Pregnancy following laparoscopic myomectomy: preliminary results.

The objective of this study was to assess the outcome of pregnancy in a series of women who underwent laparoscopic myomectomy. A total of 115 women underwent laparoscopic myomectomy for pressure and pain (76.5%), abnormal bleeding (52.2%) and/or infertility (29.6%). Follow up data were obtained either by reviewing the patient's chart or returned questionnaire. Of the 115 women, there were 42 pregnancies in 31 patients. Two women were lost to follow-up. Of the remaining 40 pregnancies, six ended with vaginal delivery at term. Caesareans were performed in 22 cases, including 21 at term and one at 26 weeks gestation. Two pregnancies were associated with a normal delivery, but the mode of delivery is unknown. Eight resulted in first trimester pregnancy loss, one was an ectopic pregnancy, and one patient underwent elective termination. Spontaneous uterine rupture was not noted during pregnancy or at term in any of the cases. Average length of follow-up from the date of surgery was 43 months, with a range of 9-99 months. Our series did not confirm the hypothesis that laparoscopic myomectomy is associated with an increased risk for uterine dehiscence during pregnancy. However, a larger series is needed to make a conclusive judgement.

Recurrence rate after laparoscopic myomectomy.

STUDY OBJECTIVE: To determine the recurrence rate of myomas after laparoscopic myomectomy. DESIGN: Retrospective review (Canadian Task Force classification II-2). SETTING: Tertiary referral center. PATIENTS: One hundred fourteen women (age 25-51 yrs, median 38 yrs) who were followed for an average of 37 months (range 6-120 mo). INTERVENTION: Laparoscopic myomectomy. MEASUREMENTS AND MAIN RESULTS: Follow-up data were obtained by chart review and from returned questionnaires. Variables were date of surgery, first diagnosis of recurrence, and last follow-up visit. There were 38 (33.3%) recurrences after an average interval of 27 months. Twenty-four of these women did not require treatment. Eight underwent a second laparoscopic myomectomy, and one had a third. One patient had myomectomy and then hysterectomy, and six patients chose hysterectomy to treat the first recurrence. Cumulative risk of recurrence (Kaplan-Meier curve) was 10.6% after 1 year, 31.7% after 3 years, and 51.4% after 5 years. CONCLUSION: Although laparoscopic myomectomy is associated with less morbidity than removal by laparotomy, our results suggest that recurrence of myomas may be higher with the laparoscopic approach. Of 38 women with recurrent myoma, however, only 14 (36.8%) required additional surgery.

Laparoscopic trachelectomy for persistent pelvic pain and endometriosis after supracervical hysterectomy.

OBJECTIVES: To discuss the safety of laparoscopic removal of the cervical stump after supracervical hysterectomy. DESIGN: Retrospective review of six cases. SETTING: Center for Special Pelvic Surgery, a tertiary referral center. PATIENT(S): Between August 1993 and December 1995, six patients underwent laparoscopic removal of the cervical stump. Their mean age was 43.1 years (range 32 to 56 years). All women had pelvic pain, and one had abnormal bleeding. Three patients had histories of severe endometriosis only, one had extensive endometriosis with adhesions, one had severe adhesions and leiomyomas, and one had all three conditions at hysterectomy. INTERVENTION(S): Laparoscopic trachelectomy. MAIN OUTCOME MEASURE(S): Laparoscopic findings and intraoperative and postoperative complications. RESULT(S): The mean blood loss was 100 mL (range 50 to 200 mL). There were no major intraoperative or postoperative complications. CONCLUSION(S): Cervical stump removal can be accomplished laparoscopically by an experienced surgeon.

Long-Term Follow-up of Laparoscopic Myomectomy

One hundred fourteen women (average age 37.1 yrs) underwent laparoscopic myomectomy for pain (77.8%), abnormal bleeding (53.1%), and infertility (20.8%). The location and depth of penetration of the myoma(s) were determined by ultrasonography and laparoscopic assessment. Follow-up data were obtained either by review of patient charts or returned questionnaires. Relevant risk factors for recurrence were isolated by discriminant analysis. The cumulative risk of recurrence was 10.6% after 1 year, 31.7% after 3 years, and 51.4% after 5 years. Associated risk factors were the number of myomas and the depth of infiltration. Patients without recurrence had an average of 2.5 ± 2.3 fibroids and those with recurrences had 4.1 ± 2.9 myomas (p <0.01). The recurrence rates for pedunculated, subserosal, and intramural myomas were 0.0%, 11.8%, and 44.9%, respectively (p <0.01). Myoma size, patient age, parity, and postoperative pregnancies had no influence on the recurrence rate. The cumulative risk of recurrence after laparoscopic myomectomy seems to be higher than that reported after laparotomy.

Pregnancy after Laparoscopic Myomectomy

We evaluated the safety of laparoscopic myomectomy in 114 women (average age 37.1 yrs, mean 34.1 ± 3.6 yrs) who desired future pregnancy. The indications were pain (77.8%), abnormal bleeding (53.1%), and infertility (20.8%). Follow-up data were obtained by reviewing patient charts or returned questionnaires. Student's nonpaired two-way t test was used to compare characteristics of women with and without subsequent pregnancy complications. The average number of myomas was 3.0 ± 2.9 and the mean size was 5.9 ± 3.0 cm. In 52.4% of cases the deepest infiltrating myoma was intramural, in 42.9% subserosal, and in 4.7% pedunculated. Thirty-one pregnancies occurred in 29 women. Of the 26 that could be followed, 5 ended with vaginal delivery at term. Cesarean sections were performed in 14 women, 9 at term, 1 at 26 weeks, and 4 at unknown gestational age. Six women miscarried in the first trimester and one had an ectopic pregnancy. Spontaneous uterine rupture was not noted during pregnancy or at delivery. Compared with women with ectopic pregnancies, miscarriages, and preterm deliveries, those who delivered at term were younger (33.1 ±1.9 vs 36.6 ± 4.8 yrs, p <0.05) and had fewer myomas at surgery (1.9 ± 2.0 vs 4.8 ± 3.0, p <0.01). Those who had intramural myomas were most likely to develop complications during pregnancy. Uterine rupture during pregnancy and labor is a rare complication of myomectomy by laparotomy, and only a few cases have been reported after laparoscopic myomectomy.

Removal of Adnexal Masses by Operative Laparoscopy During Pregnancy

We evaluated the outcomes of pregnancies in nine women who underwent removal of an adnexal mass by operative laparoscopy during pregnancy. These patients, who would otherwise have undergone exploratory laparotomy, were treated by diagnostic and operative laparoscopy using the carbon dioxide laser and electrocoagulation. Gestational ages ranged from 12 to 22 weeks (mean 15 wks). Indications for the surgery were persistent complex or enlarged adnexal mass (7), painful adnexal mass (1), and acute abdomen and intraabdominal hemorrhage (1). Procedures performed were ovarian cystectomy (7), paratubal cyst removal (1), and evacuation of pelvic hematoma (1). Operating time ranged from 55 to 150 minutes (mean 101 min). Peritoneal washings were always obtained. No tocolytics were used during or after surgery. Normal fetal heart tones were auscultated postoperatively in the recovery room. There were no complications secondary to the surgery. Six women delivered at term with weight appropriate for gestational age (AGA). One patient had premature rupture of membranes at 31 weeks' with delivery of a viable AGA infant by emergency cesarean section. Two patients' pregnancies at 26 and 29 weeks are progressing normally. Operative laparoscopy for certain pelvic pathology may be performed safely with no complications to the pregnancy.

A new method for laparoscopic access to the space of Retzius during retropubic cystourethropexy.

PURPOSE: We assessed the feasibility of a new technique for laparoscopic dissection of the space of Retzius. MATERIALS AND METHODS: In 10 women 40 to 70 years old (median age 45) undergoing laparoscopic retropubic cystourethropexy for stress urinary incontinence hydrodissection was used to create a pneumo-subperitoneal space. A suction irrigator probe was inserted into a mid peritoneal incision created with a 5 mm. trocar above the symphysis pubis between the 2 umbilical ligaments. The subperitoneal space was developed and insufflated with carbon dioxide without incising the peritoneum. RESULTS: All procedures were completed laparoscopically without intraoperative or postoperative complications. Operative time for cystourethropexy ranged from 30 to 70 minutes (median 40). Estimated blood loss ranged from less than 50 to 300 ml. (median 100). Patients were discharged from the hospital within 24 to 48 hours. All patients reported satisfactory relief of symptoms at 3 to 6 months of followup. CONCLUSIONS: The new technique is not difficult and may minimize tissue injury. Pneumosubperitoneal pressure provides clear exposure of the space of Retzius with minimal bleeding.