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Medicina (Kaunas, Lithuania) Nov 2022Leiomyomas are the most common pelvic tumors. Submucosal fibroids are a common cause of abnormal bleeding and infertility. Hysteroscopic myomectomy is the definitive... (Review)
Review
Leiomyomas are the most common pelvic tumors. Submucosal fibroids are a common cause of abnormal bleeding and infertility. Hysteroscopic myomectomy is the definitive management of symptomatic submucosal fibroids, with high efficacy and safety. Several techniques have been introduced over time and will be covered in depth in this manuscript. Advances in optics, fluid management, electrosurgery, smaller diameter scopes, and tissue removal systems, along with improved training have contributed to improving the safety and efficiency of hysteroscopic myomectomy.
Topics: Female; Pregnancy; Humans; Uterine Myomectomy; Uterine Neoplasms; Hysteroscopy; Leiomyoma; Infertility
PubMed: 36422166
DOI: 10.3390/medicina58111627 -
Fertility and Sterility Mar 2018The appropriate surgical treatment of adenomyosis, a benign invasion/infiltration of endometrial glands within the underlying myometrium, remains a subject of... (Review)
Review
The appropriate surgical treatment of adenomyosis, a benign invasion/infiltration of endometrial glands within the underlying myometrium, remains a subject of discussion. Since 1990, in place of the classical V-shaped resection method, various kinds of surgical management have been attempted, including a uterine muscle flap method that emphasizes fertility preservation, an asymmetric dissection method, and various modified reduction methods. Laparoscopic adenomyomectomy has also become an alternative to laparotomy for surgically managing the focal type of adenomyosis, although it seems to be associated with a higher risk of uterine rupture than laparotomy. This article reviews the surgical treatment of adenomyosis, including 23 uterine rupture cases that occurred during post-adenomyomectomy pregnancies, and provides an updated picture of the state of the field.
Topics: Adenomyosis; Dissection; Female; Fertility Preservation; Humans; Laparoscopy; Postoperative Complications; Risk Factors; Surgical Flaps; Treatment Outcome; Uterine Diseases; Uterine Myomectomy; Uterus
PubMed: 29566853
DOI: 10.1016/j.fertnstert.2018.01.032 -
The New England Journal of Medicine Jul 2020Uterine fibroids, the most common type of tumor among women of reproductive age, are associated with heavy menstrual bleeding, abdominal discomfort, subfertility, and a... (Comparative Study)
Comparative Study Randomized Controlled Trial
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.).
Topics: Adult; Female; Humans; Hysteroscopy; Intention to Treat Analysis; Intraoperative Complications; Laparoscopy; Leiomyoma; Length of Stay; Menorrhagia; Middle Aged; Ovarian Reserve; Postoperative Complications; Quality of Life; Reoperation; Uterine Artery Embolization; Uterine Myomectomy; Uterine Neoplasms; Uterus
PubMed: 32726530
DOI: 10.1056/NEJMoa1914735 -
Health Technology Assessment... Apr 2022Uterine fibroids are the most common tumour in women of reproductive age and are associated with heavy menstrual bleeding, abdominal discomfort, subfertility and reduced... (Randomized Controlled Trial)
Randomized Controlled Trial
BACKGROUND
Uterine fibroids are the most common tumour in women of reproductive age and are associated with heavy menstrual bleeding, abdominal discomfort, subfertility and reduced quality of life. For women wishing to retain their uterus and who do not respond to medical treatment, myomectomy and uterine artery embolisation are therapeutic options.
OBJECTIVES
We examined the clinical effectiveness and cost-effectiveness of uterine artery embolisation compared with myomectomy in the treatment of symptomatic fibroids.
DESIGN
A multicentre, open, randomised trial with a parallel economic evaluation.
SETTING
Twenty-nine UK hospitals.
PARTICIPANTS
Premenopausal women who had symptomatic uterine fibroids amenable to myomectomy or uterine artery embolisation were recruited. Women were excluded if they had significant adenomyosis, any malignancy or pelvic inflammatory disease or if they had already had a previous open myomectomy or uterine artery embolisation.
INTERVENTIONS
Participants were randomised to myomectomy or embolisation in a 1 : 1 ratio using a minimisation algorithm. Myomectomy could be open abdominal, laparoscopic or hysteroscopic. Embolisation of the uterine arteries was performed under fluoroscopic guidance.
MAIN OUTCOME MEASURES
The primary outcome was the Uterine Fibroid Symptom Quality of Life questionnaire (with scores ranging from 0 to 100 and a higher score indicating better quality of life) at 2 years, adjusted for baseline score. The economic evaluation estimated quality-adjusted life-years (derived from EuroQol-5 Dimensions, three-level version, and costs from the NHS perspective).
RESULTS
A total of 254 women were randomised - 127 to myomectomy (105 underwent myomectomy) and 127 to uterine artery embolisation (98 underwent embolisation). Information on the primary outcome at 2 years was available for 81% ( = 206) of women. Primary outcome scores at 2 years were 84.6 (standard deviation 21.5) in the myomectomy group and 80.0 (standard deviation 22.0) in the uterine artery embolisation group (intention-to-treat complete-case analysis mean adjusted difference 8.0, 95% confidence interval 1.8 to 14.1, = 0.01; mean adjusted difference using multiple imputation for missing responses 6.5, 95% confidence interval 1.1 to 11.9). The mean difference in the primary outcome at the 4-year follow-up time point was 5.0 (95% CI -1.4 to 11.5; = 0.13) in favour of myomectomy. Perioperative and postoperative complications from all initial procedures occurred in similar percentages of women in both groups (29% in the myomectomy group vs. 24% in the UAE group). Twelve women in the uterine embolisation group and six women in the myomectomy group reported pregnancies over 4 years, resulting in seven and five live births, respectively (hazard ratio 0.48, 95% confidence interval 0.18 to 1.28). Over a 2-year time horizon, uterine artery embolisation was associated with higher costs than myomectomy (mean cost £7958, 95% confidence interval £6304 to £9612, vs. mean cost £7314, 95% confidence interval £5854 to £8773), but with fewer quality-adjusted life-years gained (0.74, 95% confidence interval 0.70 to 0.78, vs. 0.83, 95% confidence interval 0.79 to 0.87). The differences in costs (difference £645, 95% confidence interval -£1381 to £2580) and quality-adjusted life-years (difference -0.09, 95% confidence interval -0.11 to -0.04) were small. Similar results were observed over the 4-year time horizon. At a threshold of willingness to pay for a gain of 1 QALY of £20,000, the probability of myomectomy being cost-effective is 98% at 2 years and 96% at 4 years.
LIMITATIONS
There were a substantial number of women who were not recruited because of their preference for a particular treatment option.
CONCLUSIONS
Among women with symptomatic uterine fibroids, myomectomy resulted in greater improvement in quality of life than did uterine artery embolisation. The differences in costs and quality-adjusted life-years are very small. Future research should involve women who are desiring pregnancy.
TRIAL REGISTRATION
This trial is registered as ISRCTN70772394.
FUNDING
This study was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme, and will be published in full in ; Vol. 26, No. 22. See the NIHR Journals Library website for further project information.
Topics: Female; Humans; Hysterectomy; Leiomyoma; Male; Pregnancy; Quality of Life; Uterine Artery Embolization; Uterine Myomectomy
PubMed: 35435818
DOI: 10.3310/ZDEG6110 -
The Cochrane Database of Systematic... Jan 2020Fibroids are the most common benign tumours of the female genital tract and are associated with numerous clinical problems including a possible negative impact on... (Meta-Analysis)
Meta-Analysis
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; I = 0%; very low-quality evidence), preterm delivery rate (OR 0.70, 95% CI 0.11 to 4.29; participants = 177; two studies; I = 0%, very low-quality evidence), clinical pregnancy rate (OR 0.96, 95% CI 0.52 to 1.78; 177 participants; two studies; I = 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; I = 0%, very low-quality evidence), or caesarean section rate (OR 0.69, 95% CI 0.34 to 1.39; participants = 177; two studies; I = 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.
Topics: Abortion, Spontaneous; Cesarean Section; Female; Humans; Infertility, Female; Leiomyomatosis; Live Birth; Pregnancy; Pregnancy Rate; Randomized Controlled Trials as Topic; Uterine Myomectomy; Uterine Neoplasms
PubMed: 31995657
DOI: 10.1002/14651858.CD003857.pub4 -
Radiology Feb 2023Laparoscopic myomectomy, a common gynecologic operation in premenopausal women, has become heavily regulated since 2014 following the dissemination of unsuspected... (Review)
Review
Laparoscopic myomectomy, a common gynecologic operation in premenopausal women, has become heavily regulated since 2014 following the dissemination of unsuspected uterine leiomyosarcoma (LMS) throughout the pelvis of a physician treated for symptomatic leiomyoma. Research since that time suggests a higher prevalence than previously suspected of uterine LMS in resected masses presumed to represent leiomyoma, as high as one in 770 women (0.13%). Though rare, the dissemination of an aggressive malignant neoplasm due to noncontained electromechanical morcellation in laparoscopic myomectomy is a devastating outcome. Gynecologic surgeons' desire for an evidence-based, noninvasive evaluation for LMS is driven by a clear need to avoid such harms while maintaining the availability of minimally invasive surgery for symptomatic leiomyoma. Laparoscopic gynecologists could rely upon the distinction of higher-risk uterine masses preoperatively to plan oncologic surgery (ie, potential hysterectomy) for patients with elevated risk for LMS and, conversely, to safely offer women with no or minimal indicators of elevated risk the fertility-preserving laparoscopic myomectomy. MRI evaluation for LMS may potentially serve this purpose in symptomatic women with leiomyomas. This evidence review and consensus statement defines imaging and disease-related terms to allow more uniform and reliable interpretation and identifies the highest priorities for future research on LMS evaluation.
Topics: Female; Humans; Leiomyosarcoma; Leiomyoma; Uterine Neoplasms; Uterine Myomectomy; Hysterectomy; Laparoscopy; Magnetic Resonance Imaging
PubMed: 36194109
DOI: 10.1148/radiol.211658 -
Fertility and Sterility Jan 2021
Topics: Female; Fertility; Humans; Laparoscopy; Sutures; Uterine Myomectomy
PubMed: 33272636
DOI: 10.1016/j.fertnstert.2020.09.149 -
Ginekologia Polska 2020The incidence of uterine fibroids, which comprise one of the most common female pelvic tumors, is almost 70-75% for women of reproductive age. With the development of... (Review)
Review
The incidence of uterine fibroids, which comprise one of the most common female pelvic tumors, is almost 70-75% for women of reproductive age. With the development of surgical techniques and skills, more individuals prefer minimally invasive methods to treat uterine fibroids. There is no doubt that minimally invasive surgery has broad use for uterine fibroids. Since laparoscopic myomectomy was first performed in 1979, more methods have been used for uterine fibroids, such as laparoscopic hysterectomy, laparoscopic radiofrequency volumetric thermal ablation, and uterine artery embolization, and each has many variations. In this review, we compared these methods of minimally invasive surgery for uterine fibroids, analyzed their benefits and drawbacks, and discussed their future development.
Topics: Female; Humans; Hysterectomy; Laparoscopy; Leiomyoma; Minimally Invasive Surgical Procedures; Uterine Myomectomy; Uterine Neoplasms
PubMed: 32266956
DOI: 10.5603/GP.2020.0032 -
Acta Obstetricia Et Gynecologica... Jul 2016There is concern about the risk of uterine rupture in the subsequent pregnancy after myomectomy. This risk is reported in literature to be around 0.7-1%. The aim of this... (Review)
Review
INTRODUCTION
There is concern about the risk of uterine rupture in the subsequent pregnancy after myomectomy. This risk is reported in literature to be around 0.7-1%. The aim of this study was to evaluate the incidence of uterine rupture and associated risk factors in women who had a trial of labor after prior myomectomy.
MATERIAL AND METHODS
A systematic review of the literature was performed including all cohort studies with at least five cases reporting outcomes of pregnancies after prior myomectomy. The terms "myomectomy", "pregnancy", "trial of labor" and "uterine rupture" were used in PubMed and EMBASE searches for identification purposes. Every reference was reviewed for possible inclusion and all eligible cases of uterine rupture were considered.
RESULTS
Twenty-three studies with at least five cases of pregnancy after myomectomy were identified, with an overall incidence of uterine rupture of 0.6% (0.3-1.1%) (n = 11/1825). Of these 23 studies, 11 studies reported detailed data about trial of labor after myomectomy and related pregnancy outcomes, including 1034 pregnancies and 756 viable (≥24 weeks) deliveries. The overall incidence of uterine rupture after myomectomy in the included studies was 0.93% (0.45-1.92%) (n = 7/756); specifically, it was 0.47% (0.13-1.70%) (n = 2/426) in women undergoing trial of labor after myomectomy, and 1.52% (0.65-3.51%) (n = 5/330) in women before the onset of labor. Of the seven uterine ruptures, five (71%) occurred within 36 weeks (range 24-40 weeks).
CONCLUSIONS
Trial of labor after myomectomy is associated with a 0.47% risk of uterine rupture. There were no identified risk factors among the variables studied. The present systematic review of the literature revealed that uterine rupture after prior myomectomy occurred mainly before 36 weeks and before labor.
Topics: Delivery, Obstetric; Female; Humans; Pregnancy; Pregnancy Outcome; Trial of Labor; Uterine Myomectomy; Uterine Rupture
PubMed: 27154306
DOI: 10.1111/aogs.12920 -
International Journal of Gynaecology... Feb 2023To determine treatment options (myomectomy vs. uterine artery embolization (UAE)) for women wishing to avoid hysterectomy. (Randomized Controlled Trial)
Randomized Controlled Trial
Effects on heavy menstrual bleeding and pregnancy of uterine artery embolization (UAE) or myomectomy for women with uterine fibroids wishing to avoid hysterectomy: The FEMME randomized controlled trial.
OBJECTIVE
To determine treatment options (myomectomy vs. uterine artery embolization (UAE)) for women wishing to avoid hysterectomy.
METHODS
A multicenter randomized controlled trial was conducted on 254 women and data were collected on fibroid-specific quality of life (UFS-QOL), loss of menstrual blood, and pregnancy.
RESULTS
At 4 years, the mean difference in the UFS-QOL was 5.0 points (95% confidence interval (CI) -1.4 to 11.5; P = 0.13) in favor of myomectomy. This was not statistically significant as it was at 2 years. There were no differences in bleeding scores, rates of amenorrhea, or heavy bleeding. Of those who were still menstruating, the majority reported regular or fairly regular periods: 36 of 48 (75%) in the UAE group and 30 of 39 (77%) in the myomectomy group. Twelve women after UAE and six women after myomectomy became pregnant (4 years) with seven and five live births, respectively (hazard ratio 0.48, 95% CI 0.18-1.28). There was no difference between the levels of hormones associated with the uterine reserve in each group.
CONCLUSION
Leiomyoma are common in reproductive-aged women, causing heavy menses and subfertility. Among women with uterine fibroids, myomectomy resulted in better fibroid-related quality of life at 4 years, compared with UAE but the treatments decreased menstrual bleeding equally. There was also no significant difference in the impact of treatment on ovarian reserve.
Topics: Pregnancy; Female; Humans; Adult; Uterine Myomectomy; Uterine Artery Embolization; Quality of Life; Uterine Neoplasms; Menorrhagia; Leiomyoma; Hysterectomy; Treatment Outcome
PubMed: 36511801
DOI: 10.1002/ijgo.14626