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1.
Cochrane Database Syst Rev ; 1: CD003857, 2020 01 29.
Artigo em Inglês | MEDLINE | ID: mdl-31995657

RESUMO

BACKGROUND: Fibroids are the most common benign tumours of the female genital tract and are associated with numerous clinical problems including a possible negative impact on fertility. In women requesting preservation of fertility, fibroids can be surgically removed (myomectomy) by laparotomy, laparoscopically or hysteroscopically depending on the size, site and type of fibroid. Myomectomy is however a procedure that is not without risk and can result in serious complications. It is therefore essential to determine whether such a procedure can result in an improvement in fertility and, if so, to then determine the ideal surgical approach. OBJECTIVES: To examine the effect of myomectomy on fertility outcomes and to compare different surgical approaches. SEARCH METHODS: We searched the Cochrane Gynaecology and Fertility Group (CGFG) Specialised Register, CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL, Epistemonikos database, World Health Organization (WHO) International Clinical Trials Registry Platform search portal, Database of Abstracts of Reviews of Effects (DARE), LILACS, conference abstracts on the ISI Web of Knowledge, OpenSigle for grey literature from Europe, and reference list of relevant papers. The final search was in February 2019. SELECTION CRITERIA: Randomised controlled trials (RCTs) examining the effect of myomectomy compared to no intervention or where different surgical approaches are compared regarding the effect on fertility outcomes in a group of infertile women suffering from uterine fibroids. DATA COLLECTION AND ANALYSIS: Data collection and analysis were conducted in accordance with the procedure suggested in the Cochrane Handbook for Systematic Reviews of Interventions. MAIN RESULTS: This review included four RCTs with 442 participants. The evidence was very low-quality with the main limitations being due to serious imprecision, inconsistency and indirectness. Myomectomy versus no intervention One study examined the effect of myomectomy compared to no intervention on reproductive outcomes. We are uncertain whether myomectomy improves clinical pregnancy rate for intramural (odds ratio (OR) 1.88, 95% confidence interval (CI) 0.57 to 6.14; 45 participants; one study; very low-quality evidence), submucous (OR 2.04, 95% CI 0.62 to 6.66; 52 participants; one study; very low-quality evidence), intramural/subserous (OR 2.00, 95% CI 0.40 to 10.09; 31 participants; one study; very low-quality evidence) or intramural/submucous fibroids (OR 3.24, 95% CI 0.72 to 14.57; 42 participants; one study; very low-quality evidence). Similarly, we are uncertain whether myomectomy reduces miscarriage rate for intramural fibroids (OR 1.33, 95% CI 0.26 to 6.78; 45 participants; one study; very low-quality evidence), submucous fibroids (OR 1.27, 95% CI 0.27 to 5.97; 52 participants; one study; very low-quality evidence), intramural/subserous fibroids (OR 0.80, 95% CI 0.10 to 6.54; 31 participants; one study; very low-quality evidence) or intramural/submucous fibroids (OR 2.00, 95% CI 0.32 to 12.33; 42 participants; one study; very low-quality evidence). This study did not report on live birth, preterm delivery, ongoing pregnancy or caesarean section rate. Laparoscopic myomectomy versus myomectomy by laparotomy or mini-laparotomy Two studies compared laparoscopic myomectomy to myomectomy at laparotomy or mini-laparotomy. We are uncertain whether laparoscopic myomectomy compared to laparotomy or mini-laparotomy improves live birth rate (OR 0.80, 95% CI 0.42 to 1.50; 177 participants; two studies; I2 = 0%; very low-quality evidence), preterm delivery rate (OR 0.70, 95% CI 0.11 to 4.29; participants = 177; two studies; I2 = 0%, very low-quality evidence), clinical pregnancy rate (OR 0.96, 95% CI 0.52 to 1.78; 177 participants; two studies; I2 = 0%, very low-quality evidence), ongoing pregnancy rate (OR 1.61, 95% CI 0.26 to 10.04; 115 participants; one study; very low-quality evidence), miscarriage rate (OR 1.25, 95% CI 0.40 to 3.89; participants = 177; two studies; I2 = 0%, very low-quality evidence), or caesarean section rate (OR 0.69, 95% CI 0.34 to 1.39; participants = 177; two studies; I2 = 21%, very low-quality evidence). Monopolar resectoscope versus bipolar resectoscope One study evaluated the use of two electrosurgical systems during hysteroscopic myomectomy. We are uncertain whether bipolar resectoscope use compared to monopolar resectoscope use improves live birth/ongoing pregnancy rate (OR 0.86, 95% CI 0.30 to 2.50; 68 participants; one study, very low-quality evidence), clinical pregnancy rate (OR 0.88, 95% CI 0.33 to 2.36; 68 participants; one study; very low-quality evidence), or miscarriage rate (OR 1.00, 95% CI 0.19 to 5.34; participants = 68; one study; very low-quality evidence). This study did not report on preterm delivery or caesarean section rate. AUTHORS' CONCLUSIONS: There is limited evidence to determine the role of myomectomy for infertility in women with fibroids as only one trial compared myomectomy with no myomectomy. If the decision is made to have a myomectomy, the current evidence does not indicate a superior method (laparoscopy, laparotomy or different electrosurgical systems) to improve rates of live birth, preterm delivery, clinical pregnancy, ongoing pregnancy, miscarriage, or caesarean section. Furthermore, the existing evidence needs to be viewed with caution due to the small number of events, minimal number of studies and very low-quality evidence.


Assuntos
Infertilidade Feminina/cirurgia , Leiomiomatose/cirurgia , Miomectomia Uterina/métodos , Neoplasias Uterinas/cirurgia , Aborto Espontâneo/epidemiologia , Cesárea/estatística & dados numéricos , Feminino , Humanos , Infertilidade Feminina/etiologia , Leiomiomatose/complicações , Nascimento Vivo/epidemiologia , Gravidez , Taxa de Gravidez , Ensaios Clínicos Controlados Aleatórios como Assunto , Neoplasias Uterinas/complicações
2.
Am J Obstet Gynecol ; 222(4): 345.e1-345.e22, 2020 04.
Artigo em Inglês | MEDLINE | ID: mdl-31678093

RESUMO

BACKGROUND: Uterine fibroids may decrease quality of life in a significant proportion of affected women. Myomectomy offers a uterine-sparing treatment option for patients with uterine fibroids that can be performed abdominally, laparoscopically (with or without robotic assistance), and hysteroscopically. Quality of life information using validated measures for different myomectomy routes, especially hysteroscopic myomectomy, is limited. OBJECTIVE: To compare women's perception of their short-term health-related quality of life measures and reported time to return to usual activities and return to work for different routes of myomectomy. MATERIALS AND METHODS: Comparing Options for Management: Patient-centered Results for Uterine Fibroids (COMPARE-UF) is a prospective nationwide fibroid registry that enrolled premenopausal women seeking treatment for uterine fibroids at 8 clinical sites. For this analysis, we included women undergoing hysteroscopic, abdominal, or laparoscopic myomectomy who completed the postprocedure questionnaire scheduled between 6 and 12 weeks after surgery. Health-related quality of life outcomes, such as pain, anxiety, and return to usual activitie, were assessed for each route. The hysteroscopic myomectomy group had large differences in demographics, fibroid number, and uterine size compared to the other groups; thus, a direct comparison of quality of life measures was performed only for abdominal and laparoscopic approaches after propensity weighting. Propensity weighting was done using 24 variables that included demographics, quality of life baseline measures, and fibroid and uterine measurements. RESULTS: A total of 1206 women from 8 COMPARE-UF sites underwent myomectomy (338 hysteroscopic, 519 laparoscopic, and 349 abdominal). All women had substantial improvement in short-term health-related quality of life and symptom severity scores, which was not different among groups. Average symptom severity scores decreased about 30 points in each group. Return to usual activities averaged 0 days (interquartile range, 0-14 days) for hysteroscopic myomectomy, 21 days (interquartile range, 14-28 days) for laparoscopic myomectomy, and 28 days (interquartile range, 14-35 days) for abdominal myomectomy. After propensity adjustment, quality of life outcomes in the laparoscopic and abdominal myomectomy groups were similar except for more anxiety in the laparoscopic myomectomy group and slightly more pain in the abdominal myomectomy group. After propensity weighting, return to usual activities favored laparoscopic compared to abdominal procedures; median time was the same at 21 days, but the highest quartile of women in the abdominal group needed an additional week of recovery (interquartile range,14.0-28.0 for laparoscopic versus 14.0-35.0 for abdominal, P < .01). Time to return to work was also longer in the abdominal arm (median, 22 days; interquartile range, 14-40 days, versus median, 42; interquartile range, 27-56). CONCLUSION: Women who underwent myomectomy had substantial improvement in health-related quality of life, regardless of route of myomectomy. After propensity weighting, abdominal myomectomy was associated with a nearly 2-week longer time to return to work than laparoscopic myomectomy.


Assuntos
Leiomioma/cirurgia , Qualidade de Vida , Miomectomia Uterina/métodos , Neoplasias Uterinas/cirurgia , Adulto , Ansiedade/etiologia , Feminino , Humanos , Histeroscopia/efeitos adversos , Histeroscopia/psicologia , Laparoscopia/efeitos adversos , Laparoscopia/psicologia , Pessoa de Meia-Idade , Dor Pós-Operatória/etiologia , Período Pós-Operatório , Qualidade de Vida/psicologia , Sistema de Registros , Retorno ao Trabalho/estatística & dados numéricos , Procedimentos Cirúrgicos Robóticos/efeitos adversos , Procedimentos Cirúrgicos Robóticos/psicologia , Índice de Gravidade de Doença , Inquéritos e Questionários , Fatores de Tempo , Miomectomia Uterina/efeitos adversos , Miomectomia Uterina/psicologia
3.
BMJ Case Rep ; 12(12)2019 Dec 11.
Artigo em Inglês | MEDLINE | ID: mdl-31831516

RESUMO

A 34-year-old patient underwent a laparoscopic myomectomy, complicated by a profound episode of bradycardia and hypotension following intramyometrial infiltration of vasopressin (20 IU), promptly corrected with intravenous ephedrine (6 mg) and glycopyrrolate (200 µg). At extubation, pink frothy fluid was noted in the endotracheal tube; she was visibly distressed, desaturated to 89% in air and was coughing up pink stained fluid. Acute pulmonary oedema secondary to vasopressin was suspected. A tight-fitting oxygen mask (100%) with positive end expiratory pressure was applied and intravenous furosemide (20 mg) and diamorphine (4 mg, 1 mg increments) were administered to facilitate diuresis and oxygenation. Chest X-ray confirmed acute pulmonary oedema. Arterial blood gas demonstrated type 2 respiratory failure. Over 12 hours, the oxygen was weaned to 1 L/min. She demonstrated excellent diuresis. Troponin and brain-natriuretic peptide were elevated, but echocardiogram was normal. The cardiology diagnosis was vasopressin-induced coronary vasospasm, precipitating acute pulmonary oedema. She was discharged home on day 5.


Assuntos
Edema Pulmonar/induzido quimicamente , Miomectomia Uterina/métodos , Vasoconstritores/efeitos adversos , Vasopressinas/efeitos adversos , Adulto , Extubação/efeitos adversos , Bradicardia/induzido quimicamente , Relação Dose-Resposta a Droga , Feminino , Humanos , Respiração com Pressão Positiva , Edema Pulmonar/terapia , Miomectomia Uterina/efeitos adversos , Vasoconstritores/administração & dosagem , Vasoconstritores/farmacocinética , Vasopressinas/administração & dosagem , Vasopressinas/farmacocinética
4.
Medicine (Baltimore) ; 98(49): e18301, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31804377

RESUMO

RATIONALE: Uterine leiomyoma, which is very common gynecological tumor in the reproductive years, is extremely rare in adolescence. We herein report a case of a uterine leiomyoma treated with laparoscopic surgery in an adolescent. PATIENT CONCERNS: A 13-year-old girl with no gravida and her first menses at 11 years of age reported feeling bloated. She had a regular menstrual cycle but felt increased abdominal distension. DIAGNOSIS: Transabdominal ultrasound and magnetic resonance imaging revealed uterine leiomyoma with a diameter of 10 cm. INTERVENTION: Laparoscopic myomectomy was performed. OUTCOMES: The total weight of the leiomyoma removed was 660 g with pathological diagnosis of uterine leiomyoma. The postoperative course was uneventful. The patient was free of disease at the follow-up consultation 18 months after the treatment. LESSONS: Laparoscopic approach is a very useful and minimally invasive surgery for symptomatic leiomyoma in adolescents.


Assuntos
Laparoscopia/métodos , Leiomioma/cirurgia , Miomectomia Uterina/métodos , Neoplasias Uterinas/cirurgia , Adolescente , Feminino , Humanos , Leiomioma/diagnóstico por imagem , Neoplasias Uterinas/diagnóstico por imagem
5.
Taiwan J Obstet Gynecol ; 58(6): 888-890, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31759550

RESUMO

OBJECTIVE: Big submucosal myoma often causes heavy menstrual bleeding and are complicated in hysterscopic surgery. High Intensity Focused Ultrasound (HIFU), is a method for myoma ablation therapy, which may benefit on size reduction, and assist following hysterscopic myomectomy. CASE REPORT: Two cases, case one,. 44-year-old female with 3.8 cm submucosal myoma, STEPW (Size, Topography, Extension, Penetration and Wall) score 6 and case 2. 48-year-old female, with 6.0 cm submucosal myoma, STEPW score 8, both received HIFU treatment before hysterscopic myomectomy was done. The myomas reduced after 5 months with improvement of anemia. The following hysterscopic myomectomy shows less operative time and fewer blood loss. CONCLUSION: HIFU reduce size of submucosal myoma and may improve anemia after months. Less operating time and blood loss were demonstrated in the following hysterscopic myomectomy. For well selected patients, combined treatment with HIFU and hysteroscopic resection may decrease complication rate.


Assuntos
Ablação por Ultrassom Focalizado de Alta Intensidade/métodos , Histeroscopia/métodos , Leiomioma/cirurgia , Miomectomia Uterina/métodos , Neoplasias Uterinas/cirurgia , Adulto , Feminino , Humanos , Leiomioma/diagnóstico , Imagem por Ressonância Magnética , Pessoa de Meia-Idade , Índice de Gravidade de Doença , Neoplasias Uterinas/diagnóstico
6.
Eur J Obstet Gynecol Reprod Biol ; 243: 168-172, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31715456

RESUMO

OBJECTIVES: Our primary objective was to assess patient awareness by observing Google Trends comparing search terms used in relation to morcellation rather than morcellation alone. Our secondary objective was to review trends and locations of publications on leiomyosarcoma and morcellation following the US Food and Drug Administration (FDA) position statement. STUDY DESIGN: To assess Internet trends, we obtained the relative search volume (RSV) for each month from 1 January 2004 to 1 March 2019 from Google Trends using the terms 'fibroid', 'morcellation', and 'fibroid cancer'. RSV ranges from 0 to 100 with 100 being peak popularity for the term, and all other monthly search activity relative to the peak. To assess academic trends, we performed a systematic review of published literature discussing fibroid morcellation within the same time period. We used a two-way independent t-test to compare median RSV, and chi-squared test to compare academic output. P < 0.05 was considered statistically significant. RESULTS: Search volume for 'morcellation' peaked during the FDA statement (RSV 0.5 to 2.9, t = 17.5, p < 0.05) but was not sustained. There is an increase in 'fibroid' activity post-FDA statement (RSV 68.8 to 76.3, t = 3.9, p < 0.05). 'Fibroid cancer' remained static throughout (t = 1.5, p = 0.1 and t=-0.5, p = 0.6). Afro-Caribbean countries had the highest RSV for 'fibroid', whereas 'morcellation' RSV was highest in predominantly Western countries. There was a significant increase in the rate of papers published on the subject following the FDA statement (6.8 vs 55.6 papers per year, 95% CI -53.96 to -43.64, p < 0.0001). No academic papers on morcellation were published from countries with the highest RSV for 'fibroid'. CONCLUSION: Our study suggests that interest in uterine fibroids has increased since the FDA statement, but the public are perhaps unaware or not concerned of the consequent potential risk of leiomyosarcoma following morcellation. Countries where fibroid interest is highest are not necessarily those that can offer power morcellation. Further studies are required to address how the Internet influences patient choice and informed consent, and how medical professionals can use it to further educate patients on the risks and benefits of laparoscopic myomectomy and power morcellation.


Assuntos
Comportamento de Busca de Informação , Leiomioma/cirurgia , Leiomiossarcoma/epidemiologia , Morcelação/métodos , Editoração/tendências , Ferramenta de Busca/tendências , Miomectomia Uterina/métodos , Neoplasias Uterinas/cirurgia , Feminino , Conhecimentos, Atitudes e Prática em Saúde , Humanos , Internet , Leiomioma/patologia , Leiomiossarcoma/patologia , Estados Unidos , United States Food and Drug Administration , Neoplasias Uterinas/patologia
7.
Eur J Obstet Gynecol Reprod Biol ; 243: 41-45, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31671290

RESUMO

OBJECTIVE: Evaluation of five years follow up of the clinical recurrence after hysteroscopic myomectomies with MyoSure® morcellator in our district. STUDY DESIGN: Premenopausal patients from April 2013 to October 2018, with symptoms of abnormal uterine bleeding, and/or infertility, and sonographic suspicion of submucosal myoma, confirmed by diagnostic hysteroscopy prior to myomectomy were included in the prospective, not randomized cohort study (N = 320). All patients had a follow up visit between three to six months post procedure. Further follow up was established by chart review. The information was extracted from the medical records. Patient characteristics were expressed as mean ±â€¯SD or median (interquartile range) for continuous data (assumption of normality assessed using the Kolmogorov-Smirnov test). Dependence relationship between presence of corporal myomas and the performance of a major long-term surgery, and between the amount of submucosal myomas and clinical recurrence throughout the 5 years of follow-up were studied were studied by χ2. RESULTS: After one year follow up, no recurrence or symptoms were noted. 53 (16.6%) re-morcellations were performed due to incomplete resection. At the second year, three women who were discharged previously were classified as recurrence (0.9%). There were 99 women remaining to be evaluated (30.90%) in the second year. A percentage estimation of 5-6 recurrences with the 100% of women evaluated. In the third year, only one woman was classified as recurrence (0.3%), with 176 (55%) women not evaluated. At the fourth and fifth year of follow-up, 75% are still awaiting complete of the study five years. No relationship was observed in the presence of corporal myomas and recurrence throughout the 5 years of follow-up (χ2 = 0.000, p = 0.994). Dependence relationship was observed between the presence of corporal myomas and the performance of a major long-term surgery (χ2 = 11.757, p = .001, OR = 3.528). CONCLUSION: In office hysteroscopic mechanical myomectomy with MyoSure® morcellator of submucosal fibromas was a highly effective therapy for women, at three years of follow-up. It appears to give satisfactory long-term results with a low recurrence rate and without significant complications.


Assuntos
Histeroscopia/métodos , Leiomioma/cirurgia , Recidiva Local de Neoplasia/epidemiologia , Miomectomia Uterina/métodos , Neoplasias Uterinas/cirurgia , Adulto , Estudos de Coortes , Feminino , Seguimentos , Humanos , Histerectomia/estatística & dados numéricos , Leiomioma/diagnóstico por imagem , Leiomioma/patologia , Pessoa de Meia-Idade , Recidiva Local de Neoplasia/diagnóstico por imagem , Recidiva Local de Neoplasia/cirurgia , Estudos Prospectivos , Reoperação , Carga Tumoral , Neoplasias Uterinas/diagnóstico por imagem , Neoplasias Uterinas/patologia
8.
Eur J Obstet Gynecol Reprod Biol ; 243: 179-184, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31585677

RESUMO

Minimally invasive techniques for myomectomy are based on the rationale of preserving the myometrial integrity, in order to spare muscular and fibro-neurovascular myometrial fibers and ensure complete and bloodless myoma removal. Post-operative myometrial vascularization is crucial in injured muscle regeneration. The post-surgical myometrial healing is needful for uterine reproductive function. Neurotransmitters and neurofibers were analyzed in the myoma pseudocapsule surrounding fibroid. They activate signaling molecule synthesis and release which, in turn, promote cell activation and induce muscle regeneration and growth. Pseudocapsule damage during myomectomy may lead to a reduction of neuropeptides and neurofibers at the hysterotomic site, to a poor physiological myometrial healing, with more fibrosis due to hypoxia, ischemia and necrosis. These pathophysiological events cause deficit in myometrial neurotransmission, muscular impulse and contractility, with ultimately impaired uterine muscle function during pregnancy, labor and delivery. Hence, during myomectomy, all manipulations should be performed as precisely and bloodlessly as possible, avoiding extensive, high wattage diathermocoagulation or excessive tissue manipulation or muscular trauma. Any iatrogenic pseudocapsule damage may alter neurotransmitter function during successive myometrial healing, impacting negatively on uterine repair and on eventual pregnancies. Hence the reasoned myomectomy on a biological basis, the "intracapsular myomectomy", satisfied these surgical and physiological requirements. It was described precisely and firstly by the hysteroscopy, with the image magnification of the preservation of the myoma pseudocapsule. The "intracapsular hysteroscopic myomectomy" demonstrated the safe and effective removal of submucous myomas with intramural development. It allowed to completely remove the myoma in one or two surgical steps, saving the pseudocapsule and the surrounding healthy myometrium. The respect of the myometrium and the reduced thermal injury, a part the excellent outcomes in terms of surgical complications prevention, post-surgical fibrosis and intrauterine synechiae reduction, highlighted the physiological development of a successive pregnancy, without any myometrial complications during pregnancy, labor and delivery.


Assuntos
Histeroscopia/métodos , Leiomioma/cirurgia , Miométrio/irrigação sanguínea , Miométrio/inervação , Miomectomia Uterina/métodos , Neoplasias Uterinas/cirurgia , Feminino , Humanos , Miométrio/fisiologia , Regeneração
9.
Int J Med Robot ; 15(6): e2038, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31503368

RESUMO

BACKGROUND: This retrospective study aimed to compare the surgical outcomes and morbidity of the vascular control technique in robotic myomectomy with the conventional technique. METHODS: Thirty-two consecutive patients who underwent robotic myomectomy using laparoscopic vascular clamps in 2017 to 2019 (the practice change cohort) were retrospectively comparted with 32 case-matched consecutive patients who underwent the conventional robotic myomectomy (the historical cohort). The primary outcome was the operative blood loss and hemoglobin change. RESULTS: The two cohorts had similar baseline characteristics. The mean operative blood loss and hemoglobin changes were lower in the practice change cohort than in the historical cohort (P < .001 and P = .005, respectively). Other postoperative outcomes were similar between two cohorts. CONCLUSION: The vascular control technique in robotic myomectomy appears to be effective and safe in the management of selective patients with symptomatic myomas.


Assuntos
Perda Sanguínea Cirúrgica/prevenção & controle , Procedimentos Cirúrgicos Robóticos , Miomectomia Uterina/métodos , Procedimentos Cirúrgicos Vasculares , Adulto , Transfusão de Sangue , Estudos de Casos e Controles , Feminino , Hemoglobinas/análise , Humanos , Laparoscopia , Leiomioma/cirurgia , Pessoa de Meia-Idade , Mioma/cirurgia , Dor Pélvica/cirurgia , Estudos Retrospectivos , Resultado do Tratamento , Neoplasias Uterinas/cirurgia , Útero/cirurgia , Adulto Jovem
10.
J Laparoendosc Adv Surg Tech A ; 29(11): 1475-1480, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31424320

RESUMO

Background: To overcome the limitations of single-port laparoscopic myomectomy (SP-LM) and robotic single-site myomectomy (RSSM), we designed a new surgical technique, the so-called hybrid RSSM (H-RSSM), by integrating the advantages of both procedures. This study describes the surgical technique of H-RSSM and reports our initial experiences. Materials and Methods: Between February 2018 and September 2018, H-RSSM was performed in 25 women with symptomatic fibroids. During the H-RSSM, the enucleation of the fibroid was carried out using single-port laparoscopy and the uterine defect was repaired using robotic single-site surgery. To assess the feasibility and efficacy of H-RSSM, the results of this study were compared with those of our previous study on SP-LM and its modified surgical technique, so-called single-port laparoscopically assisted transumbilical ultraminilaparotomic myomectomy (SPLA-TUM). Results: The mean operation time, hemoglobin change, return of bowel activity, and length of hospital stay were 69.4 ± 18.2 minutes, 1.2 ± 0.9 g/dL, 37.1 ± 15.5 hours, and 4.0 ± 0.8 days, respectively. There was no conversion to laparotomy or multiport laparoscopy. There were no surgical or wound complications. Comparing with SP-LM and SPLA-TUM, H-RSSM had significantly shorter operation time and return of bowel activity. Conclusion: H-RSSM can reduce operating time and the conversion rate to multiport laparoscopy and can be considered a feasible alternative for selected patients with symptomatic fibroids. However, further studies are needed to clearly demonstrate these benefits.


Assuntos
Leiomioma/cirurgia , Procedimentos Cirúrgicos Robóticos/métodos , Miomectomia Uterina/métodos , Neoplasias Uterinas/cirurgia , Adulto , Perda Sanguínea Cirúrgica , Feminino , Hemoglobinas/metabolismo , Humanos , Intestinos/fisiologia , Laparoscopia , Tempo de Internação , Pessoa de Meia-Idade , Duração da Cirurgia , Recuperação de Função Fisiológica
11.
Tokai J Exp Clin Med ; 44(3): 54-58, 2019 Sep 20.
Artigo em Inglês | MEDLINE | ID: mdl-31448397

RESUMO

INTRODUCTION: After a FDA recommendation in April 2014, power morcellation (PM) in laparoscopic myomectomy (LM) has become less common. We now collect a myoma using manual morcellation (MM) from a wound in the umbilical region. In this study, we compared the PM and MM methods. METHODS: The subjects were 69 patients who underwent LM from April 2013 to March 2016 using PM (n = 37) or MM (n = 32). With PM, the myoma was collected using a 4-hole 12-mm parallel trocar in the left lower abdomen. Using MM, an EZ ACCESSTM (2-cm skin incision) was placed on the umbilical region, and the myoma was put in a collection purse and guided into the access hole for MM using scissors under direct vision. RESULTS: None required allogeneic transfusion or a transition to open surgery, and had surgical or post surgical complications. At multiple linear regression analysis, which was adjusted by age, body mass index, and intraoperative blood loss, significant difference was not observed in operation time between the PM and MM groups. CONCLUSION: Manual morcellation was found to be a safe method for collection of myoma that prevents scattering of tissues and does not prolong the operation time.


Assuntos
Laparoscopia/métodos , Leiomioma/cirurgia , Morcelação/métodos , Miomectomia Uterina/métodos , Neoplasias Uterinas/cirurgia , Fatores Etários , Perda Sanguínea Cirúrgica/estatística & dados numéricos , Índice de Massa Corporal , Feminino , Humanos , Duração da Cirurgia , Análise de Regressão , Estudos Retrospectivos
13.
Eur J Obstet Gynecol Reprod Biol ; 239: 52-59, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31181399

RESUMO

OBJECTIVE: We systematically evaluated if there are any clinical differences in the safety and feasibility of single port laparoscopic myomectomy when compared to conventional laparoscopic myomectomy. STUDY DESIGN: A meta-analysis and systematic review was conducted in accordance with the PRISMA statement. We searched different databases including Medline, Embase, Cochrane, and Google Scholar up to April 2018. Comparative studies as randomized controlled trials and prospective and retrospective cohort studies were included. RESULTS: A meta-analysis was performed on the safety, feasibility, and potential benefits. Two randomized controlled trials and six cohort studies (2 prospective and 4 retrospective) were meta-analyzed to compare the surgical outcomes of 907 patients. Rates of minor complications were not different between the two groups [OR 1.33 (0.67, 2.63), I2 = 0%]. Major complications requiring re-operation occurred in two cases in the single port group and in the conventional group respectively. There was no significant statistical difference between the groups. Conversion to laparotomy did not occur in either group, and the conversion rate from single port to the multi-port operation was 2.1% (6/288). The pain score one hour after operation was significantly lower in the single port group [MD -0.41 point (-0.63, -0.18), I2 = 3.7%]. However, this difference was not observed at six and 24 h postoperatively. There was no difference in the operation time, estimated blood loss, or hemoglobin decrease between the two groups. CONCLUSION: A meta-analysis showed that single port laparoscopic myomectomy is comparable to conventional laparoscopic myomectomy in terms of safety and feasibility and more advantageous in terms of immediate postoperative pain. If performed based on the appropriate patient selection criteria including size and number of myoma, single port laparoscopic myomectomy can have similar surgical outcomes to those of conventional laparoscopic myomectomy. Further research and resources are required to identify whether single port laparoscopic myomectomy is more beneficial in terms of cosmetic results, patient satisfaction, and pregnancy outcomes.


Assuntos
Laparoscopia/métodos , Miomectomia Uterina/métodos , Humanos
14.
J Robot Surg ; 13(4): 585-588, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31062181

RESUMO

Uterine fibromatosis is common in women, with an estimated prevalence of up to 15-50% after 35 years. About 80% of women affected by fibromatosis have symptoms and require medical or surgical treatment. Nowadays, the gold standard for the surgical treatment of uterine fibromatosis is the use of minimally invasive surgery. The surgical skills and improvements offered by robotic approach can be relevant in reproductive surgery, in particular in minimally invasive myomectomy. However, the lack of tactile feedback of robotic platform is an important technical drawback that can reduce the accuracy of surgical procedures. Here, we present the design and the preliminary test of the wearable fabric, yielding display wearable haptic interfaces able to generate a real-time tactile feedback in terms of stiffness for applications in gynecologic robotic surgery. We preliminarily tested the device in the simulation of a real scenario of conservative myomectomy with the final purpose of increasing the accuracy and precision during surgery. The future goal is the integration of a haptic device with the commercially available robotic surgical systems with the purpose of improving the precision and accuracy of the surgical operation, thus allowing a better understanding concerning the anatomical relationship of the target structures. This in turn could determine a change in the surgical strategy in some cases, letting some patients selected for a demolitive approach retaining their uterus. This could improve surgical outcomes in fertile women enrolled for minimally invasive surgery for uterine fibroids and may be a facilitation for young gynecological surgeons or during residency teaching plans and learning programs.


Assuntos
Procedimentos Cirúrgicos Robóticos/instrumentação , Miomectomia Uterina/métodos , Dispositivos Eletrônicos Vestíveis , Feminino , Fibroma/cirurgia , Humanos , Procedimentos Cirúrgicos Minimamente Invasivos/instrumentação , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Procedimentos Cirúrgicos Robóticos/métodos , Percepção do Tato , Miomectomia Uterina/instrumentação , Neoplasias Uterinas/cirurgia , Útero/cirurgia
15.
Medicine (Baltimore) ; 98(18): e15466, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-31045825

RESUMO

We aimed to investigate the feasibility of robotic adenomyomectomy and compared surgical outcomes between laparoscopic and robotic approaches for adenomyomectomy.We retrospectively reviewed the data of women who were diagnosed with adenomyosis and underwent adenomyomectomy through a minimally invasive approach between January 2014 and March 2018 at the CHA Gangnam Medical Center, Seoul, Republic of Korea. Patient demographics and operation-related outcomes were compared between the robotic and laparoscopic surgery groups.We evaluated 43 women who underwent adenomyomectomy through a minimally invasive approach (21 underwent a laparoscopic and 22 underwent a robotic adenomyomectomy). All 22 women who had originally been scheduled to undergo robotic adenomyomectomy could successfully undergo the robotic surgery without requiring conversion to laparotomy and/or serious complications. No statistically significant differences in patient demographics were observed between the robotic and the laparoscopic surgery groups. No significant intergroup difference was observed in the operative time, estimated blood loss, weight of the resected nodule, and length of hospitalization (160.0 vs 212.5 min, P = .106; 500.0 vs 300.0 mL, P = .309; 60.0 vs 70.0 g, P = .932; and 5.0 vs 6.0 days, P = .277). No serious perioperative complications were observed in either group.Robotic adenomyomectomy is feasible for women with adenomyosis. Surgical outcomes of robotic adenomyomectomy were comparable to those of a laparoscopic approach. There was, however, no superiority of robotic adenomyomectomy in terms of surgical outcomes. Further multicenter prospective studies using standardized surgical procedures are needed to confirm the conclusion of this study.


Assuntos
Adenomiose/cirurgia , Laparoscopia/métodos , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Procedimentos Cirúrgicos Robóticos/métodos , Miomectomia Uterina/métodos , Adulto , Estudos de Viabilidade , Feminino , Humanos , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do Tratamento
16.
Taiwan J Obstet Gynecol ; 58(3): 423-427, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-31122536

RESUMO

OBJECTIVES: To evaluate the feasibility and safety of two-port myomectomy using bag-contained manual morcellation compared to three-port myomectomy using power morcellation. MATERIAL AND METHODS: A retrospective chart review was conducted for 428 cases of either two-port or three-port laparoscopic myomectomy performed by single operator in the university hospital between January 2011 and December 2016. RESULTS: The cohorts of three-port myomectomy with power morcellation was consisted of two hundred and forty-eight patients. One hundred and eighty patients underwent two-port myomectomy with manual morcellation in contained bag. Two-port group showed shorter hospital stay (5.16 ± 1.39 d vs. 4.83 ± 1.19 d, p = 0.001), less estimated blood loss (61.8 ± 58.2 mL vs. 50.2 ± 52.4 mL, p = 0.001), and higher hemoglobin level at postoperative day 1 (10.7 ± 1.17 g/dL vs. 11.0 ± 1.14 g/dL, p = 0.028) with statistical significance. Morcellation time (25.8 ± 9.30 min vs. 18.9 ± 10.11 min, p = 0.001) and total operative time (82.4 ± 30.19 min vs. 76.4 ± 25.47 min, p = 0.047) were also significantly shorter in two-port group. There were no identified spillages of fibroids, ruptures of specimen bag during manual morcellation in two-port myomectomy. In both groups, there were no cases of leiomyosarcoma diagnosed postoperatively. CONCLUSION: Two-port laparoscopic myomectomy with bag-contained manual morcellation is a feasible and safe alternative for three-port with power morcellation. Its surgical outcomes were shown to be superior to conventional laparoscopic myomectomy according to our study but further evaluation in near future is needed.


Assuntos
Leiomioma/cirurgia , Morcelação/instrumentação , Miomectomia Uterina/métodos , Neoplasias Uterinas/cirurgia , Adulto , Estudos de Casos e Controles , Feminino , Humanos , Tempo de Internação , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Duração da Cirurgia , Estudos Retrospectivos
17.
Updates Surg ; 71(4): 637-643, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-30941703

RESUMO

The objective of the study was to review the reported cases of uncommon benign uterine tumors managed by laparoscopy. Medline database was searched using predefined search terms linked to atypical leiomyomas, leiomyoma variants, laparoscopy and morcellation. Quality of articles was assessed using Joanna Briggs Institute (JBI) critical appraisal tool. Due to heterogeneity in reporting characteristics of the patients, radiological findings, macroscopic findings, histological characteristics and follow-up, we performed a narrative synthesis. We included 109 cases of leiomyoma variants managed by laparoscopy. This stands for an incidence of 2.5% out of all the included laparoscopic management of leiomyomas. These cases were approached as classic leiomyoma. Only after the final histological results that their uncommon aspect was diagnosed. Intra-operatively, the management was similar to that of leiomyoma, with either myomectomy or hysterectomy performed depending on each individual case. Follow-up of these cases was variable: one case (0.9%) recurred as peritoneal sarcoma after 5 years of follow-up. It is important for the gynecologist, radiologist and pathologist to be aware about leiomyoma variants trying to diagnose them preoperatively. Strict follow-up of these cases is mandatory, because of the risk of recurrence and the very low but possible risk of future sarcomas.


Assuntos
Histerectomia , Laparoscopia , Leiomioma/cirurgia , Miomectomia Uterina , Neoplasias Uterinas/cirurgia , Feminino , Humanos , Histerectomia/efeitos adversos , Histerectomia/métodos , Laparoscopia/efeitos adversos , Laparoscopia/métodos , Leiomioma/diagnóstico , Leiomioma/patologia , Complicações Pós-Operatórias , Miomectomia Uterina/efeitos adversos , Miomectomia Uterina/métodos , Neoplasias Uterinas/diagnóstico , Neoplasias Uterinas/patologia
18.
Fertil Steril ; 111(6): 1259-1261, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-31030890

RESUMO

OBJECTIVE: To describe laparoscopic management of a case of leyomiomatosis peritonealis disseminata associated with ovarian endometriosis. DESIGN: Surgical video article. SETTING: Academic hospital. PATIENT: We present a case of a 30-year-old woman referred to our clinic for abdominal and pelvic pain and dyspareunia. A hysteroscopic myomectomy was reported as previous surgical history. At ultrasound examination, a left ovarian cyst of 4 cm suspected for typical endometrioma and a mild hydroureteronephrosis of left kidney were revealed. The patient was scheduled for laparoscopic surgery. INTERVENTIONS: During laparoscopy, multiple nodules were found simulating widespread metastases involving colon, small bowel, omentum, right diaphragmatic dome, gastric surface, vesico-uterine area and abdominal peritoneum. Several biopsies and a peritoneal washing were performed, suspecting a peritoneal carcinomatosis. The histological frozen section examination revealed a possible benign disease, requiring further immunohistochemical study that diagnosed leiomyomatosis peritonealis. A second laparoscopy was then performed after one month. Enucleation of the left ovarian endometriotic cyst with classic stripping technique was performed. The left ureter was compressed by a fibrotic nodule of 5 cm that was isolated and removed. Operating time was 80 minutes. The postoperative course was uneventful and the patient was discharged on postoperative day 2. MAIN OUTCOME MEASURES: Description of a case of leiomyomatosis peritonealis disseminata in a patient with no previous history of intra-abdominal morcellation. RESULTS: The removal of the left ovarian endometriotic cyst and the periureteral nodule was successfully performed. The patient reported good health conditions without hydroureteronephrosis at six months follow up visit. CONCLUSIONS: Leiomyomatosis peritonealis disseminata is a rare clinical disorder characterized by proliferation of nodules, consisted by smooth muscle cells. The association of this condition with endometriosis has been described in other studies. Despite several medical therapies have been proposed (chemotherapy, aromatase inhibitor, gonadotropin-releasing hormone agonist), surgical excision remains a good option, frequently performed for symptoms palliation. Laparoscopic approach might be considered the procedure of choice in case of symptomatic women with leiomyomatosis peritonealis disseminata.


Assuntos
Endometriose/cirurgia , Histeroscopia , Leiomiomatose/cirurgia , Doenças Ovarianas/cirurgia , Neoplasias Peritoneais/cirurgia , Miomectomia Uterina/métodos , Adulto , Endometriose/complicações , Endometriose/patologia , Feminino , Humanos , Leiomiomatose/complicações , Leiomiomatose/patologia , Doenças Ovarianas/complicações , Doenças Ovarianas/patologia , Neoplasias Peritoneais/complicações , Neoplasias Peritoneais/secundário , Resultado do Tratamento
19.
Fertil Steril ; 111(6): 1252-1258.e1, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-30982607

RESUMO

OBJECTIVE(S): To determine the association of operative time (ORT) with perioperative morbidity and whether there is an ORT at which minimally invasive myomectomy becomes inferior to laparotomy. DESIGN: Retrospective cohort study. SETTING: Not applicable. PATIENT(S): Myomectomy cases identified by CPT code from 2005 to 2016. INTERVENTION(S): Cases were stratified and analyzed by surgical approach and 90-minute intervals. MAIN OUTCOME MEASURE(S): Thirty-day postoperative morbidity. RESULT(S): A total of 11,709 myomectomies were identified; 4,673 (39.9%) were minimally invasive, 6,997 (59.8%) were abdominal, and 39 (0.3%) were conversions. The incidence of complications significantly increased with ORT. After adjusting for confounders, mean ORT in minutes (95% confidence interval) was 113 (111-115) for abdominal, 156 (153-159) for minimally invasive, and 172 (148-200) for conversions. Despite shorter ORT, morbidity was greater in abdominal cases (16% vs. 5.7%), with the highest rates in converted cases (20.5%). The minimally invasive approach in general had lower odds of complications (odds ratio, 0.23; 95% confidence interval, 0.19-0.26). However, when minimally invasive surgery ORT reached ≥ 270 minutes, the odds of a composite complication variable increased compared with abdominal cases <90 minutes (odds ratio, 2.30; 95% confidence interval, 1.69-3.13). Of minimally invasive cases, 88% were completed in <270 minutes. CONCLUSION(S): ORT was predictive of complications for both minimally invasive and abdominal myomectomies. Despite longer ORTs, minimally invasive procedures generally had superior 30-day outcomes up to 270 minutes. Careful patient counseling and preparation to increase surgical efficiency should be prioritized for either approach.


Assuntos
Laparoscopia , Leiomioma/cirurgia , Duração da Cirurgia , Miomectomia Uterina/métodos , Neoplasias Uterinas/cirurgia , Adulto , Tomada de Decisão Clínica , Bases de Dados Factuais , Feminino , Humanos , Laparoscopia/efeitos adversos , Leiomioma/patologia , Seleção de Pacientes , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Miomectomia Uterina/efeitos adversos , Neoplasias Uterinas/patologia
20.
Gynecol Obstet Invest ; 84(6): 548-554, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30965324

RESUMO

AIM: To determine the optimal hemostatic technique for laparoscopic myomectomy (LM) by comparing temporary uterine artery blockage alone or combined with blockage of the utero-ovarian vessels. PATIENTS: Women with symptomatic uterine myoma attending the Department of Obstetrics and Gynecology in Jinhua Municipal Central Hospital. METHOD: A total of 200 patients with symptomatic uterine fibroids were randomly divided into Group A (n = 65), Group B (n = 67) and Group C (n = 68). At the beginning of the procedure, 6 U of vasopressin was injected into the myometrium of all women. LM was performed in Group A; temporary bilateral uterine artery occlusion and myomectomy were performed in Group B and temporary bilateral uterine artery and utero-ovarian vessel occlusion was performed in Group C. We then evaluated operative time, perioperative bleeding, follow-up relief of menorrhagia, and the recurrence of fibroids. RESULTS: General characteristics of the patients were similar across all 3 groups. All patients underwent successful laparoscopic operation and none of the cases needed to be converted to laparotomy; there were no intraoperative complications. There was no significant difference in the operative time between groups (p = 0.332 and p = 0.346 for single-myoma and multiple-myoma respectively), and for both single and multiple-myoma groups, the blood loss was significantly lower in Group C than Groups A and B (p < 0.001). There were no differences in the recurrence rate and menorrhagia symptom relief outcomes when -compared across the 3 groups at the 30-month follow-up (p = 0.953 and p = 0.841, respectively). At final follow-up, the pregnancy rate of the sexually active patients without contraception was not statistically significant (p = 0.958). The fertility index of anti-Mullerian hormone showed no statistical difference between groups preoperatively or at 2 days, 3 months, 6 months, and 1 year postoperatively (p = 0.998, p = 0.965, p = 0.999, p = 0.994 and p = 0.993, respectively). CONCLUSION: LM with temporary bilateral uterine artery and utero-ovarian vessels occlusion has the advantages of less intraoperative bleeding compared with LM and laparoscopic transient uterine artery ligation and does not increase the mean operative time.


Assuntos
Perda Sanguínea Cirúrgica/prevenção & controle , Laparoscopia/métodos , Leiomioma/cirurgia , Artéria Uterina , Miomectomia Uterina/métodos , Neoplasias Uterinas/cirurgia , Adulto , Constrição , Feminino , Humanos , Menorragia/cirurgia , Recidiva Local de Neoplasia/epidemiologia , Duração da Cirurgia , Ovário/irrigação sanguínea , Gravidez , Taxa de Gravidez , Resultado do Tratamento
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