Pregnancy outcome after emergency uterine artery embolisation for management of intractable haemorrhage associated with laparoscopic-assisted myomectomy.

The feasibility of emergency uterine artery embolisation (UAE) after diagnosis by three-dimensional computed tomographic angiography (CTA) for conservative management of intractable haemorrhage associated with laparoscopic-assisted myomectomy (LAM) was evaluated. In 764 women undergoing LAM, 12 cases were managed by emergency UAE to achieve haemostasis after evaluation by CTA. In two cases, bleeding was diagnosed in the postoperative period, while, in another 10 cases, bleeding was identified at the near-end stage of the surgical procedure. Uterine preservation was achieved in all cases. Among five women desiring child bearing, five spontaneous conceptions and one conception by assisted reproductive technology occurred. Five pregnancies resulted in live birth by caesarean section. Emergency UAE could be a useful minimally invasive option for the salvage of intractable haemorrhage associated with LAM to avoid exploratory laparotomy and/or hysterectomy. In women with fertility wish, pregnancy outcomes were favourable with high number of spontaneous pregnancy rate and without significant negative effects.Impact statementWhat is already known on this subject? Uterine myoma is the most common benign pelvic tumour in women. Myomectomy is indicated as the primary intervention for women with symptomatic myoma, who are of reproductive age and desire uterine preservation, since it can significantly improve symptoms and quality of life and, in some clinical situations, improve reproductive outcomes. Intractable haemorrhage associated with any forms of myomectomy is a potentially life-threatening condition with potential loss of future fertility. However, clear consensus on its management are not well known so far.What do the results of this study add? Emergency uterine artery embolisation after diagnosis by three-dimensional computed tomographic angiography has been effective in preserving the uterus with avoidance of laparotomy and/or life-saving hysterectomy as a salvage therapy for intractable haemorrhage associated with laparoscopic-assisted myomectomy. Significant adverse outcomes were not observed. Furthermore, in women desiring child bearing, a high rate of spontaneous conceptions with live birth by caesarean section was achieved after these combined interventions.What are the implications of these findings for clinical practice and/or further research? Endovascular embolisation could be considered as a minimally invasive alternative with favourable pregnancy outcome to treat intractable haemorrhage associated with myomectomy.

Identification of Leiomyoma Cell Sheets in Peritoneal Washings Retrieved by an Intraoperative Red Blood Cell Salvage Device during Laparoscopic-Assisted Myomectomy with in-Bag Manual Tissue Extraction: A Pilot Study.

STUDY OBJECTIVE: To examine whether peritoneal washings during laparoscopic-assisted myomectomy with in-bag manual tissue extraction can contain spilled leiomyoma cell sheets. DESIGN: Retrospective observational study (Canadian Task Force classification II-2). SETTING: Departments of Obstetrics and Gynecology and Diagnostic Pathology at a general hospital. PATIENTS: Twenty-four women. INTERVENTIONS: Hysterotomy followed by complete enucleation by blunt and sharp dissection was performed. Enucleated myomas were placed into a retriever bag and extracted through a suprapubic or umbilical mini-laparotomic incision by manual morcellation with a surgical scalpel. A histological examination was performed to identify the dispersed leiomyoma cell sheets in trapped tissues on the surface of a defoaming sponge equipped in the reservoir of an intraoperative red blood cell salvage device, which was used to collect peritoneal washing fluid along with blood. MEASUREMENTS AND MAIN RESULTS: Bag rupture was not observed in any case; however, apparent leiomyoma cell sheets were identified in 20 of 24 cases (83.3%). No devices or procedures that were used for myomectomy could completely prevent leiomyoma cells from appearing in the peritoneal washing fluid. CONCLUSION: Even when careful in-bag tissue extraction of myomas was performed in laparoscopic-assisted myomectomy, dispersion of leiomyoma cell was identified in most cases. Further study is needed to show that the feasibility of rigorous washing to reduce the potential risk of leiomyoma cell dissemination.