The correct answer is 5. An asymptomatic myoma of this size that does not deform the endometrial cavity is not a problem for pregnancy.

[HIDDEN] An asymptomatic myoma of this size that does not deform the endometrial cavity is not a problem for pregnancy.

A 32-year-old asymptomatic woman goes for a gynecological health check-up because she wishes to become pregnant. During this check-up, a 4cm uterine myoma is detected, partly intramural and partly subserosal, located on the anterior aspect of the uterus and which does not deform the endometrial cavity. What approach would you recommend?

Myoma embolization by arterial catheterization.

Treatment with Gn-Rh analogues for three months before attempting pregnancy.

Attempting pregnancy without any previous treatment.

Uterine artery embolization as a treatment option for uterine myomas.

Information is still being collected on the long-term clinical responses and appropriate patient selection for UAE. Prospective RCTs have not been performed to compare the clinical results from UAE with more conventional therapies for symptomatic uterine leiomyomata. At least three attempts at conducting such RCTs have been unsuccessful because of poor patient accrual that related to differing patient expectation and desires, clinical bias, insurance coverage, and the tendency that patients who have exhausted other treatment options may be disposed more favorably to less invasive treatments. Other comparative studies have serious limitations. For example, the retrospective study that compared outcomes after abdominal myomectomy with UAE suggested that patients who received UAE were more likely to require further invasive treatment by 3 years than were recipients of myomectomy. Lack of randomization introduced a selection bias because women in the group that underwent UAEwere older and were more likely to have had previous surgeries. A prospective study of "contemporaneous cohorts," which excluded patients who had sub-mucosal and pedunculated subserosal myomas, sought to compare quality of life measures and adverse events in patients who underwent UAE or hysterectomy. The investigators concluded that both treatments resulted in marked improvement in symptoms and quality of life scores, but complications were higher in the group that underwent hysterectomy over 1 year. In this study,however, a greater proportion of patients who underwent hysterectomy had improved pelvic pain scores. Furthermore, hysterectomy eliminates uterine bleeding and the risk for recurrence of myomas. Despite the lack of controlled studies that compared UAE with conventional surgery, and despite limited extended outcome data, UAE has gained rapid acceptance, primarily because the procedure preserves the uterus, is less invasive, and has less short-term morbidity than do most surgical options. The cost of UAE varies by region, but is comparable to the charges for hysterectomy and is less expensive than abdominal myomectomy. The evaluation before UAE may entail additional fees for diagnostic testing, such as MRI, to assess the uterine size and screen for adenomyosis. Other centers have recommended pretreatment ultrasonography, laparoscopy, hysteroscopy, endometrial biopsy, and biopsy of large fibroids to evaluate sarcoma. Generally,after UAE the recovery time and time lost from work are less; however, the potential need for subsequent surgery may be greater when compared with abdominal myomectomy. Any center that offers UAE should adhere to published clinical guidelines,maintain ongoing assessment of quality improvements measures, and observe strict criteria for obtaining procedural privileges. After McLucas advocated that gynecologists learn the skill to perform UAE for managing symptomatic myomas, the Society of Interventional Radiology responded with a precautionary commentary on the level of technical proficiency that is necessary to maintain optimum results from UAE. The complexity of pelvic arterial anatomy, the skill that is required to master modern coaxial microcatheters, and the hazards of significant patient radiation exposure were cited as reasons why sound training and demonstration of expertise be obtained before clinicians are credentialed to perform UAE.A collaboration between the gynecologist and the interventional radiologist is necessary to optimize the safety and efficacy of UAE. The primary candidates for this procedure include women who have symptomatic uterine fibroids who no longer desire fertility, but wish to avoid surgery or are poor surgical risks. The gynecologist is likely to be the primary initial consultant to patients who present with complaints of symptomatic myomas. Therefore, they must be familiar with the indications, exclusions, outcome expectations, and complications of UAE in their particular center. When hysterectomy is the only option, UAE should be considered. Appropriate diagnostic testing should aid in the exclusion of most, but not all, gynecologic cancers and pregnancy. Other contraindications include severe contrast medium allergy, renal insufficiency, and coagulopathy. MRI may be used to screen women before treatment in an attempt to detect those who have adenomyosis; patients should be aware that UAE is less effective in the presence of solitary or coexistent adenomyosis. Because some women may experience ovarian failure after UAE, additional studies to determine basal follicle-stimulating hormone and estradiol before and after the procedure may provide insight into UAE-induced follicle depletion.UAE is a unique new treatment for uterine myomas, and is no longer considered investigational for symptomatic uterine fibroids. There is international recognition that data are needed from RCTs that compare UAE with surgical alternatives. Current efforts to provide prospective objective assessment of treatment outcomes and complications after UAE will help to optimize patient selection and clinical guidelines. FIBROID should provide critical data for the assessment of safety and outcomes measures for women who receive UAE for symptomatic uterine myomas.

Myomas and assisted reproductive technologies: when and how to act?

The effect of myomas on reproductive outcome has been the subject of many studies; however, a definitive answer is still missing. Therefore, the authors have tried to outline some guidelines for the management of women who have uterine myomas and desire to conceive. The location and size of the myomas are the two parameters that influence the success of a future pregnancy. Subserosal myomas seem to have little, if any,effect on reproductive outcome, especially if they are up to 5 to 7 cm in diameter. Intramural myomas that do not encroach upon the endometrium also can be considered to be relatively harmless to reproduction, if they are smaller than 4 to 5 cm in diameter. This is the ambiguous gray zone of the subject, and where research should be focused before a consensus can be established. Myomas that compress the uterine cavity with an intramural portion (submucous myoma type II) and submucous myomas significantly reduce pregnancy rates, and should be removed before assisted reproductive techniques are used. Hysteroscopic myomectomy is the gold standard for the treatment of submucous myomas. For other myomas, abdominal myomectomy, or laparoscopic myomectomy--when the experience of the surgeon and the facilities are sufficient--are the best alternatives. In most of the literature, the pregnancy rates were increased and the miscarriage rates were decreased after surgery with these two techniques. Other alternative treatment modalities, such as CUV, laparoscopic myolysis, or MRI-guided focused ultrasound, are to be monitored and evaluated thoroughly before they are applied as routine procedures.

Myoma Expulsion after Uterine Artery Embolization.

Uterine leiomyomas are the most common benign pelvic tumors in women over 35 years and can be symptomatic or asymptomatic. Among the main treatment strategies, there are hormone therapy, hysterectomy, myomectomy, and uterine artery embolization (UAE), a recent and promising treatment for patients who wish to avoid hysterectomy. Ideal candidates for UAE are women with symptomatic uterine leiomyomas that present no desire for pregnancy, premenopausal and heavy menstrual bleeding, or dysmenorrhea caused by intramural fibroids. <iCase Presentation</i. A 36-year-old female diagnosed with leiomyomas and an extensive history of failed previous treatments who, in order to preserve her uterus, underwent UAE and had tumor expulsion 15 days after the procedure. The patient remained eight months in amenorrhea and, currently, presents normal hormone levels and irregular periods. UAE presents itself as a minimally invasive procedure and as an efficient alternative for those patients who wish to preserve their uteri and also improve their symptoms and quality of life.

[Ability to conceive and the course of pregnancy in women after laparoscopic myomectomy].

The aim of the study was to assess fertility of patients after myomectomy. The study included a group of 32 patients, aged 22-41, who underwent laparoscopic myomectomy. Primary infertility was diagnosed in 23 women (71.8%), whereas secondary infertility in 9 women (28.2%). Indications for surgery were rapid growth of myoma during last year and intramural myoma > 3 cm in diameter. The incision of the uterus and removal of myomas was made with harmonic scalpel. The average diameter of the largest myoma was 5.6 cm (range 3-11 cm). The number of myomas observed during operation ranged from 1 to 6. No conversion to laparotomy was performed. The average operation time was 85 min (range 60-185 min). After the operation 13 patients became pregnant, which constitutes 40.6%. Pregnancy ended with birth at term in 9 patients (28.1%), spontaneous abortion occurred in 4 patients (12.5%). Three-dimensional ultrasonography was performed after miscarriage and normal uterine cavity was observed. No obstetric complications were diagnosed in women who conceived. The main conclusions of the study are: 1. Uterine myomas constitute one of the significant causes of infertility and myomectomy using laparoscopy increases the chance of pregnancy. 2. Laparoscopy seems to be a promising and feasible method of myomectomy in women at reproductive age.

Uterine myomectomy

Myomectomy during pregnancy Leiomyomata tend to grow during pregnancy but only the large ones causing endometrial cavity distortion could interfere with the growing pregnancy directly. Generally, surgeons tend to stay away from operative interventions during the pregnancy because of the risk of haemorrhage and the concern that the pregnancy may be interrupted. Also, after a pregnancy, myomas tend to shrink naturally. However, in selected cases myomectomy may become necessary during pregnancy, or also at the time of a caesarean section to gain access to the baby. References Gynecological surgery

[Uterine artery embolization for myomas treatment].

Myoma treatment by uterine artery embolisation (UAE) using non-spherical PVA particles or calibrated tris-acryl microspheres>500μm is effective in more than 90 % of cases in the short-term. In the long-term, menorrhagia, bulk-related symptoms and pelvic pain are significantly improved or eliminated in 75 % of cases at 5 to 7 years. At 6 months, uterine volume reduction and larger myoma volume reduction varies between 30 to 60 % and 50 to 80 % respectively. During hospital stay the complication rate is very low, less than 3 % mostly urinary infection and pain. Secondary hysterectomy for complication is less than 2 % at 3 months. Definitive amenorrhea is reported in less than 5 % of cases in women of more than 45-year of age. No significant impact of embolization on hormonal function has been reported in women less than 45 years with normal baseline function. UAE is not indicated for submucous myomas. Randomized studies comparing embolization to hysterectomy demonstrate that reinterventions are more frequently performed after embolization. Secondary hysterectomy is performed in 13 to 24 % of cases at 2 years and in up to 28 % of cases at 5 years. Hospital stay, duration of recovery and time off work are shorter after embolization compared to hysterectomy. Embolization is cheaper than hysterectomy at 12 and 24 months even taking into consideration the additional costs of imaging and reinterventions. UAE is a good alternative treatment in women with unique myoma of less than 10cm and multiple myomas around 15cm. This treatment should be proposed to women each time possible. Randomized studies comparing embolization to myomectomy demonstrate that in the short and mid-term there is no difference in terms of control of menorrhagia and bulk-related symptoms. Uterine volume reduction and quality of life were not different at 6 months. Periprocedural and 30-day complication rates are not different. At 6 months, the rate of complications is higher after myomectomy. Reinterventions are more frequent after embolization compared to myomectomy. Hospital stay, duration of recovery and time off work are shorter after embolization compared to myomectomy. UAE is less aggressive than myomectomy and should be proposed as a conservative alternative treatment. Embolization should be considered with caution in pregnancy-seeking women since there is still a lack of good quality data available in the specific group of patients. FSH level is more frequently elevated after embolization compared to myomectomy. Pregnancy rate and term pregnancy rate are higher after myomectomy compared to embolization. Spontaneous abortion is more frequent after embolization than after myomectomy. At this time, UAE is not indicated excepted in studies or in specific cases when the woman want a pregnancy. Embolization performed before myomectomy (preoperative or combined procedures) can be discussed for an individual patient but there is not enough data to support its routine use.

[Management of menometrorrhagia in women with and without pregnancy intention: hierarchy of therapies].

The first line of treatment recommended for women with idiopathic menorrhagia is pharmaceutical agents, i.e. levonorgestrel intra-uterine device, tranexamic acid, estroprogestatif pills, oral progestin and non-sterodial anti-inflammatory drugs. The second line of treatment is surgical, using endometrial curettage for women who desire pregnancy in the future. On the other hand, in women who no longer intend to get pregnant either endometrial ablation or hysterectomy can be used. The menorrhagia associated with endometrial polyps is treated through the hysteroscopic polypectomy, which result can be improved by the use of the levonorgestrel intra-uterine device or the endometrial ablation. The menorrhagia related to submucosal myomas is managed by hysteroscopic myomectomy, either as a first line of treatment or following the failure of the pharmaceutical management. The first line of treatment of interstitial myomas is represented by the medical management, followed by laparoscopic or abdominal myomectomy for women who still want to be pregnant, and by myomectomy or uterine arteries embolization for women who no longer desire pregnancy. Hysterectomy is the most efficient treatment of menorrhagia due to interstitial myomas, and may be proposed either as a third line of treatment for the myomectomy and embolization failures or as a second line of treatment for women who do not wish to conserve their uterus. Finally, the treatment for women with clinically or radiologically suspected adenomyosis is medical, followed by hysterectomy for women who desire no pregnancy.

[Embolization of uterine fibroids and infertility: is a clinical trial conceivable?].

Uterine artery embolization is a recent technique intended for treating uterine fibroids, as an alternative to hysterectomy. The possible side effects putting at stake the prognosis of fertility after embolization are considered as a brake to its use for the treatment of infertility associated with myoma. Secondary hysterectomy and permanent amenorrhea are the two main risks. But they are not so frequent and can be prevented. To date, the experience in the field of fertility and pregnancy after arterial embolization for fibroids is quite limited. However, first results are encouraging and not very different from those observed after surgical myomectomy. A therapeutic trial using arterial embolization for the management of fibroids within a context of infertility can be devised in the presence of submucosal or intramural myomas responsible for metromenorrhagia and with no major infertility factors associated. It is likely that uterine artery embolization should provide results equivalent or superior to those of surgical myomectomy in case of numerous and intramural fibroids with no prevailing myoma. Arterial embolization could be also interesting in case of recurrent myoma after laparotomic myomectomy.

Gynecology_Novak

New appearance of fibroids is not more common following laparoscopic myomectomy when compared with abdominal myomectomy. Eighty-one women randomized to either laparoscopic or abdominal myomectomy were followed with transvaginal sonography every 6 months for at least 40 months (160). Fibroids larger than 1 cm were detected in 27% of women following laparoscopic myomectomy compared to 23% in the abdominal myomectomy group, and no woman in either group required any further intervention. Uterine artery embolization (UAE) is an effective treatment for selected women with uterine fibroids. The effects of UAE on early ovarian failure, fertility and pregnancy are unclear.

Surgery_Schwartz

of uterine myomas.Menorrhagia resulting from leiomyomas can be severe at times, requiring hospitalization or transfusion. Examination typically reveals an enlarged and irregular uterus. Diagnosis is usually made by transvaginal ultrasonography. Other diagnos-tic modalities, including MRI, computed tomography (CT), and hysterosalpingogram or saline-infused hysterosalpingography, are especially useful in the cases of submucosal and intrauterine myomas. Management options of leiomyomas are tailored to the individual patient depending on her age and desire for fertil-ity and the size, location, and symptoms of the myomas. Con-servative management options include oral contraceptive pills (OCPs), medroxyprogesterone acetate, GnRH agonists, uterine artery embolization, myomectomy, and hysterectomy.32-34 Uter-ine artery embolization is contraindicated in patients planning future pregnancy and may result in acute degeneration of myo-mas requiring hospitalization for pain control. Myomectomy is

[Methods and efficacy of medical and surgical treatment of non functional menorrhagia].

To assess the efficacy of therapies in menorrhagia related to atypical endometrial hyperplasia, polyps, myoma, adenomyosis and arteriovenous malformation of the uterus. Medline and Cochrane contents were searched to June 2008. Atypical endometrial hyperplasia is classically treated by hysterectomy, but may temporarily regress under hormone therapy (progestins, Gn-RH agonists) in women of childbearing age. Hysteroscopic resection is the standard treatment for endometrial polyps. Recurrence of bleeding is reduced by combining it with endometrial ablation. Myoma-related menorrhagia can be treated by Gn-RH agonists for 3 months or levonorgestrel in utero (LNG-IUS). Hysteroscopic resection is the standard treatment of submucous myomas. Interstitial myomas can be treated by myomectomy, myolysis, uterine artery embolisation or occlusion, or hysterectomy. Laparoscopic myomectomy and uterine artery embolisation are effective, well tolerated, and the best researched. LNG-IUS is effective and well tolerated to treat adenomyosis-related menorrhagia. The effect of other conservative treatments of the uterus (endometrial ablation, uterine artery embolisation or occlusion) is limited, especially in case of deep and extensive adenomyosis. Uterine artery embolisation is the standard treatment for arteriovenous malformation. Numerous medical and technical innovations have been recently developed as conservative treatments for menorrhagia. However, hysterectomy remains the standard treatment of atypical endometrial hyperplasia and adenomyosis.

Gynecology_Novak

An inability to evaluate the ovaries on pelvic examination is not an indication for surgery. Myomectomy should be considered as a safe alternative to hysterectomy, even for those women who have large uterine fibroids and wish to retain their uterus. Submucous fibroids, sometimes associated with increased menstrual bleeding or infertility, often can be removed hysteroscopically. Routine ultrasound follow-up is sensitive, but may detect many clinically insignificant fibroids. Uterine artery embolization (UAE) is an effective treatment for selected women with uterine fibroids. The effects of UAE on early ovarian failure, fertility, and pregnancy are unclear.

Gynecology_Novak

142. Darwish AM, Ahmad AM, Mohammad AM. Cervical priming prior to operative hysteroscopy: a randomized comparison of laminaria versus misoprostol. Hum Reprod 2004;19:2391–2394. 143. Murakami T, Hayasaka S, Terada Y, et al. Predicting outcome of one-step total hysteroscopic resection of sessile submucous myoma. J Minim Invasive Gynecol 2008;15:74–77. 144. Indman PD. Hysteroscopic treatment of submucous myomas. Clin Obstet Gynecol 2006;49:811–820. 145. Loffer FD, Bradley LD, Brill AI, et al. Hysteroscopic ﬂuid monitoring guidelines. The ad hoc committee on hysteroscopic training guidelines of the American Association of Gynecologic Laparoscopists. J Am Assoc Gynecol Laparosc 2000;7:167–168. 146. Murakami T, Tamura M, Ozawa Y, et al. Safe techniques in surgery for hysteroscopic myomectomy. J Obstet Gynaecol Res 2005;31:216– 223. 147. Indman PD. Hysteroscopic treatment of menorrhagia associated with uterine leiomyomas. Obstet Gynecol 1993;81:716–720. 148.

Uterine myomectomy

Laparoscopy Using the laparoscopic approach the uterus is visualized and its fibroids located and removed. Studies have suggested that laparoscopic myomectomy leads to lower morbidity rates and faster recovery than does laparotomic myomectomy. As with hysteroscopic myomectomy, laparoscopic myomectomy is not generally used on very large fibroids. A study of laparoscopic myomectomies conducted between January 1990 and October 1998 examined 106 cases of laparoscopic myomectomy, in which the fibroids were intramural or subserous and ranged in size from 3 to 10 cm.

Gynecology_Novak

147. Indman PD. Hysteroscopic treatment of menorrhagia associated with uterine leiomyomas. Obstet Gynecol 1993;81:716–720. 148. Mints M, Radestad A, Rylander E. Follow up of hysteroscopic surgery for menorrhagia. Acta Obstet Gynecol Scand 1998;77:435– 438. 149. Glasser MH, Zimmerman JD. The HydroThermAblator system for management of menorrhagia in women with submucous myomas: 12-to 20-month follow-up. J Am Assoc Gynecol Laparosc 2003;10: 521–527. 150. Sabbah R, Desaulniers G. Use of the NovaSure impedance controlled endometrial ablation system in patients with intracavitary disease: 12month follow-up results of a prospective, single-arm clinical study. J Minim Invasive Gynecol 2006;13:467–471. 151. Malone L. Myomectomy: recurrence after removal of solitary and multiple myomas. Obstet Gynecol 1969;34:200–203. 152. Parker WH. Uterine myomas: management. Fertil Steril 2007;88:255–271. 153.

Uterine myomectomy

Myomectomy, sometimes also called fibroidectomy, refers to the surgical removal of uterine leiomyomas, also known as fibroids. In contrast to a hysterectomy, the uterus remains preserved and the woman retains her reproductive potential. Indications The presence of a fibroid does not mean that it needs to be removed. Removal is necessary when the fibroid causes pain or pressure, abnormal bleeding, or interferes with reproduction. The fibroids needed to be removed are typically large in size, or growing at certain locations such as bulging into the endometrial cavity causing significant cavity distortion. Treatment options for uterine fibroids include observation or medical therapy, such a GnRH agonist, hysterectomy, uterine artery embolization, and high-intensity focused ultrasound ablation.

Surgery_Schwartz

Uter-ine artery embolization is contraindicated in patients planning future pregnancy and may result in acute degeneration of myo-mas requiring hospitalization for pain control. Myomectomy is indicated in patients with infertility thought secondary to fibroids and for those with symptomatic fibroids who wish to preserve their reproductive capacity. Hysterectomy is the only definitive therapy. Treatment with GnRH agonists for 3 months prior to surgery may be administered in anemic patients, and it may allow them time to normalize their hematocrit, avoiding transfusions; GnRH also decreases blood loss at hysterectomy and shrinks the myomas by an average of 30%. The latter may make the preferred vaginal surgical approach more feasible.Endometrial Hyperplasia. Endometrial hyperplasia is caused by chronic unopposed hyperestrogenic state (relative absence of progesterone) and is characterized by proliferation of endo-metrial glands resulting in increased gland-to-stroma ratio. It can be

Gynecology_Novak

After an exhaustive review of the medical literature published between 1975 and 2000, with evaluation of 637 relevant articles and careful study of 200 articles, the authors found no satisfactory answers to fundamental question about fibroid treatments (83). Women and their physicians need information on which to base decisions regarding possible treatments. This section summarizes the literature regarding the management of fibroids. Treatment options include observation, medical therapy, hysteroscopic myomectomy, laparoscopic myomectomy, hysterectomy, uterine artery embolization, and focused ultrasound.

Gynecology_Novak

The surgical options range from a variety of techniques for endometrial ablation or resection to hysterectomy to a variety of conservative surgical techniques for management of uterine leiomyoma, including hysteroscopy with resection of submucous leiomyomas, laparoscopic techniques of myomectomy, uterine artery embolization, and magnetic resonance–guided focused ultrasonography ablation (see Chapters 23 and 24) (143,189). The choice of procedure depends on the cause of the bleeding, the patient’s preferences, the physician’s experience and skills, the availability of newer technologies, and a careful assessment of risks versus benefits based on the patient’s medical condition, concomitant gynecologic symptoms or conditions, and desire for future fertility. The assessment of the relative advantages, risks, benefits, complications, and indications of these procedures is a subject of ongoing clinical research. Various techniques of endometrial ablation were compared with the gold

Gynecology_Novak

128. Parker WH, Rodi IA. Patient selection for laparoscopic myomectomy. J Am Assoc Gynecol Laparosc 1994;2:23–26. 129. Jin C, Hu Y, Chen X, et al. Laparoscopic versus open myomectomya meta-analysis of randomized controlled trials. Eur J Obstet Gynecol Reprod Biol 2009;145:14–21. 130. Malzoni M, Rotond M, Perone C, et al. Fertility after laparoscopic myomectomy of large uterine myomas: operative technique and preliminary results. Eur J Gynaecol Oncol 2003;24:79–82. 131. Andrei B, Crovini G, Rosi A. Uterine myomas: pelviscopic treatment. Clin Exp Obstet Gynecol 1999;26:44–46. 132. Koh C, Janik G. Laparoscopic myomectomy: the current status. Curr Opin Obstet Gynecol 2003;15:295–301. 133. Agarwala N, Liu CY. Safe entry techniques during laparoscopy: left upper quadrant entry using the ninth intercostal space–a review of 918 procedures. J Minim Invasive Gynecol 2005;12:55–61. 134.

Critical Steps to Performing a Successful Single-site Laparoscopic Myomectomy for Large Pedunculated Myoma during Pregnancy.

To demonstrate tips and tricks for the successful use of single-site laparoscopic surgery for pedunculated myomectomy during pregnancy. Stepwise demonstration with narrated video footage. An academic tertiary care hospital affiliated with Baylor College of Medicine. Our patient is a 39-year-old pregnant G1P0010 with a symptomatic 12-cm degenerating pedunculated myoma refractory to conservative pain management. Recent literature has indicated that most laparotomic myomectomies performed during pregnancy showed overall positive pregnancy outcomes and low complications. This indicates that myomectomy in pregnancy is safe and can be used in cases unresponsive to conservative management [1]. However, cases in literature discussing the single-site techniques for laparoscopic myomectomy during pregnancy have been sparse [2]. Four case series were reviewed; a total of 62 pregnant patients underwent laparoendoscopic single-site surgery without any complications [3-6]. Using laparoscopy in myomectomy compared with laparotomy during pregnancy permits decreased postoperative pain, quicker recovery, and lowered risk of postoperative complications [5,7,8]. Single-site laparoscopic surgery also aids in improved patient cosmesis and can be used for the myoma removal. Literature has demonstrated that single-site laparoscopy is safe and feasible during all stages of pregnancy [3,4]. Nevertheless, this approach may be challenging for inexperienced surgeons owing to the lack of triangulation and crowding of instruments in single-site laparoscopy [5]. At 21 weeks and 3 days pregnancy, our patient underwent single-incision laparoscopic surgery myomectomy. A 2.5-cm skin incision was made at the umbilicus to the abdominal cavity, and a GelPOINT Mini was inserted. Through the laparoscope, we can observe that a 12-cm pedunculated myoma was protruding from the right uterine fundus on a 4-cm stalk. A 0-Vicryl suture was tied around the base of the stalk. The stalk was then cauterized with bipolar energy and transected with the harmonic scalpel, completely detaching the myoma. Subsequently, an Endo Catch bag was placed around the myoma and brought up to the umbilical incision. Using a scalpel, bag-contained morcellation was completed within 22 minutes and the contents removed. As a result, the estimated blood loss was 50 cc and the total operative time was 123 minutes. The extended operating time was caused by slow movements to avoid disrupting the fetus. She had an unremarkable postoperative course, no medications were needed for pain management, and she was discharged home on postoperative day 2. At 38 weeks, she successfully delivered with elective cesarean delivery with no complications. Histopathology showed fragments of leiomyoma with diffuse necrosis. Tips and tricks: 1. Single-site entry technique uses the open Hasson technique, which reduces the risk of injury to the pregnant uterus and dilated surrounding vessels. 2. Through a 2.5-cm incision, the surgeon placed a suture in the myoma stalk because other hemostasis agents such as vasopressin are contraindicated in pregnancy. 3. Owing to difficulties related to single-site surgery, the surgeon should possess extensive expertise in single-site surgery. 4. Manipulation of the uterus should be minimized to reduce the disturbance of the pregnant uterus. 5. V-loc suture allows for faster and simplified uterine incision closure. 6. If the surgeon encounters excessive difficulty during the surgery, a 5-mm accessory port can be placed. 7. During tissue extraction, gentle traction should be used to reduce provoking the pregnant uterus. 8. When transecting the myoma stalk, it is important to leave a stump of more than 1 cm to increase suturing ease and prevent accidental suturing of the uterus. Single-incision laparoscopic surgery myomectomy for pedunculated myoma may be a practical technique in women refractive to conservative management. When performed by an experienced surgeon, the patient may benefit from faster specimen removal and recovery.

[Management of uterine myomas in women of fertile age].

Review of current knowledge about uterine fibroids management in young women. Analysis of possible diagnostic and therapeutic algorithms regarding fertility preserving. Review article. Department of Obstetrics and Gynecology, 1st Faculty of Medicine and the General Faculty Hospital, Charles University, Prague. Analysis of the facts in literature (texts in medical journals, monographies, textbooks, internet database Medline and Ovid) and authors' clinical experience. Alternatives of treatment of infertility in women with uterine fibroids have significantly enlarged in past 10 years. However none of the indicated methods is perfect. Expectation does not exclude the risk of growth of fibroids and abortion. The effect of pharmacological therapy is only temporary. Myomectomy is associated with the risk of surgical complications, fibroids' recurrence and uterine rupture in subsequent gestation. Although uterine artery embolisation (on an average) halves the fibroids volume, the long-term effect of the method on female fertility is still unknown. Nevertheless it seems convenient to advise the active approach to all women planning pregnancy and having significant (submucous or intramural) fibroid even before spontaneous or assisted conception. Most recent studies indicate significant improvement of reproduction outcomes after myomectomy, especially in young women with the absence of other factors of infertility. Only the results of randomized, controlled trials (that are still awaited) will inform us about comparison of the effects and risks of myomectomy and uterine artery embolization in management of infertility.

Port site parasitic leiomyoma after laparoscopic myomectomy: a case report and review of the literature.

Uterine fibroids are the commonest benign gynecological tumors. Laparoscopic myomectomy is becoming increasingly popular as one of the surgical treatment options for symptomatic cases. Large tissues such as leiomyomas or even the uterus need to be morcellated in order to be retrieved from the abdominal cavity. Some of the morcellated fragments or small fibroids may be accidentally left in the abdominal cavity during the retrieval process. These may subsequently become implanted in the abdominal cavity, develop blood supply from the surrounding structures, and grow to form parasitic myomas with varied clinical presentation, depending on the location and size. A 47-year-old African woman presented to our hospital 6 years after laparoscopic myomectomy with a lower abdominal mass. Her work-up revealed an anterior abdominal wall mass consistent with uterine leiomyoma. She was scheduled for excision of the mass, which was subsequently histologically confirmed to be a uterine fibroid. Parasitic leiomyomas are a rare late complication of power morcellation following laparoscopic myomectomy or hysterectomy. Most patients present with an abdominal/pelvic mass and may need surgical excision to relieve the symptoms. Care should be taken during power morcellation to prevent excessive fragmentation of the tissues, some of which may become implanted and persist to form parasitic myomas. Moreover, effort should be made to retrieve all myoma fragments by carefully checking the abdominal cavity. Whenever possible, the morcellation should be done in a containment bag.

[New options in the diagnosis and management of uterine myoma].

Myoma accounts for nearly 95% of all benign tumors of female genital organs and is the most common neoplasm of female genital tract. Along with thorough history and gynecologic examination, ultrasound study is of utmost importance in the diagnosis of myoma; magnetic resonance (MR) study may also be required in rare cases. A number of therapeutic options are available for the management of myoma, ranging from medicamentous therapy through operative procedures (e.g., total or supracervical hysterectomy or myoma enucleation) and novel non-operative procedures (e.g., embolization of uterine artery (EUA) and magnetic resonance guided focused ultrasound (MRgFUS). Discomforts caused by a myoma are an absolute indication for treatment. Therapeutic option to be chosen is determined by the number, size and location of myomas, and the patient's preferences. Therapeutic choice should rely on the patient's decision for or against treatment, sparing the uterus. An individualized treatment protocol should be tailored for each patient.

[Efficacy of general magnetotherapy in conservative therapy of uterine myoma in women of reproductive age].

Sixty women of the reproductive age with uterine myoma were divided into two groups. Thirty patients of the study group received combined therapy plus general magnetotherapy (GMT). Patients of the control group received only combined treatment. Ultrasound investigation registered a reduction in the size of myoma nodes by 16.7% in the study group, while in the controls myoma size did not change (p < 0.05). 1-year follow-up data for the study group demonstrated no cases of the myoma growth while 16.6% of the controls showed growth of myoma nodes, in 6.6% of them supravaginal myoma amputation was made for rapidly growing myoma.

The management of uterine fibroids in women with otherwise unexplained infertility.

To provide recommendations regarding the best management of fibroids in couples who present with infertility. Usual and novel treatment options for fibroids will be reviewed with emphasis on their applicability in women who wish to conceive. Management of fibroids in women wishing to conceive first involves documentation of the presence of the fibroid and determination of likelihood of the fibroid impacting on the ability to conceive. Treatment of fibroids in this instance is primarily surgical, but must be weighed against the evidence of surgical management improving clinical outcomes, and risks specific to surgical management and approach. The outcomes of primary concern are the improvement in pregnancy rates and outcomes with management of fibroids in women with infertility. Published literature was retrieved through searches of PubMed, MEDLINE, the Cochrane Library in November 2013 using appropriate controlled vocabulary (e.g., leiomyoma, infertility, uterine artery embolization, fertilization in vitro) and key words (e.g., fibroid, myomectomy). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies published in English and French. There were no date restrictions. Searches were updated on a regular basis and incorporated in the guideline to November 2013. Grey (unpublished literature) was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. The quality of evidence in this document was rated using the criteria described by the Canadian Task Force on Preventive Health Care (Table). These recommendations are expected to allow adequate management of women with fibroids and infertility, maximizing their chances of pregnancy by minimizing risks introduced by unnecessary myomectomies. Reducing complications and eliminating unnecessary interventions are also expected to decrease costs to the health care system. Summary Statements 1. Subserosal fibroids do not appear to have an impact on fertility; the effect of intramural fibroids remains unclear. If intramural fibroids do have an impact on fertility, it appears to be small and to be even less significant when the endometrium is not involved. (II-3) 2. Because current medical therapy for fibroids is associated with suppression of ovulation, reduction of estrogen production, or disruption of the target action of estrogen or progesterone at the receptor level, and it has the potential to interfere in endometrial development and implantation, there is no role for medical therapy as a stand-alone treatment for fibroids in the infertile population. (III) 3. Preoperative assessment of submucosal fibroids is essential to the decision on the best approach for treatment. (III) 4. There is little evidence on the use of Foley catheters, estrogen, or intrauterine devices for the prevention of intrauterine adhesions following hysteroscopic myomectomy. (II-3) 5. In the infertile population, cumulative pregnancy rates by the laparoscopic and the minilaparotomy approaches are similar, but the laparoscopic approach is associated with a quicker recovery, less postoperative pain, and less febrile morbidity. (II-2) 6. There are lower pregnancy rates, higher miscarriage rates, and more adverse pregnancy outcomes following uterine artery embolization than after myomectomy. (II-3) Studies also suggest that uterine artery embolization is associated with loss of ovarian reserve, especially in older patients. (III) Recommendations 1. In women with infertility, an effort should be made to adequately evaluate and classify fibroids, particularly those impinging on the endometrial cavity, using transvaginal ultrasound, hysteroscopy, hysterosonography, or magnetic resonance imaging. (III-A) 2. Preoperative assessment of submucosal fibroids should include, in addition to an assessment of fibroid size and location within the uterine cavity, evaluation of the degree of invasion of the cavity and thickness of residual myometrium to the serosa. A combination of hysteroscopy and transvaginal ultrasound or hysterosonography are the modalities of choice. (III-B) 3. Submucosal fibroids are managed hysteroscopically. The fibroid size should be < 5 cm, although larger fibroids have been managed hysteroscopically, but repeat procedures are often necessary. (III-B) 4. A hysterosalpingogram is not an appropriate exam to evaluate and classify fibroids. (III-D)  5. In women with otherwise unexplained infertility, submucosal fibroids should be removed in order to improve conception and pregnancy rates. (II-2A) 6. Removal of subserosal fibroids is not recommended. (III-D) 7. There is fair evidence to recommend against myomectomy in women with intramural fibroids (hysteroscopically confirmed intact endometrium) and otherwise unexplained infertility, regardless of their size. (II-2D) If the patient has no other options, the benefits of myomectomy should be weighed against the risks, and management of intramural fibroids should be individualized. (III-C) 8. If fibroids are removed abdominally, efforts should be made to use an anterior uterine incision to minimize the formation of postoperative adhesions. (II-2A) 9. Widespread use of the laparoscopic approach to myomectomy may be limited by the technical difficulty of this procedure. Patient selection should be individualized based on the number, size, and location of uterine fibroids and the skill of the surgeon. (III-A) 10. Women, fertile or infertile, seeking future pregnancy should not generally be offered uterine artery embolization as a treatment option for uterine fibroids. (II-3E).

[Surgical treatment of uterine myoma: need for surgery and long-term results].

We analysed the indications to myomectomy in females in reproductive age and estimated efficasy of this treatment. 112 patients aged 23-45 were analysed. Most common indication to this procedure were: menorrhagia--45.54%, myoma found at gynecological examination--21.43%, adnexal mass--20.54% and pelvic pain--15.18%. 54.46% patients were parous, 34.82% nulligravid and 10.72% had a history of spontaneous abortion. There was low percentage of intraoperation complications--2.67%, as well as postoperation complications--3.57%. More than 5 years follow-up revealed recurrent myoma in 14.28% females and in 6.25% hysterectomy was performed. Cervical polypus was found in 8.04%, endometrial hyperplasia in 2.68%. 18.75% patients had menorrhagia and 5.36% abdominal pain. Successful pregnancies have occurred in 42.11% infertile women prior to surgery but with patent fallopian tubes. Our study shows that myomectomy is safe and well accepted method of treatment for uterine myomas however always stands a risk of recurrents.

Surgery_Schwartz

GY, Jung SE, Choi KH. Dif-fuse and focal adenomyosis: MR imaging findings. Radio-graphics. 1999;19:S161-S170. 32. Filicori M, Hall DA, Loughlin JS, Rivier J, Vale W, Crowley WF, Jr. A conservative approach to the management of uter-ine leiomyoma: pituitary desensitization by a luteinizing hormone-releasing hormone analogue. Am J Obstet Gynecol. 1983;147:726-727. 33. Matsuo H, Maruo T. GnRH analogues in the manage-ment of uterine leiomyoma (in Japanese). Nippon Rinsho. 2006;64(suppl 4):75-79.Brunicardi_Ch41_p1783-p1826.indd 182218/02/19 4:35 PM 1823GYNECOLOGYCHAPTER 41 34. Szabo E, Nagy E, Morvay Z, Palko A, Csernay L. Uterine artery embolization for the conservative management of leio-myoma (in Hungarian). Orv Hetil. 2001;142:675-680. 35. Mutter GL. Diagnosis of premalignant endometrial disease. J Clin Pathol. 2002;55:326-331. 36. Kurman RJ, Kaminski PF, Norris HJ. The behavior of endome-trial hyperplasia. A long-term study of “untreated” hyperplasia in 170 patients. Cancer.

The management of uterine leiomyomas.

The aim of this guideline is to provide clinicians with an understanding of the pathophysiology, prevalence, and clinical significance of myomata and the best evidence available on treatment modalities. The areas of clinical practice considered in formulating this guideline were assessment, medical treatments, conservative treatments of myolysis, selective uterine artery occlusion, and surgical alternatives including myomectomy and hysterectomy. The risk-to-benefit ratio must be examined individually by the woman and her health care provider. Implementation of this guideline should optimize the decision-making process of women and their health care providers in proceeding with further investigation or therapy for uterine leiomyomas, having considered the disease process and available treatment options, and reviewed the risks and anticipated benefits. Published literature was retrieved through searches of PubMed, CINAHL, and Cochrane Systematic Reviews in February 2013, using appropriate controlled vocabulary (uterine fibroids, myoma, leiomyoma, myomectomy, myolysis, heavy menstrual bleeding, and menorrhagia) and key words (myoma, leiomyoma, fibroid, myomectomy, uterine artery embolization, hysterectomy, heavy menstrual bleeding, menorrhagia). The reference lists of articles identified were also searched for other relevant publications. Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. There were no date limits but results were limited to English or French language materials. Searches were updated on a regular basis and incorporated in the guideline to January 2014. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, and national and international medical specialty societies. The majority of fibroids are asymptomatic and require no intervention or further investigations. For symptomatic fibroids such as those causing menstrual abnormalities (e.g. heavy, irregular, and prolonged uterine bleeding), iron defficiency anemia, or bulk symptoms (e.g., pelvic pressure/pain, obstructive symptoms), hysterectomy is a definitive solution. However, it is not the preferred solution for women who wish to preserve fertility and/or their uterus. The selected treatment should be directed towards an improvement in symptomatology and quality of life. The cost of the therapy to the health care system and to women with fibroids must be interpreted in the context of the cost of untreated disease conditions and the cost of ongoing or repeat investigative or treatment modalities. The quality of evidence in this document was rated using the criteria described in the Report of the Caadian Task Force on Preventive Health Care (Table 1). Summary Statements 1. Uterine fibroids are common, appearing in 70% of women by age 50; the 20% to 50% that are symptomatic have considerable social and economic impact in Canada. (II-3) 2. The presence of uterine fibroids can lead to a variety of clinical challenges. (III) 3. Concern about possible complications related to fibroids in pregnancy is not an indication for myomectomy except in women who have had a previous pregnancy with complications related to these fibroids. (III) 4. Women who have fibroids detected in pregnancy may require additional maternal and fetal surveillance. (II-2) 5. Effective medical treatments for women with abnormal uterine bleeding associated with uterine fibroids include the levonorgestrel intrauterine system, (I) gonadotropin-releasing hormone analogues, (I) selective progesterone receptor modulators, (I) oral contraceptives, (II-2) progestins, (II-2) and danazol. (II-2) 6. Effective medical treatments for women with bulk symptoms associated with fibroids include selective progesterone receptor modulators and gonadotropin-releasing hormone analogues. (I) 7. Hysterectomy is the most effective treatment for symptomatic uterine fibroids. (III) 8. Myomectomy is an option for women who wish to preserve their uterus or enhance fertility, but carries the potential for further intervention. (II-2) 9. Of the conservative interventional treatments currently available, uterine artery embolization has the longest track record and has been shown to be effective in properly selected patients. (II-3) 10. Newer focused energy delivery methods are promising but lack long-term data. (III) Recommendations 1. Women with asymptomatic fibroids should be reassured that there is no evidence to substantiate major concern about malignancy and that hysterectomy is not indicated. (III-D) 2. Treatment of women with uterine leiomyomas must be individualized based on symptomatology, size and location of fibroids, age, need and desire of the patient to preserve fertility or the uterus, the availability of therapy, and the experience of the therapist. (III-B) 3. In women who do not wish to preserve fertility and/or their uterus and who have been counselled regarding the alternatives and risks, hysterectomy by the least invasive approach possible may be offered as the definitive treatment for symptomatic uterine fibroids and is associated with a high level of satisfaction. (II-2A) 4. Hysteroscopic myomectomy should be considered first-line conservative surgical therapy for the management of symptomatic intracavitary fibroids. (II-3A) 5. Surgical planning for myomectomy should be based on mapping the location, size, and number of fibroids with the help of appropriate imaging. (III-A) 6. When morcellation is necessary to remove the specimen, the patient should be informed about possible risks and complications, including the fact that in rare cases fibroid(s) may contain unexpected malignancy and that laparoscopic power morcellation may spread the cancer, potentially worsening their prognosis. (III-B) 7. Anemia should be corrected prior to proceeding with elective surgery. (II-2A) Selective progesterone receptor modulators and gonadotropin-releasing hormone analogues are effective at correcting anemia and should be considered preoperatively in anemic patients. (I-A) 8. Use of vasopressin, bupivacaine and epinephrine, misoprostol, peri-cervical tourniquet, or gelatin-thrombin matrix reduce blood loss at myomectomy and should be considered. (I-A) 9. Uterine artery occlusion by embolization or surgical methods may be offered to selected women with symptomatic uterine fibroids who wish to preserve their uterus. Women choosing uterine artery occlusion for the treatment of fibroids should be counselled regarding possible risks, including the likelihood that fecundity and pregnancy may be impacted. (II-3A) 10. In women who present with acute uterine bleeding associated with uterine fibroids, conservative management with estrogens, selective progesterone receptor modulators, antifibrinolytics, Foley catheter tamponade, and/or operative hysteroscopic intervention may be considered, but hysterectomy may become necessary in some cases. In centres where available, intervention by uterine artery embolization may be considered. (III-B).

[Embolization of uterine arteries during myoma treatment from the patient's point of view].

To acquire information about the patient's follow-up evaluation of treating fibroids by uterine artery embolization (UAE). A retrospective multicenter clinical trial. Department of Obstetrics and Gynaecology, 1st Faculty of Medicine and the General Faculty Hospital, Charles University, Prague. 45 women who underwent the UAE due to uterine fibroids from 1999 to 2003 were asked to complete a questionnaire. The questionnaire included 26 questions asking how the women had been informed and what they had expected. Further questions were focused on the course of embolization itself, early post-procedural difficulties (post-embolization syndrome) and patient's overall evaluation of treatment in a longer term. Those women who had completed the questionnaire and had been ready to co-operate were thereafter examined and included in the follow-up monitoring and, if necessary, further treatment was recommended. Thirty one out of 45 patients from 26 to 48 years of age, who had been addressed (68.9%) answered the questionnaire. UAE was indicated 12 times (38.7%) on account of symptoms, 10 times (32.3%) because of sterility, 5 times (16.1%) as a preventive measure within the framework of family planning and 4 times (12.9%) for an asymptomatic but growing leiomyoma. Twenty seven (87.1%) women were also offered an alternative treatment, which they refused. As far as problems are concerned, 18 (58%) women described the course of treatment as corresponding with what they had expected, 5 times it was less painful, and 8 times it was worse than expected. The long-term results were considered as positive by 87.1% of responders, only 12.9% considered the treatment as failure. 5 in 11 women planning pregnancy became pregnant, 3 of them gave birth in term and 2 miscarried in the 1st trimester. From the point of view of the patients, the evaluated method proves highly successful, it is well tolerated and it involves a low risk of complications. It is not possible, at this point, however, to give an unequivocal answer to the question whether the method should also be routinely offered to women who are planning pregnancy.

Uterine Fibroid Embolization -- Clinical Significance -- Trials and Guidelines for Treatment of Fibroids

In one study, patients having intramural fibroids larger than 4 cm were randomized to UAE (n = 58) or to myomectomy (open or laparoscopic according to surgeon preference; n = 63) and followed for two years. This is the primary study used as the rationale for making myomectomy the first-line invasive therapy in women who still wish to conceive, as 50% of UAE versus 78% of myomectomy patients were able to conceive.  UAE in this study had an increased calculated relative risk compared to myomectomy for (1) inability to conceive and (2) miscarriage (95% CI of [1] 1.11 to 4.44 and of [2] 1.25 to 6.22).  However, Gupta (2014), included Mara's patients with others having undergone myomectomy in RCTs and deemed the evidence that myomectomy provides a fertility benefit over UAE to be "low-quality evidence" that "should be regarded with extreme caution."  Another systematic review on myomectomy concluded that there is currently insufficient evidence that myomectomy improves fertility compared to UAE whether by the laparoscopic or open approach. [22]

Gynecology_Novak

Proper patient selection for myomectomy, regardless of route, is extremely important, particularly because, by age 50, the prevalence of leiomyomas may be as high as 70% in whites and 80% in women of African ancestry (44). It is relatively easy to mistakenly ascribe symptoms to the presence of leiomyomas. Unless the myoma involves the endometrial cavity, it is unlikely to contribute to heavy menstrual bleeding or infertility; the impact of intramural myomas on infertility is not well understood (45). Leiomyomas that cause pressure are often large and may be located near vital vascular structures that may preclude the laparoscopic approach even in expert hands. Many women will do well with expectant or medical management or with procedural alternatives such as uterine artery embolization. The surgeon should freely select a laparotomic approach, either at the outset or during the procedure, if technical limitations put the patient at risk or otherwise compromise the potential relevant