Comparative Analysis of Total Laparoscopic Hysterectomy Versus Non-descent Vaginal Hysterectomy for Benign Uterine Pathologies in Women: A Systematic Review.

Hysterectomy, which can be conducted through abdominal or vaginal routes, is one of the most common gynecological procedures performed worldwide. When the patient is not able to undergo a vaginal hysterectomy due to contraindications involving a narrow pelvis or endometriosis and technical difficulties, laparoscopic removal of the uterus is the recommended method over abdominal hysterectomy. Additionally, the type of surgery depends on the expertise of the surgeon. Therefore, this systematic review aimed to evaluate different measures related to total laparoscopic (TLH) versus non-descent vaginal hysterectomy (NDVH) in women with benign uterine pathologies. ScienceDirect, PubMed, and Google Scholar databases were searched from 2019 to 2023 for a literature review using keywords including "Non-descent Vaginal Hysterectomy," AND "Total Laparoscopic Hysterectomy," AND "Benign Uterine Pathologies." This systematic review includes five studies based on the selection criteria. The data were extracted and a quality assessment of the studies was performed. The review concluded that NDVH has an advantage over TLH as a scarless surgery performed in a very short period and with minimum blood loss with fewer complications and in terms of cost-effectiveness. However, the postoperative parameters and satisfaction with the TLH technique were better than the NDVH technique, but the procedure was much more time-consuming and needed laparoscopic surgical expertise. The duration of hospitalization in NDVH and TLH was nearly the same. Furthermore, both techniques could be employed for salpingo-oophorectomy or when there are adnexal masses and adhesions present; however, TLH may be the best course of action.

Hemoperitoneum caused by spontaneous rupture of a leiomyoma: A case report.

Uterine myomas, fibroids or leiomyomas are benign neoplasms that can present as abnormal uterine bleeding and pressure symptoms. Significant complications are infrequent, but they can be life-threatening. This is a case of a ruptured fibroid where excessive intra-abdominal bleeding resulted in hemoperitoneum. In this clinical scenario, timely recognition and intervention were essential to prevent morbidity and mortality. This article discusses the diagnostic challenges and surgical management of a case of hemoperitoneum resulting from spontaneous haemorrhage from a ruptured vessel on the surface of a subserosal leiomyoma. A 42-year-old patient with a known multi-fibroid uterus awaiting elective surgery presented with acute-onset abdominal pain to the emergency department. She had a distended, tender abdomen. Laboratory tests and contrast computerised tomography revealed haemorrhage with no clear source of bleeding. Emergency midline laparotomy revealed active bleeding from the surface of a posterior subserosal leiomyoma with 1950 mL hemoperitoneum. A total abdominal hysterectomy was performed, and the patient had an uncomplicated recovery. The pre-operative haemoglobin level was 80 g/L, which normalized after several blood transfusions. Histopathological examination confirmed multiple leiomyomas and haemorrhage associated with ischaemic changes. Hemoperitoneum from a bleeding degenerating leiomyoma is an exceedingly uncommon complication. The atypical presentation of abdominal pain and the presence of a multi-fibroid uterus posed diagnostic challenges. This case underscores the importance of considering leiomyomas as a potential cause of acute abdominal pain and bleeding. Timely surgical intervention, supported by a multidisciplinary approach, is essential for optimal patient outcome.

Uterine Leiomyoma Journey With Acessa ProVu System Using General Anesthesia Under Laparoscopic Ultrasound Guidance: A Case Report.

This case report details the evaluation and management of a 40-year-old woman presenting with heavy menstrual bleeding and severe dysmenorrhea. Despite three months of combined oral contraceptives, symptoms persisted. The patient denied other systemic symptoms, with no weight loss, fatigue, or urinary/fecal symptoms. No visual, cardiovascular, pulmonary, abdominal, neurological, or mental health issues were reported. Pelvic imaging revealed a 7 cm × 4.3 cm FIGO 4 fibroid. The chosen treatment was laparoscopic radiofrequency ablation (Acessa) due to its efficacy, safety, and faster recovery. The case highlights the importance of a comprehensive approach to diagnosing and treating abnormal uterine bleeding.

A Vagino-Laparoscopic Strategy for Hysterectomy of Large Uteri to Ease Surgical Challenges.

Purpose: To develop a vagino-laparoscopic strategy for hysterectomy (VLH) to treat uteri with large fibroids at ≥ 16 weeks of gestation to ease surgical challenges. Patients and Methods: This was an observational study conducted in our private general hospital on 64 consecutive cases involving uteri with large and benign fibroids at ≥ 16 weeks of gestation. We excluded cases with an associated ventro-fixed uterus and large cervical fibroids. Interventions: The VLH strategy involves vaginal separation of the uterosacral with the uterine arteries followed by laparoscopic separation of the remaining upper pedicles. The uterus was then removed vaginally. Results: The largest uteri receiving treatment was at 26 weeks of gestation and the mean uterus weight was 869.60 ± 275.10 g (range: 500-1900 g). The VLH strategy was successful in 63 (98.43%) cases irrespective of the configuration of the uterus. One case (1.56%) required mini-laparotomy conversion due to the need for adhesiolysis; this case exhibited extensive adhesion of the rectum to the posterior wall of the uterus due to a history of previous myomectomy of the posterior wall. There were no conversions due to failed laparoscopic exposure of the adnexal or uterine vascular pedicles, or due to uncontrolled intraoperative bleeding. There were no cases of urinary tract injury or other major complications. The vaginal detachment of uterosacral ligaments before the laparoscopic phase of the VLH strategy increased upwards mobility and dislodged the cervico-isthmic level of large uteri from the narrow lower aspect of the pelvis to the upper wider part of the pelvis; this eased the surgical challenges associated with such cases and avoided complications during laparoscopy. Conclusion: We developed a vagino-laparoscopic strategy for hysterectomy that can ease the technical challenges associated with the majority of large uteri.

Hemoperitoneum due to spontaneous bleeding from a smooth muscle tumor of uncertain malignant potential: A rare case report.

INTRODUCTION AND IMPORTANCE: Smooth muscle tumors of uncertain malignant potential (STUMPs) are uncommon tumors representing an extremely rare cause of hemoperitoneum. CASE PRESENTATION: We report a case of a 48-year-old Caucasian, premenopausal woman that presented in the emergency department with acute abdominal pain. There was no remarkable past medical and surgical history except from a known uterine leiomyoma. The ultrasound and the computed tomography imaging showed an intraperitoneal fluid collection and a heterogenous uterine mass. The patient underwent emergent exploratory laparotomy; a subserosal uterine tumor was identified with an actively bleeding vessel on its surface. The uterine lesion was completely excised and the histopathology set the diagnosis of a STUMP. After consultation on the significance of this finding with the patient, an abdominal total hysterectomy and bilateral salpingo-oophorectomy were scheduled and performed and the subsequent histopathology detected no malignancy. CLINICAL DISCUSSION: This case demonstrates that a STUMP may be a rare cause of acute intraperitoneal bleeding. Careful evaluation of clinical history, imaging findings and, if needed, surgical exploration are important for the diagnosis, while appropriate follow-up is also of major importance for the management of these rare tumors. CONCLUSION: We presented an extremely rare case of hemoperitoneum due to spontaneous bleeding from a STUMP. From an oncological perspective, this case poses a diagnostic, management and follow-up challenge.

Cotyledonoid Dissecting Leiomyoma: A Rare Variant of Leiomyoma of the Uterus.

Cotyledonoid dissecting leiomyoma is a rare variant of leiomyoma and has only been reported a few times in the literature. As a result of its alarming gross and radiologic appearance, it must be differentiated from other malignant smooth muscle tumors. We report a case of cotyledonoid dissecting leiomyoma in an African American premenopausal woman with a medical history of anemia, abnormal uterine bleeding, and a cervical mass. A total hysterectomy was performed on the patient. On pathological examination, the gross and microscopic appearance of the tumor was consistent with that described in previous reports of cotyledonoid dissecting leiomyoma. However, our case showed focal areas of increased mitotic activity with 5 mitoses per high power field but no tumor cell necrosis or cellular atypia. This tumor does not have malignant potential, but clinicians and pathologists must be aware of its existence to avoid overtreating patients.

Recurrence of Uterine Smooth Muscle Tumor of Uncertain Malignant Potential: A Systematic Review of the Literature.

Background: This study aimed to systematically review the existing literature on uterine smooth muscle tumor of uncertain malignant potential (STUMP) to provide information about characteristics and outcomes of patients and the risk factors for recurrence over a period of 60 years (1960−2021). Methods: According to PRISMA guidelines, we searched for "uterine smooth muscle tumor of uncertain malignant potential" in PubMed (all fields) and Scopus (Title/Abstract/Keywords) databases (accessed on 1 January 2022). Relevant articles were obtained in full-text format and screened for additional references. The only filter used was the English language. Studies including full case description of patients with histopathological diagnosis of STUMP in accordance with Stanford criteria were included. Results: Thirty-four studies, including 189 cases, were included. The median age was 43 years, and in 21.5% of cases there was a recurrence of the disease. Bivariate analysis showed a significant association between use of morcellation without bag and risk of recurrence (p = 0.001). Unprotected morcellation during demolitive or conservative surgery was independently associated with a higher risk of disease recurrence with a relative risk of 2.94 (p < 0.001). A significant progressive decrease in the recurrence rate was observed over time (r = −0.671, p = 0.008). The percentage of patients who underwent surgery followed by in-bag protected morcellation significantly increased after the publication of the U.S. Food and Drug Administration alert about the risk linked to this procedure (p = 0.01). Conclusions: Unprotected morcellation of the lesion is associated with the relapse of the disease. However, this clinical condition showed a drastic decrease over time. This could likely be due to the increased awareness by surgeons of the importance of customizing surgical treatment.

A Study on Clinico-Pathological Profile of Breast Cancer Patients and Their Correlation With Uterine Fibroids Using Hormone Level and Receptor Status Assessment.

Purpose: To study the clinico-pathological profile of breast cancer patients and the prevalence of uterine fibroids in them, their hormonal levels and hormone receptor status. Patients and methods: 52 patients with breast cancer who attended AIIMS Bhopal from November 2018 to January 2020 were selected, with their clinical details, triple assessment and other investigations for further management being performed and recorded. The presence of uterine fibroids was assessed using ultrasound of the abdomen, and for patients who had undergone hysterectomy, previous medical records were examined to ascertain the history of uterine fibroids. Serum levels of estrogen and progesterone were assessed using chemi-luminescent micro-particle immune assay (CMIA). Results: The mean age of patients was 50.35 ± 10.87 years. 36.54% of our patients had uterine fibroids, of whom 15.38% had undergone hysterectomy for the same, and 21.15% was detected on ultrasound of the abdomen during evaluation. Among patients with uterine fibroids, 84.2% were hormone receptor-positive, while in patients without uterine fibroids, only 57.6% had positive receptors. (P = 0.049). Among premenopausal patients, there was a statistically significant difference in serum progesterone values between patients with and without uterine fibroids. Conclusion: The prevalence of uterine fibroids in our study group of breast cancer patients was found to be high. The role of estrogen and progesterone in the pathophysiology of both diseases and the common risk factors involved may biologically explain this finding. Breast cancer and other estrogen associated disorders may hold future research prospects.

Endovascular management of extensive iliocaval thrombosis secondary to synchronous uterine myoma compression and May-Thurner syndrome.

This report presents a 42-year-old African American woman with bilateral lower extremity pain, swelling, and paresthesias. Imaging demonstrated a large fibroid uterus with a mass effect in proximity to an iliocaval venous thrombosis. Mechanical thrombectomy was performed with recurrent infrarenal vena cava and bilateral iliac thrombosis, prompting hysterectomy. A subsequent intravascular ultrasound examination demonstrated relief of the external caval compression, but with left iliac vein compression by the right common iliac artery. The patient was managed successfully with mechanical thrombectomy and venous stenting. This case highlights the benefit of a multidisciplinary approach to complex iliocaval thrombosis from both an obstructive uterine myoma and May-Thurner syndrome.

Successful Laparoscopic-Assisted Supracervical Hysterectomy in a 14-Week-Sized Fibroid Uterus: An Autobiographical Case Report.

Uterine leiomyomas are a very common gynecological condition. This case report describes the author's experience pursuing definitive treatment of a 14-week-sized fibroid uterus, the associated menometrorrhagia, and bulk symptoms. Barriers still remain if women of reproductive age prefer ovary-sparing hysterectomy. Laparoscopic supracervical hysterectomy with contained morcellation remains a well-tolerated and low-risk option dependent on surgeon expertise and informed patient consent. Literature review reveals the psychosocial and financial burden of uterine leiomyomas may present multiple challenges, affecting the quality of life.

The Association Between Ferritin and Vitamin D Levels in Premenopausal Fibroid Uterus Cases With Anemia.

Objective The present study aimed to evaluate the association between serum ferritin and vitamin D levels in fibroid uterus cases presenting with anemia. Methods Sixty premenopausal women with uterine fibroids (30 associated with anemia and 30 without anemia) were enrolled as cases and control. All participants were evaluated on the basis of a questionnaire, which included queries related to obstetric, medical, and sociodemographic history. Peripheral blood smear, complete blood count (CBC), hemoglobin (Hb), and serum ferritin concentration were measured by a fully automated analyzer, and 25(OH) vitamin D level was measured by enzyme-linked immunosorbent assay (ELISA). Results There was a significant difference in ferritin levels between cases and control (p<0.001). The exposure to sunlight was moderate (one-hour exposure) in all subjects, eliminating the confounding effect of sunlight exposure influencing vitamin D levels. The median vitamin D level in cases was 5.0 ng/ml [interquartile range (IQR): 4.8], and that in control was 18.4 ng/ml (IQR: 7.9; p<0.001). A strong positive correlation of (r)=0.616 (p<0.001) was found between serum ferritin and vitamin D levels. Conclusion Fibroid uterus cases with anemia are more prone to vitamin D deficiency as compared to cases without anemia. Vitamin D estimation in fibroid uterus cases presenting with anemia would be useful for better patient management.

Robot-assisted laparoscopic myomectomy for FIGO type II sub-mucosal leiomyoma without endometrial injury for a patient with history of miscarriage

To introduce a technique for robot-assisted laparoscopic myomectomy for FIGO type II sub-mucosal leiomyoma with >50% myometrial extension, without endometrial injury. A narrated video demonstration of our technique has been provided. Our patient was a 35-year-old, gravida 1, para 0 woman with secondary infertility. She had been married for three years. She complained of heavy menstrual bleeding and severe dysmenorrhea with a pain score of 10 on visual analogue scale (VAS). Surgery was done after thorough counseling and an informed consent was obtained. Institutional Review Board number: KC17OESI0375, approval date: 21.09.2018. Several steps can be taken to help prevent endometrial injury, and these include: (1) proper preoperative imaging to plan surgery; (2) use of intraoperative ultrasound to determine best location of incision; (3) use of a "cold cut" technique with monopolar curved scissors without energy to avoid obscuring the border between the leiomyoma and the endometrium; (4) careful millimeter by millimeter dissection; (5) use of diluted indigo carmine to aid delineation of the endometrial cavity during dissection. The patient had a normal post-operative course. On follow-up her VAS pain score was 0. Transvaginal ultrasound repeated four months postoperatively showed normalization of uterine anatomy and endometrial contour. Robot-assisted laparoscopic myomectomy may be an option to preserve fertility and minimize endometrial injury. This surgical method allows complete removal of large sub-mucosal leiomyomas in one session with exact suturing.

Bilateral abdominopelvic lymphoceles secondary to huge uterine leiomyomas: A case report.

Pelvic lymphocele secondary to uterine leiomyoma has not been previously reported. We report a case of abdominopelvic lymphocele associated with huge uterine fibroids which was managed conservatively. A 39-year-old unmarried lady presented with pressure symptoms in pelvis was diagnosed to have a huge uterine leiomyomas occupying the entire abdomen. Magnetic resonance imaging of pelvis and abdomen demonstrated multiple uterine fibroids. In addition, bilateral cystic structures were seen in the pelvis with extension to the para-colic gutters. During myomectomy, bilateral abdominopelvic lymphoceles were noted which required only fine-needle aspiration. Follow up abdominal ultrasound at 6 weeks, demonstrated spontaneous resolution of these lesions. The pressure exerted by these huge uterine leiomyomas might have possibly obstructed the lymphatic drainage leading to bilateral abdominopelvic lymphoceles. These secondary lymphoceles resolve spontaneously and does not need any further diagnostic procedures or surgical interventions.

Perinatal outcome and long-term pediatric morbidity of pregnancies with a fibroid uterus.

BACKGROUND: Uterine fibroids are a common morbidity in women and its prevalence is increasing with age. As maternal age rises, fibroids become more prevalent during pregnancy. AIM: To assess perinatal outcome and long-term health of children to mothers with uterine fibroids during pregnancy. STUDY DESIGN: A population-based cohort analysis assessing long-term hospitalizations of offspring, up to the age of 18 years, due to gastrointestinal, neurological, cardiovascular, endocrine, and respiratory morbidity, following pregnancies diagnosed with and without a fibroid uterus. Multivariable generalized estimating equation (GEE) analysis adjusted for maternal clusters and other possible confounders was performed. Kaplan-Meier survival curves and Cox survival regression models were used to compare cumulative morbidity incidence and control for confounders. SUBJECTS: All singleton deliveries occurring between 1991 and 2014. OUTCOME MEASURES: Perinatal outcome and long-term pediatric morbidity. RESULTS: A total of 242,445 singleton deliveries were included; 0.5% of which were diagnosed with uterine fibroids (n = 1237). In the GEE multivariable analyses, advanced maternal age, hypertensive disorder and diabetes mellitus, fetal growth restriction, low birthweight (<2500 g), and small for gestational age newborns, were all independently associated with uterine fibroids during pregnancy. Hospitalizations up to the age of 18 years in the different health categories were comparable between the groups, using Cox regression models, controlled for clinically significant confounders in the long-term outcomes. CONCLUSION: Maternal uterine fibroids appear to negatively impact perinatal outcome, mainly fetal growth. However, no independent major impact on future health of the offspring can be detected.

Sonographically Guided Office Endometrial Sampling: Indications and Results.

OBJECTIVES: The purpose of this study was to identify clinical indications in which endometrial sampling was performed under transabdominal ultrasound (US) guidance and to evaluate the outcomes of this approach in an academic practice. METHODS: We retrieved data from the electronic medical record for all patients referred to the gynecologic US unit for transabdominal US-guided endometrial sampling from January 2011 to June 2017. Data retrieved included age, parity, previous cesarean delivery or pelvic surgery, indication for endometrial biopsy, US abnormalities, clinical reasoning for US-guided sampling, and pathologic reports. RESULTS: A total of 113 patients were referred for US-guided sampling between January 2011 and June 2017. We identified the following reasons for US-guided biopsy referral: failed blind biopsy attempt, fibroids, uterine position or anomaly, need for targeted sampling, cervical stenosis, and other indications. Ninety-five of the 113 patients (84%) underwent successful US-guided endometrial sampling. Forty of the 113 patients were referred after a failed blind biopsy, with 83% subsequently undergoing successful US-guided endometrial sampling. Of the 30 patients referred for fibroids, 29 (97%) underwent successful US-guided sampling. High success rates were also noted for transabdominal US guidance referrals for the uterine position or anomaly (86%) and the need for targeted sampling (83%). CONCLUSIONS: Our results suggest that endometrial sampling performed under US guidance could be considered for patients with a failed blind approach, fibroids, uterine anomalies, and interest in targeted sampling. In such cases, US-guided sampling could be considered before surgical options.

Doppler sonography of perifibroid and intrafibroid arteries of uterine leiomyomas.

OBJECTIVE: To sonographically evaluate the dominant fibroid nodule vascularity and flow velocity pattern of perifibroid and intrafibroid arteries. METHODS: We recruited 140 women with uterine fibroids. Their uteri were scanned to determine the vascularity of fibroid nodules and the Doppler indices of the fibroid arteries. RESULTS: The median volume of the dominant leiomyoma nodule was 133 cm3 (range=1.5-2,575 cm3). Eighty-three subjects (59.3%) had a dominant leiomyoma nodule volume of ≤200.0 cm3 while the volume of the dominant leiomyoma nodule was >200.0 cm3 in 57 (40.7%) subjects. The dominant fibroid nodule was vascular in 137 (97.9%) subjects and avascular in 3 (2.1%). All the perifibroid artery indices (except the end-diastolic velocity [EDV] and diastolic average ratio [DAR]) are significantly higher than those of the intrafibroid artery. The mean Doppler indices of perifibroid vs. intrafibroid arteries as follows: peak systolic velocity (PSV; 52.1 vs. 45.4 cm/s); EDV (21.1 vs. 22.4 cm/s); time-averaged maximum velocity (TAMX; 31.5 vs. 30.4 cm/s); time- averaged mean velocity (Tmean; 14.3 vs. 13.8 cm/s); pulsatility index (PI; 1.1 vs. 0.8); resistive index (RI; 0.6 vs. 0.5); systolic-diastolic ratio (SDR; 2.7 vs. 2.1); impedance index (ImI; 2.7 vs. 2.1); and DAR (0.66 vs. 0.74); P<0.001 for all indices. CONCLUSION: The predominant pattern of fibroid vascularity is peripheral vascularity and the perifibroid artery indices (except EDV and DAR) are significantly higher than those of the intrafibroid artery. Recurrent fibroids in women with previous myomectomy had significantly higher intrafibroid PI, RI, SDR, and ImI than those without previous myomectomy.

STUMP, a surprise finding in a large fibroid uterus in a 20-year-old woman.

We report on a case of a 20-year-old nulliparous woman with menorrhagia associated with a smooth muscle tumor of uncertain malignant potential (STUMP) that was responsive to Goserelin. This case details the investigation and management of a young woman who desires ongoing fertility preservation. STUMP is a rare uterine tumor with a paucity of literature available regarding management and subsequent malignant potential, particularly in the case of a patient who desires fertility preservation.

Stroke due to Paradoxical Embolization Related to Fibroid Uterus Enlargement Compressing the Right Common Iliac Vein.

Stroke in young women is commonly cryptogenic or associated with an underlying hypercoagulable state (e.g., hormonal contraception). Paradoxical embolization has been postulated as a potential risk factor for stroke in young adults. Many sources of venous thrombosis leading to paradoxical embolization have been described. There have been few reported cases of uterine enlargement leading to iliac vein compression and paradoxical embolization. We present the case of a young adult woman who had a left middle cerebral artery infarction related to patent foramen ovale and right common iliac vein compression from an enlarged fibroid uterus.

Doppler sonography of perifibroid and intrafibroid arteries of uterine leiomyomas

OBJECTIVE: To sonographically evaluate the dominant fibroid nodule vascularity and flow velocity pattern of perifibroid and intrafibroid arteries. METHODS: We recruited 140 women with uterine fibroids. Their uteri were scanned to determine the vascularity of fibroid nodules and the Doppler indices of the fibroid arteries. RESULTS: The median volume of the dominant leiomyoma nodule was 133 cm3 (range=1.5–2,575 cm3). Eighty-three subjects (59.3%) had a dominant leiomyoma nodule volume of ≤200.0 cm3 while the volume of the dominant leiomyoma nodule was >200.0 cm3 in 57 (40.7%) subjects. The dominant fibroid nodule was vascular in 137 (97.9%) subjects and avascular in 3 (2.1%). All the perifibroid artery indices (except the end-diastolic velocity [EDV] and diastolic average ratio [DAR]) are significantly higher than those of the intrafibroid artery. The mean Doppler indices of perifibroid vs. intrafibroid arteries as follows: peak systolic velocity (PSV; 52.1 vs. 45.4 cm/s); EDV (21.1 vs. 22.4 cm/s); time-averaged maximum velocity (TAMX; 31.5 vs. 30.4 cm/s); time- averaged mean velocity (Tmean; 14.3 vs. 13.8 cm/s); pulsatility index (PI; 1.1 vs. 0.8); resistive index (RI; 0.6 vs. 0.5); systolic-diastolic ratio (SDR; 2.7 vs. 2.1); impedance index (ImI; 2.7 vs. 2.1); and DAR (0.66 vs. 0.74); P < 0.001 for all indices. CONCLUSION: The predominant pattern of fibroid vascularity is peripheral vascularity and the perifibroid artery indices (except EDV and DAR) are significantly higher than those of the intrafibroid artery. Recurrent fibroids in women with previous myomectomy had significantly higher intrafibroid PI, RI, SDR, and ImI than those without previous myomectomy.