrence rate of myomas ≤ 3 cm was higher in the laparoscopic myomectomy group (p = .022) and in patients without uterine artery ligation group (p = .028) but recurrence rates for myomas > 3 cm were similar between in groups. Pregnancy occurred in 24 of the 96 patients who underwent uterine artery ligation, and 14 pregnancies resulted in live births. CONCLUSION: Uterine artery ligation might be a suitable addition to myomectomy surgery to reduce intraoperative bleeding and the recurrence of myoma, especially in cases where more than two uterine myomas are removed laparoscopically. KEY WORDS: Laparoscopic myomectomy, Laparotomic myomectomy, Myomas, Haemorrhage, Uterine artery ligation.

Nascent myoma as a cause of urinary retention.

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

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.

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.

Three-dimensional imaging reconstruction and laparoscopic robotic surgery: a winning combination for a complex case of multiple myomectomy.

OBJECTIVE: To demonstrate the intraoperative use of three-dimensional (3D) imaging reconstruction for a complex case of multiple myomectomy assigned to robot-assisted laparoscopic surgery. DESIGN: Stepwise demonstration of the technique with narrated video footage. SETTING: University tertiary care hospital. PATIENT(S): A 36-year-old nulliparous infertile woman with multiple uterine myomas (>20) presented with menorrhagia and pelvic discomfort for many months. Because of the huge number of fibroids present, the patient was considered eligible for laparoscopic robotic-assisted myomectomy. INTERVENTION(S): A robotic-assisted laparoscopic myomectomy was performed with the use of intraoperative 3D imaging reconstruction. After opening the retroperitoneum through the adnexal triangle and identifying the ureters, to reduce intraoperative bleeding, bulldog clamps were used to temporarily reduce uterine vascularization. A multiple myomectomy was then performed with the use of tenaculum and Maryland bipolar forceps. During the intervention, the surgeon used the 3D uterine reconstruction to adapt its surgical strategy. Multilayer running closure was achieved using a bidirectional barbed suture ensuring introflexion of the serosa. Patients' consent was obtained for publication of the case; institutional review board approval was not required for this case report as per our institution's policy. MAIN OUTCOME MEASURE(S): Description of a robotic-assisted myomectomy with the intraoperative use of 3D imaging reconstruction. RESULT(S): The total operative time was 105 minutes. A total of 21 fibroids were removed with 150 mL of intraoperative blood loss. The patient was discharged the day after. CONCLUSION(S): The application of 3D imaging technology could overcome one of the limitations of robot-assisted minimally invasive surgery, the lack of haptic feedback, enabling the surgeon to rapidly locate myomas and guide the intraoperative plan to optimize the results. Additional studies evaluating the clinical impact of this technique and its improvement are required.

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.

Risk factors based on myoma characteristics for predicting postoperative complications following cesarean myomectomy.

OBJECTIVES: To evaluate the influence of myoma characteristics on cesarean myomectomy and to demonstrate its additional advantages. METHODS: Retrospective data were collected from 292 women with myomas who had undergone cesarean section at Kangnam Sacred Heart Hospital between 2007 and 2019. We performed subgroup analysis according to the type, weight, number, and size of myomas. Preoperative and postoperative hemoglobin levels, operative time, estimated blood loss, length of hospital stay, incidence of transfusion, uterine artery embolization, ligation, hysterectomy, and postoperative complications were compared among subgroups. RESULTS: There were 119 patients who had cesarean myomectomy and 173 who had cesarean section only. An increase in postoperative hospitalization and operation time was observed in the cesarean myomectomy group compared to that in the caesarean section only group (mean difference, 0.7 days, p = 0.01, 13.5 minutes, p <0.001). Estimated blood loss, hemoglobin differences, and transfusion rates were higher in the cesarean myomectomy than in the cesarean section only group. There were no differences in postoperative complications (fever, bladder injury, and ileus) between the two groups. No hysterectomy cases were reported in the cesarean myomectomy group. In subgroup analysis, the larger and heavier the myoma, the higher the risk of bleeding that led to transfusion. Estimated blood loss, differences in hemoglobin, and transfusion rate increased depending on myoma size and weight. A significant increase in postoperative hospitalization was observed in women with larger and heavier myomas. However, there was no statistical difference among the three types of myomas. CONCLUSION: In cesarean myomectomy, larger (≥ 10 cm), and heavier myomas (≥ 500 g), were associated with postoperative outcomes, but not the number or type of myoma. The safety of cesarean myomectomy is not inferior to that of caesarean section only, considering its positive effects such as gynecological symptom relief and avoidance of the next surgery.

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

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

Comparison of cesarean delivery outcome after robotic and laparoscopic myomectomy.

OBJECTIVE: The aim of this study was to determine whether robotic myomectomy (RM) resulted in any measurable clinical improvement over laparoscopic myomectomy (LM) in subsequent cesarean delivery. MATERIALS AND METHODS: The medical records of 273 patients who had undergone LM or RM followed by subsequent cesarean delivery for the period of September 2015 to December 2020 were retrospectively reviewed. The patients were divided into LM (n = 222) and RM (n = 51) groups. The cesarean delivery outcomes between the two groups were compared. RESULTS: RM had significantly more myomas removed (6.0 ± 4.8 vs. 3.6 ± 3.5, p < 0.001) and a larger size of largest myoma (7.7 ± 2.4 vs. 6.1 ± 2.4, p = 0.002) at myomectomy compared with LM. However, there were no significant differences in the groups' surgical characteristics at cesarean section, in their pregnancy complications, or in adhesion formation. CONCLUSIONS: Although more and larger myomas were removed in the RM group, RM showed similar cesarean delivery outcomes and adhesion formation to LM.

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.

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

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

Beyond the learning curve: improving outcomes in Robotic myomectomy compared to laparoscopic myomectomy.

Uterine myomas are benign tumours frequently seen in women of reproductive age. Myomectomy remains a viable option for treating this condition in women who wish to preserve their uterus. We undertook this study to compare the peri-operative surgical outcomes of Robotic myomectomy (RM) with laparoscopic myomectomy (LM) in Indian patients of uterine myomas after the initial learning curve of RM was achieved. A retrospective chart review was performed for the patients who underwent RM or LM for the treatment of uterine myomas. A total of 177 patients, 116 in the RM group and 61 in the LM group, were included in the study. The mean age in the RM and LM group was 34.31 ± 5.40 years and 33.54 ± 4.96 years, respectively (p = 0.355). The mean total operative time was marginally more in RM group (127.37 ± 110.67 vs. 120.66 ± 44.27, p = 0.650) but the difference was not statistically significant. Patients in the RM group had significantly less blood loss (115.43 ± 79.43 vs. 340.98 ± 453.9 ml, p = < 0.0001), hospital stay (1.28 ± 0.49 vs. 1.92 ± 1.05 days, p = < 0.0001), requirement of blood transfusion (93.97 vs. 81.97%, p = 0.031) and requirement of intravenous (IV) analgesia (41.38 vs. 34.43%, p = 0.019) as compared to the patients in the LM group. The Robotic myomectomy significantly reduces blood loss, the duration of hospital stay, and requirement of blood transfusions and IV analgesia as compared to the laparoscopic myomectomy.

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

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

Use of Barbed Suture in Laparoscopic Myomectomy with Large Posterior Myoma.

OBJECTIVE: To assess the safety and efficacy of barbed suture laparoscopic myomectomy for large posterior myoma compared to conventional suture. STUDY DESIGN: Descriptive study. PLACE AND DURATION OF STUDY: Department of Gynecology, Affiliated Women and Children's Hospital of Ningbo University, Ningbo, Zhejiang, China between July 2019 and June 2020. METHODOLOGY: All cases of laparoscopic myomectomy for large posterior myoma (≥8cm in the largest diametre) were retrospectively reviewed. The surgical technique was identical except the selection of suture material. A comparison between the barbed suture and conventional suture was performed in terms of clinical characteristics and surgical outcomes such as total operative time, suture time, intraoperative blood loss, and changes in hemoglobin concentration. RESULTS: A total of 48 eligible cases, 24 cases with barbed sutures and 24 cases with conventional sutures were included in the final analysis. Patients' clinical characteristics such as age, body mass index, number, and size of myomas were similar between the two groups. In patients with barbed sutures, the time for suturing, the total operative time, intraoperative blood loss, and the changes in hemoglobin concentration were significantly lower than in conventional sutures (all p<0.05). No significant differences in time for enucleation, time for morcellation, and postoperative complications were found between the two groups. Two patients with conventional sutures received postoperative emergent uterine artery embolization and three patients received a blood transfusion. CONCLUSIONS: The use of barbed sutures could reduce the difficulty and enhance safety in laparoscopic myomectomy for large posterior myoma. KEY WORDS: Barbed suture, Laparoscopy, Myomectomy, Posterior.

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

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