Effects of selective blockage of utero-ovarian anastomoses on clinical results of uterine artery occlusion.

BACKGROUND: We assessed the results and impact of blockage of utero-ovarian anastomoses (UOA) on clinical outcome in women treated by laparoscopic uterine artery occlusion for uterine fibroids. METHODS: Between 2004 and 2005, we prospectively analyzed the clinical data for 23 laparoscopic uterine artery occlusion cases combined with blockage of utero-ovarian anastomoses (Group A) and 67 laparoscopic uterine artery occlusion cases alone (Group B). RESULTS: Of these 23 patients with UOA (mean age, 36.7+/-2.8 years), 10 patients (43.4%) had anastomoses bilaterally and 13 patients (56.6%) had unilateral anastomoses. Mean fibroid size reduction after LUAO and anastomoses blockage was 32.5% from baseline (P<0.001). In patients with LUAO, the mean DF size after surgery was estimated at 38.7+/-19.2 mm, which translated to a mean fibroid size reduction of 30.6% from baseline (P<0.001). No case of clinical failure or recurrence was found in Group A patients with UOA (mean follow-up, 15.6 months), who were treated with combined surgery. At a mean clinical follow-up of 18.2 months (Group B), 6 patients (8.9%) elected to undergo further surgical intervention for clinical failure and recurrence, including 4 myomectomies and 2 hysterectomies. The statistical difference between groups was not significant (P=0.33). CONCLUSION: Laparoscopic blockage of utero-ovarian anastomoses combined with uterine artery occlusion is a safe, feasible surgical procedure in women with symptomatic fibroids. Combining the uterine artery occlusion and blockage of UO anastomoses may be a useful procedure for the decreasing rate of clinical failure and recurrence. This premise should be confirmed in a larger prospective multicenter study.

Inflammatory responses after laparoscopic uterine myomectomy compared to open surgery in current clinical practice.

OBJECTIVE: To determine the differences in inflammatory response and clinical outcome of current clinical practice in women undergoing laparoscopic myomectomy (LM) and abdominal myomectomy (AM) for symptomatic fibroid. METHODS: A total of 36 women entered the study between October 2004 to June 2005 at the Department of Gynecology and Obstetrics and the Endoscopy Training Center at the Baby Friendly Hospital in Kladno, Czech Republic, based upon an ultrasonographic assessment size of dominant fibroid (DM) before surgery. All women were allocated to one of 2 groups: group 1 (n=17), DM <6 cm and treated with LM, and group 2 (n=19) DM > or =6 cm, treated with open myomectomy. Surgical characteristics, hospital stay and complications were analyzed. Blood samples for assay of the acute phase reactants and markers of tissue trauma [C-reactive protein (CRP), interleukin-6 (IL-6), serum amyloid A (SAA), white blood cell count (WBC) and creatine kinase (CK)] were taken preoperatively and on the first and third postoperative day. RESULTS: The difference between the groups in the mean size of DM was statistically significant (4.8 cm in group 1 versus 6.9 cm in group 2, p<0.05). Statistically, significant differences were found between the compared groups in intra-operative blood loss (p<0.05) and length of hospital stay (p<0.001). No complication was reported after LM. There were significantly higher levels of CRP, IL-6, SAA, WBC and CK in both groups after surgery. Increased levels of IL-6, WBC and CK were greatest on the first postoperative day in both groups, and increased levels of CRP and SAA on the third postoperative day in the open group. The serum CRP, IL-6, SAA, WBC, CK and the fall in hemoglobin were statistically different between the 2 groups. CONCLUSION: Compared with open myomectomy, LM was associated with a less intensive inflammatory response and a more favorable clinical outcome.

Complications and myoma recurrence after laparoscopic uterine artery occlusion for symptomatic myomas.

AIM: To determine the frequency and severity of complications and the recurrence of fibroids as a result of laparoscopic occlusion of the uterine artery (LOUA) in women with symptomatic fibroids. METHODS: One hundred and fourteen women with symptomatic fibroids were treated using ultrasonically activated shears, clips or electrosurgery. A retrospective evaluation of the complications and recurrence rate was carried out. For each patient, the analysis took place at least 3 months after the procedure was performed. Each complication was categorized using the complication classifications developed by the Czech Society of Gynecologic Endoscopy and a modified set of the classifications of the American College of Obstetricians and Gynecologists. All adverse events that occurred during the follow-up period were included, in addition to those that occurred after the 3 months minimum interval. RESULTS: A total of eight women (7.1%, 95% confidence intervals [CI], 3.3-14.4) experienced complications; one of these women had two complications, resulting in a total of nine adverse events. There were no intraoperative complications and no permanent injuries. Two women required supracervical hysterectomy and myomectomy, respectively, as a result of fibroid necrosis. One patient had an undiagnosed endometrial stromal sarcoma after 12 months of LOUA. The rate of fibroid recurrence was 9.0% (10 patients). The recurrence-free survival interval rate (no clinical failure, no recurrence) at 23.6 months (median) follow-up was 88.3% (CI 84.9-93.5). CONCLUSION: The rate of complications and fibroid recurrence was low in patients undergoing LOUA.

Laparoscopic myomectomy with lateral dissection of the uterine artery.

BACKGROUND: We assessed the results and impact of lateral uterine artery dissection on clinical outcome following laparoscopic myomectomy. METHODS: We retrospectively analyzed the clinical data for 27 laparoscopic myomectomy cases (Group I) and 54 laparoscopic myomectomy cases combined with lateral uterine artery dissection (Group II) between January 2001 and August 2004 in one center. Only 81 patients who had dominant fibroids between 4 cm and 10 cm in diameter were included in the study. We assessed the clinical outcomes: perioperative blood loss, operating time, hospital stay, complications, hemoglobin decrease, inflammatory response, and tissue markers (C-reactive protein, white blood cells, creatinine kinase) changes. RESULTS: The mean operating time was 70.37 minutes in group I and 78.61 minutes in group II. The mean length of hospital stay was 2.7 days versus 2.2 days, respectively (P>0.05). The difference in intraoperative blood loss was 70.1 mL (147.7 mL vs 77.3 mL, Group I) and 33.9 mL (105 mL vs 71.1 mL, Group II); estimated postoperative blood loss was statistically significant (P<0.001, P<0.05, respectively). Group 2 demonstrated a less intense stress response in C-reactive protein (P<0.001) and white blood cell count (P<0.05). CONCLUSION: The dissection of the uterine artery in laparoscopic myomectomy is a feasible operative procedure with a low rate of complications. The procedure reduced perioperative blood loss and resulted in significant improvement in fibroid-related symptoms.

Variability of the origin of the uterine artery: laparoscopic surgical observation.

AIM: To categorize the surgical anatomic variants of the origins of the uterine arteries and to clarify the difference in the description of the internal iliac artery in the contemporary anthropologic, radiologic and surgical system. METHODS: One hundred women with symptomatic fibroids were treated using retroperitoneal laparoscopic dissection of the uterine vessels (LDUV). Retrospective evaluation of the operative records and videos was carried out. The anatomical classification of Adachi (type I-V) was modified for surgical purposes (type I-IV). RESULTS: Laparoscopic retroperitoneal dissection and LDUV were carried out successfully using an ultrasonic operative technique in all women. The branching of the branches of the internal iliac artery was studied on the right side of the pelvis. Of the 100 uterine arteries that were evaluated, 81% were classifiable types and 19% of surgical dissections were inconclusive. Classification was as follows: type I, 30.8%; type II, 23.4%; type III, 45.6%; and type IV was not found. Modified surgical classification type III (visceral branches arising from the umbilical artery and the internal pudendal artery) was claimed to be statistically the most common type. CONCLUSION: Laparoscopic dissection of the uterine artery close to the origin of the uterine artery can be carried out safely in the most frequent types of surgical classification. The meticulous dissection of the uterine artery in cases in which the uterine artery does not arise typically from an unobliterated segment of the internal iliac artery was recommended.

Laparoscopic detection of sentinel lymph nodes using blue dye in women with cervical and endometrial cancer.

BACKGROUND: One of the cornerstones of gynecologic cancer surgery is the assessment and removal of the regional lymph nodes (LNs). Vital blue dye was used to shown the feasibility and accuracy of laparoscopic intraoperative lymphatic mapping of the sentinel lymph nodes (SNs) in patients with cervical and endometrial cancer (EC). MATERIAL/METHODS: Thirty-two women were submitted to laparoscopic staging of cervical and endometrial cancer. Patent blue dye (BPD) was intraoperatively injected into the cervix in 6 cases with stage I and one case with stage II cervical cancer. In 25 cases of stage I EC, the BPD was intraoperatively injected into the cervix and uterine fundus. After the BPD procedure, the patients underwent pelvic lymphadenectomy or para-aortic lymph node dissection and either laparoscopically assisted vaginal hysterectomy (26 patients) or laparoscopic radical hysterectomy (5 patients). RESULTS: Laparoscopically assisted surgical staging was successfully performed in all cases. SN detection was successful in 100% of 7 women with cervical cancer. In one patient with advanced cervical cancer the metastatic SN was found. A deposition of dye into at least one lymph node was found in 21 out of 25 cases (84%) in women with EC. Uptake of the BPD was observed in a total of 53 (14.4%) of 367 LNs. Histological analysis of two LNs of the 53 were positive for metastases, whereas the remaining 51 were negative. CONCLUSIONS: With the use of laparoscopy, accurate detection using blue dye on sentinel lymph nodes in uterine cancer is feasible technique.

Laparoscopic pelvic lymphadenectomy in the surgical treatment of endometrial cancer: results of a multicenter study.

OBJECTIVE: To analyze the results and determine the contribution of laparoscopic pelvic lymphadenectomy in the surgical treatment of women with endometrial cancer and compare with the open technique. METHODS: A prospective multicenter study was carried out on 120 women who underwent laparoscopic surgery (96 women) and open procedures (24 women) for endometrial cancer between April 1996 and March 2000. RESULTS: Four patients whose laparoscopic surgery was completed by laparotomy were excluded from the study. The other 92 laparoscopic procedures were successfully completed. Laparoscopically assisted surgical staging (LASS) was performed based on the grade of the tumor and the depth of myometrial invasion. Sixty-seven of the patients underwent hysterectomy, bilateral salpingooophorectomy (BSO), and pelvic lymphadenectomy, and 25 women also had para-aortic lymph node sampling dissection. Eleven of these patients had positive pelvic or para-aortic nodes. The mean operating time for the laparoscopic procedure was significantly longer (173.8 min, P < 0.0001) than the time for the open procedure (135.0 min). The rate of complications was similar in both groups. The recovery time was significantly reduced (P < 0.0001). CONCLUSION: The laparoscopic approach to hysterectomy and lymphadenectomy for early stage endometrial carcinoma is an attractive alternative to the abdominal surgical approach. The advantages of laparoscopically assisted surgical staging are patient related. Because the abdominal incision is avoided, the recovery time is reduced. Laparoscopic pelvic lymph node dissection is a procedure that is appropriate, when applicable.