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1.
Niger J Clin Pract ; 23(11): 1523-1529, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-33221776

RESUMO

Background: Acute postoperative pain after myomectomy can impair patient function. Like all other postoperative pain, it is a challenge requiring solution, particularly in developing countries. Ultrasound-guided transversus abdominis plane (TAP) block and wound infiltration (WI) are both known to be effective in managing postoperative pain. It is not certain if transversus abdominis plain block would be superior to wound infiltration. Aims: It was hypothesized that the TAP block has similar analgesic effectiveness to wound infiltration. Subjects and Methods: This study was a randomized controlled trial involving, seventy-four (74) patients scheduled for myomectomy at the University of Benin Teaching Hospital Benin City, Nigeria under the subarachnoid block, which were randomized into TAP and WI group preoperatively. The ultrasound-guided bilateral TAP block group and wound infiltration group (subfascial and subcutaneous infiltration) each used 40 mL of 0.25% of plain bupivacaine to achieve postoperative analgesia. The time to first analgesic request, numerical pain rating scale (NRS) score at rest, and movement were assessed. Data were analyzed using SPSS version 16 (Chicago Il, USA). Results: The time to first analgesic request was significantly delayed in the TAP block group compared to the wound infiltration group [240 (131, 375) min vs 170 (128, 187) minutes. P = 0.006]. The proportions of patients with NRS score ≤3 at the time of first analgesic requests were significantly more in the TAP block group (P < 0.001). The analgesic consumed by the TAP block group was significantly low compared to the WI group. There were no incidences of complications due to TAP block or wound infiltration. Conclusion: TAP block provided a longer duration of analgesia and a clinically superior quality of analgesia to wound infiltration.


Assuntos
Analgesia/métodos , Bupivacaína/administração & dosagem , Bloqueio Nervoso/métodos , Dor Pós-Operatória/prevenção & controle , Ultrassonografia de Intervenção , Miomectomia Uterina/efeitos adversos , Músculos Abdominais/diagnóstico por imagem , Músculos Abdominais/inervação , Adulto , Anestésicos Locais/administração & dosagem , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Bloqueio Nervoso/efeitos adversos , Nigéria , Manejo da Dor , Medição da Dor , Dor Pós-Operatória/etiologia , Resultado do Tratamento , Ultrassonografia/efeitos adversos , Adulto Jovem
2.
Anesth Analg ; 131(5): 1599-1606, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-33079884

RESUMO

BACKGROUND: Oxycodone has been shown to be an effective analgesic for early postoperative analgesia, especially for abdominal operations associated with severe visceral pain. However, the dose needed varies depending on the operation and application of multimodal analgesia, such as local ropivacaine wound infiltration. Therefore, we conducted this study to estimate the median effective dose (ED50) of oxycodone that provides analgesia for hysterectomy and myomectomy with local ropivacaine wound infiltration. METHODS: In this dose-finding study, the ED50 of oxycodone for postoperative analgesia was estimated separately for laparoscopic hysterectomy, transabdominal hysterectomy, laparoscopic myomectomy, and transabdominal myomectomy. We used the sequential allocation designed by Dixon. Trials were conducted simultaneously in the 4 surgical type groups. A predefined dose of oxycodone was injected 30 minutes before the end of the operation with an initial dose of 0.1 mg/kg. A series of trials were performed following the rule of a relative 10% increase in dose after inadequate analgesia and a relative 10% decrease in dose after adequate analgesia. The study was conducted until the collection of 7 crossover points was achieved. Local ropivacaine wound infiltration was administered during abdominal stitching. The mean blood pressure (MBP) and heart rate (HR) were analyzed to assess the hemodynamic changes associated with oxycodone administration. RESULTS: A total of 113 patients were included in the estimation of ED50: 28 each in the laparoscopic hysterectomy group and transabdominal myomectomy group, 27 in the transabdominal hysterectomy group, and 30 in the laparoscopic myomectomy group. The estimated oxycodone ED50 (95% confidence interval [CI]) after laparoscopic hysterectomy, transabdominal hysterectomy, laparoscopic myomectomy, and transabdominal myomectomy was 0.060 mg/kg (0.053-0.068), 0.079 mg/kg (0.072-0.086), 0.060 mg/kg (0.051-0.071), and 0.092 mg/kg (0.086-0.098), respectively, for postoperative analgesia with local ropivacaine wound infiltration. The ED50 of oxycodone was different between laparoscopic surgeries and transabdominal surgeries (P < .001). The MBP and HR before and after oxycodone injection were different, regardless of surgical type. CONCLUSIONS: The oxycodone ED50 for postoperative analgesia was lower for laparoscopic hysterectomy (0.060 mg/kg) and laparoscopic myomectomy (0.060 mg/kg) than for transabdominal hysterectomy (0.079 mg/kg) and transabdominal myomectomy (0.092 mg/kg) when combined with local ropivacaine wound infiltration. A single intravenous injection of oxycodone is associated with an acceptable decrease in MBP and HR within a short time.


Assuntos
Analgésicos Opioides/administração & dosagem , Analgésicos Opioides/uso terapêutico , Anestésicos Locais/uso terapêutico , Histerectomia/efeitos adversos , Oxicodona/administração & dosagem , Oxicodona/uso terapêutico , Dor Pós-Operatória/tratamento farmacológico , Ropivacaina/uso terapêutico , Miomectomia Uterina/efeitos adversos , Adulto , Anestesia Local , Anestésicos Locais/administração & dosagem , Pressão Sanguínea/efeitos dos fármacos , Relação Dose-Resposta a Droga , Método Duplo-Cego , Feminino , Frequência Cardíaca/efeitos dos fármacos , Humanos , Injeções Intravenosas , Laparoscopia , Pessoa de Meia-Idade , Medição da Dor , Estudos Prospectivos , Ropivacaina/administração & dosagem
4.
J Vasc Interv Radiol ; 31(10): 1552-1559.e1, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32917502

RESUMO

PURPOSE: To conduct a population-level analysis of surgical and endovascular interventions for symptomatic uterine leiomyomata by using administrative data from outpatient medical encounters. MATERIALS AND METHODS: By using administrative data from all outpatient hospital encounters in California (2005-2011) and Florida (2005-2014), all patients in the outpatient setting with symptomatic uterine leiomyomata were identified. Patients were categorized as undergoing hysterectomy, myomectomy, uterine artery embolization (UAE), or no intervention. Hospital stay durations and costs were recorded for each encounter. RESULTS: A total of 227,489 patients with uterine leiomyomata were included, among whom 39.9% (n = 90,800) underwent an intervention, including hysterectomy (73%), myomectomy (19%), or UAE (8%). The proportion of patients undergoing hysterectomy increased over time (2005, hysterectomy, 53.2%; myomectomy, 26.9%; UAE, 18.0%; vs 2013, hysterectomy, 80.1%; myomectomy, 14.4%; UAE, 4.0%). Hysterectomy was eventually performed in 3.5% of patients who underwent UAE and 4.1% who underwent myomectomy. Mean length of stay following hysterectomy was significantly longer (0.5 d) vs myomectomy (0.2 d) and UAE (0.3 d; P < .001 for both). The mean encounter cost for UAE ($3,772) was significantly less than those for hysterectomy ($5,409; P < .001) and myomectomy ($6,318; P < .001). Of the 7,189 patients who underwent UAE during the study period, 3.5% underwent subsequent hysterectomy. CONCLUSIONS: The proportion of women treated with hysterectomy in the outpatient setting has increased since 2005. As a lower-cost alternative with a low rate of conversion to hysterectomy, UAE may be an underutilized treatment option for patients with uterine leiomyomata.


Assuntos
Procedimentos Endovasculares/tendências , Histerectomia/tendências , Leiomioma/terapia , Padrões de Prática Médica/tendências , Embolização da Artéria Uterina/tendências , Miomectomia Uterina/tendências , Neoplasias Uterinas/terapia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , California , Redução de Custos , Análise Custo-Benefício , Bases de Dados Factuais , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/economia , Feminino , Florida , Custos Hospitalares/tendências , Humanos , Histerectomia/efeitos adversos , Histerectomia/economia , Leiomioma/economia , Tempo de Internação , Pessoa de Meia-Idade , Saúde da População , Complicações Pós-Operatórias/etiologia , Padrões de Prática Médica/economia , Estudos Retrospectivos , Fatores de Tempo , Resultado do Tratamento , Embolização da Artéria Uterina/efeitos adversos , Embolização da Artéria Uterina/economia , Miomectomia Uterina/efeitos adversos , Miomectomia Uterina/economia , Neoplasias Uterinas/economia , Adulto Jovem
5.
N Engl J Med ; 383(5): 440-451, 2020 07 30.
Artigo em Inglês | MEDLINE | ID: mdl-32726530

RESUMO

BACKGROUND: Uterine fibroids, the most common type of tumor among women of reproductive age, are associated with heavy menstrual bleeding, abdominal discomfort, subfertility, and a reduced quality of life. For women who wish to preserve their uterus and who have not had a response to medical treatment, myomectomy and uterine-artery embolization are therapeutic options. METHODS: We conducted a multicenter, randomized, open-label trial to evaluate myomectomy, as compared with uterine-artery embolization, in women who had symptomatic uterine fibroids and did not want to undergo hysterectomy. Procedural options included open abdominal, laparoscopic, or hysteroscopic myomectomy. The primary outcome was fibroid-related quality of life, as assessed by the score on the health-related quality-of-life domain of the Uterine Fibroid Symptom and Quality of Life (UFS-QOL) questionnaire (scores range from 0 to 100, with higher scores indicating a better quality of life) at 2 years; adjustment was made for the baseline score. RESULTS: A total of 254 women, recruited at 29 hospitals in the United Kingdom, were randomly assigned: 127 to the myomectomy group (of whom 105 underwent myomectomy) and 127 to the uterine-artery embolization group (of whom 98 underwent embolization). Data on the primary outcome were available for 206 women (81%). In the intention-to-treat analysis, the mean (±SD) score on the health-related quality-of-life domain of the UFS-QOL questionnaire at 2 years was 84.6±21.5 in the myomectomy group and 80.0±22.0 in the uterine-artery embolization group (mean adjusted difference with complete case analysis, 8.0 points; 95% confidence interval [CI], 1.8 to 14.1; P = 0.01; mean adjusted difference with missing responses imputed, 6.5 points; 95% CI, 1.1 to 11.9). Perioperative and postoperative complications from all initial procedures, irrespective of adherence to the assigned procedure, occurred in 29% of the women in the myomectomy group and in 24% of the women in the uterine-artery embolization group. CONCLUSIONS: Among women with symptomatic uterine fibroids, those who underwent myomectomy had a better fibroid-related quality of life at 2 years than those who underwent uterine-artery embolization. (Funded by the National Institute for Health Research Health Technology Assessment program; FEMME Current Controlled Trials number, ISRCTN70772394.).


Assuntos
Leiomioma/cirurgia , Qualidade de Vida , Embolização da Artéria Uterina , Miomectomia Uterina , Neoplasias Uterinas/cirurgia , Adulto , Feminino , Humanos , Histeroscopia , Análise de Intenção de Tratamento , Complicações Intraoperatórias , Laparoscopia , Leiomioma/terapia , Tempo de Internação , Menorragia , Pessoa de Meia-Idade , Reserva Ovariana , Complicações Pós-Operatórias , Reoperação/estatística & dados numéricos , Embolização da Artéria Uterina/efeitos adversos , Miomectomia Uterina/efeitos adversos , Miomectomia Uterina/métodos , Neoplasias Uterinas/terapia , Útero/cirurgia
6.
J Ayub Med Coll Abbottabad ; 32(2): 198-203, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32583994

RESUMO

BACKGROUND: Uterine myomas are most common non-cancerous tumours in reproductive period. The fertility preserving surgery, i.e., myomectomy as compared to hysterectomy, is associated with massive blood loss due to dissection of huge fibroids making it technically difficult procedure. Misoprostol (a uterotonic) is an effective option amongst different interventions used to reduce intraoperative blood loss during myomectomy. This randomized control trial investigated effectiveness of single dose of rectal misoprostol given preoperatively in reducing intraoperative blood loss during abdominal myomectomy.. METHODS: Fifty Patients undergoing abdominal myomectomy were selected for the study. Twenty-five patients were given 800 micrograms misoprostol per rectally half an hour before surgery while rest received placebo, i.e., control group. Number and weight of surgical packs were recorded both Pre and post operatively to assess blood loss. Preoperative and 24 hrs postoperative haemoglobin was also recorded. Data analysed by SPSS-20. RESULTS: Mean of age, parity and myoma size were not statistically different between the two groups. However intraoperative blood loss (as measured by weighing and counting number of swabs used) and postoperative haemoglobin after 24 hours were significantly different between two groups with p-value <0.01. CONCLUSIONS: Single dose of misoprostol given preoperatively via rectal route is effective in reducing intraoperative blood loss during abdominal myomectomy. Misoprostol must be used in different doses and routes in order to investigate its effectiveness in reducing intraoperative blood loss.


Assuntos
Perda Sanguínea Cirúrgica/prevenção & controle , Misoprostol/uso terapêutico , Ocitócicos/uso terapêutico , Miomectomia Uterina/efeitos adversos , Feminino , Humanos , Histerectomia/efeitos adversos , Misoprostol/administração & dosagem , Ocitócicos/administração & dosagem
7.
Cochrane Database Syst Rev ; 5: CD013352, 2020 May 06.
Artigo em Inglês | MEDLINE | ID: mdl-32374421

RESUMO

BACKGROUND: Uterine leiomyomas, also referred to as myomas or fibroids, are benign tumours arising from the smooth muscle cells of the myometrium. They are the most common pelvic tumour in women. The estimated rate of leiomyosarcoma, found during surgery for presumed benign leiomyomas, is about 0.51 per 1000 procedures, or approximately 1 in 2000. Treatment options for symptomatic uterine leiomyomas include medical, surgical, and radiologically-guided interventions. Laparoscopic myomectomy is the gold standard surgical approach for women who want offspring, or otherwise wish to retain their uterus. A limitation of laparoscopy is the inability to remove large specimens from the abdominal cavity through the laparoscope. To overcome this challenge, the morcellation approach was developed, during which larger specimens are broken into smaller pieces in order to remove them from the abdominal cavity via the port site. However, intracorporeal power morcellation may lead to scattering of benign tissues, with the risk of spreading leiomyoma or endometriosis. In cases of unsuspected malignancy, power morcellation can cause unintentional dissemination of malignant cells, and lead to a poorer prognosis by upstaging the occult cancer. A strategy to optimise women's safety is to morcellate the specimens inside a bag. In-bag morcellation may avoid the dissemination of tissue fragments. OBJECTIVES: To evaluate the effectiveness and safety of protected in-bag extracorporeal manual morcellation during laparoscopic myomectomy compared to intra-abdominal uncontained power morcellation. SEARCH METHODS: On 1 July 2019, we searched; the Cochrane Gynaecology and Fertility Group Specialized Register of Controlled Trials, CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL, LILACS, PubMed, Google Scholar, and two trials registers. We reviewed the reference lists of all retrieved full-text articles, and contacted experts in the field for additional and ongoing trials. SELECTION CRITERIA: We included all randomised controlled trials comparing in-bag extracorporeal manual morcellation versus intracorporeal uncontained power morcellation during laparoscopic myomectomy in premenopausal women. DATA COLLECTION AND ANALYSIS: We followed standard Cochrane methods. Two review authors independently reviewed the eligibility of trials, extracted data, and evaluated the risk of bias. Data were checked for accuracy. The summary measures were reported as risk ratios (RR) or mean differences (MD) with 95% confidence interval (CI). The outcomes of interest were a composite of intraoperative and postoperative complications, operative times, ease of morcellation, length of hospital stay, postoperative pain, conversion to laparotomy, and postoperative diagnosis of leiomyosarcoma. Results for the five main outcomes follow. MAIN RESULTS: We included two trials, enrolling 176 premenopausal women with fibroids, who underwent laparoscopic myomectomy. The experimental group received in-bag manual morcellation, during which each enucleated myoma was placed into a specimen retrieval bag, and manually morcellated with scalpel or scissors. In the control group, intracorporeal uncontained power morcellation was used to reduce the size of the myomas. No intraoperative complications, including accidental morcellation of the liver, conversion to laparotomy, endoscopic bag disruption, bowel injury, bleeding, accidental injury to any viscus or vessel, were reported in either group in either trial. We found very low-quality evidence of inconclusive results for total operative time (MD 9.93 minutes, 95% CI -1.35 to 21.20; 2 studies, 176 participants; I² = 35%), and ease of morcellation (MD -0.73 points, 95% CI -1.64 to 0.18; 1 study, 104 participants). The morcellation operative time was a little longer for the in-bag manual morcellation group, however the quality of the evidence was very low (MD 2.59 minutes, 95% CI 0.45 to 4.72; 2 studies, 176 participants; I² = 0%). There were no postoperative diagnoses of leiomyosarcoma made in either group in either trial. We are very uncertain of any of these results. We downgraded the quality of the evidence due to indirectness and imprecision, because of limited sites in high-income settings and countries, small sample sizes, wide confidence intervals, and few events. AUTHORS' CONCLUSIONS: There are limited data on the effectiveness and safety of in-bag morcellation at the time of laparoscopic myomectomy compared to uncontained power morcellation. We were unable to determine the effects of in-bag morcellation on intraoperative complications as no events were reported in either group. We are uncertain if in-bag morcellation improves total operative time or ease of morcellation compared to control. Regarding morcellation operative time, the quality of the evidence was also very low and we cannot be certain of the effect of in-bag morcellation compared to uncontained morcellation. No cases of postoperative diagnosis of leiomyosarcoma occurred in either group. We found only two trials comparing in-bag extracorporeal manual morcellation to intracorporeal uncontained power morcellation at the time of laparoscopic myomectomy. Both trials had morcellation operative time as primary outcome and were not powered for uncommon outcomes such as intraoperative complications, and postoperative diagnosis of leiomyosarcoma. Large, well-planned and executed trials are needed.


Assuntos
Laparoscopia/métodos , Leiomioma/cirurgia , Morcelação/métodos , Miomectomia Uterina/métodos , Neoplasias Uterinas/cirurgia , Adulto , Feminino , Humanos , Complicações Intraoperatórias/etiologia , Laparoscopia/efeitos adversos , Tempo de Internação , Pessoa de Meia-Idade , Morcelação/efeitos adversos , Morcelação/instrumentação , Duração da Cirurgia , Complicações Pós-Operatórias/etiologia , Ensaios Clínicos Controlados Aleatórios como Assunto , Manejo de Espécimes/instrumentação , Manejo de Espécimes/métodos , Miomectomia Uterina/efeitos adversos , Adulto Jovem
8.
Am J Obstet Gynecol ; 223(3): 413.e1-413.e7, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32229194

RESUMO

BACKGROUND: Myomectomy is associated with a significant risk of hemorrhage. Tranexamic acid is a synthetic lysine derivative with antifibrinolytic activity used in other surgical disciplines to reduce blood loss during surgery. However, its utility in gynecologic surgery is not well understood. OBJECTIVE: This study aimed to determine the effect of early administration of intravenous tranexamic acid on perioperative bleeding and blood transfusion requirements in women undergoing myomectomy. STUDY DESIGN: This study was a double-blinded, randomized, placebo-controlled trial conducted in an academic teaching hospital. Women with symptomatic fibroids thought to be at risk for large intraoperative blood loss who met the following criteria were included in the study: (1) at least 1 fibroid ≥10 cm, (2) any intramural or broad ligament fibroid ≥6 cm, and/or (3) at least 5 total fibroids based on preoperative imaging. Patients were randomized to receive a single intravenous bolus injection of tranexamic acid 15 mg/kg (intervention group) versus an intravenous bolus injection of saline of equivalent volume (placebo group) 20 minutes before the initial surgical incision. Perioperative bleeding was defined by measuring intraoperative estimated blood loss, change between pre- and postoperative hemoglobin, and frequency of blood transfusions. Estimated blood loss was calculated by combining the blood volume collected within the suction canister and the weight of used sponges. The 2 groups were compared for age; body mass index; perioperative hemoglobin and hematocrit; perioperative blood loss; duration of surgery; blood transfusion requirements; and the number, total weight, and volume of myomas removed. RESULTS: A total of 60 patients (30 per arm) were enrolled into the study between March 1, 2015, and January 29, 2018. Age, body mass index, baseline hemoglobin and/or hematocrit, number and total weight of myomas removed, and size of myomas did not differ between arms. Of 60 patients, 32 (53%) had laparoscopic myomectomy, 24 (40%) had robotic myomectomy, and 4 (7%) had laparotomy. Median estimated blood loss was 200 mL for the tranexamic acid group and 240 mL for the placebo group (P=.88). There was no difference in median duration of surgery (165 vs 164 minutes; P=.64) or change in perioperative hemoglobin (1.00 vs 1.1 g/dL; P=.64). Patients in the tranexamic acid group did not require blood transfusions; however, 4 patients (13.3%) in the placebo group (P=.11) required blood transfusions. CONCLUSION: Intravenous administration of tranexamic acid in patients undergoing laparoscopic or robotic myomectomies was not associated with decreased blood loss.


Assuntos
Antifibrinolíticos/uso terapêutico , Ácido Tranexâmico/uso terapêutico , Hemorragia Uterina/prevenção & controle , Miomectomia Uterina/efeitos adversos , Adulto , Antifibrinolíticos/administração & dosagem , Perda Sanguínea Cirúrgica , Método Duplo-Cego , Feminino , Humanos , Injeções Intravenosas , Complicações Intraoperatórias/prevenção & controle , Ácido Tranexâmico/administração & dosagem , Resultado do Tratamento , Hemorragia Uterina/etiologia
9.
BJOG ; 127(11): 1422-1428, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32285586

RESUMO

OBJECTIVE: To compare the long-term symptom alleviation and re-intervention of high-intensity focused ultrasound (HIFU) ablation and secondary myomectomy for women with recurrent symptomatic uterine fibroids following myomectomy. DESIGN: A retrospective analysis. SETTING: A general hospital in China. POPULATION: One hundred and eighty-eight women with recurrent symptomatic uterine fibroids following myomectomy. METHODS: Women who underwent HIFU ablation (n = 101) and secondary myomectomy (n = 87) at Chinese PLA General Hospital from January 2008 to December 2016 were analysed. Symptom relief and recurrence were evaluated using the transformed symptom severity scale (tSSS). The additional intervention and treatment-related complications were also recorded and compared. MAIN OUTCOME MEASURES: Difference in symptom alleviation, recurrence, re-intervention and complications. RESULTS: Follow-up time was comparable for the two groups (56 versus 60 months; P = 0.88). Regarding tSSS, at 3 months there was improvement in all tSSS for both treatment groups. The time to re-intervention was shorter in the myomectomy group. The cumulative risk for re-intervention after HIFU ablation at 1 and 3 years was lower than that after secondary myomectomy (0% versus 4.8%, 3.2% versus 11.9%, respectively); however, no significant difference was observed at 5 and 8 years. There were fewer adverse events in the HIFU ablation group than the myomectomy group (59.4% versus 77%, P = 0.01). CONCLUSIONS: High-intensity focused ultrasound ablation of recurrent symptomatic uterine fibroids offers comparable long-term alleviation of symptoms with longer time interval to re-intervention and fewer adverse events compared with secondary myomectomy. TWEETABLE ABSTRACT: High-intensity focused ultrasound ablation of recurrent uterine fibroids offered a longer time interval to re-intervention and fewer adverse events compared with myomectomy.


Assuntos
Ablação por Ultrassom Focalizado de Alta Intensidade , Leiomioma/cirurgia , Recidiva Local de Neoplasia/cirurgia , Miomectomia Uterina , Neoplasias Uterinas/cirurgia , Adulto , China , Feminino , Ablação por Ultrassom Focalizado de Alta Intensidade/efeitos adversos , Humanos , Pessoa de Meia-Idade , Complicações Pós-Operatórias , Reoperação , Estudos Retrospectivos , Miomectomia Uterina/efeitos adversos
10.
Fertil Steril ; 113(3): 618-626, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-32192594

RESUMO

OBJECTIVE: To compare long-term health-related quality of life (HRQOL) 1 year after hysterectomy or myomectomy for treatment of uterine fibroids (UFs) and to determine whether route of procedure, race, or age affected improvements in HRQOL. DESIGN: Prospective cohort study. SETTING: Eight clinical sites throughout the United States. PATIENT(S): A total of 1,113 premenopausal women with UFs who underwent hysterectomy or myomectomy as part of Comparing Options for Management: Patient-Centered Results for Uterine Fibroids. INTERVENTION(S): None. MAIN OUTCOME MEASURE (S): Self-reported HRQOL measures including Uterine Fibroid Symptom Quality of Life, the European QOL 5 Dimension Health Questionnaire, and the visual analog scale at baseline and 1-year after hysterectomy or myomectomy. RESULT (S): Hysterectomy patients were older with a longer history of symptomatic UF compared with myomectomy patients. There were no differences in baseline HRQOL. After adjustment for baseline differences between groups, compared with myomectomy, patients' HRQOL (95% confidence interval [CI], 5.4, 17.2) and symptom severity (95% CI, -16.3, -8.8) were significantly improved with hysterectomy. When stratified across race/ethnicity and age, hysterectomy had higher HRQOL scores compared with myomectomy. There was little difference in HRQOL (95% CI, 0.1 [-9.5, 9.6]) or symptom severity (95% CI, -3.4 [-10, 3.2]) between abdominal hysterectomy and abdominal myomectomy. CONCLUSION (S): HRQOL improved in all women 1 year after hysterectomy or myomectomy. Hysterectomy patients reported higher HRQOL summary scores compared with myomectomy patients. When stratified by route, minimally invasive hysterectomy had better HRQOL scores than minimally invasive myomectomy. There was little difference in scores with abdominal approaches.


Assuntos
Histerectomia , Leiomioma/cirurgia , Qualidade de Vida , Miomectomia Uterina , Neoplasias Uterinas/cirurgia , Adulto , Estudos de Coortes , Pesquisa Comparativa da Efetividade , Feminino , Seguimentos , Humanos , Histerectomia/efeitos adversos , Histerectomia/reabilitação , Histerectomia/estatística & dados numéricos , Leiomioma/epidemiologia , Leiomioma/psicologia , Pessoa de Meia-Idade , Gravidez , Estudos Prospectivos , Inquéritos e Questionários , Resultado do Tratamento , Embolização da Artéria Uterina/efeitos adversos , Embolização da Artéria Uterina/reabilitação , Embolização da Artéria Uterina/estatística & dados numéricos , Miomectomia Uterina/efeitos adversos , Miomectomia Uterina/reabilitação , Miomectomia Uterina/estatística & dados numéricos , Neoplasias Uterinas/epidemiologia , Neoplasias Uterinas/psicologia
11.
BMC Womens Health ; 20(1): 52, 2020 03 12.
Artigo em Inglês | MEDLINE | ID: mdl-32164632

RESUMO

BACKGROUND: Acute water intoxication after hysteroscopy is a rare, life-threatening condition, often accompanied with delayed diagnosis owing to masked symptoms because of general anesthesia. CASE PRESENTATION: Herein we presented a 39-year-old female who presented with cardiac arrest after hysteroscopic myomectomy because of acute water intoxication and survived after extracorporeal membrane oxygenation, continuous venous-venous hemofiltration, and aggressive high sodium fluid resuscitation. CONCLUSION: Failure to recognize and treat this condition appropriately may lead to potentially lethal cardiopulmonary complications.


Assuntos
Oxigenação por Membrana Extracorpórea , Parada Cardíaca/etiologia , Hipocinesia/diagnóstico por imagem , Complicações Intraoperatórias , Edema Pulmonar/diagnóstico por imagem , Irrigação Terapêutica/efeitos adversos , Miomectomia Uterina/efeitos adversos , Neoplasias Uterinas/cirurgia , Intoxicação por Água/complicações , Adulto , Terapia de Substituição Renal Contínua/métodos , Ecocardiografia , Feminino , Humanos , Histeroscopia , Gravidez , Tomografia Computadorizada por Raios X , Água , Intoxicação por Água/terapia
12.
Curr Pharm Des ; 26(3): 318-325, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32013843

RESUMO

Following the FDA safety communication of 2014 increasing attention has been to the treatment of uterine fibroids, due to the suspicion of a potential leiomyosarcoma (ULM). FDA banned the use of power morcellation in the US, since this technique is likely to spread malignant cells from an unsuspected ULM. We criticized the medical legal consequences of this banning among gynecologists and patients, focusing on the drawbacks of biology and surgery. The authors analyzed literature data on one side, on the incidence, diagnosis and treatment of leiomyoma and ULM, and the other side, on the power morcellations and related critical issues, trying to highlight their main controversial aspects and to outline the possible impact on patients and on medical responsibility. The alternative methods to power morcellation are more invasive surgical solutions (as mini laparotomy or culdotomy), which inevitably involve associated risks with the surgical procedure as such and always request the containing bags. Although the in-bag morcellation is a promising technique, currently the used devices are largely off-label. This highlights the surgical risk, in case of complications, of suffering for malpractice claims both for not having used a containment system, favoring the spread of the neoplasm, and for its off-label use. Since the diagnosis of ULM is by histology after surgery, the fear of legal consequences or medical malpractice for unknown ULM power morcellation, should be targeted to analyze, in terms of cost/benefit ratio, the surgical priority. It should focus on the prevention of the risk of having a rare and statistically limited ULM or on the surgical-related complications, often linked to a slowdown minimally invasive surgery, or on the use of the authorized in-bag morcellations.


Assuntos
Laparoscopia , Leiomioma , Morcelação/efeitos adversos , Miomectomia Uterina/efeitos adversos , Neoplasias Uterinas , Feminino , Humanos , Leiomioma/cirurgia , Estudos Prospectivos , Neoplasias Uterinas/cirurgia
13.
Biomed Res Int ; 2020: 4208497, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32090092

RESUMO

Purpose: To assess the feasibility rate of one-step hysteroscopic myomectomy according to the technique adopted. Methods: In July 2016, PubMed, ClinicalTrials.gov, SCOPUS, Scielo, and AJOL databases were used for searching references. Series of in-patient hysteroscopic myomectomies reporting success rate in only one-step procedure, categorization of submucous fibroids, explanation of the surgical technique, and description of patients were considered eligible for meta-analysis (retrospective, prospective randomized studies). Two authors extracted the data. Rate of myomectomies accomplished in only a surgical step and rate of intraoperative complications were extracted per protocol. A modified GRADE score was used for quality assessment. Random-effect models were already assumed. Mean rates were compared among subgroups. Results: One thousand two hundred and fifty-seven studies were screened and 241 of these were read for eligibility. Seventy-eight series were included in qualitative synthesis and 24 series were included in quantitative synthesis. Wide heterogeneity was found. In series with <50% of G2 myomas treated, the slicing technique feasibility rate was 86.5% while techniques for enucleating the deep portion of the myomas showed a feasibility rate of 92.3% (p < 0.001). In series with ≥50% of G2 myomas treated, the slicing technique feasibility rate was 70.6% while techniques for enucleating the deep portion of myomas showed a feasibility rate of 88.4% (p < 0.001). In series with ≥50% of G2 myomas treated, the slicing technique feasibility rate was 70.6% while techniques for enucleating the deep portion of myomas showed a feasibility rate of 88.4% (. Conclusion: In case of submucous myomas with intramural development, the slicing technique was correlated with a lower rate of in-patient hysteroscopic myomectomies accomplished in a one-step procedure and a higher complications rate.


Assuntos
Histeroscopia , Pacientes Internados , Miomectomia Uterina , Adulto , Estudos de Viabilidade , Feminino , Humanos , Histeroscopia/efeitos adversos , Pessoa de Meia-Idade , Mioma/cirurgia , Complicações Pós-Operatórias/etiologia , Miomectomia Uterina/efeitos adversos , Adulto Jovem
14.
Intern Med ; 59(1): 93-99, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-31902910

RESUMO

Atypical hemolytic uremic syndrome (aHUS) is an extremely rare condition caused by an excessive activation of the complement pathway based on genetic or acquired dysfunctions in complement regulation, leading to thrombotic microangiopathy (TMA). A complement-amplifying condition (CAC) can trigger aHUS occurrence along with complement abnormality. We herein report a case of severe TMA after laparoscopic myomectomy in a healthy woman. This case was eventually diagnosed as complement-mediated TMA secondary to surgical invasive stress as a CAC, with no definitive diagnosis of aHUS despite a genetic test. The patient fully recovered after several eculizumab administrations.


Assuntos
Anticorpos Monoclonais Humanizados/uso terapêutico , Laparoscopia/efeitos adversos , Hemorragia Pós-Operatória/complicações , Microangiopatias Trombóticas/tratamento farmacológico , Miomectomia Uterina/efeitos adversos , Adulto , Inativadores do Complemento/uso terapêutico , Feminino , Humanos , Doenças Raras , Microangiopatias Trombóticas/diagnóstico , Microangiopatias Trombóticas/etiologia
15.
Eur J Obstet Gynecol Reprod Biol ; 245: 107-113, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31891893

RESUMO

OBJECTIVE: Myomectomy is the standard surgical treatment for symptomatic uterine leiomyomas, especially for patients wishing to preserve their fertility. However, this procedure is associated with adhesion formation. Several strategies have been proposed to reduce them. Cellulose absorbable barrier is widely used. We aimed to assess its effectiveness in the prevention of de-novo adhesion formation after laparoscopic myomectomy. STUDY DESIGN: A systematic review and meta-analysis was performed by searching electronic databases (i.e. MEDLINE, Scopus, ClinicalTrials.gov, EMBASE, Sciencedirect, the Cochrane Library at the CENTRAL Register of Controlled Trials, Scielo) from their inception until May 2019. We included all randomized clinical trials (RCT) comparing use of cellulose absorbable barrier (i.e. intervention group) with either placebo or no treatment (i.e. control group) in the prevention of de-novo adhesion formation at the time of laparoscopic myomectomy. Primary and secondary outcomes were defined before data extraction. The primary outcome was the incidence of adhesions at second-look laparoscopy. The secondary outcome was the operative time. RESULTS: Three RCT, including 366 participants, were included. All trials evaluated women undergoing laparoscopic myomectomy who were randomized to intervention (either oxidized regenerated cellulose or carboxymethylcellulose powder adhesion barrier) or no treatment (control group). Women who received treatment had significantly lower incidence of adhesions at the second look laparoscopy (RR 0.63, 95 % CI 0.40-0.99). Interventions with use of cellulose absorbable barrier were 4 min longer (MD 4 min, 95 % CI 2.82-5.18). CONCLUSION: Use of cellulose absorbable barrier at the time of laparoscopic myomectomy reduces the risk of postoperative adhesions.


Assuntos
Implantes Absorvíveis , Celulose Oxidada/administração & dosagem , Laparoscopia/efeitos adversos , Complicações Pós-Operatórias/prevenção & controle , Doenças Uterinas/prevenção & controle , Miomectomia Uterina/efeitos adversos , Adulto , Feminino , Humanos , Laparoscopia/métodos , Complicações Pós-Operatórias/etiologia , Ensaios Clínicos Controlados Aleatórios como Assunto , Aderências Teciduais/etiologia , Aderências Teciduais/prevenção & controle , Resultado do Tratamento , Doenças Uterinas/etiologia , Miomectomia Uterina/métodos
16.
J Minim Invasive Gynecol ; 27(3): 633-638, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-31419494

RESUMO

STUDY OBJECTIVE: To compare enucleation time, total operative time, and perioperative complications during laparoscopic myomectomy in patients pretreated with ulipristal acetate (UPA) compared with untreated patients. DESIGN: Prospective, observational pilot study. SETTING: Tertiary referral center of minimally invasive gynecologic surgery, Sant'Orsola Academic Hospital, Bologna, Italy. PATIENTS: Seventy-four of 108 patients scheduled for laparoscopic myomectomy from January to November 2017 were enrolled. INTERVENTIONS: Laparoscopic myomectomy following pretreatment with UPA or no hormonal pretreatment therapy. MEASUREMENTS AND MAIN RESULTS: Of the 74 patients who were enrolled, 29 were pretreated with UPA (UPA group), and 45 did not receive any hormonal therapy before surgery (control group). Surgeons, blinded to patient pre-operative treatment, completed a 3-item questionnaire after each procedure to evaluate surgical difficulty. Based on surgeon response, myomas in the UPA group appeared softer and more difficult to enucleate because of less clear cleavage planes than the control group. The overall difficulty of myoma detachment from the myometrium was judged considerably higher in the UPA group. Despite this, enucleation time, total operative time, and perioperative complications were not statistically different in the 2 groups. CONCLUSION: Myomas in patients pretreated with UPA are subjectively less easy to enucleate; however, surgical times and perioperative outcomes are not affected by pretreatment with UPA.


Assuntos
Leiomioma/tratamento farmacológico , Leiomioma/cirurgia , Norpregnadienos/administração & dosagem , Miomectomia Uterina , Neoplasias Uterinas/tratamento farmacológico , Neoplasias Uterinas/cirurgia , Adolescente , Adulto , Estudos de Casos e Controles , Terapia Combinada , Esquema de Medicação , Feminino , Humanos , Itália , Laparoscopia/efeitos adversos , Laparoscopia/métodos , Pessoa de Meia-Idade , Duração da Cirurgia , Projetos Piloto , Complicações Pós-Operatórias/etiologia , Cuidados Pré-Operatórios/métodos , Estudos Prospectivos , Resultado do Tratamento , Miomectomia Uterina/efeitos adversos , Miomectomia Uterina/métodos , Adulto Jovem
17.
J Minim Invasive Gynecol ; 27(2): 548-550, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-31574314

RESUMO

Studies have demonstrated that during hysteroscopic myomectomy with bipolar diathermy, carbon monoxide is produced and enters the patient's circulation. However, little is known regarding the immediate or long-term sequelae of transient rises in carboxyhemoglobin levels during hysteroscopic surgery. This paper aims to suggest recommendations for acute evaluation, management, patient counseling, and future research. We present a case of a 36-year-old woman (Gravida 0, Para 0) with abnormal uterine bleeding-leiomyoma and resultant anemia, undergoing hysteroscopic resection of a large submucous myoma. During surgery, the patient was found to have a critically elevated level of carboxyhemoglobin and accompanying electrocardiogram derangements. She was managed with prolonged intubation, 100% O2, and trending of her carboxyhemoglobin levels before extubation. This demonstrates the importance of being cognizant of the potentially toxic gaseous byproducts of bipolar resection and of including intravasation of these byproducts in one's consideration of patient safety during extensive resections. Bipolar hysteroscopic resection of large leiomyomas may result in critically high carboxyhemoglobin levels, which can impair end-organ oxygen delivery with resultant ischemia; the risks of myocardial ischemia should be discussed with the anesthesia team before attempting an extensive resection. Electrocardiogram changes indicative of ischemia should prompt discontinuation of the case. Finally, carboxyhemoglobin poisoning should be included in the differential diagnosis of patients who demonstrate longer-than-expected anesthesia recovery times after bipolar resection of large submucous leiomyomas, and they should be managed with repeat evaluation of carboxyhemoglobin levels, supplemental oxygen, and cardiac monitoring.


Assuntos
Carboxihemoglobina/metabolismo , Isquemia/sangue , Leiomioma/cirurgia , Complicações Pós-Operatórias/sangue , Hemorragia Uterina/cirurgia , Miomectomia Uterina/efeitos adversos , Neoplasias Uterinas/cirurgia , Adulto , Carboxihemoglobina/análise , Estado Terminal/terapia , Eletrocardiografia , Feminino , Humanos , Histeroscopia/efeitos adversos , Histeroscopia/métodos , Isquemia/etiologia , Isquemia/terapia , Leiomioma/sangue , Leiomioma/complicações , Duração da Cirurgia , Complicações Pós-Operatórias/diagnóstico , Hemorragia Uterina/etiologia , Neoplasias Uterinas/sangue , Neoplasias Uterinas/complicações
18.
J Minim Invasive Gynecol ; 27(1): 155-159, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-30926366

RESUMO

STUDY OBJECTIVE: To evaluate the differences in perioperative outcomes and immediate complication rates between laparoscopic myomectomy for submucous myomas and laparoscopic myomectomy for myomas in other locations. DESIGN: Retrospective cohort study. SETTING: University-affiliated hospital in London. PATIENTS: A total of 350 patients with symptomatic uterine myomas underwent laparoscopic myomectomy. Thirty-three of these were performed for submucous myomas (group 1), and 317 were for myomas in other uterine locations (group 2). INTERVENTIONS: Analysis of prospectively collected data on patient demographics, myoma characteristics, perioperative outcomes, and immediate complications. MEASUREMENTS AND MAIN RESULTS: Patient demographics, including age, body mass index, and parity, were similar in the 2 groups. No significant differences in myoma characteristics were seen between groups 1 and 2, including the mean dimension of largest myoma (7.1 vs 7.8 cm, respectively; p = .35), mean number of myomas removed (3.8 vs 4.1; p = .665), and mean mass of myomas removed (142.0 g vs 227.3 g; p = .186). There were also no significant between-group differences in any perioperative outcomes, including mean blood loss (226.8 mL vs 266.4 mL; p = .373), duration of surgery (103 minutes vs 113 minutes; p = .264), and duration of hospital stay (1.4 days vs 1.7 days; p = .057). No complications arose from laparoscopic resection of submucous myomas. CONCLUSION: Laparoscopic myomectomy for submucous myomas has similar perioperative outcomes and immediate complications as laparoscopic myomectomy for other myomas and can be considered for large or type 2 submucous myomas.


Assuntos
Laparoscopia/métodos , Leiomioma/cirurgia , Miométrio/cirurgia , Miomectomia Uterina/métodos , Neoplasias Uterinas/cirurgia , Adulto , Estudos de Coortes , Feminino , Humanos , Laparoscopia/efeitos adversos , Leiomioma/patologia , Tempo de Internação , Miométrio/patologia , Duração da Cirurgia , Gravidez , Estudos Retrospectivos , Miomectomia Uterina/efeitos adversos , Neoplasias Uterinas/patologia
19.
J Minim Invasive Gynecol ; 27(1): 195-199, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-30936030

RESUMO

STUDY OBJECTIVE: Our primary goal was to uncover preoperative and intraoperative risk factors that prevented same-day discharge (SDD) after myomectomy in a setting where SDD was the standard of care. Uncovered predictors would serve to enhance patient counseling and medical optimization before surgery. DESIGN: Single-center retrospective cohort study. SETTING: Urban university hospital center, by fellowship-trained minimally invasive gynecologic surgeons. PATIENTS: A total of 315 consecutive patients undergoing minimally invasive myomectomy between March 2012 and May 2018. INTERVENTION: Minimally invasive myomectomy. MEASUREMENTS AND MAIN RESULTS: Preoperative and intraoperative characteristics were collected for analysis as predictors of SDD vs overnight admission. Comparisons of demographic, clinical, imaging, and operative characteristics were made using appropriate statistical methods for normally distributed, skewed, and categorical variables. Length of stay was analyzed as a categorical variable, SDD vs overnight admission. A logistic regression model was used to evaluate SDD vs any overnight stay. Out of the 315 patients undergoing laparoscopic myomectomy, 208 (66.03%) were discharged on the same day, and 107 (33.96%) were admitted for at least 1 day after surgery. The patients were more likely to be admitted overnight if they were of Asian ethnicity (p = .01), or if they had a lower preoperative Hct (36.15 vs 37.57; p < .003). An increase in any myoma characteristic metric was associated with overnight stay after surgery; these included mean myoma weight (512.0 g vs 310.1 g; p < .001), estimated size of the largest myoma on imaging (9.01 cm vs 7.77 cm; p < .001), and number of myomas removed (6.59 vs 5.57; p = .021). Other statistically significant differences between the overnight admission and SDD groups were mean estimated blood loss (599.4 mL vs 221.9 mL; p < .001), operative time (224.4 minutes vs 140.9 minutes; p < .001), and surgery end time (15:02 hours vs 12:43 hours; p < .001). Intraoperative complications associated with overnight admission were estimated blood loss >1 L (p < .001) and any intraoperative transfusion (p < .001). The adjusted logistic regression model identified an increase in operative time (by 60 minutes) and later surgery end time (by 60 minutes) as predictors of an overnight stay, whereas an 5% increase in preoperative hematocrit was associated with a 34% decrease in odds for an overnight stay. CONCLUSION: Perioperative factors, such as preoperative hematocrit, and myoma characteristics, as well as intraoperative factors, such as prolonged operative time and surgery end-time, are independent predictors of overnight hospital admission after minimally invasive myomectomy. Our present data can be used to provide better patient counseling before surgery.


Assuntos
Leiomioma/cirurgia , Procedimentos Cirúrgicos Minimamente Invasivos/efeitos adversos , Admissão do Paciente , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/terapia , Miomectomia Uterina/efeitos adversos , Neoplasias Uterinas/cirurgia , Adulto , Instituições de Assistência Ambulatorial/normas , Instituições de Assistência Ambulatorial/estatística & dados numéricos , Estudos de Coortes , Feminino , Hospitais com Alto Volume de Atendimentos/normas , Hospitais com Alto Volume de Atendimentos/estatística & dados numéricos , Hospitais Universitários/normas , Hospitais Universitários/estatística & dados numéricos , Humanos , Laparoscopia/efeitos adversos , Laparoscopia/métodos , Laparoscopia/estatística & dados numéricos , Leiomioma/diagnóstico , Leiomioma/epidemiologia , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Procedimentos Cirúrgicos Minimamente Invasivos/estatística & dados numéricos , Admissão do Paciente/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , Prognóstico , Estudos Retrospectivos , Fatores de Risco , Miomectomia Uterina/métodos , Miomectomia Uterina/estatística & dados numéricos , Neoplasias Uterinas/diagnóstico , Neoplasias Uterinas/epidemiologia
20.
J Minim Invasive Gynecol ; 27(1): 178-185.e1, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-30936031

RESUMO

STUDY OBJECTIVE: To investigate whether the rate of increase in the performance of abdominal myomectomy over a laparoscopic approach after the US Food and Drug Administration (FDA) safety communication regarding morcellator use for myomectomy differs among races. DESIGN: Retrospective cohort study. SETTING: The American College of Surgeons National Surgical Quality Improvement data. PATIENTS: Patients aged 18 to 55 years who underwent either laparoscopic or abdominal myomectomy, excluding malignant cases, emergency cases, operations performed by nongynecologic specialists, and cases in which myomectomy was performed during cesarean section. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The odds ratios of abdominal myomectomy over laparoscopic myomectomy before and after the release of the FDA communication were calculated in 3 race categories: white, African American, and other races. In a logistic regression analysis adjusted for possible confounders, including all races, the odds ratio of abdominal myomectomy before and after the FDA communication was 1.30 (95% confidence interval [CI], 1.20-1.41; p <.001). In a logistic regression analysis with a product term of FDA communication exposure and race as a possible effect modifier, the African American population showed a significantly greater change in the odds of abdominal myomectomy over laparoscopic myomectomy in comparison with the white population (1.22; 95% CI, 1.02-1.47; p = .03). In contrast, other races showed no significant change (.83; 95% CI, .64-1.08; p = .17). CONCLUSION: After the FDA communication, the odds ratio of abdominal myomectomy was disproportionately increased in the African American population.


Assuntos
Disparidades em Assistência à Saúde/etnologia , Laparoscopia , Laparotomia , Leiomioma/cirurgia , Morcelação/métodos , Miomectomia Uterina/métodos , Neoplasias Uterinas/cirurgia , Adolescente , Adulto , Afro-Americanos/estatística & dados numéricos , Comunicação , Grupo com Ancestrais do Continente Europeu/estatística & dados numéricos , Feminino , Fidelidade a Diretrizes/normas , Fidelidade a Diretrizes/estatística & dados numéricos , Disparidades em Assistência à Saúde/normas , Disparidades em Assistência à Saúde/estatística & dados numéricos , Humanos , Histerectomia/métodos , Histerectomia/estatística & dados numéricos , Laparoscopia/métodos , Laparoscopia/estatística & dados numéricos , Laparotomia/métodos , Laparotomia/estatística & dados numéricos , Leiomioma/etnologia , Pessoa de Meia-Idade , Morcelação/efeitos adversos , Morcelação/estatística & dados numéricos , Segurança do Paciente/normas , Segurança do Paciente/estatística & dados numéricos , Estudos Retrospectivos , Estados Unidos/epidemiologia , United States Food and Drug Administration/normas , Miomectomia Uterina/efeitos adversos , Miomectomia Uterina/estatística & dados numéricos , Neoplasias Uterinas/etnologia , Adulto Jovem
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