Single incision robotic myomectomy: selection criteria, learning curve and cost.

The article "Comparison of operative and fertility outcomes of single-incision robotic myomectomy: a retrospective single-center analysis of 286 cases" by Kim et al. compares the effectiveness of robotic single-port myomectomy against the traditional multiport approach. The study finds similar operating outcomes, complication rates, and pregnancy rates in expert hands for both methods. Our systematic review supports these findings, revealing no significant differences in operative time, blood loss, or complication rates. Recent meta-analysis further emphasizes the benefits of the single-port approach in reducing morcellation time, overall operative duration, and blood loss. Our letter seeks insights on patient selection criteria to minimize conversion rates between surgical approaches and inquiries on learning curve differences. Additionally, we seek cost analysis details for both techniques. We appreciate the authors' valuable contributions to this field.

Laparoscopic continuous seromuscular circumsuture for myomectomy: a real-world, retrospective, East-Asian cohort study.

OBJECTIVE: This study aimed to introduce a novel laparoscopic haemostasis for myomectomy and investigate the independent risk factors for uterine fibroid recurrence. DESIGN: A retrospective cohort study. SETTING: Following strengthening the reporting of observational studies in epidemiology (STROBE) criteria, a retrospective study of prospectively collected available data of the consecutive patients who underwent the myomectomy in the department of obstetrics and gynaecology of the single centre between February 2018 and December 2020. PARTICIPANTS: 177 patients who underwent laparoscopic myomectomy resection were enrolled in the present cohort study. MATERIALS AND METHODS: Patients were classified into two groups according to their different methods of haemostasis in laparoscopic surgery. Recurrence-free survival was compared between the groups during an average follow-up of nearly 2 years. RESULTS: Of the 177 patients from 672 consecutive patients in the retrospective cohort, laparoscopic circular suture and baseball suture were carried out in 102 (57.6%) and 75 (42.4%) patients, respectively. The total amount of blood lost during surgery varied significantly (37.6 vs 99.5 mL) (p<0.001). Univariable analyses identified that age ≥40 years, position at intramural myoma, multiple fibroids and largest fibroid volume ≥50 mm3 (HR 2.222, 95% CI 1.376 to 3.977, p=0.039; HR 3.625, 95% CI 1.526 to 6.985, p=0.003; HR 3.139, 95% CI 1.651 to 5.968, p<0.001; HR 2.328, 95% CI 0.869 to 3.244, p=0.040, respectively) are independent risk factor of the recurrence of uterine fibroids. The formula of the nomogram prediction model was established as the practical clinical tool. CONCLUSION: The laparoscopic continuous seromuscular circumsuture for myomectomy can effectively reduce the amount of surgical bleeding and accelerate the perioperative recovery for surgical safety. The main factors affecting the recurrence of uterine fibroids were age, location, number and volume of uterine fibroids. The nomogram can more straightforwardly assist clinicians to determine the risk of recurrence after laparoscopic myomectomy.

Recurrence complicated with peritoneal dissemination after single-port gasless myomectomy for cellular uterine leiomyoma: A case report and literature review.

RATIONALE: Cellular uterine leiomyomas (CL) represent the prevailing subtype among uterine leiomyomas. In this study, we report a case of recurrent peritoneal disseminated uterine fibroids 2 years after single-port laparoscopic gasless myomectomy. This article endeavors to examine the potential limitations of the aforementioned surgical procedure and outline the distinguishing features of recurrent cases with primary postoperative pathology as CL. Additionally, it aims to provide a summary of previous retrospective studies on CL and propose the existence of immunohistochemical molecules that may serve as predictors for the postoperative recurrence of cellular uterine fibroids. The ultimate objective is to enhance clinicians' comprehension of the disease. PATIENT CONCERNS: Two years ago, the patient underwent a single-port gasless laparoscopic myomectomy for uterine fibroids. Gynecological color Doppler ultrasound conducted 3 months ago revealed recurrence of uterine fibroids, and the patient experienced abdominal distension, mild urinary frequency, and constipation for the past month. DIAGNOSES: After the second surgical procedure, a comprehensive pathological examination and immunohistochemical analysis of both the uterine mass and metastatic lesions revealed that the definitive diagnosis was CLs. INTERVENTIONS: The patient underwent the total hysterectomy, bilateral salpingectomy, pelvic adhesiolysis, omental mass resection, mesenteric mass resection, and pelvic peritoneal mass resection. All specimens were sent for rapid frozen examination and showed to be leiomyomas. OUTCOMES: The patient was discharged from the hospital on the 10th day after the operation. At the date of writing the article, the patient had no recurrence for 1 year and 5 months. LESSONS: The single-port gasless approach did not achieve the desired reduction in fibroid recurrence, as anticipated by the surgeon. The act of pulling the tumor towards the abdominal incision for resection, on the contrary, may serve as an iatrogenic factor contributing to postoperative recurrence of CL into peritoneal dissemination leiomyomatosis. The single-port gasless assisted bag may be a more suitable option for myomectomy. The utmost effort should be made to prevent the potential recurrence of myoma caused by iatrogenic factors.

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

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

Robot-assisted laparoscopic myomectomy: Technique & brief literature review.

The worldwide growth of robot-assisted laparoscopic surgery has been exponential since its FDA approval for use in gynecologic surgery in the spring of 2005. This growth has spanned the entire gamut of gynecologic procedures and pathology. One area that has leveraged the unique aspects of robotics has been its application to the conservative surgical management of uterine fibroids. This manuscript will review the surgical technique and highlight the current situation regarding the scientific literature with an evidence-based focus on the role of robot-assisted laparoscopic myomectomy (RALM) with the daVinci Surgical System (Intuitive Surgical, Sunnyvale, CA).

Adverse outcomes related to morcellation in Total Laparoscopic Hysterectomy.

OBJECTIVE: This study aimed to comprehensively evaluate the complications associated with morcellation in Total Laparoscopic Hysterectomy (TLH) procedures, providing evidence-based insights to enhance patient safety and surgical efficacy. DATA SOURCES: A comprehensive literature search was conducted using multiple databases, including PubMed, EMBASE, Google Scholar, and Cochrane Central Register of Controlled Trials. The inclusion criteria were Studies that focused on morcellation and morcellation-related complications were included. The risk of bias in the included studies was assessed using established evaluation scales. METHODS OF STUDY SELECTION: Thirteen studies investigating complications associated with morcellation in TLH (Total Laparoscopic Hysterectomy) were included in this review.This review covers intraoperative blood loss, length of hospital stay, loss of bag integrity, mean uterine specimen and weight, morcellation time, operation time, and TLH morcellation complications. TABULATION, INTEGRATION, AND RESULTS: The selected studies covered different approaches and aspects related to this procedure, providing valuable insights into the factors associated with complications and efficacy of the technique in various clinical settings.This review highlights the importance of evaluating and considering complications associated with morcellation in TLH. CONCLUSION: The findings of this review provide valuable insights into complications associated with morcellation in TLH. Clinicians could use this information to make informed decisions, implement safe protocols, and improve patient care. Addressing these complications will enhance the safety and efficacy of morcellation for TLH. Ethical Compliance: All procedures performed in this study involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

Pregnancy Outcomes After Laparoscopic Radiofrequency Ablation of Uterine Leiomyomas Compared With Myomectomy.

OBJECTIVE: To compare pregnancy outcomes after laparoscopic radiofrequency ablation and myomectomy. METHODS: The ULTRA (Uterine Leiomyoma Treatment With Radiofrequency Ablation) study is an ongoing multicenter prospective cohort study with longitudinal follow-up up to 5 years comparing outcomes of radiofrequency ablation with myomectomy in premenopausal women older than age 21 years with symptomatic uterine leiomyomas. Participants were queried every 6 months after surgery to assess the incidence of pregnancy and pregnancy outcomes. RESULTS: Among 539 women enrolled in ULTRA, a total of 37 participants (mean age at first pregnancy 35.0±4.7 years) conceived 43 times as of March 2023 (22 radiofrequency ablation, 21 myomectomy). The average length of follow-up time after all procedures was 2.5±1.0 years. The baseline miscarriage rate in the study population was 33.3%. In participants who underwent radiofrequency ablation, 9 of 22 pregnancies (40.9%, 95% CI, 20.3-61.5%) ended in first-trimester miscarriage, 11 resulted in live births (50.0%, 95% CI, 29.1-70.9%), one resulted fetal death at 30 weeks of gestation, and one resulted in uterine rupture during miscarriage treatment with misoprostol 10 weeks after radiofrequency ablation. Among the live births in the radiofrequency ablation group, 45.5% were by vaginal delivery. In the myomectomy group, 9 of 21 pregnancies (42.9%, 95% CI, 21.7-64.0%) ended in first-trimester miscarriage and 12 resulted in live births (57.1%, 95% CI, 36.0-78.3%). There were no significant differences in the likelihood of live birth or miscarriage between the study groups. CONCLUSION: Full-term pregnancy and vaginal delivery are achievable after radiofrequency ablation of leiomyomas. However, in this interim analysis, the miscarriage rate in both radiofrequency ablation and myomectomy groups was higher than expected for women in this age group. Long-term data collection in the ongoing ULTRA study aims to further understand pregnancy outcomes after radiofrequency ablation compared with myomectomy. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov , NCT0210094.

Antenatal myomectomy of huge pedunculated fibroid.

A female patient in her 20s presented at 10 weeks of pregnancy with abdominal pain. She was known to have a 17-cm fibroid a year ago, which, on repeat imaging, was found to have increased in size to 29 cm. A 12-cm increase in size over a year therefore led to concerns that it would increase in pregnancy, causing risk of thrombosis, decrease in venous return, miscarriage, fibroid torsion, fibroid necrosis, preterm labour and uterine rupture. Following a multidisciplinary team review with obstetricians, neonatologists, gynaecologists and radiologists, the patient opted to proceed with an open myomectomy at 14 weeks gestation, which was performed successfully. The pregnancy continued uneventfully until term when she delivered a healthy girl infant at 38+2 weeks via an elective caesarean section.

Prognostic and reproductive outcomes in women who had uterine myomas removed during cesarean section and sutured using different techniques.

BACKGROUND: In this study, the prognostic and reproductive outcomes of women who underwent excision of uterine myomas and were sutured using different techniques while undergoing a cesarean section were investigated. METHODS: A total of 299 females who underwent cesarean section between January 2015 and June 2022 due to a scarred uterus were enrolled in this study. These participants were segregated into two categories: the experimental group (comprising 155 cases) in which uterine myoma (single lesion) was excised during the cesarean procedure, and the control group (consisting of 144 cases) in which only the cesarean section was conducted. A comparison between the two groups was carried out based on the following parameters: volume of intraoperative bleeding (mL), additional measures taken for intraoperative hemostasis (n, %), percentage (%) of patients experiencing postoperative fever, duration required for the passage of gas (hours [h]), length of hospital stay (days [d]), weight of newborns (kg) and their Apgar scores, and the reproductive outcomes of the experimental group assessed two years after the surgical procedure. RESULTS: In the experimental group, the amount of bleeding during surgery, occurrence of postoperative fever among women, time taken for patients to resume passing gas, and length of hospital stay were 540.65 ± 269.12 mL, 9.03%, 15.99 ± 4.68 h, and 5.08 ± 1.18 days, respectively. In contrast, the control group had values of 409.03 ± 93.24 mL, 2.77%, 16.24 ± 4.92, and 4.47 ± 0.70 days, respectively (P < 0.05). No notable increase was observed in the need for additional intraoperative hemostasis measures, and there was no significant difference in the time it took for patients to pass gas after the surgery. All newborns had positive health status. In the experimental group, 25 patients underwent subsequent pregnancies, and 15 of them successfully reached full-term deliveries, all of which had positive outcomes. CONCLUSION: Combining myomectomy with various suture methods during cesarean delivery did not cause excessive bleeding and resulted in healthy newborns. This approach offers the advantage of avoiding additional surgeries under anesthesia and can be considered a viable option. Subsequent pregnancies after myomectomy were considered high-risk.

C-section technique vs minilaparotomy after minimally invasive uterine surgery: a retrospective cohort study.

PURPOSE: Uterine leiomyomas are benign uterine tumors. The choice of surgical treatment is guided by patient's age, desire to preserve fertility or avoid "radical" surgical interventions such as hysterectomy. In laparotomy, the issue of extracting the fibroid from the cavity does not arise. However, in laparoscopy and robotic surgery, this becomes a challenge. The aim of the present study was to determine the optimal surgical approach for fibroid extraction following laparoscopic or robotic myomectomy in terms of postoperative pain, extraction time, overall surgical time, scar size, and patient satisfaction. METHODS: A total of 51 patients met the inclusion criteria and were considered in our analysis: 33 patients who had undergone the "ExCITE technique" (Group A), and 18 patients a minilaparotomy procedure (Group B), after either simple myomectomy, multiple myomectomy, supracervical hysterectomy, or total hysterectomy. The diagnosis of myoma was histologically confirmed in all cases. RESULTS: Regarding the postoperative pain evaluation, at 6 h, patients reported 4 [3-4] vs 6 [5.3-7] on the VAS in Group A and B, as well as at 12 h, 2 [0-2] vs 3.5 [2.3-4] in Group A and B, respectively: both differences were statistically significant (p < 0.001). No statistically significant difference at 24 h from surgery was found. All patients in Group A were satisfied with the ExCITE technique, while in Group B only 67% of them. The length of the hospital stay was significantly shorter in Group A as compared to Group B (p = 0.007). In terms of the operative time for the extraction of the surgical specimen, overall operative time, and the scar size after the surgery, there was a statistically significant difference for those in Group A. CONCLUSION: The ExCITE technique does not require specific training and allows the surgeon to offer a minimally invasive surgical option for patients, with also an aesthetic result. It is a safe and standardized approach that ensures tissue extraction without the need for mechanical morcellation.

Perioperative and reproductive outcomes' comparison of mini-laparotomy and laparoscopic myomectomy in the management of uterine leiomyomas: a systematic review.

OBJECTIVE: To evaluate and compare mini-laparotomy (MLPT) with laparoscopic (LPS) myomectomy perioperative and reproductive outcomes. METHODS: We systematically searched for related articles in the MEDLINE, Embase, Web of Science and the Cochrane library databases. Nine studies (4 randomized, 3 retrospective, 1 prospective and 1 case-control study) which involved 1723 patients met the inclusion criteria and were considered eligible for inclusion. RESULTS: Demographic characteristics were similar between the two groups. LPS was associated with shorter hospital stay (p = 0.04), lower blood loss (p < 0.00001), shorter duration of median ileus (p < 0.00001) and fewer episodes of postoperative fever (p = 0.04). None of the reproductive factors examined (pregnancy rate, preterm delivery, vaginal delivery and delivery with caesarean section) in women diagnosed with unexplained infertility and/or symptomatic leiomyomas reached statistical significance although the results represent a small size effect. CONCLUSION: Our analysis demonstrated that LPS seems to be an alternative, safe and reliable surgical procedure for uterine leiomyoma treatment and in everyday practice seems to offer improved outcomes-regarding at least the perioperative period-over MLPT.

Efficacy and safety of V-Loc™ barbed sutures versus conventional suture techniques in gynecological surgery: a systematic review and meta-analysis.

PURPOSE: One of the most challenging tasks in laparoscopic gynecological surgeries is suturing. Knotless barbed sutures are intended to enable faster suturing and hemostasis. We carried out a meta-analysis to compare the efficacy and safety of V-Loc™ barbed sutures (VBS) with conventional sutures (CS) in gynecological surgeries. METHODS: We systematically searched PubMed and EMBASE for studies published between 2010 and September 2021 comparing VBS to CS for OB/GYN procedures. All comparative studies were included. Primary analysis and subgroup analyses for the different surgery and suturing types were performed. Primary outcomes were operation time and suture time; secondary outcomes included post-operative complications, surgical site infections, estimated blood loss, length of stay, granulation tissue formation, and surgical difficulty. Results were calculated as weighted mean difference (WMD) or risk ratio (RR) and 95% confidence intervals (CI) with a random effects model, and a sensitivity analysis for study quality, study size, and outlier results was performed. PROSPERO registration: CRD42022363187. RESULTS: In total, 25 studies involving 4452 women undergoing hysterectomy, myomectomy, or excision of endometrioma. VBS were associated with a reduction in operation time (WMD - 17.08 min; 95% CI - 21.57, - 12.59), suture time (WMD - 5.39 min; 95% CI - 7.06, - 3.71), surgical site infection (RR 0.26; 95% CI 0.09, 0.78), estimated blood loss (WMD - 44.91 ml; 95% CI - 66.01, - 23.81), granulation tissue formation (RR 0.48; 95% CI 0.25, 0.89), and surgical difficulty (WMD - 1.98 VAS score; 95% CI - 2.83, - 1.13). No difference between VBS and CS was found regarding total postoperative complications or length of stay. Many of the outcomes showed high heterogeneity, likely due to the inclusion of different surgery types and comparators. Most results were shown to be robust in the sensitivity analysis except for the reduction in granulation tissue formation. CONCLUSION: This meta-analysis indicates that V-Loc™ barbed sutures are safe and effective in gynecological surgeries as they reduce operation time, suture time, blood loss, infections, and surgical difficulty without increasing post-operative complications or length of stay compared to conventional sutures.

Postoperative results of myomectomy performed during caesarean section in a tertiary care center. A retrospective study.

AIM: The aim of this study was to assess the postoperative results of patients who underwent myomectomy during caesarean section in a tertiary center, to investigate whether cesarean myomectomy leads to increased morbidity and to contribute to the literature. MATERIALS AND METHODS: This study was designed retrospectively and conducted to compare the preoperative and postoperative results of 121 patients who underwent myomectomy during cesarean and 149 patients who had only cesarean section in a tertiary center between 1.1.2020-1.1.2022. RESULTS: Although the study did not show a significant prolongation in terms of operative time, a significant relationship was found in the length of hospital stay. Hemoglobin levels after myomectomy were significantly lower than the group without myomectomy in the study. Additionally, preterm delivery rate was higher in the myomectomy group. CONCLUSION: As this study showed us a significant decrease in hemoglobin levels after cesarean and myomectomy, it is appropriate to perform this operation, when necessary, by experienced surgeons and in tertiary centers. KEY WORDS: Cesarean section, Myomectomy, Myomectomy during cesarean section.

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.

Procedural sedation and analgesia versus general anesthesia for hysteroscopic myomectomy (PROSECCO trial): A multicenter randomized controlled trial.

BACKGROUND: Hysteroscopic resection is the first-choice treatment for symptomatic type 0 and 1 fibroids. Traditionally, this was performed under general anesthesia. Over the last decade, surgical procedures are increasingly being performed in an outpatient setting under procedural sedation and analgesia. However, studies evaluating safety and effectiveness of hysteroscopic myomectomy under procedural sedation are lacking. This study aims to investigate whether hysteroscopic myomectomy under procedural sedation and analgesia with propofol is noninferior to hysteroscopic myomectomy under general anesthesia. METHODS AND FINDINGS: This was a multicenter, randomized controlled noninferiority trial conducted in 14 university and teaching hospitals in the Netherlands between 2016 and 2021. Inclusion criteria were age ≥18 years, maximum number of 3 type 0 or 1 fibroids, maximum fibroid diameter 3.5 cm, American Society of Anesthesiologists class 1 or 2, and having sufficient knowledge of the Dutch or English language. Women with clotting disorders or with severe anemia (Hb < 5.0 mmol/L) were excluded. Women were randomized using block randomization with variable block sizes of 2, 4, and 6, between hysteroscopic myomectomy under procedural sedation and analgesia (PSA) with propofol or under general anesthesia (GA). Primary outcome was the percentage of complete resections, assessed on transvaginal ultrasonography 6 weeks postoperatively by a sonographer blinded for the treatment arm and surgical outcome. Secondary outcomes were the surgeon's judgment of completeness of procedure, menstrual blood loss, uterine fibroid related and general quality of life, pain, recovery, hospitalization, complications, and surgical reinterventions. Follow-up period was 1 year. The risk difference between both treatment arms was estimated, and a Farrington-Manning test was used to determine the p-value for noninferiority (noninferiority margin 7.5% of incomplete resections). Data were analyzed according to the intention-to-treat principle, including a per-protocol analysis for the primary outcome. A total of 209 women participated in the study and underwent hysteroscopic myomectomy with PSA (n = 106) or GA (n = 103). Mean age was 45.1 [SD 6.4] years in the PSA group versus 45.0 [7.7] years in the GA group. For 98/106 women in the PSA group and 89/103 women in the GA group, data were available for analysis of the primary outcome. Hysteroscopic resection was complete in 86/98 women (87.8%) in the PSA group and 79/89 women (88.8%) in the GA group (risk difference -1.01%; 95% confidence interval (CI) -10.36 to 8.34; noninferiority, P = 0.09). No serious anesthesiologic complications occurred, and conversion from PSA to GA was not required. During the follow-up period, 15 serious adverse events occurred (overnight admissions). All were unrelated to the intervention studied. Main limitations were the choice of primary outcome and the fact that our study proved to be underpowered. CONCLUSIONS: Noninferiority of PSA for completeness of resection was not shown, though there were no significant differences in clinical outcomes and quality of life. In this study, hysteroscopic myomectomy for type 0 and 1 fibroids with PSA compared to GA was safe and led to shorter hospitalization. These results can be used for counseling patients by gynecologists and anesthesiologists. Based on these findings, we suggest that hysteroscopic myomectomies can be performed under PSA in an outpatient setting. TRIAL REGISTRATION: The study was registered prospectively in the Dutch Trial Register (NTR 5357; registration date: 11 August 2015; Date of initial participant enrollment: 18 February 2016).

Racial disparities between measures of area deprivation and financial toxicity, and uterine volume in myomectomy patients.

BACKGROUND: At time of myomectomy, a surgical procedure to remove uterine fibroids, Black women tend to have larger uteri than White women. This makes Black patients less likely to undergo a minimally invasive myomectomy which has been shown to have less postoperative pain, less frequent postoperative fever and shorter length of stay compared to abdominal myomectomies. The associations between individual financial toxicity and community area deprivation and uterine volume at the time of myomectomy have not been investigated. METHODS: We conducted a secondary data analysis of patients with fibroids scheduled for myomectomy using data from a fibroid treatment registry in [location]. We used validated measures of individual-level Financial Toxicity (higher scores = better financial status) and community-level Area Deprivation (ADI, high scores = worse deprivation). To examine associations with log transformed uterine volume, we used linear regression clustered on race (Black vs. White). RESULTS: Black participants had worse financial toxicity, greater deprivation and larger uterine volumes compared with White participants. A greater Financial Toxicity score (better financial status) was associated with lower uterine volume. For every 10 unit increase in Financial Toxicity, the mean total uterine volume decreased by 9.95% (Confidence Interval [CI]: -9.95%, -3.99%). ADI was also associated with uterine volume. A single unit increase in ADI (worse deprivation) was associated with a 5.13% (CI: 2.02%, 7.25%) increase in mean uterine volume. CONCLUSION: Disproportionately worse Financial Toxicity and ADI among Black patients is likely due to structural racism - which now must be considered in gynecologic research and practice. TRIAL REGISTRATION: Not applicable.

Surgical techniques for mini-laparotomy myomectomy.

CONTEXT AND BACKGROUND: The prevalence of uterine fibroids is estimated to be approximately 80%. Fibroids can be associated with abnormal uterine bleeding, pressure symptoms, and infertility. Given this high prevalence, approximately 30,000 myomectomies are performed in the United States per year. Minimally invasive approaches are preferred, if feasible. The minimally invasive techniques include laparoscopic, robot-assisted, hysteroscopic, and mini-laparotomy. OBJECTIVE: To discuss the multiple techniques for optimizing the use of mini-laparotomy in minimally invasive myomectomy. DESIGN: We use intraoperative surgical video to demonstrate techniques that optimize the use of the mini-laparotomy for myomectomy. SETTING: Cleveland Clinic. PATIENT(S): Patient's undergoing fertility preserving, minimally invasive myomectomy at the Cleveland Clinic. The patient(s) included in this video gave consent for publication of the video and posting of the video online, including social media, the journal website, scientific literature websites (such as PubMed, ScienceDirect, and Scopus), and other applicable sites. INTERVENTION(S): After the surgeon has selected to proceed with mini-laparotomy myomectomy, different techniques can be employed to optimize management. We demonstrate and discuss these techniques to ensure that surgeons have a set of tools to tackle a fibroid uterus. These techniques include direct palpation of the fibroids, use of a uterine manipulator to visualize the endometrial cavity, use of the uterine manipulator to aid in repair of the cavity if entered, suturing technique that avoids the endometrial cavity and therefore limits foreign body exposure and decreases intrauterine adhesion formation, utilization of barbed suture in a layered fashion, in-situ debulking to avoid injury to fallopian tubes and other critical uterine structures, easy identification of the optimal enucleation plane, use of single hysterotomy for multiple fibroids, visualization of the "Tortuga" sign, and evaluation of the abdominal cavity using the mini-laparotomy site as a port site. To limit postoperative adhesion formation, the investigators place cellulose-based adhesion barriers with peritoneum closure. Although the need for prolonged postoperative observation can be made on a case-by-case basis, we consider this as an outpatient surgery and anticipate same-day discharge for our patients. MAIN OUTCOME MEASURE(S): In this video, we perform a mini-laparotomy myomectomy optimally and describe the techniques employed. RESULT(S): Specific techniques employed in mini-laparotomy myomectomy make the case safe, effective, and can lead to same-day discharge. CONCLUSION(S): Mini-laparotomy myomectomy is a technique used to perform minimally invasive myomectomy. Following the discussed steps, surgeons can be more confident in performing this method of myomectomy.

Application of single-port procedure and ERAS management in the laparoscopic myomectomy.

OBJECTIVE: Advances in surgical techniques and perioperative management are the two major contributing factors to improved surgical outcomes. The purpose of the current study was to compare the efficacy of single-port surgery and perioperative enhanced recovery after surgery (ERAS) management in laparoscopic myomectomy. METHODS: The present study included 120 patients undergoing laparoscopic myomectomy in the Gynecological Ward of Quzhou Affiliated Hospital of Wenzhou Medical University. According to the traditional perioperative management mode and ERAS management, multi-port and single-port procedures, all patients were assigned to the Conventional-SPLS (Single-Port Laparoscopic Surgery with conventional perioperative care) group (n = 34), Conventional-Multi (multi-port laparoscopic surgery with conventional perioperative care) group (n = 47), and ERAS (multi-port laparoscopic surgery with ERAS perioperative care) group (n = 39). The surgical outcomes of the three groups were compared operation time, intraoperative blood loss, variations in postoperative hemoglobin, postoperative walking time, postoperative flatus expelling time, postoperative hospital stay, and visual analog scale (VAS) scores at 6 and 12 h following surgery. RESULTS: The ERAS group recovered the quickest in terms of postoperative walking time and flatus expelling duration. The ERAS group also recovered the shortest postoperative hospital stay (3.85 ± 1.14 days), which differed significantly from that in the Conventional-Multi group, but not significantly from that in the Conventional-SPLS group. In terms of VAS scores at 6 and 12 h after surgery, the ERAS group had the lowest pain intensity, which differed significantly from that of the other two groups. The effect of surgical procedures or postoperative care on hospital stay was assessed using multiple regression analysis. The results demonstrated that ERAS was an important independent contributor to reducing postoperative hospital stay (ß = 0.270, p = 0.002), while single-port surgery did not affect this index (ß = 0.107, p = 0.278). CONCLUSION: In laparoscopic myomectomy, perioperative ERAS management could control postoperative pain and shorten hospital stay. Single-port surgery could speed up the recovery of gastrointestinal function and postoperative walking time, but it did not affect postoperative pain management or the length of hospital stay. Thus, the most effective approach to improving postoperative outcomes in laparoscopic myomectomy was the application of perioperative ERAS management.

Risk of leakage with a new detachable multi-hard-port containment system for power morcellation during gynecologic laparoscopy: An in vitro study.

BACKGROUND: Laparoscopic surgery has been a milestone for minimally invasive surgeries. But safe removal of large uterine tissue is a challenge for minimally invasive procedures, and there still exists concern about the dissemination of benign or occult malignant uterine tissue during the use of the morcellator. Different tissue containment systems have been used in laparoscopic power morcellation. However, a risk of leakage still exists in clinical practice. In this study, we aimed to evaluate leakage and tissue dissemination associated with a new detachable multi-hard-port containment system for tissue removal during laparoscopic myomectomy morcellation. METHODS: Beef tongue specimens were stained with methylene blue solution and morcellated in a plastic trainer box under laparoscopic guidance. The morcellation test in vitro conditions comprised two different containment systems to simulate laparoscopic power morcellation, specifically a polyurethane bag with two pipes (control group) and a detachable multi-hard-port containment system (experimental group). Insufflation pressure was set at 14 mmHg. Three methods are used to detect the leakage The procedure times were recorded. Thirty trials were performed using a multi-port approach and the two tissue containment systems. RESULTS: The leakage rate was 0.03% (n = 30) for the experimental group and 26.6% (n = 30) for the control group (p < 0.005). Morcellation time was significantly shorter in the experimental group than in the control group (p < 0.001). Median bag introduction time was shorter in the experimental group than in the control group; however, removal time differences were not significant. CONCLUSIONS: This study quantified the low leakage rate during morcellation and the improved convenience of operation provided by a new tissue containment system.

Efficacy and safety of robot-assisted laparoscopic myomectomy versus laparoscopic myomectomy: a systematic evaluation and meta-analysis.

OBJECTIVE: Systematic evaluation of the efficacy and safety of robotic-assisted laparoscopic myomectomy (RALM) versus laparoscopic myomectomy (LM). METHODS: PubMed, Embase, The Cochrane Library, and Web of Science database were searched by computer to seek relevant literature in order to compare the efficacy and safety of RALM with that of LM from the establishment of the databases to January 2023, and Review Manager 5.4 software was utilized to perform a meta-analysis on the literature. RESULTS: A total of 15 retrospective clinical controlled studies were included. There exists a total of 45,702 patients, among 11,618 patients in the RALM group and the remaining 34,084 patients in the LM group. Meta-analysis results revealed that RALM was associated with lesser intraoperative bleeding (MD = - 32.03, 95%CI - 57.24 to - 6.83, P = 0.01), lower incidence of blood transfusions (OR = 0.86, 95%CI 0.77 to 0.97, P = 0.01), shorter postoperative hospital stay (MD = - 0.11, 95%CI - 0.21 to - 0.01, P = 0.03), fewer transitions to open stomach (OR = 0.82, 95%CI 0.73 to 0.92, P = 0.0006), and lower incidence of postoperative complications (OR = 0.58, 95%CI 0.40 to 0.86, P = 0.006) than LM, whereas LM is more advantageous in terms of operative time (MD = 38.61, 95%CI 19.36 to 57.86, P < 0.0001). There was no statistical difference between the two surgical methods in terms of maximum myoma diameter (MD = 0.26, 95%CI - 0.17 to 0.70, P = 0.24). CONCLUSION: In the aspects of intraoperative bleeding, lower incidence of blood transfusions, postoperative hospital stay, transit open stomach rate, and postoperative complications, RALM has a unique advantage than that of LM, while LM has advantages over RALM in terms of operative time.