Efficacy and safety of robot-assisted laparoscopic myomectomy versus laparoscopic myomectomy: a systematic evaluation and meta-analysis
World journal of surgical oncology. 2023;21(1):230
OBJECTIVE Systematic evaluation of the efficacy and safety of robotic-assisted laparoscopic myomectomy (RALM) versus laparoscopic myomectomy (LM). METHODS PubMed, Embase, The Cochrane Library, and Web of Science database were searched by computer to seek relevant literature in order to compare the efficacy and safety of RALM with that of LM from the establishment of the databases to January 2023, and Review Manager 5.4 software was utilized to perform a meta-analysis on the literature. RESULTS A total of 15 retrospective clinical controlled studies were included. There exists a total of 45,702 patients, among 11,618 patients in the RALM group and the remaining 34,084 patients in the LM group. Meta-analysis results revealed that RALM was associated with lesser intraoperative bleeding (MD = - 32.03, 95%CI - 57.24 to - 6.83, P = 0.01), lower incidence of blood transfusions (OR = 0.86, 95%CI 0.77 to 0.97, P = 0.01), shorter postoperative hospital stay (MD = - 0.11, 95%CI - 0.21 to - 0.01, P = 0.03), fewer transitions to open stomach (OR = 0.82, 95%CI 0.73 to 0.92, P = 0.0006), and lower incidence of postoperative complications (OR = 0.58, 95%CI 0.40 to 0.86, P = 0.006) than LM, whereas LM is more advantageous in terms of operative time (MD = 38.61, 95%CI 19.36 to 57.86, P < 0.0001). There was no statistical difference between the two surgical methods in terms of maximum myoma diameter (MD = 0.26, 95%CI - 0.17 to 0.70, P = 0.24). CONCLUSION In the aspects of intraoperative bleeding, lower incidence of blood transfusions, postoperative hospital stay, transit open stomach rate, and postoperative complications, RALM has a unique advantage than that of LM, while LM has advantages over RALM in terms of operative time.
Triple vs. single uterine tourniquet to reduce hemorrhage at myomectomy: a randomized trial
Archives of gynecology and obstetrics. 2023
PURPOSE This study aimed to compare the effect of triple uterine tourniquet and single tourniquet on intraoperative blood loss during open myomectomy. METHODS Women were randomized to undergo open myomectomy with a triple (n = 30) or single uterine tourniquet (n = 30). All symptomatic women aged 18-48 who had three or more myomas or at least one myoma greater than 8 cm if there were less than three myomas were eligible for the study. The primary outcome variable was the volume of intraoperative blood loss. The sample size was set to detect a 240 ml difference in blood loss with 80% power at α = 0.05, with an effect size of 0.8. The rate of transfusions, change in hemoglobin, volume of drains, operation time, tourniquet time, and perioperative complications were secondary outcomes. RESULTS We found no significant difference in intraoperative blood loss between triple and single uterine tourniquets (527 [102-2931]) ml vs. 508 [172-2764] ml, p = 0.238). Between the single and triple tourniquet groups, the median weight of myoma (379 [136-3850] vs. 330 [140-1636] g, p = 0.451) and median number (1 [1-18] vs. 2 (1-13), p = 0.214), total operation time (84 ± 31 min vs. 79 ± 27 min, p = 0.503), ischemia time (35 ± 21 min vs. 30 ± 14 min., p = 0.238), drain volume at 48th hour (196 ± 89)ml vs. 243 ± 148 ml, p = 0.144) and decrease in hemoglobin (2.3 ± 1.8 g/dl vs. 2.8 ± 1.4 g/dl, p = 0.437) were similar. Eight (27%) patients in the triple tourniquet group and 12 (40%) patients in the single tourniquet group were transfused (p = 0.273). One patient underwent hysterectomy 6-8 h after myomectomy in a single tourniquet group. CONCLUSION There was no clinically significant difference in intraoperative blood loss between triple and single uterine tourniquets during open myomectomy. CLINICAL TRIAL REGISTRATION NUMBER AND DATE OF REGISTRATION ClinicalTrials.gov ID: NCT02392585, 03/13/2015.
A comparison of the effect of placental extraction from exteriorized versus non-exteriorized uterus on blood loss during caesarean section in Nigerian women
African journal of reproductive health. 2023;27(9):65-75
The purpose of this study was to determine the effect of placenta extraction from exteriorized uterus versus placenta extraction from non- exteriorized uterus on blood loss during caesarean section (CS). It was a randomized control study in which 98 women undergoing caesarean section were allocated randomly to either the placental delivery from exteriorized uterus or placental delivery from non-exteriorized uterus. The main outcome measure was intraoperative blood loss, and Intention to treat analysis was used. More participants in the non-exteriorized placenta removal group had blood loss ≥500mls (P-value <0.001). Logistic regression showed about 5times likelihood of having blood loss of 500mls or more in the non-exteriorized group (P< 0.001; OR: 5.67; 95%CI: 2.38-13.40). The mean estimated blood loss was 54.1mL less in exteriorized placenta removal group (476.12±160.86 versus 530.20±145.18; P-value = 0.084). The mean changes in haemoglobin concentration in exteriorized and non-exteriorized groups were 0.68±0.19g/dL and 0.74±0.20g/dL; P = 0.131) respectively. This study showed statistically significant difference in blood loss of 500mls or more in the placenta delivery from non-exteriorized compared to the exteriorized group. However, there was no significant difference in the mean blood loss, duration of surgery, and change in haemoglobin between the two groups.
Barbed versus conventional suture in laparoscopic myomectomy: A randomized controlled study
Turkish journal of obstetrics and gynecology. 2023;20(2):126-130
OBJECTIVE To compare the surgical and clinical results of traditional absorbable polyglactin 910 and barbed sutures in laparoscopic myomectomy. MATERIALS AND METHODS This single-center randomized study included 75 women who underwent laparoscopic myomectomy. The uterine wall defects were closed with a continuous conventional absorbable polyglactin 910 suture (Vicryl; Ethicon, Somerville, NJ, USA) in 41 women and with a unidirectional barbed suture (V-Loc 180; Covidien, Mansfield, MA, USA) in 34 women. RESULTS The time required to suture the uterine wall defect was lower in the V-Loc group than in the Vicryl group (p=0.007). However, no significant difference was observed in the operative time between the two study groups. The intraoperative blood loss and need for postoperative blood transfusion were significantly lower in the barbed group than in the Vicryl group (p=0.018 and p=0.048, respectively). CONCLUSION In laparoscopic myomectomy cases, the unidirectional barbed suture is more effective than the conventional absorbable suture. Barbed sutures facilitate the suturing process and reduce the time required to suture the uterine wall defect, blood loss, and the need for postoperative blood transfusion.
Minimizing blood loss in laparoscopic myomectomy with temporary occlusion of the hypogastric artery
Frontiers in medicine. 2023;10:1216455
INTRODUCTION Uterine leiomyomas are common benign pelvic tumors. Currently, laparoscopic myomectomy (LM) is the preferred treatment option for women in the fertile age group with symptomatic myomas. The authors hypothesize that combining LM with a bilateral temporary occlusion of the hypogastric artery (TOHA) using vascular clips minimizes uterine blood flow during surgery and can significantly reduce surgery-associated blood loss. MATERIALS AND METHODS This single-center, prospective randomized study was conducted at the Department of Obstetrics and Gynecology, Municipal Emergency Clinical Hospital Timisoara, Romania. Patients aged between 18 and 49 who preferred laparoscopic myomectomy and wished to preserve fertility were included, provided they had intramural uterine leiomyomas larger than 4 cm in diameter that deformed the uterine cavity. The study analyzed data from 60 laparoscopic myomectomies performed by a single surgeon between January 2018 and December 2020. Patients were randomly assigned to either: "LM + TOHA" group (29 patients), and "LM" group (31 patients). The study's main objective was to evaluate the impact of TOHA on perioperative blood loss, expressed as mean differences in Hb (delta Hb). RESULTS Delta Hb was statistically lower in the "LM + TOHA" group compared to "LM" group, with mean ± standard (min-max): 1.68 ± 0.67 (0.39-3.99) vs. 2.63 ± 1.06 (0.83-4.92) g/dL, respectively (p < 0.001). There was a statistically significant higher need for postoperative iron perfusion in the "LM" group, specifically 0 vs. 12 patients (p < 0.001), and lower postoperative anemia in "LM + TOHA" group (p < 0.001). Necessary artery clipping time was 10.62 ± 2.47 (7-15) minutes, with no significant impact on overall operative time: 110.2 ± 13.65 vs. 106.3 ± 16.48 (p = 0.21). There was no difference in the length of hospitalization or 12-month post-intervention fertility. DISCUSSION Performing bilateral TOHA prior to laparoscopic myomectomy has proven to be a valuable technique in reducing surgery-associated blood loss, while minimizing complications during surgery, with no significant increase in the overall operative time. CLINICAL TRIAL REGISTRATION ISRCTN registry, (www.isrctn.com), identifier ISRCTN66897343.
Effects of misoprostol in reducing blood loss during abdominal myomectomy in Nigeria
Nigerian journal of clinical practice. 2023;26(4):454-462
BACKGROUND Despite using a tourniquet to reduce bleeding during abdominal myomectomy, the procedure is still complicated by significant intraoperative bleeding. AIM: To determine whether misoprostol and tourniquet compared with tourniquet alone would significantly reduce bleeding during abdominal myomectomy at two tertiary hospitals in Enugu. MATERIALS AND METHODS This study is an open-label randomized controlled trial. A total of 126 consenting participants were recruited from women booked for abdominal myomectomy at the study centers over 7 months. They were randomized into groups A (vaginal misoprostol 400 μg) and B (no misoprostol) one hour before surgery. Intraoperatively, all participants had a tourniquet application. Intraoperative and postoperative blood loss was compared between the two groups. Descriptive and inferential analyses were carried out using IBM SPSS Version 22.0. A P- value of < 0.05 was considered statistically significant. RESULTS An intention-to-treat analysis was carried out. All 63 participants (100%) and 56 (90%) completed the study according to the protocol in groups A and B, respectively. Socio-demographic characteristics were not significantly different in both groups. The mean intraoperative blood loss in the "misoprostol group" (522.6 ± 127.91 ml) was significantly lower than in the "no-misoprostol group" (583.5 ± 186.20 ml), with P = 0.028. The difference in mean hemoglobin (g/dl) was lower in the "misoprostol group" than in the "no-misoprostol group" (1.3 ± 0.79 vs. 1.9 ± 0.89, P < 0.001). The mean 48 hours postoperative blood loss (ml) between the two groups was 323.8 ± 221.44 vs. 549.4 ± 519.72), with P = 0.001. CONCLUSION Among women receiving tourniquet during myomectomy in Enugu, the additional use of vaginal misoprostol 400 μg significantly reduced intraoperative blood loss.
Combined Efficacy of Balloon Occlusion and Uterine Artery Embolization on Coagulation Function in Patients with High-Risk Placenta Previa during Cesarean Section
International journal of clinical practice. 2022;2022:7750598
PURPOSE The present study was performed in order to investigate the conbined effect of balloon occlusion and uterine artery embolization on coagulation function in patients with high-risk placenta previa during cesarean section. METHODS There involved a total of 38 patients with high-risk placenta previa undergoing cesarean section in our hospital from August 2019 to January 2021. The patients enrolled were randomly divided into study group (19 cases, receiving balloon occlusion combined with uterine artery embolization) and control group (19 cases, receiving conventional cesarean section). The operation time, intraoperative blood loss, plasma injection volume and hospital stay of the two groups were recorded. Moreover, the postoperative coagulation function indexes, including thrombin time (TT), fibrinogen (FBI), activated partial thromboplastin time (APTT) and prothrombin time (PT), were monitored and compared. Neonatal Apgar score and postoperative complications of the two groups were regarded as parameters for comparison. RESULTS The intraoperative blood loss, plasma injection volume and hospital stay of the study group were significantly lower compared with the control group (P < 0.05), whereas the operation time of the two groups was comparable (P > 0.05). Compared with the control group, the levels of TT, APTT and PT were lower while the level of FBI was higher in the study group (P < 0.05). The Apgar 1-min and 5-min scores of newborns were compared between the two groups (P > 0.05). However, the incidence of postoperative complications in the study group showed evidently lower outcomes compared with the control group (P < 0.05). CONCLUSION The combined approach of balloon occlusion and uterine artery embolization offered potential for improving the coagulation function of patients with high-risk placenta previa during cesarean section. In addition, the approach reduced the amount of blood loss and plasma injection, shortened the length of hospital stay, which was believed available for wide clinical application.
Techniques for managing an impacted fetal head at caesarean section: A systematic review
European journal of obstetrics, gynecology, and reproductive biology. 2022;281:12-22
A complication arising at caesarean birth when the baby's head is deeply engaged in the pelvis and may be difficult to deliver, is known as an 'impacted fetal head'. This obstetric emergency occurs in 16% of second stage caesarean sections. Multiple techniques are described in the literature to manage the complication but there is no consensus regarding which technique results in the best maternal and neonatal outcomes. The objective of this review is to determine which technique for managing impacted fetal head at caesarean section has the best maternal and neonatal outcomes. A literature search of three electronic databases was conducted in November 2021. Studies directly comparing two methods for the management of impacted fetal head at caesarean section in the second stage were included. Systematic reviews, meta-analyses, case-control studies, and studies not fitting the search criteria were excluded. Data was extracted in Covidence and meta-analysis of the six most commonly reported outcomes was conducted using RevMan 5.4. In total, 16 studies (3344women) were included. 13 studies (2506women) compared the push method with reverse breech extraction. meta-analysis showed that risk of extension of the uterine incision, blood transfusion, bladder injury, postpartum haemorrhage, NICU admission and Apgar score <7 at 5 min were significantly higher with the push method compared with reverse breech extraction. Three studies (838women) compared the push method with Patwardhan's technique. meta-analysis of studies comparing the push method with Patwardhan's technique found no significant differences between the two groups in any of the six maternal or neonatal outcomes. Evidence derived from small, inadequately powered studies suggests reverse breech extraction is associated with better outcomes than the push method. The method which produces the best outcomes is still unknown as not all methods have been tested. Further high quality, adequately powered RCTs are warranted for definitive conclusions to be drawn and to ameliorate the paucity of evidence on how best to manage this complication.
Therapeutic effect of Internal iliac artery ligation and uterine artery ligation techniques for bleeding control in placenta accreta spectrum patients: A meta-analysis of 795 patients
Frontiers in surgery. 2022;9:983297
Placenta accreta spectrum (PAS) can cause complications like hysterectomy or death due to massive pelvic bleeding. We aim to evaluate the efficacy of two different arterial ligation techniques in controlling postpartum haemorrhage and minimizing bleeding complications. We searched six databases. 11 studies were finally included into our review and analysis. We graded their quality using the Cochrane tool for randomized trials and the NIH tool for retrospective studies. Our analysis showed that internal iliac artery ligation has no significant effect on bleeding control (MD = -248.60 [-1045.55, 548.35] P = 0.54), while uterine artery ligation significantly reduced the amount of blood loss and preserved the uterus (MD = -260.75, 95% CI [-333.64, -187.86], P < 0.00001). Uterine artery ligation also minimized the need for blood transfusion. Bleeding was best controlled by combining both uterine artery ligation with uterine tamponade (MD = 1694.06 [1675.34, 1712.78], P < 0.00001). This combination also showed a significant decrease in hysterectomy compared to the uterine artery ligation technique alone. Bilateral uterine artery ligation in women with placenta accreta spectrum can effectively reduce the amount of bleeding and the risk of complications. The best bleeding control tested is a combination of both, uterine artery ligation and cervical tamponade. These techniques may offer an easy and applicable way to preserve fertility in PAS patients. Larger randomized trials are needed to define the best technique.
Prophylactic intraoperative uterine artery embolization for the management of major placenta previa
The Journal of Maternal-Fetal & Neonatal Medicine : The Official Journal of the European Association of Perinatal Medicine, the Federation of Asia and Oceania Perinatal Societies, the International Society of Perinatal Obstetricians. 2022;35(17):3359-3364
PURPOSE Placenta previa is a major cause of maternal morbidity and mortality, associated to a high risk of peripartum hemorrhage and hysterectomy. We aimed to verify if prophylactic intraoperative uterine artery embolization in patients with placenta previa and at least one additional risk of bleeding (major placenta previa), can reduce hemorrhage, need for blood transfusions, peripartum hysterectomy and maternal morbidity. MATERIALS AND METHODS We enrolled 76 patients with major placenta previa; a specific multidisciplinary protocol was designed for management, including ultrasound evaluation, hospitalization at 34 weeks, antenatal corticosteroids and scheduled cesarean section at 35-36 weeks. 44 patients (control group or CTR) were treated with elective cesarean section, 32 patients (embolized group or EMB) underwent selective catheterization of bilateral uterine arteries before cesarean section and subsequent uterine embolization. In both cases cesarean section was performed by a senior surgeon. RESULTS Significant differences were found in term of intraoperative blood loss (CTR: 1431 ml; EMB: 693 ml); despite an high percentage of CTR patients had a bleeding greater than 1000 ml (56%), the need for blood transfusion was not significantly different between the two groups. Time of surgery was higher in the EMB group, considering that embolization procedure required approximatively 30 min. Three patients from the CTR group needed hysterectomy and ICU admission, compared to none in the EMB group. Duration of hospitalization and neonatal outcome were similar. Uterine embolization was not related to any short or long-term complications; return to normal menses and preservation of fertility were confirmed at follow up. CONCLUSIONS Our results are promising, although we believe that a major contribution is referable to the multidisciplinary approach rather than the procedure itself. Nevertheless, we demonstrated the feasibility and safety of preventive uterine embolization in patients with placenta previa; in order to establish its prophylactic role in the prevention of peripartum hemorrhage, randomized trial should be carried out, on a larger population.