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Objectives: To compare surgeon responses regarding their surgical plan before and after receiving a patient-specific three-dimensional (3D)-printed model of a patient's multifibroid uterus created from their magnetic resonance imaging., Methods: 3D-printed models were derived from standard-of-care pelvic magnetic resonance images of patients scheduled for surgical intervention for multifibroid uterus. Relevant anatomical structures were printed using a combination of transparent and opaque resin types. 3D models were used for 7 surgical cases (5 myomectomies, 2 hysterectomies). A staff surgeon and 1 or 2 surgical fellow(s) were present for each case. Surgeons completed a questionnaire before and after receiving the model documenting surgical approach, perceived difficulty, and confidence in surgical plan. A postoperative questionnaire was used to assess surgeon experience using 3D models., Results: Two staff surgeons and 3 clinical fellows participated in this study. A total of 15 surgeon responses were collected across the 7 cases. After viewing the models, an increase in perceived surgical difficulty and confidence in surgical plan was reported in 12/15 and 7/15 responses, respectively. Anticipated surgical time had a mean ± SD absolute change of 44.0 ± 47.9 minutes and anticipated blood loss had an absolute change of 100 ± 103.5 cc. 2 of 15 responses report a change in pre-surgical approach. Intra-operative model reference was reported to change the dissection route in 8/15 surgeon responses. On average, surgeons rated their experience using 3D models 8.6/10 for pre-surgical planning and 8.1/10 for intra-operative reference., Conclusions: Patient-specific 3D anatomical models may be a useful tool to increase a surgeon's understanding of complex gynaecologic anatomy and to improve their surgical plan. Future work is needed to evaluate the impact of 3D models on surgical outcomes in gynaecology., (Copyright © 2024. Published by Elsevier Inc.)

Introduction: Eighty-five per cent of uterine inversions are puerperal. Non-puerperal uterine inversion is usually caused by tumours that exert a traction force on the fundus of the uterus. This causes the uterus to be partially or completely inverted. It is commonly related to benign tumours like submucosal leiomyomas. Nevertheless, malignancies are an infrequent association., Case Presentation: We report a case of a 35-year-old female patient, medically and surgically free, gravida0 para0, complaining of menometrorrhagia associated with pelvic pain for 2 years. A suprapubic ultrasound scan showed an enlarged, globular uterus with a heterogeneous, undefined mass of 49 mm in size. MRI scan showed the appearance of a U-shaped uterine cavity and a thickened inverted uterine fundus with an endometrial infiltrating mass of 25 mm. Intraoperative exploration showed uterine inversion involving the ovaries; the fallopian tubes and the round ligaments and a necrotic intracavitary mass. The malignancy of the tumor was confirmed through anatomopathological examination as Adenosarcoma., Conclusions: Uterine inversion is rare outside the puerperal period, and malignant etiology must not be overlooked. Therefore, comprehensive care with meticulous etiological investigation is crucial.

Aim: To study the incidence, extent and fate of uterine ischaemia as one of the forms of non-target embolisation following uterine artery embolisation (UAE), as detected on immediate post-embolisation and contrast-enhanced magnetic resonance imaging (MRI) examinations at the 3-month follow-up., Materials and Methods: A retrospective study was undertaken comprising 43 women (mean age: 44.8 ± 3.79 years). MRI was performed before, immediately after (within 6 h), and 3 months after successful UAE. Areas of uterine ischaemia were identified on immediate post-embolisation MRI as regions of newly developed (compared to pre-embolisation MRI) absent enhancement within the uterus not corresponding to the location of the leiomyoma. The volume of the ischaemic region was calculated using the formula (height × length × width × 0.523)., Results: Uterine ischaemia was encountered in 29 patients (67.44%). The mean volume of the ischaemic region immediately after UAE was 29.29 ± 19.15 ml (range: 7.36-87.71 ml). At 3-month follow-up, it was 0.35 ± 0.95 ml (range: 0-3.5 ml) with 25 (86%) patients showing complete resolution of the ischaemia. The mean reduction in the volume of the ischaemic region at the 3-month follow-up was 98.24 ± 5.72% (range: 72-100%). This volume reduction was statistically significant (p<0.0001)., Conclusion: Uterine ischaemia as a form of non-target embolisation following UAE might be encountered in up to two thirds of patients. These ischaemic areas are significantly reduced at the 3-month follow-up with up to 86% of cases showing complete reversibility of the ischaemia., (Copyright © 2021 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.)

Leiomyoma is a benign mesenchymal tumor that develops from smooth muscle cells. It can present in various histological variants. Leiomyoma with bizarre nuclei is an infrequent variant of uterine smooth muscle neoplasm. It is characterized by focally or diffusely distributed bizarre cells on the background of a typical leiomyoma. These bizarre cells are large, multinucleated, or multilobulated and have an eosinophilic cytoplasm. Even though leiomyomas with bizarre nuclei display benign clinical behavior, their differential diagnosis from leiomyosarcoma can sometimes be difficult. Leiomyoma has been described most commonly in the uterus. There is no case of leiomyoma originating from paratubal cysts described in the literature. In this article, we present a rare case of leiomyoma with bizarre nuclei originating from a paratubal cyst.

Objective: The purpose of present report is an effective clinical approach to incarcerated uterus by the trimester of pregnancy, in this case and 54 cases reported previously., Case Report: A woman at 18 + 5 weeks of gestation was referred with abdominal pain and urinary dysfunction. In pelvic examination, the cervix was not seen and huge myoma was located at retroverted anterior uterine wall and the elongated cervix was pulled up above the bladder in ultrasonography. The uterine incarceration was confirmed by magnetic resonance imaging. The manual reduction of uterus was attempted with knee-chest-position repeatedly. However, this was unsuccessful because large fibroid was impacted and immovable. Therefore, laparotomy was conducted for repositioning of uterus. Pregnancy was maintained without any complication and a 4250 g healthy female infant was delivered by cesarean section., Conclusion: By analyzing of several cases, useful diagnostic modalities and effective management should be approached according to trimester of pregnancy., Competing Interests: Declaration of competing interest The authors have no conflicts of interest relevant to this article., (Copyright © 2021. Published by Elsevier B.V.)

Purpose: Uterine angiomyolipoma (AML) is a rare condition involving benign tumors composed of varying proportions of blood vessels, fat, and epithelioid or spindled smooth muscle cells. We analyzed the clinicopathological features, diagnosis and treatment methods, and prognosis of uterine AML., Methods: We retrospectively analyzed the clinical-pathological data of eight patients with pathologically diagnosed uterine AML at a single center from January 2008 to July 2020., Results: The mean age of the patients was 50 years (range, 41-62). One patient was asymptomatic; the main clinical manifestations of the others included vaginal bleeding (3), menorrhagia (2), abdominal pain (1), and dysmenorrhea with adenomyosis (1). In one case, fat components observed via abdominal computed tomography led to a diagnosis of uterine leiomyolipoma; the rest were diagnosed as uterine leiomyoma (4), uterine fibroid degeneration (2), and pelvic mass (1). The lesions were in the body of the uterus (6), the fundus of the uterus (1), and the broad ligament (1). Seven patients had a focal soft tumor texture, and one had a tough texture; the lesions were yellow (3), yellow-white (3), and pinkish white (2). Surgeries included transabdominal myomectomy (2), transabdominal hysterectomy (2), transabdominal hysterectomy/bilateral salpingo-oophorectomy (2), and laparoscopic total hysterectomy/bilateral salpingectomy (2). The median follow-up time was 72 months. No relapses were reported., Conclusion: Uterine AML has a low incidence rate and is most likely to occur in perimenopausal women. The clinical manifestations are similar to those of uterine leiomyomas, but AML should be suspected if the internal echo of the uterine tumor is uneven and contains adipose tissue.

A number of benign and malignant gynaecological conditions can cause infertility. Advancements in assisted reproductive technologies have facilitated the rapidly evolving subspecialty of fertility preservation. Regardless of clinical indication, women now have the reproductive autonomy to make fully informed decisions regarding their future fertility. In particular, there has been an increasing interest and demand among patients and healthcare professionals for fertility-sparing surgery. Gynaecologists find themselves continually adapting surgical techniques and introducing novel procedures to facilitate this rapidly emerging field and anaesthetists need to manage the consequent physiological demands intra-operatively. Not only is it important to understand the surgical procedures now undertaken, but also the intra-operative management in an ever evolving field. This article reviews the methods of fertility-sparing surgery and also describes important anaesthetic challenges including peri-operative care for women undergoing complex fertility-sparing surgeries such as uterus transplantation., (© 2021 Association of Anaesthetists.)

Purpose: To assess the feasibility and safety of total laparoscopic hysterectomy (TLH) for uteri ≥ 1.5 kg., Methods: We prospectively evaluated all elective TLHs (with or without adnexectomy) performed for fibromatous uteri between August 2009 and August 2019 in the Department of Obstetrics and Gynecology, Sirai Hospital, Carbonia, and the Department of Gynecologic Oncology, Businco Hospital, Azienda Ospedaliera Brotzu, Cagliari. Patients with large myomatous uteri (uterine weight ≥ 1.5 kg on pathology reports) were included in the analysis. We examined all procedures and collected data about intra- and post-operative short-term and long-term complications, intraoperative blood loss, operative time, hospital stay, and time to achieve well-being., Results: Seventy-eight patients were included. The median weight was 2,000 g (range 1,500-11,000 g), estimated blood loss was 100 mL (range 10-700 mL), operating time was 135 min (range 60-300 min), and hospital stay was 2 days (range 2-5 days). Conversion to laparotomy occurred in 4 patients (5.1%) with uterine weight ranging from 3 to 5.5 kg, due to severe adherence syndrome or inadequate visualization. As for intraoperative complications, 1 patient (who had the largest removed uterus weighing 11,000 g) experienced an intraoperative ureteral injury (grade III). No major postoperative complications occurred., Conclusions: This study provides the largest case series of TLH for fibromatous uteri > 1.5 kg and includes some of the largest uteri reported to date in the literature (weighing 5,320, 5,720, and 11,000 g, respectively). The study reaffirms the feasibility and safety of a minimally invasive hysterectomy even in the case of abnormally large uteri.

Objective: To demonstrate a novel technique to surgically treat certain vaginal conditions., Design: Technical video demonstrating 2 cases in which the technique is used., Setting: Gynecological Minimally Invasive and Robotic Surgery Unit at Clínica Universitaria (private clinic), Concepción, Chile., Interventions: Local institutional review board was consulted, and this study was exempted from approval. Institutional ethics committee approved the study and publication of these data. A 35-year-old woman with a bicornuate unicollis uterus presented with dyspareunia. Her examination revealed an incomplete longitudinal vaginal septum. Her right hemivagina was slightly wider than the left one. With the patient under spinal anesthesia, we performed a complete resection of the septum using the single-port/pneumovagina technique (SPPT). A 36-year-old woman who was nulligravida presented with dyspareunia. On clinical exam she had a 3-cm leiomyoma in the proximal vaginal third. Doppler-powered pelvic ultrasound ruled out any vascular communication with the cervix. We performed a vaginal myomectomy using the SPPT under spinal anesthesia. In this particular case we used a fourth trocar in the gel cap to use a myoma screw. With this technique we created a pneumovagina occluding the introitus with the aid of a single-port device (GelPoint Path; Applied Medical, Rancho Santa Margarita, CA). We selected this particular device, designed for transanal surgery, because its access channel avoids gas leakage after applying gentle pressure on the cap. The working cannel is 4 × 4.5 cm, and up to 4 trocars can be inserted in the gel cap. We use 12 mm Hg of pressure to create the pneumovagina and 5 L/min flow to maintain it. Similar approaches have been described for treating eroded and/or infected sacrocolpopexy mesh [1-3]. One could question the utility of this approach over conventional vaginal surgery, and in this sense we believe it provides both the surgeon and surgical assistant a much more comfortable and ergonomic position while performing surgery. It also improves the view of anatomic structures for the surgical team, which in conventional vaginal surgery is limited only to the surgeon. Both procedures were uneventful. The operation time for the first patient was 5 minutes, and the patient was discharged 4 hours later. The operation time for the second patient lasted 35 minutes, and she was discharged 12 hours later., Conclusion: The creation of a pneumovagina with the application of a single-port device provides an excellent view of vaginal structures and allows the application of laparoscopic techniques to perform vaginal surgeries in a much more ergonomic fashion compared with conventional vaginal surgery., (Copyright © 2019 AAGL. Published by Elsevier Inc. All rights reserved.)

Our insights into the molecular pathogenesis of uterine smooth muscle tumors have improved significantly. Accordingly, in the present review, we advocate a more refined risk assessment for patients considering surgical removal of fibroids or hysterectomy, respectively, requiring morcellation. For this procedure, the risk estimates given for the iatrogenic spread of a previously unexpected malignancy considerably vary among different studies. Nearly all previous studies conducted retrospectively refer to the risk of a patient having an unexpected malignancy at the time of surgery. We feel that, more appropriately, risk should refer to the number of tumors because, as a rule, every single nodule arises independently and, thus, carries an independent risk of being malignant or not. Furthermore, whether so-called parasitic fibroids carry an underestimated risk of stepwise malignant transformation is discussed., (Copyright© 2020, International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.)

Study Objective: To evaluate uterine scar features after laparoscopic myomectomy (LM) compared with myomectomy performed by laparoscopy initially and then completed with minilaparotomy (LAM)., Design: Prospective cohort study., Setting: An academic center for advanced endoscopic gynecologic surgery., Patients: Sixty-nine symptomatic women who underwent myomectomy between July and December 2018., Intervention: Patients underwent LM or LAM and 3-month follow-up ultrasonography., Measurements and Main Results: Forty-four patients underwent LM and 25 underwent LAM. Demographic data, intraoperative parameters, and postoperative outcomes were collected. Two-dimensional color Doppler ultrasound was done at a 3-month follow-up to evaluate myomectomy scar features, myometrial thickness, and the presence of and vascularity of a heterogeneous mass. These features were compared with those of the intact myometrium on the opposite wall of the patient's uterus. The 2 groups had similar demographic characteristics, and there were no significant between-group differences in the number, maximum diameter, type, or location of myomas. The mean myometrial thickness at the scar site was 18.9 ± 3.22 mm in the LM group and 19.7 ± 3.50 mm in the LAM group, with no significant difference between the 2 groups. There was no meaningful difference in vascularity between the scar and normal myometrium. Heterogeneous masses were detected in 23% of patients in the LM group and in 24% of those in the LAM group. Other than mean operative time (207 minutes for LM vs 150 minutes for LAM; p < .001) and mean postoperative reduction in hemoglobin (1.77 mg/dL for LM vs 2.35 mg/dL for LAM; p = .023), there were no other statistical differences between the 2 groups. One patient in the LM group experienced a bowel injury resulting from morcellation., Conclusion: There were no differences in myometrial scar features after LM compared with after LAM, implying effective suturing via both approaches., (Copyright © 2019 AAGL. Published by Elsevier Inc. All rights reserved.)

Background: Transfemoral access is the traditional gold standard for uterine artery angiography; however, transradial access is gaining in popularity because of its decreased complication profile and patient preference. We present a case of a patient who underwent successful total abdominal hysterectomy for symptomatic uterine fibroids with ambiguous pelvic vasculature that would have been otherwise aborted if it were not for intraoperative transradial access angiography., Case Presentation: A 52-year-old Caucasian woman presented to her gynecologist for an elective total abdominal hysterectomy and bilateral salpingo-oophorectomy. During preoperative imaging, a 15-cm mass consistent with a uterine fibroid was identified, and the patient's gynecologist decided to treat her with surgical resection, given the fibroid's size. The procedure was halted upon discovery of a complicated vascular plexus at the fundus of the uterus, and an intraoperative vascular consult was requested. The vascular operator used a transradial access to perform pelvic angiography in real time to identify the complicated pelvic vasculature, which allowed the gynecologist to surgically resect the uterine fibroid. The patient was discharged on postoperative day 4 without any complications., Conclusions: Intraoperative imaging is a useful technique for the identification of complicated anatomical structures during surgical procedures. The successful outcome of this case demonstrates an additional unique benefit of transradial access and highlights an opportunity for interdisciplinary collaboration for management of complicated surgical interventions.

Background: There are currently sparse data on the relationship between surgeon- and patient-related factors and perioperative morbidity in the setting of elective hysterectomy for the larger uterus., Objective: We sought to evaluate the impact of surgeon case volume on perioperative adverse events in women undergoing minimally invasive hysterectomy for uteri >250 g., Study Design: This is a retrospective cohort study of all women who underwent total vaginal, total laparoscopic, laparoscopic-assisted vaginal, or robotic-assisted total laparoscopic hysterectomy from January 2014 through July 2016. Hysterectomy was performed for: fibroids, pelvic pain, abnormal uterine bleeding, or prolapse. Patients were identified by Current Procedural Terminology codes and the systemwide electronic medical record was queried for demographic and perioperative data. Perioperative adverse events were defined a priori and classified using the Clavien-Dindo scale. Surgeon case volume was defined as the mean number of minimally invasive hysterectomy cases performed per month by each surgeon during the study period., Results: In all, 763 patients met inclusion criteria: 416 (54.5%) total laparoscopic hysterectomy, 196 (25.7%) robotic-assisted total laparoscopic hysterectomy, 90 (11.8%) total vaginal hysterectomy, and 61 (8%) laparoscopic-assisted vaginal hysterectomy. Mean (±SD) age was 47.3 ± 6.1 years, and body mass index was 31.1 ± 7.4 kg/m 2 . In all, 66 surgeons performed minimally invasive hysterectomy for uteri >250 g during the study period, and the median rate of minimally invasive hysterectomy cases for large uteri per month was 3.4 (0.4-3.7) cases/month. The median (IQR) uterine weight was 409 (308-606.5) g. The rate of postoperative adverse events Dindo grade >2 was 17.8% (95% confidence interval, 15.2-20.7). The overall rate of intraoperative adverse events was 4.2% (95% confidence interval, 2.9-5.9). The rate of conversion to laparotomy was 5.5% (95% confidence interval, 4.0-7.4). There was no significant difference in adverse event rates between the routes of minimally invasive hysterectomy cases (25.6% vs 17.5% vs 18.0% vs 14.8% for total laparoscopic hysterectomy, robotic-assisted laparoscopic hysterectomy, total vaginal hysterectomy, and laparoscopic-assisted vaginal hysterectomy, respectively, P = .2). In a logistic regression model controlling for age, body mass index, uterine weight, operating time, and history of laparotomy, higher monthly minimally invasive hysterectomy volume was significantly associated with the likelihood that a patient would experience a postoperative adverse event (adjusted odds ratio, 1.1 for each additional minimally invasive hysterectomy case for large uteri per month; 95% confidence interval, 1.0-1.3). When controlling for the same variables, a higher incidence of intraoperative complications was significantly associated with monthly minimally invasive hysterectomy case volume (adjusted odds ratio, 1.5 for each additional minimally invasive hysterectomy case for large uteri per month; 95% confidence interval, 1.20-2.08). Increasing age was associated with a lower incidence of complications (adjusted odds ratio, 0.9 for each additional year; 95% confidence interval, 0.8-0.9). Higher monthly minimally invasive hysterectomy volume was associated with a lower rate of conversion from a minimally invasive approach to laparotomy (adjusted odds ratio, 0.4 for each additional minimally invasive hysterectomy case for large uteri per month; 95% confidence interval, 0.2-0.5)., Conclusion: The overall rate of serious adverse events associated with minimally invasive hysterectomy for uteri >250 g was low. Higher monthly minimally invasive hysterectomy case volume was associated with a higher rate of intraoperative and postoperative adverse events but was associated with a lower rate of conversion to laparotomy., (Copyright © 2018 Elsevier Inc. All rights reserved.)

We analyzed cytokine profile in blood serum of patients with uterine myoma and revealed significantly reduced level of IFNγ and a tendency towards a decrease in the levels of IL-1β and TNFα; the levels of IL-6, IL-8, and IL-12p70 did not differ from those in healthy women. The drop in the concentrations of factors responsible for inflammation and angiogenesis in tissues are unfavorable for proliferation and differentiation of the uterine tissues.

The leiomyomas are a common gynecologic entity that may present unusual growth patterns or unusual locations. Its atypical presentations creates a diagnostic challenge. This is a case report of a parasitic leiomyoma located in the anterior abdominal wall in a 53 years old woman with pelvic compressive and urinary symptoms, with no history of any gynecological surgery. This case illustrates the diagnostic difficulties and describes the complementary images used in the preoperative evaluation.

Purpose of Review: Since the recent black-box warning regarding the use of electromechanical morcellation, there has been a hesitancy to utilize the product and even to perform other types of morcellation by gynecologists. Unfortunately, this Food and Drug Administration action and the continued public criticisms of this procedure are grounded in poor data and faulty reasoning. To truly perform informed consent to patients considering procedures involving morcellation, a thorough review of the facts, not alternative facts, must be communicated., Recent Findings: Misrepresentation of the ethics surrounding this procedure, the role of informed consent and the risks and benefits as determined by evidence-based medicine have led to confusion and poor public policy. Today's evidence suggests that the procedure is indeed ethical when full disclosure of the risks and benefits is presented via informed consent. Risks of the procedure have been exaggerated significantly, and little attention has been paid to the risks of denying morcellation procedures to patients. Attempts to condemn gynecologists as acting contrary to established surgical principles do not coincide with facts., Summary: Morcellation is a controversial technique which undoubtedly has a role as well as limitations. To appropriately determine if the procedure is indicated and acceptable to the patient, full disclosure of the best available evidence is necessary.

Objectives: To develop and evaluate the efficacy and feasibility of Intracapsular Rotary-cut Procedure (IRCP) in laparoscopic myomectomy (LM)., Study Design: It is a retrospective study conducted in Peking University Shenzhen Hospital (PUSH) in Shenzhen, China. A total of 96 patients who were treated with LM because of big and moderate size of myomas in PUSH from January 2013 and December 2015 were enrolled in this study. Among them 35 were managed with IRCP -integrated LM as the study group, while the other 61 were treated with normal LM as the control group. The core steps of IRCP include minimized uterine incision, rotary cuttings in the fibroid inside the pseudocapsule, and preserving the fibers and vessels of the fibroid pseudocapsule. The operation data and outcome variables of each patient in the two groups were collected and compared to evaluate the efficacy and feasibility of this new improved surgery procedure., Results: The ages, body mass indexes, main indication for myomectomy, and the diameters, numbers and types of the fibroids of patients in the two groups were similar. There is no significant difference in enucleation time and days of postoperative in-hospital staying between the two groups. In comparison with normal LM, application of IRCP significantly reduced the length of uterine incisions (P=0.000), the overall time of operations (P=0.001), and the time for uterine cavity suturing (P=0.000), and application of IRCP was also associated with less operation bleeding (P=0.003) and postoperative hemoglobin dropping (P=0.001). Five cases (8.2%) in the control group were referred to laparotomy, while no case was done so in the study group. No patient in the study group needed blood transfusion but six patients (9.8%) in the control group did. Follow-up to all the patients showed no uterine malignant tumor., Conclusions: Our study provided strong supportive evidences showing that Intracapsular Rotary-cut Procedures is safe and practicable. The less uterine incision length, less surgery time, and less bleeding than the normal LM procedures all suggests that IRCP should be adopted in LM for facilitation to the operation procedures, minimization of operative invasiveness, and protection to patients' infertility., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Background: Gynecologic surgeries are performed through abdominal, vaginal, laparoscopic, or robot-assisted laparoscopic routes. However, if the pelvis is not accessible by one of these routes, there are no published reports to guide pelvic surgeons., Case: A 34-year-old conjoined twin status postseparation with uterine didelphys and absence of her left colon and sacrum underwent hemihysterectomy, at which time her müllerian anomaly was unknown. She re-presented with vaginal bleeding and pain eventually attributed to a retained uterine horn. Conservative management failed. Given dense adhesions, traditional approaches to hysterectomy were not successful. She underwent a transperineal hemisupracervical hysterectomy., Conclusion: We propose a novel approach to the pelvis to guide surgeons when traditional approaches are not feasible. We also describe an instance of a retained uterine didelphys horn.

The treatment of intrauterine masses, such as endometrial polyps and leiomyomas, has undergone a technological revolution in the past few decades. Gynecologists may now choose from a variety of unipolar and bipolar resectoscopes as well as an assortment of both mechanical and bipolar hysteroscopic morcellators. We present a comparison of these technologies to better practitioners understanding of the strengths and limitations of these devices.

Background: Total laparoscopic hysterectomy (TLH) has demonstrated to be feasible and safe in the presence of very large uteri. However, it is currently difficult to establish the upper uterine weight limit for successful performance of a laparoscopic hysterectomy., Case Presentation: Here we report the case of a TLH performed for a very large fibromatous uteri weighing 5320 g in a 40-year-old Caucasian woman. The surgery had no complications with an operating time of approximately 220 min. The patient was discharged from the hospital on postoperative day 3 in very good condition. To our knowledge, the present paper is the only to describe a uterus of this size removed by laparoscopic hysterectomy., Conclusions: Our case demonstrates that uterine size is not a determinant for a final surgical decision to use laparoscopic hysterectomy. Therefore, if not contraindicated by the patient's comorbidities or peculiar anatomical conditions, we believe that laparoscopic hysterectomy could be performed in the presence of large uteri without hypothetical weight limits.

Objective: Laparoscopic approaches are the gold standard surgical treatment for intramural and subserous fibroids, whereas submucosal myomas can be treated via hysteroscopy. Removal of intramural myomas often requires a subsequent reconstruction of the uterine wall that ranges from single- to multiple-layer sutures to complex reconstructions. Several classification systems are currently used to characterize uterine fibroids, all of which focus on the assessment of submucosal fibroids during hysteroscopic myomectomy. There are no classification systems for the comprehensive localization of fibroids or for uterine reconstruction after myomectomy. Therefore, the aim of this study was to validate a new scoring system developed by our group to classify uterine leiomyoma as well as a standardized assessment scoring system for uterine reconstruction after surgical myomectomy., Methods/patients: To validate the uterine fibroid and uterine reconstruction classification systems, a retrospective review of 136 patients undergoing surgical myomectomy and uterine reconstruction at a single tertiary institution was performed. The age of the patient, duration of surgery, number, size, and location of excised fibroids, number of uterine incisions, level of uterine reconstruction, desire for future pregnancies, pre- and postoperative hemoglobin concentrations, duration of postoperative hospitalization, and operating surgeon were obtained by medical chart review. For each patient, a specific fibroid score and the level of uterine reconstruction were determined according to the classification systems. Correlations between the uterine fibroid and reconstruction scores, as well as between the classification scores and perioperative parameters, were analyzed., Results: The newly developed classification system for uterine fibroids incorporates the number, location, and size of myomas, as well as the number of uterine incisions required for myomectomy. The uterine reconstruction scoring system comprises four levels of reconstruction, ranging from no reconstruction to advanced reconstruction. Outcomes from 136 patients showed a correlation between uterine fibroid and uterine reconstructive scores. High fibroid scores were correlated with higher levels of reconstruction. Both scoring systems showed associations with the duration of surgery, intraoperative blood loss, and days of hospitalization., Conclusions: This study presents the first scoring system for uterine fibroids that incorporates all possible fibroid locations and a standardized assessment of uterine reconstruction. Scoring systems were validated in a large cohort, and a correlation was identified between uterine fibroid and uterine reconstruction scores. In daily clinical practice, this scoring system allows a better planning of surgery, specifically of the estimated duration of surgery, blood loss, and time of hospitalization.

Introduction: Hysterectomy is one of the most frequently performed gynecological operations worldwide. Due to patient perceived advantages of technical development laparoscopic hysterectomy has become a widely used method. The attitude of patients, surgeons and service providers to laparoscopic procedures is not uniform, but total laparoscopic hysterectomy has prevailed due to its advantages from other types of laparoscopic hysterectomies. Coagulation of the uterine arteries at their origin during the standardized method of total laparoscopic hysterectomy provides further benefits for this procedure., Aim: Our aim was the presentation of our experience together with a review of the relevant literature., Method: Operations were performed with the coagulation of the uterine arteries at their origin right at the beginning of the procedure. Inclusion criteria were the use of the standardized method, video documentation of the surgery, and pre- and postoperative haemostatus results., Results: Our results confirm that the procedure involves an acceptable operating time that is comparable to that of open abdominal and vaginal hysterectomies, minimal blood loss that is far less than that in open procedures, a much shorter duration of hospitalization and a low complication rate., Conclusion: In skilled hands with proper knowledge of the anatomy the standardized method of total laparoscopic hysterectomy with the coagulation of the uterine arteries at their origin is a safe and reproducible technique which suitably utilizes the advantages of minimally invasive surgery. Orv. Hetil., 2017, 158(8), 298-303.

Purpose: To analyze whether a large uterine size was associated with increased rate of intraoperative and postoperative surgical complications in patients who underwent total laparoscopic hysterectomy (TLH) for myomatous uteri., Methods: We examined prospectively data from 461 consecutive TLHs performed by a single surgeon between August 2004 and August 2014 at the Department of Obstetrics and Gynecology, Sirai Hospital, Carbonia, and at the Department of Gynecologic Oncology, Businco Hospital, Cagliari, Italy. Demographic and surgical data were stratified by uterine weight (range 90-5500 g) into four groups: <300 g; from 300 to 500 g; from 500 to 800 g; and >800 g. Outcomes examined included blood loss, operative time, intraoperative and postoperative complications, and duration of hospital stay. A linear regression analysis was performed to identify whether uterine weight was an independent predictor affecting these outcomes. In addition, BMI, previous surgery with adhesiolysis, and endometriosis were tested as a predictor of surgical complications and outcomes., Results: No significant difference was found in intraoperative and postoperative complications, as well as hospital stay, by uterine weight. Increased uterine size was significantly associated with longer operative time and increased blood loss. Beside uterine weight, prior surgery was predictive of postoperative complications. In contrast, higher BMI was not associated with increased complication rate. Independent predictors of longer operative time included previous surgery, endometriosis, and BMI., Conclusions: Our results showed that in experienced hands, TLH is feasible and safe also in presence of very large uteri. TLH results in a few complications and short hospital stay regardless of uterine weight.

Objective: To determine the presence, differential expression, and regulation of epidermal growth factor-containing fibulin-like extracellular matrix protein 1 (EFEMP1) in uterine leiomyomas., Design: Laboratory in vivo and in vitro study with the use of human leiomyoma and myometrial tissue and primary cells., Setting: Academic medical center., Sample(s): Leiomyoma and myometrial tissue samples and cultured cells., Intervention(s): 5-Aza-2'-deoxycytidine (5-aza-dC) treatment., Main Outcome Measure(s): Fold-change difference between EFEMP1 and fibulin-3 expression in leiomyoma tissue and cells compared with matched myometrial samples, and fold-change difference in EFEMP1 expression with 5-Aza-dC treatment., Result(s): In vivo, EFEMP1 expression was 3.19-fold higher in myometrial tissue than in leiomyoma tissue. EFEMP1 expression in vitro was 5.03-fold higher in myometrial cells than in leiomyoma cells. Western blot and immunohistochemistry staining of tissue and cells confirmed similar findings in protein expression. Treatment of leiomyoma cells with 5-Aza-dC resulted in increased expression of EFEMP1 in vitro., Conclusion(s): The EFEMP1 gene and its protein product, fibulin-3, are both significantly down-regulated in leiomyoma compared with myometrium when studied both in vivo and in vitro. The increase in EFEMP1 expression in leiomyoma cells with 5-Aza-dC treatment suggest that differential methylation is responsible, in part, for the differences seen in gene expression., (Copyright © 2016 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To determine prognostic factors associated with cold-knife morcellation during vaginal hysterectomy., Methods: We conducted a retrospective cohort study evaluating all consecutive patients undergoing a vaginal hysterectomy between January 1, 2009, and August 31, 2014. The primary outcome was the utilization of uncontained vaginal morcellation performed using cold-knife wedge resection at the time of vaginal hysterectomy. Secondary outcomes included perioperative data. Significant factors were included in a multivariate logistic regression model to the binary variable vaginal morcellation at the time of vaginal hysterectomy., Results: A total of 743 women met study inclusion criteria and underwent vaginal hysterectomy with intact uterine removal (n=383) or with uterine morcellation (n=360) with and without other vaginal procedures. A nonparametric Wilcoxon-rank-sum test and χ test were used to compare the cohorts of patients with and without morcellation. Characteristics associated with significantly increased likelihood of morcellation included younger age, non-Caucasian race, American Society of Anesthesiologists class 1 or 2, lower parity, lower number of prior vaginal deliveries, absence of prolapse, presence of leiomyoma, and an enlarged uterus. A multivariate logistic model utilizing factors most likely associated with morcellation revealed lack of prolapse (adjusted odds ratio [OR] 3.87, P<.001), leiomyoma (adjusted OR 2.77, P=.035), and larger uterine weight (adjusted OR 7.25, P<.001) increased the likelihood of morcellation. Prior vaginal delivery was associated with a decreased likelihood of morcellation (adjusted OR 0.79, P=.005)., Conclusion: Vaginal hysterectomy with morcellation is associated with the following factors: absence of prior vaginal delivery, absence of prolapse, presence of leiomyoma, and a uterus larger than normal size.

In order to ensure safe magnetic resonance-guided, high-intensity focused, ultrasound ablation of uterine leiomyomas, the ultrasound beam path should be free of intervening scar and bowel. Pre-treatment MRI of a 9-cm long and 7.7-cm wide leiomyomatous uterus in a 39-year-old woman with menorrhagia and abdominopelvic pain initially demonstrated a focused ultrasound treatment path without a bowel between the uterus and the abdominal wall. On the day of ablation, however, multiple loops of bowel were observed in the ultrasound beam path by MRI. Uterine repositioning was accomplished with a 76-mm donut vaginal pessary, which anteverted the fundus and successfully displaced the bowel. A vaginal pessary may aid in repositioning an axial or retroverted uterus to enable ablation of uterine leiomyomas., (© 2015 S. Karger AG, Basel.)

Uterine myoma is the most frequent benign tumor of female organs. Intraligamentary myomas in the broad ligament are rare. We present a case of 50 years old patient with 22 cm intraligamentary myoma with cystic degeneration, who is referred to the Gynecological Department of Ob/Gyn Hospital "Dr. Shterev" with complains of severe pain. This case is interesting for its rareness and diagnostic dilemma, because degenerative myomas can imitate malignant mass. Total laparoscopic hysterectomy with ablastic vaginal morcellation of the specimen in endobag was performed. The patient was discharged from the clinic next day.

We describe a case of a 35-year-old woman with a pedunculated uterine leiomyoma with diffuse hydropic degeneration presenting as a giant abdominal mass. The patient was admitted in the emergency department because of diffuse abdominal bloating and discomfort. Ultrasonography (US) showed a heterogeneous abdominopelvic mass. Magnetic resonance imaging (MRI) was performed to further characterise and revealed a myometrial pedunculated tumour. Despite its marked T2-signal heterogeneity and volume, there were no other suspicious findings to suggest a malignant nature; therefore, fertility-sparing myomectomy was performed. Leiomyomas frequently undergo degenerative changes altering their imaging appearances. Leiomyomas with uncommon degenerative changes may be difficult to differentiate from malignant myometrial tumours, based solely on imaging. To the best of our knowledge, a diffuse hydropic degeneration imaging appearance has only been described twice in the literature. We describe the imaging appearance of this rare form of leiomyoma drawing attention to its differential diagnosis., (2015 BMJ Publishing Group Ltd.)

To assess the feasibility and safety of laparoscopic myomectomy without coagulation for uterine corpus leiomyoma between 4 and 9 cm in diameter with types 2-5. A total of 109 patients with uterine corpus myoma, single or multiple, between 4 and 9 cm in diameter with types from 2 to 5 were included who underwent laparoscopic myomectomy without using any unipolar or bipolar coagulation. Surgery time, intraoperative blood loss, hemoglobin decline on the first day after surgery and average days of post-operative hospitalization were recorded. The mean operative time was 70 ± 25 min (range 35-140 min). Mean blood loss during operation was 138 ml (range 20-400 ml), mean hemoglobin decline on the first day after surgery was 1.5 ± 0.75 g/dl (range 0-3.2 g/dl), and mean hospitalization time was 3.2 days (range 2-6 days). No patient required a blood transfusion. There were no major post-operative complications. Laparoscopic myomectomy without coagulation is feasible and safe for uterine corpus leiomyoma between 4 and 9 cm in diameter with types 2-5.

Purpose: Surgical myomectomy is currently regarded as the standard conservative treatment for patients who wish to preserve their fertility. However, it presents two main problems: the intra- and postoperative risk of bleeding and the risk of recurrence of leiomyomas. Preventive occlusion of uterine arteries was described during laparoscopic myomectomy as one of the procedures addressing these issues., Methods: We conducted a literature review to define the role of preventive uterine artery occlusion during laparoscopic myomectomy., Results: Nine non-randomized case-control studies and two randomized controlled trials were identified. The permanent and bilateral uterine artery occlusion technique is the most studied in the literature. The main purpose of facilitating the operative procedure by reducing blood loss has not been clearly demonstrated in randomized trials. Observational comparative studies found an improvement in the effectiveness of treatment, both on clinical symptoms and on the recurrence of leiomyomas. Finally, there are few data examining the effect of uterine artery occlusion on later fertility in female patients of childbearing age, which limits its current use., Conclusion: The preventive occlusion of uterine arteries is a safe surgical technique that can be performed during laparoscopic myomectomy. Further randomized studies are needed to better define the role of uterine artery occlusion in the surgical strategy, especially for women who want to preserve their fertility.

Recurrent pregnancy loss (RPL) is defined as two or more failed clinical pregnancies before 20 weeks' gestation and may be caused by genetic, endocrinologic, anatomic and immunologic abnormalities. Anatomic uterine anomalies include congenital malformations (bicornuate, didelphic, septate and unicornuate uteri) and acquired defects (fibroids, adenomas, adhesions and polyps). Women with septate and bicornuate uteri, intrauterine adhesions, and some adenomas and fibroids are at increased risk of RPL. Data support surgical treatment of all of these lesions except bicornuate uteri. The role of polyps in RPL is unclear. Minimally invasive options for surgical correction of intrauterine lesions include hysteroscopy, laparoscopy with and without robotic assistance and minilaparotomy.

Objective: To identify the characteristics of cases and fibroids that will indicate which patients should undergo myomectomy to improve fertility., Materials and Methods: We recruited patients (n=101) who had undergone myomectomy to improve fertility and received follow-up care for at least six months by the hospital. Medical records were retrospectively reviewed to analyze the pregnancy rates after myomectomy and to identify clinical factors that correlate with pregnancy rates. Cumulative pregnancy rates were analyzed using the Kaplan-Meier method and the Log rank test. The patients were then divided into three groups according to the timing of the myomectomy. The analysis was performed for all patients, for patients in the post-superovulation and/or intrauterine insemination (post-SO/IUI) group and the post-assisted reproductive technology (post-ART) group combined, and for patients in the post-ART group., Results: Sixty-three pregnancies were achieved by 58 patients (57.4%) who underwent myomectomy. The mean time period between surgery and conception was 9.8 months. Most pregnancies (91.5%) were achieved within two years after surgery. Pregnancy rates were higher in patients aged less than 36 years, with no male factors, and without severe endometriosis, in comparison with patients 36 years of age or older (p<0.05), with male factor (p<0.05), and severe endometriosis (p<0.05). In the analysis of the post-ART group, pregnancy rates were higher (p<0.05) in cases where enucleation had penetrated the endometrial cavity in comparison with patients where the cavity was not penetrated; however, fibroid characteristics did not correlate with the post-myomectomy pregnancy rate in the post-SO/IUI plus post-ART group., Conclusion: Post-myomectomy pregnancy rates were higher in women who did not have additional infertility factors. These results suggest that the removal of fibroids benefits especially patients who suffer from infertility of an otherwise unknown cause: surgery should be strongly recommended for these patients. Our study also shows the difficulty in identifying fibroids for removal to improve fertility. Further studies are needed to develop new diagnostic techniques for identifying patients who can improve fertility with myomectomy., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

Objectives: The volume of a fibroid uterus before performing hysterectomy is typically estimated through bimanual examination and confirmed by ultrasonography. This study compares estimated volumes by bimanual examination and ultrasound examination with MRI and actual volumes obtained from histopathology, as gold standards., Study Design: We used data from a previous prospective randomized multi-center trial that compared hysterectomy and uterine artery embolization (UAE) for the treatment of symptomatic fibroids. All patients underwent bimanual vaginal examination and pelvic ultrasonography. Those women randomized to UAE received a pelvic MRI. For women randomized to hysterectomy, the exact uterine volume was based on histopathologic examination. We compared the calculated volumes based on ultrasound parameters and estimated volume based on bimanual examination with either the calculated volumes of the pelvic MRI parameters or the calculated volume based on the exact weight during histological examinations., Results: Our study demonstrated poor agreement between ultrasound and bimanual examination compared with exact volume during histopathologic examination and MRI-based volume. The agreement within the patient group with uterine volume >233 g and >747 g was fair to good. For those women with a uterine volume between 233 and 747 g, the agreement was poor when comparing bimanual estimates with volume obtained from MRI or histolopathologic examination. Within this volume group, the agreement on uterine volume between ultrasound and MRI or histopathologic examination was fair., Conclusions: Our study shows that uterine volume as estimated by ultrasound and bimanual examination can be used for small or large uteri. For uteri with an intermediate volume, bimanual examination and ultrasound are less reliable., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

Uterine leiomyomas are one of the most common benign smooth muscle tumors in women, with a prevalence of 20 to 40% in women over the age of 35 years. Fifty percent of them may necessitate treatment, because of bleeding, pelvic pain and infertility. Laparoscopic myomectomy is one of the treatment options. The major concern of myomectomy either by open procedure or by laparoscopy is the bleeding encountered during the operation. One of the methods to reduce the intraoperative blood loss and to prevent excessive bleeding is the clipping of both uterine arteries and aa. ovaricae.

Objective: To evaluate the differences in the intraoperative blood loss during laparoscopic myomectomy with or without uterine artery clipping (UAC)., Methods: From January 2013 to April 2015, we enrolled prospectively 119 women with symptomatic intramural myomas who were scheduled to undergo laparoscopic myomectomy (37 with UAC (study group) and 82 without (control group))., Results: Characteristics of the myomas, operating time, duration of hospital stay and blood loss were comparable between the two groups. The average operating time and blood loss were 75 +/- 11 minutes and 100 +/- 20 ml for the experimental group and 60 +/- 9 minutes and 178 +/- 56 ml for the control group respectively statistically significant., Conclusion: Concurrent UAC during laparoscopic myomectomy reduces the intraoperative blood loss and the frequency of excessive bleeding. This study demonstrated the superiority of laparoscopic uterine artery ligation combined with myomectomy in treatment of symptomatic myomas.

Concepts of medical treatment are constantly evolving and improving. This opportunity provides treatment with High Intensity Focused Ultrasound (HIFU). In Europe and Asia more than 10,000 patients with uterine fibroids have been successfully treated with HIFU technology until now. This is completely innovative technology for non-invasive extracorporeal treatment of benign and malignant tumors. Neighboring healthy tissue is not damaged. The main indication in HIFU-Center in Pleven is uterine fibroid. It is the most common solid tumor in the female pelvis and is the leading cause of hysterectomy. The methods of treatment are hysterectomy, myomectomy or embolization of uterine arteries. HIFU-methodology allows non-invasive treatment of fibroids disease.

Leiomyomas are benign soft-tissue neoplasms that arise from smooth muscle. Relief of symptoms (abnormal uterine bleeding, pain, pressure) is the major goal in management of women with significant symptoms. For symptomatic myomas, hysterectomy is a definitive solution; however, there are emerging less-invasive options. Magnetic resonance imaging-guided focused ultrasound surgery, cryomyolysis, and temporary occlusion of the uterine arteries are treatment options that are minimally invasive interventions with the benefit of preserving the uterus. This review summarizes procedure techniques, eligibility, complications, and outcomes of these alternate therapies., (Published by Elsevier Inc.)

Aim: Myosin is involved in cell contraction and motility, but it is unclear whether it is involved in cell proliferation in uterine myoma. In this study therefore we aimed to explore the role of myosin in uterine myoma., Material and Methods: Immunohistochemistry and real-time polymerase chain reaction were used to determine the expression of myosin light chain (MLC), myosin heavy chain (MHC) and myosin light chain kinase (MLCK) in patient uterine myoma and adjacent smooth muscle tissue. Human uterine fibroid cells were isolated and cultured in vitro, myosin heavy chain 11 (MHC subtype expressed in uterine fibroid cells) was knocked down by RNA interference to reduce the expression of myosin, then cell proliferation was determined by the methyl thiazol tetrazolium bromide method. To explore the possible mechanism of reduced cell proliferation after myosin heavy chain 11 knockdown, the downstream proteins collagen I, insulin-like growth factor-1, fibronectin and proteoglycans were analyzed., Results: Expression of MLC, MHC, MLCK and p-MLCK in uterine myoma cells was significantly higher than in adjacent smooth muscle cells. After knockdown of MHC, smooth muscle cell proliferation decreased, and the production of collagen I, insulin-like growth factor-1 and fibronectin was also reduced, but proteoglycans did not show any significant change., Conclusion: Myosin is overexpressed in uterine myoma, and the overexpression of myosin is associated with both uterine contraction and tumor development of uterine myoma., (© 2014 The Authors. Journal of Obstetrics and Gynaecology Research © 2014 Japan Society of Obstetrics and Gynecology.)

Objective: To evaluate the effectiveness of uterine-sparing interventions for women with symptomatic uterine fibroids who wish to preserve their uterus., Design: Systematic review and indirect comparison meta-analysis., Methods: MEDLINE, EMBASE, CENTRAL, conference proceedings, trial registers and reference lists were searched up to October 2013 for randomized controlled trials., Main Outcome Measures: Outcome measures were patient satisfaction, re-intervention and complications rates, reproductive outcomes, and hospitalization and recovery times., Results: Five trials, involving 436 women were included; two compared uterine artery embolization with myomectomy and three compared uterine artery embolization with laparoscopic uterine artery occlusion. Indirect treatment comparison showed that myomectomy and uterine artery embolization resulted in higher rates of patient satisfaction (odds ratio 2.56, 95% credible interval 0.56-11.75 and 2.7, 95% credible interval 1.1-7.14, respectively) and lower rates of clinical failure (odds ratio 0.29, 95% credible interval 0.06-1.46 and 0.37, 95% credible interval 0.13-0.93, respectively) than laparoscopic uterine artery occlusion. Myomectomy resulted in lower re-intervention rate than uterine artery embolization (odds ratio 0.08, 95% credible interval 0.02-0.27) and laparoscopic uterine artery occlusion (odds ratio 0.08, 95% credible interval 0.01-0.37) even though the latter techniques had an advantage over myomectomy because of shorter hospitalization and quicker recovery. There was no evidence of difference between the three techniques in ovarian failure and complications rates. The evidence for reproductive outcomes is poor., Conclusion: Our study's results suggest that laparoscopic uterine artery occlusion is less effective than uterine artery embolization and myomectomy in treatment of symptomatic fibroids. The choice between uterine artery embolization and myomectomy should be based on individuals' expectations and fully informed discussion., (© 2014 Nordic Federation of Societies of Obstetrics and Gynecology.)

Uterine fibroid tumors (leiomyomas) are the most common benign pelvic tumors in women and are the major indication for hysterectomy. Fibroid tumors are more common and more severe among African American women. Although this disease disproportionately affects the African American population, we understand little about what causes the disparity. Fibroid tumors should be considered a public health issue, given the magnitude of the problem and the costs of health care for this disease. In this review, we examine the burden of disease from fibroid tumors in the African American population and review the natural history, diagnosis, and treatment of uterine fibroid tumors, with emphasis on how these can differ, depending on race. We also focus on the socioeconomic burden caused by the disease and describe the anticipated influence of new health care reforms and funding mechanisms for fibroid tumor research., (Copyright © 2014 Mosby, Inc. All rights reserved.)

Objective: Uterine artery occlusion by laparoscopy (UAOL) has been used for the treatment of uterine fibroids and beneficial effects to patients have been shown in clinical studies since 2000. Fibroid cells are more susceptible to apoptosis than myometrial cells under hypoxic conditions, but the molecular mechanisms underlying this effect remain unclear. The aim of this study was to investigate the role of intracellular calcium (Ca(2+)) release mediated by Ca(2+) channel inositol 1,4,5 trisphosphate receptor1 (IP3R1)/ryanodine receptor1 (RYR1) in the apoptosis of uterine fibroid cells under hypoxia., Study Design: We compared the expressions of IP3R1 and RYR1 in fibroid and surrounding myometrial tissue from 20 patients before UAOL. After 6h treatment under hypoxia (1% O2) with or without Ca(2+) channel blockers (heparin or/and ruthenium red), the intracellular Ca(2+) concentration, cytochrome c (Cytc) protein and cell apoptosis were determined., Results: IP3R1 and RYR1 mRNA and protein levels were significantly higher in fibroid than in myometrial tissues. Under hypoxic conditions, Ca(2+) concentration in fibroid cells was significantly higher than in myometrial cells (Ca(2+): 82.69±16.92nmol/L vs 46.14±9.11nmol/L, P<0.05), and Cytc increased similarly in fibroid cells. These increases in Ca(2+) concentration, Cytc and cell apoptosis were significantly reversed by calcium blocker in fibroid cells., Conclusion: This study demonstrated that intracellular calcium release mediated by IP3R1/RYR1 could induce apoptosis in uterine fibroid cells under hypoxic conditions, and was responsible for the susceptibility to apoptosis of fibroid cells under UAOL., (Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.)

Objective: To investigate the risk of adhesions after laparoscopic myomectomy (LM). To establish the percentage of adhesions, their kind, situation and magnitude., Materials and Methods: For the period form June 2011 to November 2013 totally 81 patients were operated by LM. In the study only patients with intramural leymyomas bigger than 5 sm were included. For this period 14 patients had second-look because of the need of another operation--LS or Ceasarean section. 22 myoma incisions were checked. We established 35.7% adhesions per patient. After LM adnexas were engaged in 14.2%., Conclusion: The factors, responsible for the formation of postoperative adhesions are: the location of the myoma in the posterior uterine wall, excessive accumulation of suturing materials and additional operative interventions. For patients underwent LM and willing pregnancy we recommend second look laparoscopy.

Bidirectional barbed suture introduces a new paradigm in laparoscopic suturing. The aim of our study is to evaluate the efficacy and safety of using bidirectional barbed suture in laparoscopic myomectomy. It included 102 women, requiring a laparoscopic myomectomy for symptomatic uterine fibroids from June 2011 to May 2014. They are divided into two groups according to the thread used for closing the uterine incision. We used bidirectional barbed suture Quill and Vicryl in the control group. The mean operative time was shorter in the Quill group than in control group. Both intraoperative blood loss and drop of hemoglobin were significantly lower in the Quill group. The use of bidirectional barbed suture appears to be safe for closing the hysterotomy site during a laparoscopic myomectomy.

Objective: To assess the mid-term efficacy of magnetic resonance-guided high-intensity focused ultrasound (MR-HIFU) using a volumetric ablation technique for treating uterine fibroids., Methods: Forty-six premenopausal women with 58 symptomatic uterine fibroids were prospectively included for MR-HIFU. After treatment, CE-MRI allowed measurement of the non-perfused volume (NPV) ratio, defined as the non-enhancing part of the fibroid divided by fibroid volume. Clinical symptoms and fibroid size on T2W-MRI were quantified at 3 and 6 months' follow-up. The primary endpoint was a clinically relevant improvement in the transformed Symptom Severity Score (tSSS) of the Uterine Fibroid Symptom and Quality of Life questionnaire, defined as a 10-point reduction., Results: Volumetric ablation resulted in a mean NPV ratio of 0.40 ± 0.22, with a mean NPV of 141 ± 135 cm(3). Mean fibroid volume was 353 ± 269 cm(3) at baseline, which decreased to 271 ± 225 cm(3) at 6 months (P < 0.001), corresponding to a mean volume reduction of 29 % ± 20 %. Clinical follow-up showed that 54 % (25/46) of the patients reported a more than 10-point reduction in the tSSS. Mean tSSS improved from 50.9 ± 18.4 at baseline to 34.7 ± 20.2 after 6 months (P < 0.001)., Conclusion: Volumetric MR-HIFU is effective for patients with symptomatic uterine fibroids. At 6 months, significant symptom improvement was observed in 54 % of patients., Key Points: • Volumetric MR-guided high-intensity focused ultrasound is a novel ablation technique for leiomyomatosis. • We prospectively evaluated the outcome of volumetric MR-HIFU ablation for symptomatic fibroids. • This study showed that volumetric MR-HIFU results in an effective treatment. • A randomised controlled trial would set this technique in an appropriate context.

It is not easy to establish the true impact of fibroids on fertility. Fibroidectomy in sterile patients with subserosal fibroids does not offer the best results for patients with in situ fibroids. Women with intramural fibroids appear to present reduced fertility and increased miscarriage rates, compared with women without fibroids. However, fibroidectomy does not always reverse this effect (does not increase the clinical pregnancy or "take-home baby" rates), but the quality of the studies is still poor. Fibroids with a submucosal component significantly decrease implantation and pregnancy rates with regard to sterile controls. Fibroid exeresis clearly improves fertility results. There is a need for better quality studies aimed at assessing the impact of intramural fibroids, with a special focus on factors such as size, number and proximity to the endometrium. The majority of cases can be treated endoscopically. This procedure needs properly trained teams who monitor their results and who are able to offer the same guarantees that laparotomy affords, both in terms of the surgical technique and the patients' obstetric future. Laparoscopic fibroidectomy offers results comparable to laparotomy and minimizes the formation of adhesions, blood loss, hospital stay and the time to return to work. For sterile patients, laparoscopic fibroidectomy may be the first choice therapy., (Copyright © 2013 Elsevier España, S.L. All rights reserved.)

Aim: The benefit of robot-assisted laparoscopic myomectomy (RALM) over traditional laparoscopic myomectomy (TLM) remains undetermined. The aim of this study was to reveal any potential advantage of RALM over TLM., Material and Methods: Between June 2010 and October 2011, all women presenting with symptomatic uterine myomas were enrolled in this study. Perioperative variables were compared between these two groups. The patients recruited in this study were allocated into the two groups based on their financial considerations., Results: A total of 42 patients received RALM (n = 20) or TLM (n = 22) for symptomatic uterine myomas. The operation time was longer in the RALM group; but the total abdominal drainage amount on postoperative day 1 was significantly less in the RALM group than the TLM group. Multivariate analysis revealed that the RALM procedure (coefficient = 79.1, P < 0.001), number of myomas (coefficient = 15.4, P = 0.002), and the presence of a cervical myoma (coefficient = 54.9, P = 0.01) were independent factors affecting operation time; the maximum myoma diameter was the only factor affecting blood loss (coefficient = 113.4, P = 0.003). However, the RALM procedure was the only factor affecting the amount of abdominal drainage on postoperative day 1 (coefficient = -86.3, P = 0.006)., Conclusions: Although RALM is a longer operation than TLM, it might result in less postoperative abdominal drainage than TLM and help alleviate short-term morbidity., (© 2013 The Authors. Journal of Obstetrics and Gynaecology Research © 2013 Japan Society of Obstetrics and Gynecology.)

Purpose: We use a non-surgical endoloop snare technique to remove prolapsed pedunculated submucous uterine myomas under the concept that ligating the pedicle causes tumor necrosis and natural elimination of the tumor. We evaluated our method on the basis of clinical outcomes., Methods: For pertinent clinical data, we reviewed the hospital records of 11 patients treated by our new method between July 2009 and 2010 and followed up for 22-31 months., Results: Patients' mean age was 40.9 years, and the mean hemoglobin level was 10.6 g/dl. None required urgent hospitalization, blood transfusion, or laparotomy. The tumors were eliminated naturally or removed by cutting necrotic pedicle within 4-11 days. One patient required a second endoloop application. Another one patient required follow-up surgery for a second submucous myoma, adenomyosis, and persistent hypermenorrhea., Conclusions: Endoloop ligation is feasible for eliminating prolapsed pedunculated submucous myoma. It is simple and safe and can be performed in the outpatient setting.