Reporte de caso: síndrome de absorción intravascular en histeroscopia, intoxicación por glicina / Case report: Intravascular absorption syndrome in hysteroscopy, glycine intoxication

El síndrome de absorción intravascular en histeroscopia se origina por la rápida absorción vascular de soluciones isotónicas e hipotónicas utilizadas en irrigación intrauterina, ocasionando hipervolemia y dilución de electrolitos, especialmente hiponatremia. Cuando este síndrome es debido a intoxicación por glicina al 1,5% causa acidosis severa y neurotoxicidad. La incidencia de este síndrome es baja pero puede aumentar por factores como: falta de control de altura de bolsas de irrigación, ausencia de equilibrio de fluidos de soluciones de irrigación, tejidos altamente vascularizados como miomas uterinos y uso de sistema de electrocirugía monopolar. Se reporta el caso de una paciente con miomas uterinos, programada para resección mediante histeroscopia que cursa con síndrome de absorción intravascular por glicina, el temprano diagnóstico y rápido tratamiento intraoperatorio y postoperatorio permitió una evolución favorable. El manejo se basó en el uso de diuréticos, restricción de fluidos y soluciones hipertónicas de sodio.

Intravascular absorption syndrome in hysteroscopy is caused by rapid vascular absorption of isotonic and hypotonic solutions used in intrauterine irrigation, causing hypervolemia and electrolyte dilution, especially hyponatremia. When this syndrome is due to 1.5% glycine toxicity, it causes severe acidosis and neurotoxicity. The incidence of this syndrome is low but may increase due to factors such as: lack of control of the height of irrigation bags, lack of fluid balance in irrigation solutions, highly vascularized tissues such as uterine myomas and use of a monopolar electrosurgery system. The case of a patient with uterine myomas, scheduled for resection by hysteroscopy, who presents with intravascular glycine absorption syndrome, is reported. Early diagnosis and rapid intraoperative and postoperative treatment allowed a favorable evolution. Management was based on the use of diuretics, fluid restriction, and hypertonic sodium solutions.

[Iron in pre-operative stage and transfusion in patients undergoing hysterectomy]. / Hierro en etapa preoperatoria y la transfusión en pacientes sometidas a histerectomía.

Background: The correction of preoperative anemia is part of the patient blood management program, in order to improve the patient's clinical results by reducing the number of transfusions in surgery. Uterine fibroids can cause anemia, so the application of iron before hysterectomy could reduce transfusion. Objective: To evaluate the impact of iron treatment in the preoperative stage on the need for transfusion in patients with anemia secondary to myomatosis in the trans and postoperative stage of hysterectomy. Material and methods: Patients with uterine myomatosis who presented with microcytic anemia in the preoperative stage were included; clinical records were reviewed, the clinical characteristics of the population were obtained; The patients were distributed into two study groups according to whether or not they had received iron treatment; the outcome variable was the transfusion of packed erythrocytes in the first 7 days after surgery. Results: 134 patients were included, with a median fibroid size of 4 cm. 21 (15.6%) patients used iron. Patients who used iron had a relative risk (RR): 0.36 (95%CI: 0.12-1.07). Delta hemoglobin < 1 g/dL, RR: 1.59 (95%CI: 0.94-2.67). Uterine fibroid size > 5cm had a RR of 1.96 (95%CI: 1.25-3.05). Conclusion: Treatment with iron in the pre-surgical stage showed a tendency to protect transfusions in the trans and post-surgical stage. The main factor related to transfusion was fibroid size > 5 cm.

Introducción: la corrección de la anemia preoperatoria parte del programa de manejo hemático del paciente, a fin de mejorar sus resultados clínicos disminuyendo la cantidad de transfusiones en cirugía. La miomatosis uterina puede cursar con anemia, por lo que la aplicación de hierro antes de la histerectomía podría disminuir la transfusión. Objetivo: evaluar el impacto del tratamiento con hierro en la etapa prequirúrgica sobre la necesidad de transfusión en pacientes con anemia secundaria a miomatosis en la etapa trans y posoperatoria de histerectomía. Material y métodos: se incluyeron pacientes con miomatosis uterina que cursaron con anemia microcítica en la etapa preoperatoria; se realizó revisión de los expedientes clínicos y se obtuvieron las características clínicas de la población. Las pacientes se distribuyeron en dos grupos de estudio de acuerdo con el antecedente de haber recibido o no tratamiento con hierro. La variable de desenlace fue la transfusión de concentrados eritrocitarios en los primeros siete días a partir de la cirugía. Resultados: se incluyeron 134 pacientes, 21 (15.6%) utilizaron hierro. Las pacientes que utilizaron hierro tuvieron un riesgo relativo (RR) de 0.36 (IC95%: 0.12-1.07) para transfusión. La delta de hemoglobina < 1 g/dL tuvo un RR: 1.59 (IC95%: 0.94-2.67). El tamaño de mioma > 5 cm tuvo un RR: 1.96 (IC95%: 1.25-3.05). Conclusión: el tratamiento con hierro en etapa prequirúrgica mostró tendencia a protección para transfusiones en etapa trans y posquirúrgica. El principal factor relacionado para transfusión fue el tamaño del mioma > 5 cm.

Nuevo paradigma en la cirugía del mioma: reparación uterina / New paradigm in fibroid surgery: Uterine repair

Los miomas uterinos son una patología frecuente que afecta fundamentalmente a mujeres en su tercera y cuarta década de su vida. La mayoría son asintomáticos. Sin embargo, algunos pueden tener una importante repercusión clínica o en la fertilidad de la paciente. Recientemente se han producido cambios relevantes en el diagnóstico y manejo de esta entidad. En este manuscrito se pretende resumir dichos cambios abordados en el 1er Congreso Nacional de la Sociedad Española para el estudio de las Miomas y Endometriosis.(AU)

Uterine fibroids are a frequent pathology that mainly affects women in their third and fourth decade of life. Most are asymptomatic. However, some may have a significant clinical impact or on the fertility of the patient. Recently there have been relevant changes in the diagnosis and management of this entity. This paper aims to summarize these changes discussed at the 1 st National Congress of the Spanish Society for the Study of Fibroids and Endometriosis.(AU)

Intravenous leiomyomatosis: Case report and review of the literature / Leiomiomatosis intravenosa: a propósito de un caso y revisión de la literatura

Introduction: We retrospectively reviewed a case of a 42-year-old woman with intravenous leiomyomatosis. Clinical findings: The present study describes a case of IVL extending into the right internal and common iliac veins. Diagnosis: The patient was diagnosed by definitive pathological examination after a hysterectomy and double salpingectomy. Hypovolaemic shock due to delayed intraperitoneal bleeding from the ovarian vessels pedicle was observed. An emergent laparotomy for haemostasis was performed. A follow-up MRI, 2 months later, showed a polylobulated mass extending inside the right internal and common iliac veins. Intervention and result: The patient underwent a third laparotomic procedure with the removal of the right pelvic mass together with the involved veins. The postoperative course was uneventful, and the patient remains well at 3-month follow-up, with no signs of lower limb edema or venous disorders. Conclusion: Intracardiac leiomyomatosis is mostly diagnosed in premenopausal women. The most severe manifestation could be a vascular thrombosis or a right atrial tumor in the case of intracardiac involvement. Early and appropriate diagnosis is essential for optimal treatment. Surgery is the best treatment.(AU)

Introducción: Presentamos el caso de una paciente de 42 años con leiomiomatosis intravenosa. Hallazgos clínicos: El estudio presente describe un caso de IVL con afectación de las venas ilíaca común e interna derecha. Diagnóstico: La paciente fue diagnosticada mediante el examen histológico definitivo tras una histerectomía total con doble salpingectomía. Se objetivó un shock hipovolémico por sangrado intraperitoneal tardío del pedículo de vasos ováricos. Se realizó una laparotomía urgente para hemostasia. Una RMN durante el seguimiento, 2 meses después, mostró una masa polilobulada con afectación de la vena ilíaca común y la vena ilíaca interna derecha. Intervención y resultado: A la paciente se le realizó una tercera laparotomía con la extirpación de la masa pélvica derecha. El curso postoperatorio fue satisfactorio y la paciente permaneció asintomática a los 3 meses de seguimiento, sin signos de edema en extremidades inferiores ni otras afectaciones vasculares. Conclusión. La leiomiomatosis intracardíaca se diagnostica más frecuentemente en mujeres premenopáusicas. La forma de manifestación más severa sería una trombosis vascular o un tumor intracardíaco en la aurícula derecha, en el caso de afectación intracardíaca. Un diagnóstico precoz es esencial para un tratamiento óptimo. La cirugía es el mejor tratamiento.(AU)

Embolización de arterias uterinas para el manejo de miomas sintomáticos / Uterine artery embolization for the management of symptomatic fibroids

Los miomas uterinos son el tumor más frecuente en la edad reproductiva y suponen un impacto negativo en la calidad de vida de las pacientes. El tratamiento de esta entidad debe hacerse de forma individualizada. La embolización de la arteria uterina es un tratamiento mínimamente invasivo, seguro, eficaz y con una baja tasa de complicaciones cuando se usa como tratamiento de miomas sintomáticos. El objetivo de este artículo es realizar una revisión bibliográfica exhaustiva sobre el estado actual de la embolización de las arterias uterinas en el tratamiento de los miomas que incluya consideraciones previas sobre enfoques técnicos y selección de casos, resultados clínicos en comparación con otras opciones de tratamiento y resultados en términos de calidad de vida y fertilidad.(AU)

Uterine fibroids are the most common tumour in reproductive age and have a negative impact on the quality of life of patients. Cases must be treated on an individual basis. Uterine artery embolization is a minimally invasive, safe, effective treatment with a low rate of complications when used as a treatment for symptomatic fibroids. The objective of this article is to conduct a comprehensive literature review on the current status of uterine artery embolization in the treatment of fibroids, including preliminary considerations on technical approaches and case selection clinical outcomes compared with other treatment options, and outcomes in terms of quality of life and fertility.(AU)

Placenta acreta en mioma intramural uterino en una paciente primigestante: reporte de caso y revisión de la literatura

La placenta acreta se define como una invasión trofoblástica anormal de una parte o de toda la placenta a nivel de las paredes miometriales del útero. La incidencia de acretismo placentario viene cada vez más y más en aumento. El factor de riesgo más común es la presencia de cesárea y la posibilidad de cursar con acretismo placentario aumenta entre más cesáreas tenga la paciente. Hay pocos datos acerca de acretismo placentario localizado en mioma uterino, sobre todo en el contexto de una paciente primigestante. Se presenta el caso de una primigestante tardía, quien cursó con embarazo de alto riesgo dado por acretismo placentario localizado en mioma intramural; asimismo, hacemos una revisión de la literatura acerca del diagnóstico oportuno y pronóstico de esta condición. (provisto por Infomedic International)

Placenta accreta is defined as an abnormal trophoblastic invasion of part or all of the placenta at the level of the myometrial walls of the uterus. The incidence of placental accreta is increasingly on the rise. The most common risk factor is the presence of cesarean section and the likelihood of placental accreta increases the more cesarean sections the patient has. There is little data on placental accreta located in uterine myoma, especially in the context of a primigestational patient. We present the case of a late primigestation, who had a high-risk pregnancy due to placental accreta located in an intramural myoma; we also review the literature on the timely diagnosis and prognosis of this condition. (provided by Infomedic International)

Reporting of uterine fibroids on ultrasound examinations: an illustrated report template focused on surgical planning / Relato de miomas uterinos em exames de ultrassonografia: um modelo de relatório ilustrado com foco no planejamento cirúrgico

Abstract Uterine fibroids are the most common benign gynecologic tumors in women of reproductive age, and ultrasound is the first-line imaging modality for their diagnosis and characterization. The International Federation of Gynecology and Obstetrics developed a system for describing and classifying uterine fibroids uniformly and consistently. An accurate description of fibroids in the ultrasound report is essential for planning surgical treatment and preventing complications. In this article, we review the ultrasound findings of fibroids, detailing the main points to be reported for preoperative evaluation. In addition, we propose a structured, illustrated report template to describe fibroids, based on the critical points for surgical planning.

Resumo Os miomas uterinos são os tumores ginecológicos benignos mais comuns em mulheres em idade reprodutiva, sendo a ultrassonografia a modalidade de imagem de primeira linha para seu diagnóstico e caracterização. A Federação Internacional de Ginecologia e Obstetrícia desenvolveu um sistema para descrever e classificar os miomas uterinos de forma uniforme e consistente. Uma descrição precisa dos miomas no laudo ultrassonográfico é essencial para o planejamento do tratamento cirúrgico e prevenção de complicações. Neste artigo, revisamos os achados ultrassonográficos de miomas, detalhando os principais pontos a serem relatados para avaliação pré-operatória. Além disso, propomos um modelo de relatório estruturado e ilustrado para descrição de miomas, com base nos pontos críticos para o planejamento cirúrgico.

Utilidad de la histeroscopia en el manejo del sangrado uterino anorma / Usefulness of hysteroscopy in the management of abnormal uterine bleeding

La histeroscopia se considera actualmente la prueba que posibilita no solo el diagnóstico, sino también el tratamiento de enfermedad intrauterina en paciente con clínica de sangrado uterino anormal causado por anomalías estructurales, como pólipos, adenomiosis, miomas submucosos, hiperplasia endometrial o cáncer de endometrio. La miniaturización del diámetro de los histeroscopios con canal de trabajo, del minirresector bipolar y de los sistemas de morcelación histeroscópica han permitido el tratamiento en régimen ambulatorio, en ocasiones en el mismo tiempo que el diagnóstico histeroscópico, aportando mayor satisfacción, reducción riesgos quirúrgicos o derivados de la anestesia y posibilitando una rápida resolución coste-efectiva de los síntomas. En este artículo se revisa la utilidad de la histeroscopia para el diagnóstico y el tratamiento de la enfermedad estructural intrauterina causante de sangrado uterino anormal.(AU)

Hysteroscopy is currently considered the test that enables not only the diagnosis but also the treatment of intrauterine pathology in patients with symptoms of abnormal uterine bleeding caused by structural abnormalities such as polyps, adenomyosis, submucosal fibroids, endometrial hyperplasia, or endometrial cancer. The miniaturization of the diameter of hysteroscopes with working channels, the bipolar mini-resector, and the hysteroscopic morcellation systems have allowed outpatient treatment, sometimes at the same time as hysteroscopic diagnosis, providing greater satisfaction, reducing surgical and/or anaesthesia risks and enabling rapid cost-effective resolution of symptoms. This article reviews the usefulness of hysteroscopy for the diagnosis and treatment of intrauterine structural pathology causing abnormal uterine bleeding.(AU)

Torsión uterina causada por miomatosis: reporte de un caso / Uterine torsion caused by myomatosis: A case report

Resumen ANTECEDENTES: La torsión uterina es una rotación del útero sobre su eje mayor de más de 45°; por lo general sucede en torno del istmo uterino. Los leiomiomas son el factor predisponente más frecuente en úteros no grávidos. OBJETIVO: Reportar el caso de una paciente con torsión uterina cervical y miomatosis de grandes elementos. CASO CLÍNICO: Paciente de 42 años, nuligesta, con antecedente de miomatosis uterina de grandes elementos de 27 x 27 cm. Los síntomas se iniciaron con síndrome doloroso abdominal intenso, tipo cólico, localizado en el hipogastrio y la fosa iliaca. En la exploración física el abdomen se percibió doloroso a la palpación superficial y profunda, con una tumoración cercana a la cicatriz umbilical (25 cm), móvil y dolorosa. En la laparotomía exploradora se encontró líquido peritoneal hemorrágico y se observó una torsión uterina (una vuelta) cerca del cuello del útero, además de un mioma subseroso en la cara posterior, de 27 x 27 cm. El útero, los anexos y las salpinges se advirtieron con datos francos de daño vascular, con áreas de isquemia. Por lo anterior se decidieron la histerectomía total abdominal y la salpingooforectomia bilateral. El informe histopatológico reportó: útero con cambio isquémico extenso panmural, sin evidencia de neoplasia maligna. CONCLUSIONES: El dolor abdominal es el síntoma más común de la torsión uterina que puede variar de leve a agudo. El diagnóstico preoperatorio rápido y preciso de torsión uterina es decisivo y se justifica la intervención quirúrgica de urgencia.

Abstract BACKGROUND: Uterine torsion is a rare entity that is defined as a rotation of the uterus on its major axis of more than 45°, generally occurring at the level of the uterine isthmus. Leiomyomas are the most frequent predisposing factor in non-gravid uterus. OBJECTIVE: Report of a case of a gynecological patient with uterine torsion at the cervical level in a uterus with uterine myomatosis of large elements. CLINICAL CASE: A 42-year-old patient, nulliparous, with a history of uterine myomatosis with large elements of 27 x 27 cm. The symptoms began with intense abdominal pain syndrome, colic type, located in the hypogastrium and the iliac fossa. On physical examination, the abdomen was perceived as painful on superficial and deep palpation, with a mobile and painful tumor close to the umbilical scar (25 cm). In the exploratory laparotomy, hemorrhagic peritoneal fluid was found and a uterine torsion (one turn) was observed near the cervix, as well as a subserous myoma on the posterior face, measuring 27 x 27 cm. The uterus, the annexes and the salpinges were noted with frank data of vascular damage, with areas of ischemia. Therefore, total abdominal hysterectomy and bilateral salpingo-oophorectomy were decided. The histopathological report reported: uterus with extensive panmural ischemic change, without evidence of malignancy. CONCLUSIONS: In uterine torsion, abdominal pain is the most common symptom and can range from mild to severe abdominal symptoms. Therefore, a prompt and accurate preoperative diagnosis of uterine torsion is crucial and urgent surgical intervention is warranted.

Opciones terapéuticas para una joven nulípara con mioma uterino intramural gigante / Therapeutic options for a nulliparous young woman with a giant intramural uterine myoma

RESUMEN Introducción: Los leiomiomas uterinos son los tumores ginecológicos benignos más comunes; son causa de anemia, infertilidad, alteración en la implantación embrionaria, pérdida gestacional recurrente, parto prematuro e incontinencia urinaria. Su transformación maligna es excepcional. La afectación a la fertilidad, se asocia con miomas entre el 3 % y el 31 % y depende de su ubicación y tamaño, sobre todo en los que distorsionan la cavidad uterina. Objetivo: Describir las opciones terapéuticas para una joven nulípara con un mioma uterino intramural gigante. Caso Clínico: Paciente de 30 años de edad, con antecedentes de mioma uterino intramural, de 5 años de evolución, además anemia ferripriva. Aqueja menstruaciones abundantes y dolorosas, incontinencia urinaria y constipación. El tratamiento fue escalonado, mediante el uso de acetato de goserelina, embolización selectiva de las arterias uterinas y posterior miomectomía. Conclusiones: El tratamiento del mioma uterino en la mujer joven, nulípara, depende del tamaño, localización, sintomatología asociada, edad de la paciente y deseo de engendrar descendencia.

ABSTRACT Introduction: Uterine leiomyomas are the most common benign gynecological tumors; they are a cause of anemia, infertility, altered embryo implantation, recurrent gestational loss, premature delivery and urinary incontinence. Their malignant transformation is exceptional. Fertility impairment is associated with myomas in between 3 % and 31 % and depends on their location and size, especially in those that distort the uterine cavity. Objective: To describe the therapeutic options for a nulliparous girl with a giant intramural uterine fibroid. Clinical Case: A 30-year-old patient with a 5-year history of intramural uterine fibroid, in addition to iron deficiency anemia. She complains of heavy and painful periods, urinary incontinence and constipation. Treatment was staggered, using goserelin acetate, selective embolization of the uterine arteries, and subsequent myomectomy. Conclusions: The treatment of uterine fibroid in young, nulliparous women depends on the size, location, associated symptoms, age of the patient and desire to have offspring.

Perforación intestinal tras ablación por radiofrecuencia de mioma uterino. Reporte de caso y revisión bibliográfica / Intestinal perforation after transvaginal radiofrequency ablation of uterine leiomyoma. Case report and literature review

El mioma uterino es la tumoración pélvica más frecuentemente diagnosticada en mujeres en edad reproductiva. En los últimos años se ha producido una búsqueda de tratamientos mínimamente invasivos que permitan conservar el útero. La ablación por radiofrecuencia vía transvaginal permite el tratamiento de los miomas uterinos de forma segura y efectiva.Presentamos un inusual caso clínico de perforación intestinal tras la ablación por radiofrecuencia de dos miomas y presentamos una revisión de la literatura existente en relación a esta complicación de la técnica.

Uterine leiomyoma are the most common pelvic tumours diagnosed in women of reproductive age. In recent years, the search for minimally invasive treatment that allows women to preserve their uterus has resulted in transvaginal radiofrequency ablation. This procedure is safe and effective.We present a case report of intestinal perforation after transvaginal radiofrequency ablation of two uterine leiomyomas. Finally, we present a review of the literature in relation to this complication of the technique.

Mioma nascens: reporte de caso / Myoma nascens: Clinical case

Resumen ANTECEDENTES: Los miomas uterinos son los tumores ginecológicos más frecuentes durante la edad reproductiva y extremadamente raros en la preadolescencia y adolescencia temprana; representan el 1% de todos los casos. Es aún más excepcional que estos casos se manifiesten como prolapso de un mioma (mioma nascens). CASO CLINICO: Paciente de 11 años, procedente de Tunja, Colombia, con talla de 143 cm, peso 31 kg, IMC 15.15 kg/m2 (riesgo de delgadez), sin antecedentes patológicos, farmacológicos o quirúrgicos; menarquia a los 11 años, sin inicio de la vida sexual activa. Fue llevada a consulta debido a un cuadro clínico de cinco horas de evolución, consistente en la aparición de una masa de aproximadamente 3 cm de diámetro, que protruía la vagina al momento de defecar, dolorosa a la palpación, con sangrado escaso y flujo vaginal. La sospecha inicial fue: posible pólipo cervical. CONCLUSIÓN: Los casos de mioma nascens son, en general, infrecuentes, más aún en la edad pediátrica. Hacen falta estudios que permitan establecer las características biológicas de este tipo de lesiones en niñas y adolescentes que den pie a indicar el tratamiento más adecuado. El quirúrgico parece ser la opción que ha recibido mayor apoyo en otros reportes de caso. El seguimiento es decisivo debido a que se desconoce el comportamiento de este tipo de lesiones en este grupo etario.

Abstract BACKGROUND: Uterine fibroids are the most frequent gynecologic tumors during reproductive age and extremely rare in preadolescence and early adolescence, representing only 1% of all cases. It is even more exceptional that these cases manifest as myoma prolapse (myoma nascens). CLINICAL CASE: 11-year-old female patient from Tunja, Colombia, height 143 cm, weight 31 kg, BMI 15.15 kg/m2 (risk of thinness by Colombian resolution), with no pathological, pharmacological or surgical history; menarche at 11 years old, without onset of sexual life. She was taken to consultation due to a clinical picture of five hours of evolution, consisting of a mass of approximately 3 cm in diameter, protruding the vagina at the time of defecation, painful on palpation, with scanty bleeding and vaginal discharge. The initial suspicion was possible cervical polyp. CONCLUSION: Cases of myoma nascens are, in general, infrequent, even more so in pediatric age. More studies are needed to establish the biological characteristics of this type of lesions in girls and adolescents to indicate the most appropriate treatment. Surgical treatment seems to be the option that has received the most support in other case reports. Follow-up is crucial because the behavior of this type of lesions in this age group is unknown.

Bloqueio do Nervo Hipogástrico Superior (BNHS) para o manejo da dor após Embolização de Artérias Uterinas (EAU): revisão de literatura / Superior Hypogastric Nerve Block (SHNB) for pain management in Uterine Artery Embolization (UAE): a literature review

Introdução: a embolização de artérias uterinas (EAU) é uma opção terapêutica no tratamento de miomas uterinos sintomáticos; todavia, a dor pós-procedimento representa um grande desafio para essa técnica. Nesse contexto, o Bloqueio do Nervo Hipogástrico Superior (BNHS), já utilizado no tratamento de dor pélvica crônica associada à malignidade, apresenta-se como opção de intervenção intraprocedimento para melhorar a recuperação das pacientes e fomentar o uso da EAU na prática clínica. Objetivo: realizar uma revisão integrativa da literatura disponível sobre o BNHS no manejo de dor pós EAU. Métodos: bases de dados PubMed, The Cochrane Library, Lilacs e Medline foram avaliadas a partir da combinação dos termos "uterine artery embolization", "pain" e "superior hypogastric block". Foram incluídos estudos clínicos, disponíveis em texto completo, com pacientes adultas, submetidas à EAU, cujo objetivo era avaliar o uso do BNHS e seu impacto na dor pós-procedimento. Foram excluídos artigos de revisão, carta ao editor, e publicação em anais de congresso. Resultados: 8 artigos, em maior parte retrospectivos, indicaram consistência do BNHS em termos de sucesso terapêutico a curto prazo e redução da dor. Apenas uma complicação foi relatada, e evoluiu de forma satisfatória. Conclusões: BNHS tem potencial de aprimorar o manejo da dor após EAU, podendo impactar positivamente no tempo e na qualidade da recuperação, com redução da dor e consumo de opiodes no período pós-operatório. Esses benefícios valorizam o procedimento de embolização como uma alternativa a ser considerada no tratamento de leiomiomas sintomáticos para mulheres candidatas à preservação uterina.

Introduction: Uterine Artery Embolization (UAE) is a therapeutic option in the treatment of symptomatic uterine fibroids; however, post-procedure pain imposes as a great challenge in this technique. In this context, the Superior Hypogastric Nerve Block (SHNB), already used in the treatment of chronic pelvic pain associated with malignancy, presents itself as an option for intraprocedural intervention, to improve patients' recovery and to promote UAE in the clinical setting. Objective: to perform an integrative literature review about the effectiveness of SHNB in pain management after UAE. Methods: databases PubMed, The Cochrane Library, Lilacs and Medline were assessed using the combination of the terms "uterine artery embolization", "pain" and "superior hypogastric block". Clinical studies were included once available in full text, with adult patients submitted to UAE, whose objective was to evaluate the use of SHNB and its impact in post-procedure pain. Review articles, letters to the editor, and publication in conference proceedings were excluded. Results: 8 articles were found, most of them retrospective, indicated SHNB's consistency in terms of short-term therapeutic success and pain reduction. The single reported complication evolved satisfactorily. Conclusions: SHNB has the potential to improve pain management after UAE, which can positively impact recovery time and quality, with reduced pain and consumption of opioids in the postoperative period. Benefits like these can enhance the embolization procedure as an alternative to be considered for the treatment of symptomatic fibroids for women candidates for uterine preservation.

Miomectomía múltiple por vía abdominal / Multiple abdominal myomectomy

RESUMEN Se presentaron dos pacientes a las cuales se les realizó una miomectomía en los meses de enero y marzo de 2017, en la localidad de Luanda, Angola. Ambas fueron atendidas en la consulta de Ginecología por: aumento de volumen del abdomen, sangramiento genital durante la menstruación y fuera de ella, síntomas compresivos caracterizados por urgencia miccional y estreñimiento, además de infertilidad. Se les realizaron: exámenes de laboratorio, ultrasonido ginecológico y renal, así como histerosalpingografía. Después del análisis de estos exámenes se les diagnosticó una miomatosis uterina múltiple; fueron remitidas al salón de operaciones con previo consentimiento informado y se les practicó una miomectomía múltiple sin complicaciones transoperatorias. Se conservó el útero en ambas pacientes, las cuales tuvieron una recuperación postoperatoria satisfactoria. Una de estas pacientes logró un embarazo cinco meses después de la cirugía.

ABSTRACT We present two patients who had a myomectomy in January and March 2017, in Luanda, Angola. Both were treated in the Gynecology consultation due to increased abdominal volume, genital bleeding during and between periods, compressive symptoms characterized by urinary urgency, constipation and infertility. Laboratory tests, gynecological and renal ultrasound, as well as hysterosalpingography were performed. After the analysis of these tests, they were diagnosed with multiple uterine myomas, referred to the operating room with prior informed consent and underwent a multiple myomectomy without transoperative complications. The uterus was preserved in both patients, who had a satisfactory postoperative recovery. One of these patients got pregnant five months after surgery.

Clinicopathological study of cystic and atypical uterine leiomyoma: a rare entity / Estudo clinicopatológico de leiomioma uterino atípico e cístico: uma entidade rara

ABSTRACT A 43-years-old Brazilian woman, Caucasian, premenopausal, was attended with a history of lower abdominal pain, distension, and bleeding. Pelvic and transvaginal ultrasound revealed an enlarged uterus with a large, well-defined, uniformly hyperechoic lesion. The patient underwent total hysterectomy and the specimen was sent for anatomopathological evaluation. The histopathological analyses revealed a leiomyoma with extensive cystic degeneration and atypical characteristics, the immunohistochemical study confirmed the benignity of the case. The finding of atypical leiomyoma with cystic degeneration is rare and should be carefully evaluated to exclude malignant diseases.

RESUMEN Mujer brasileña de 43 años, caucásica, premenopáusica, fue atendida con antecedentes de dolor abdominal bajo, distensión y menorragias. La ecografía pélvica y transvaginal reveló un útero agrandado con una lesión grande, bien definida y uniformemente hiperecoica. La paciente fue sometida a histerectomía total y la pieza fue enviada para evaluación anatomo-patológica. Los análisis histopatológicos revelaron un leiomioma con degeneración quística extensa de características atípicas y la inmunohistoquímica confirmó la benignidad del caso. El hallazgo de un leiomioma atípico con degeneración quística es raro y debe evaluarse cuidadosamente para descartar enfermedades malignas.

RESUMO Mulher brasileira, 43 anos de idade, caucasiana, na pré-menopausa, foi atendida devido a história de dor em abdômen inferior, distensão e sangramento. A ultrassonografia pélvica e transvaginal revelou útero aumentado com grande lesão hiperecoica, bem definida e uniforme. A paciente foi submetida à histerectomia total, e a amostra foi enviada para avaliação anatomopatológica. A análise histopatológica revelou quadro de leiomioma com degeneração cística extensa e características atípicas; o estudo imuno-histoquímico confirmou a benignidade do caso. O achado de leiomioma atípico com degeneração cística é raro e deve ser cuidadosamente avaliado para excluir doenças malignas.

A propósito de un caso: útero miomatoso gigante torsionado / Torsion of a giant miomatous uterus: report of a clinical case autores

OBJETIVO: Reportar el caso de una torsión de útero, trompas y ambos ovarios a nivel de cuello uterino. Describir la patogenia, sintomatología y tratamiento, como un caso infrecuente y potencialmente grave, en la práctica clínica diaria. MATERIAL Y MÉTODOS: Analizar el curso de esta extremadamente rara patología, en una mujer postmenopáusica de 59 años. Se trata de un caso raro de torsión uterina en un útero no gestante, reportando los hallazgos en los exámenes previos a la cirugía y los hallazgos intraoperatorios e histopatológicos postcirugía. La resonancia magnética fue fundamental en el diagnóstico de la paciente y la laparotomía realizada demostró una torsión de cuerpo uterino de 360 ° a nivel de cérvix, y un gran mioma pediculado con signos de necrosis. Hemos revisado los últimos artículos de esta rara patología RESULTADOS Y DISCUSIÓN: La paciente fue operada. Se realizó una histerectomía total mediante una laparotomía media supra e infraumbilical. Los ovarios no tenían signos de necrosis. CONCLUSIONES: Debemos tener en cuenta esta posibilidad diagnóstica, en pacientes con aumento de tamaño uterino y clínica de dolor abdominal, ya que aunque es muy infrecuente, su diagnóstico es importante, ya que puede ser peligroso para la vida de la paciente.

OBJECTIVE: To report a case of torsion of the uterus, fallopian tubes and both ovaries around the uterine collum and the symptomatology, pathogenesis and treatment of this uncommon pathology. MATERIAL AND METHODS: The article analyses the course of this extremely rare pathology in a postmenopausical woman of 59 years. It is a rare case like a non gravid uterine torsion in a postmenopausical woman. We have the exams previous to the surgery, the finds intraoperative and the histolopathological reports postsurgery. RMN was the most important in diagnosis and the laparotomy showed a 360° an uterus increased on size and a big pedunculated myoma with signs of necrosis We have reviewed the latest articles on this strange pathology RESULTS AND DISCUSSION: The patient was operated. A infra-supra medium laparotomy was practiced and a total hysterectomy was made. Ovarians had not signs of necrosis. CONCLUSIONS: We must take into account, in patients with pathologies that increase uterine size and abdominal pain, the possibility of uterine torsion. Although it is a very infrequent pathology, its diagnosis is important, since it can be dangerous for the life of the patient

Use of GnRH analogues in the reduction of submucous fibroid for surgical hysteroscopy: A systematic review and meta-analysis / Uso de análogo de GnRH na redução de mioma submucoso na histeroscopia cirúrgica: Revisão sistemática e meta-análise

Abstract Objective Gonadotropin-releasing hormone analogues (GnRH-a) have been used preoperatively before hysteroscopic myomectomy to decrease the size and vascularization of the myomas, but evidence to support this practice is weak. Our objective was to analyze the use of GnRH-a in the reduction of submucous fibroid as a facilitator for surgical hysteroscopy from published clinical trials. Data sources Studies from electronic databases (Pubmed, Scielo, EMBASE, Scopus, PROSPERO), published between 1980 and December 2018. The keywords used were fibroid, GnRH analogue, submucous, histeroscopy, histeroscopic resection and their correspondents in Portuguese. Study selection The inclusion criteria were controlled trials that evaluated the GnRH-a treatment before hysteroscopic resection of submucous myomas. Four clinical trials were included in the meta-analysis. Data collection Two review authors extracted the data without modification of the original data, using the agreed form. We resolved discrepancies through discussion or, if required, we consulted a third person. Data synthesis The present meta-analysis included a total of 213 women and showed no statistically significant differences in the use of GnRH-a compared with the control group for complete resection of submucous myoma (relative risk [RR]: 0.94; 95%; confidence interval [CI]: 0.80-1.11); operative time (mean difference [MD]: - 3.81; 95%;CI : - 3.81-2.13); fluid absorption (MD: - 65.90; 95%;CI: - 9.75-2.13); or complications (RR 0.92; 95%;CI: 0.18-4.82). Conclusion The present review did not support the routine preoperative use of GnRH-a prior to hysteroscopic myomectomy. However, it is not possible to determine its inferiority when compared with the other methods due to the heterogeneity of existing studies and the small sample size.

Resumo Objetivo Análogos de hormônio liberador de gonadotrofina (GnRH-a) têm sido usados no pré-operatório de miomectomia histeroscópica para reduzir o tamanho e vascularização dos miomas, mas a evidência que suporta essa prática é fraca. Nosso objetivo foi analisar o uso de GnRH-a na redução do mioma submucoso como um facilitador de histeroscopia cirúrgica em ensaios clínicos publicados. Fonte de dados Estudos de bases de dados eletrônicas (Pubmed, Scielo, EMBASE, Scopus, PROSPERO), publicados entre 1980 e dezembro de 2018. As palavras-chave usadas foram fibroid, GnRH analogue, submucous, histeroscopy, histeroscopic resection e seus correspondentes em português. Seleção dos estudos Os critérios de inclusão foram ensaios clínicos controlados que avaliaram o tratamento com GnRH-a antes da ressecção histeroscópica de miomas submucosos. Quatro ensaios clínicos foram incluídos na meta-análise Coleta de dados Dois autores revisores extraíram os dados, sem modificarem os dados originais, usando a forma acordada. Nós resolvemos as discrepâncias através de discussão ou, se necessário, consultando um terceiro autor. Síntese dos dados A meta-análise incluiu um total de 213 mulheres e não demonstrou diferença estatisticamente significativa no uso de GnRH-a comparado com o grupo controle para ressecção completa de mioma submucoso (risco relativo [RR]: 0.94. índice de confiança [IC] 95%;: 0.80-1.11); tempo cirúrgico (diferença de média [MD]: - 3.81; IC95%;: -3.81-2.13); absorção de fluidos (MD: - 65.90; IC95%;: - 9.75-2.13); ou complicações (RR 0.92; IC95%;: 0.18-4.82). Conclusão A presente revisão sistemática não suporta o uso pré-operatório rotineiro de GnRH-a antes de miomectomia histeroscópica. No entanto, não é possível determinar sua inferioridade quando comparado aos outros métodos devido à heterogeneidade dos estudos existentes e ao pequeno tamanho da amostra.

Factors associated with the complications of hysteroscopic myomectomy / Fatores associados às complicações da miomectomia por histeroscopia

Abstract Objective To evaluate the factors associated with complete myomectomy in a single surgical procedure and the aspects related to the early complications. Methods A cross-sectional study with women with submucous myomas. The dependent variables were the complete myomectomy performed in a single hysteroscopic procedure, and the presence of early complications related to the procedure. Results We identified 338 women who underwent hysteroscopic myomectomy. In 89.05% of the cases, there was a single fibroid to be treated. According to the classification of the International Federation of Gynecology and Obstetrics (Fédération Internationale de Gynécologie et d'Obstétrique, FIGO, in French),most fibroids were of grade 0 (66.96%), followed by grade 1 (20.54%), and grade 2 (12.50%). The myomectomies were complete in 63.31% of the cases, and the factors independently associated with complete myomectomy were the diameter of the largest fibroid (prevalence ratio [PR]: 0.97; 95% confidence interval [95%CI]: 0.96-0.98) and the classification 0 of the fibroid according to the FIGO (PR: 2.04; 95%CI: 1.18-3.52). We observed early complications in 13.01% of the hysteroscopic procedures (4.44% presented excessive bleeding during the procedure, 4.14%, uterine perforation, 2.66%, false route, 1.78%, fluid overload, 0.59%, exploratory laparotomy, and 0.3%, postoperative infection). The only independent factor associated with the occurrence of early complications was incomplete myomectomy (PR: 2.77; 95%CI: 1.43-5.38). Conclusions Our results show that hysteroscopic myomectomy may result in up to 13% of complications, and the chance of complete resection is greater in small and completely intracavitary fibroids; women with larger fibroids and with a high degree of myometrial penetration have a greater chance of developing complications from hysteroscopic myomectomy.

Resumo Objetivo Avaliar os fatores associados a miomectomia por histeroscopia completa em um único procedimento e as suas complicações. Métodos Estudo de corte transversal com mulheres submetidas a histeroscopia para exérese de miomas submucosos. As variáveis dependentes foram a miomectomia completa realizada em um tempo cirúrgico único, e a presença de complicações precoces relacionadas ao procedimento. Resultados Analisamos 338 mulheres que foram submetidas a miomectomia histeroscópica. Em 89,05% dos casos, o mioma a ser tratado era único. Quanto à classificação da Federação Internacional de Ginecologia e Obstetrícia (Fédération Internationale de Gynécologie et d'Obstétrique, FIGO, em francês), a maioria era de grau 0 (66,96%), seguidos pelos graus 1 (20,54%) e 2 (12,50%). As miomectomias foram completas em 63,31% das mulheres, sendo que os fatores independentemente associados à miomectomia completa foram o diâmetro do maior mioma (razão de prevalência [RP]: 0,97; intervalo de confiança de 95% [IC95%]: 0,96-0,98) e a classificação FIGO grau 0 (RP: 2,04; IC95%: 1,18-3,52). Foram observadas complicações precoces em 13,01% dos procedimentos (4,44% apresentaram sangramento excessivo durante o procedimento, 4,14%, perfuração uterina, 2,66%, falso pertuito, 1,78%, intoxicação hídrica, 0,59%, laparotomia exploradora, e 0,3%, infecção pósoperatória). O único fator independentemente associado à ocorrência de complicações precoces foi a realização de miomectomia incompleta (RP: 2,77; IC95%: 1,43-5,38). Conclusão Nossos resultados mostram que as complicações da miomectomia por histeroscopia podem ocorrer em até 13% dos procedimentos. A chance de ressecção completa é maior em miomas pequenos e completamente intracavitários; mulheres com miomas maiores e com maior grau de penetração miometrial têm maiores chances de desenvolver complicações.

Tratamento endovascular da miomatose uterina: uma revisão sistemática / Endovascular treatment of uterine myomatosis: a systematic review

Resumo A embolização da artéria uterina (EAU) é um tratamento pouco invasivo e alternativo à cirurgia aberta no tratamento de miomatose uterina. Este estudo visa analisar a eficácia e a segurança da EAU nesses casos. Para isso, foi realizada uma revisão sistemática a partir de estudos disponíveis nas bases de dados MEDLINE/PubMed, LILACS e PEDro, via Biblioteca Virtual em Saúde. Foram encontrados 817 trabalhos; destes, 7 foram selecionados pelos critérios de elegibilidade (estudos analíticos, de corte longitudinal, retrospectivos ou prospectivos), totalizando 367 pacientes no estudo. As variáveis estudadas, bem como as características dos estudos incluídos, foram coletadas e armazenadas em um banco de dados. As taxas de redução do volume uterino e do mioma dominante foram 44,1% e 56,3%, respectivamente. A média do infarto completo do mioma dominante foi de 88,6% (82-100%). Quanto às complicações, a média obtida foi de 15±8,6 casos, sendo a maioria destas classificadas como menores, e nenhum óbito foi registrado. A média de reabordagem em valores absolutos foi de 12,2±15,5 casos. Portanto, a embolização da artéria uterina é um procedimento eficaz e com baixa taxa de complicações para o tratamento da leiomiomatose uterina na literatura analisada.

Abstract Uterine Artery Embolization (UAE) is a noninvasive alternative to open surgery for treatment of uterine myomatosis. This study aims to analyze the efficacy and safety of UAE in these cases. A systematic review was carried out of studies available on the Medline (via PubMed) and the LILACS and PEDro (via the Biblioteca Virtual em Saúde) databases. The searches found 817 studies, 7 of which were selected according to the eligibility criteria (analytical, longitudinal, retrospective, or prospective studies), with a total of 367 patients studied. The variables analyzed and the characteristics of the studies included were collated and input to a database. Rates of volume reduction of the uterus and the dominant myoma were 44.1% and 56.3%, respectively. Mean rate of complete infarction of the dominant myoma was 88.6% (82-100%). The mean number of complications observed was 15±8.6 cases, most of which were classified as minor, and no deaths were recorded. The mean number of re-interventions in absolute values was 12.2±15.5 cases. Therefore, in the literature analyzed, uterine artery embolization is an effective procedure with a low rate of complications for treatment of uterine leiomyomatosis.

Miomectomía durante el embarazo / Myomectomy during Pregnancy

Introducción: Los fibromas uterinos, también conocidos como miomas o leiomiomas son los tumores benignos más frecuentes de la porción superior del aparato genital femenino; pueden alcanzar gran tamaño y generalmente no requieren de tratamiento quirúrgico durante el embarazo. La prevalencia del mioma en el embarazo es desconocida. El manejo quirúrgico se reserva solo para los miomas complicados. Objetivo: Mostrar un caso al que se realizó la miomectomía de un gran fibroma suberoso sintomático coexistente con un embarazo de 21 semanas, debido a que no es frecuente su realización en la práctica médica. Presentación de caso: Paciente de 41 años, nulípara, de 21 semanas de gestación, con síntomas compresivos dados por vómitos, molestias digestivas e intolerancia al decúbito supino, afectada por un gran mioma, que fue sometida a miomectomía. La paciente evolucionó satisfactoriamente. Acudió a consultas prenatales cada 15 días hasta las 39,6 semanas, en que se le realizó la cesárea electiva obteniéndose un recién nacido de buen peso y Apgar. Conclusiones: La miomectomía durante el embarazo es un proceder quirúrgico seguro y eficiente con altas tasas de éxito. La discusión del caso es esencial y debe ser realizada por un equipo multidisciplinario, con experiencia probada en cirugía ginecológica(AU)

Introduction: Uterine fibroids, also known as myomas or leiomyomas are the most frequent benign tumors of the upper portion of the female genital tract. They can reach large size and generally do not require surgical treatment during pregnancy. The prevalence of myoma in pregnancy is unknown. Surgical management is reserved only for complicated myomas. Objective: To report a case in which the myomectomy was performed to a large symptomatic suberose fibroid coexisting with a 21-week pregnancy, which is not frequent in medical practice. Case report: A 41-year-old nulliparous patient, 21 weeks pregnant had compressive symptoms due to vomiting, digestive discomfort and intolerance to the supine position. She underwent myomectomy because she was affected by a large myoma. The patient evolved satisfactorily. She was followed up at prenatal consultations every 15 days until 39.6 weeks, when she had an elective caesarean section, resulting a newborn of good weight and Apgar. Conclusions: Myomectomy during pregnancy is a safe and efficient surgical procedure with high success rates. Case discussion is essential and should be carried out by a multidisciplinary team, with proven experience in gynecological surgery(AU)