Factors associated with the complications of hysteroscopic myomectomy / Fatores associados às complicações da miomectomia por histeroscopia

Abstract Objective To evaluate the factors associated with complete myomectomy in a single surgical procedure and the aspects related to the early complications. Methods A cross-sectional study with women with submucous myomas. The dependent variables were the complete myomectomy performed in a single hysteroscopic procedure, and the presence of early complications related to the procedure. Results We identified 338 women who underwent hysteroscopic myomectomy. In 89.05% of the cases, there was a single fibroid to be treated. According to the classification of the International Federation of Gynecology and Obstetrics (Fédération Internationale de Gynécologie et d'Obstétrique, FIGO, in French),most fibroids were of grade 0 (66.96%), followed by grade 1 (20.54%), and grade 2 (12.50%). The myomectomies were complete in 63.31% of the cases, and the factors independently associated with complete myomectomy were the diameter of the largest fibroid (prevalence ratio [PR]: 0.97; 95% confidence interval [95%CI]: 0.96-0.98) and the classification 0 of the fibroid according to the FIGO (PR: 2.04; 95%CI: 1.18-3.52). We observed early complications in 13.01% of the hysteroscopic procedures (4.44% presented excessive bleeding during the procedure, 4.14%, uterine perforation, 2.66%, false route, 1.78%, fluid overload, 0.59%, exploratory laparotomy, and 0.3%, postoperative infection). The only independent factor associated with the occurrence of early complications was incomplete myomectomy (PR: 2.77; 95%CI: 1.43-5.38). Conclusions Our results show that hysteroscopic myomectomy may result in up to 13% of complications, and the chance of complete resection is greater in small and completely intracavitary fibroids; women with larger fibroids and with a high degree of myometrial penetration have a greater chance of developing complications from hysteroscopic myomectomy.

Resumo Objetivo Avaliar os fatores associados a miomectomia por histeroscopia completa em um único procedimento e as suas complicações. Métodos Estudo de corte transversal com mulheres submetidas a histeroscopia para exérese de miomas submucosos. As variáveis dependentes foram a miomectomia completa realizada em um tempo cirúrgico único, e a presença de complicações precoces relacionadas ao procedimento. Resultados Analisamos 338 mulheres que foram submetidas a miomectomia histeroscópica. Em 89,05% dos casos, o mioma a ser tratado era único. Quanto à classificação da Federação Internacional de Ginecologia e Obstetrícia (Fédération Internationale de Gynécologie et d'Obstétrique, FIGO, em francês), a maioria era de grau 0 (66,96%), seguidos pelos graus 1 (20,54%) e 2 (12,50%). As miomectomias foram completas em 63,31% das mulheres, sendo que os fatores independentemente associados à miomectomia completa foram o diâmetro do maior mioma (razão de prevalência [RP]: 0,97; intervalo de confiança de 95% [IC95%]: 0,96-0,98) e a classificação FIGO grau 0 (RP: 2,04; IC95%: 1,18-3,52). Foram observadas complicações precoces em 13,01% dos procedimentos (4,44% apresentaram sangramento excessivo durante o procedimento, 4,14%, perfuração uterina, 2,66%, falso pertuito, 1,78%, intoxicação hídrica, 0,59%, laparotomia exploradora, e 0,3%, infecção pósoperatória). O único fator independentemente associado à ocorrência de complicações precoces foi a realização de miomectomia incompleta (RP: 2,77; IC95%: 1,43-5,38). Conclusão Nossos resultados mostram que as complicações da miomectomia por histeroscopia podem ocorrer em até 13% dos procedimentos. A chance de ressecção completa é maior em miomas pequenos e completamente intracavitários; mulheres com miomas maiores e com maior grau de penetração miometrial têm maiores chances de desenvolver complicações.

Incidence of Venous Air Embolism during Myomectomy: The Effect of Patient Position

PURPOSE: Venous air embolism (VAE) is characterized by the entrainment of air or exogenous gases from broken venous vasculature into the central venous system. No study exists regarding the effect of patient positioning on the incidence of VAE during abdominal myomectomy. The purpose of this study was to assess the incidence and grade of VAE during abdominal myomectomy in the supine position in comparison to those in the head-up tilt position using transesophageal echocardiography. MATERIALS AND METHODS: In this study, 84 female patients of American Society of Anesthesiologist physical status I or II who were scheduled for myomectomy under general anesthesia were included. Patients were randomly divided into two groups: supine group and head-up tilt group. Transesophageal echocardiography images were videotaped throughout the surgery. The tapes were then reviewed for VAE grading. RESULTS: In the supine group, 10% of the patients showed no VAE. Moreover, 10% of the patients were classified as grade I VAE, while 50% were categorized as grade II, 22.5% as grade III, and 7.5% as grade IV. In the head-up tilt group, no VAE was detected in 43.2% of the patients. In addition, 18.2% of the patients were classified as grade I VAE, 31.8% as grade II, and 6.8% as grade III; no patients showed grade IV. VAE grade in the head-up tilt group was significantly lower than that in the supine group (p<0.001). CONCLUSION: The incidence and grade of VAE in the head-up tilt group were significantly lower than those in the supine group during abdominal myomectomy.

True unicornuate uterus- Pseudounicornuate uterus

A 27 year old patient presented with primary infertility of 3 years' duration and also a history of myomectomy [5 years ago] was referred to our infertility clinic for investigation of infertility. The latest Hysterosalpingography [HSG] revealed an obstructed left fallopian tube with apparently a unicornuate uterus with luminal contour irregularity and normal left fallopian tube [Figure 1]. Significant information in her past medical history revealed that she had another HSG two years before and her first hysterosalpingography [HSG] showed a apparently unicornuate uterus. Additional significant information in comparison with second HSG revealed that both fallopian tubes were opacified [Figure 2]. In this case medical history also included hysteroscopic diagnosis of adhesion following open myomectomy at the age of 22. Comparison of previous graphies and hysteroscpic findings lead to a suggestion of pseudounicornuate uterus. Intrauterine adhesions develop after trauma to the basal layer of the endometrium. Unilateral excessive scarring of the uterus may lead to an obliteration of the uterine lumen resulting in an image that can mimic a unicornuate uterus [pseudounicornuate uterus] [1]. A true unicornuate uterus should be excluded from pseudounicornuate uterus by a] horizontally oriented in its long axis due to deficient development of mullerian ducts b] smooth or regular contour c] with one tube. While pseudounicornuate uterus look like acquired lesion and cicatrisation leads to a usually irregular contour and uterus is more vertical in its long axis [2]. Obtaining an accurate history, comparison of previous sonographic or laparoscopic findings, and awareness about this image of synechiae are the critical steps in differentiating a pseudounicornuate uterus from true unicornuate uterus

effect of uterine blood supply cutoff during myomectomy

Myomectomy is considered a highly morbid procedure due to the risk of high intraoperative blood loss. Meticulous surgical techniques can reduce operative morbidity. Our aim was to evaluate and compare the intraoperative blood loss between two surgical techniques: 1] the uterine vascular cutoff technique and 2] the classical technique. Retrospective chart review conducted between 1 July 2008 until 30 June 2010 in a tertiary care referral center to compare surgical outcomes of two groups. The sample included 136 patients: 30 patients had their surgeries performed with the uterine vascular cutoff technique, and the remainder [106 patients] had myomectomies performed with the classical technique. The uterine vascular cutoff technique was performed by the same surgeon for all 30 patients, whereas myomectomy with the classical technique was performed by several gynecologists. There was no significant difference between the two groups in parity and operation time; however, patients in the first group had a statistically significant higher mean age [39.1 [7.6] vs 35.8 [6.9] years; P=.025] and, on average, bigger fibroid size by gestational week [20.1 [7.3] vs 1 7 [5.2] weeks; P=.0094], with standard deviation shown in parentheses. There was a statistically significant lesser drop in hemoglobin concentration among patients in the first group [1.23 [1.2] vs 2.25 [1.4] g/dL; P=.0003], and the postoperative hemoglobin was significantly higher in the first group [10.5 [1.6] vs 9.7 [1.7] g/dL; P=.036]. The hospital stay was shorter for patients in the first group [5.8 [1.7] vs 7.1 [2.9] days; P=.031]. The vascular cutoff technique leads to less intraoperative blood loss without increasing the operative time, patients tolerate this technique very well, and the technique is associated with shorter hospital stay, all of which could contribute to less postoperative morbidity