Assessing the risk of laparoscopic morcellation of occult uterine sarcomas during hysterectomy and myomectomy: Literature review and the ISGE recommendations.

OBJECTIVE: This project of the International Society for Gynecologic Endoscopy (ISGE) had the objective to review the literature and provide recommendations on the occult sarcoma risk assessment in patients who are candidates for minimally invasive gynecological surgery involving intra-abdominal electromechanical tissue morcellation. STUDY DESIGN: The ISGE Task Force for Estimation of the Risk in Endoscopic Morcellation initially defined key topics and clinical questions which may guide a comprehensive preoperative patient assessment. A literature search within the Medline/PubMed and Cochrane Database was carried out using keywords "morcellation", "uterine fibroids", "uterine sarcoma", "myomectomy" and "hysterectomy". Relevant publications (original studies, meta-analyses and previous reviews), written in English and published until May 30th, 2017, were selected and analyzed. Previously emitted statements of 12 recognized professional societies or government institutions and their supporting literature were also studied. For each topic/clinical question, the available information was graded by the level of evidence. The ISGE recommendations were established in accordance with the evidence quality. RESULTS: In the light of available information, 9 recommendations on preoperative clinical, laboratorial and imaging evaluation of the candidates for intracorporeal uterus/leiomyoma morcellation were formulated, mainly based on consensus and expert opinions. There is a lack of high-quality evidence, which does not allow the establishment of strong recommendations. CONCLUSION: Electromechanical tissue morcellation may be used in gynecological patients who are considered "low risk" upon appropriate preoperative evaluation; however, further studies and prospective data collection are greatly needed to improve sarcoma risk assessment in women with presumed uterine leiomyomas.

Laparoscopic power morcellation of presumed fibroids.

Uterine leiomyoma is a highly prevalent benign gynecologic neoplasm that affects women of reproductive age. Surgical procedures commonly employed to treat symptomatic uterine fibroids include myomectomy or total or sub-total hysterectomy. These procedures, when performed using minimally invasive techniques, reduce the risks of intraoperative and postoperative morbidity and mortality; however, in order to remove bulky lesions from the abdominal cavity through laparoscopic ports, a laparoscopic power morcellator must be used, a device with rapidly spinning blades to cut the uterine tissue into fragments so that it can be removed through a small incision. Although the minimal invasive approach in gynecological surgery has been firmly established now in terms of recovery and quality of life, morcellation is associated with rare but sometimes serious adverse events. Parts of the morcellated specimen may be spread into the abdominal cavity and enable implantation of cells on the peritoneum. In case of unexpected sarcoma the dissemination may upstage disease and affect survival. Myoma cells may give rise to 'parasitic' fibroids, but also implantation of adenomyotic cells and endometriosis has been reported. Finally the morcellation device may cause inadvertent injury to internal structures, such as bowel and vessels, with its rotating circular knife. In this article it is described how to estimate the risk of sarcoma in a presumed fibroid based on epidemiologic, imaging and laboratory data. Furthermore the first literature results of the in-bag morcellation are reviewed. With this procedure the specimen is contained in an insufflated sterile bag while being morcellated, potentially preventing spillage of tissue but also making direct morcellation injuries unlikely to happen.

Diagnosis of deep infiltrating endometriosis: accuracy of magnetic resonance imaging and transvaginal 3D ultrasonography.

PURPOSE: To compare two different imaging modalities, magnetic resonance (MR), and three-dimensional sonography (3DUS), in order to evaluate the specific role in preoperative work-up of deep infiltrating endometriosis. MATERIALS AND METHODS: 33 women with endometriosis underwent 3DUS and MR followed by surgical and histopathological investigations. Investigators described the disease extension in the following sites: torus uterinus and uterosacral ligaments (USL), vagina, rectovaginal-septum, rectosigmoid, bladder, ovaries. Results were compared with surgical and histopathological findings. RESULTS: Ovarian and deep pelvic endometriosis were found by surgery and histology in, respectively, 24 (72.7%) and 22 (66.6%) of the 33 patients. Sensitivity and specificity values of 3DUS for the diagnosis of endometrial cysts were 87.5% and 100%, respectively; those of MRI were 96.8% and 91.1%, respectively. Sensitivity and specificity of 3DUS for the diagnosis of deep infiltrating endometriosis in specific sites were: USL 50% and 94.7%; vagina 84% and 80%; rectovaginal-septum 76.9% and 100%; rectosigmoid 33.3% and 100%; bladder 25% and 100%. Those of MR were: USL 69.2% and 94.3%; vagina 83.3% and 88.8%; rectovaginal-septum 76.4% and 100%; restosigmoid 75% and 100%; bladder 83.3% and 100%. CONCLUSIONS: MR accurately diagnoses deep infiltrating endometriosis; 3DUS accurately diagnoses deep infiltrating endometriosis in specific locations.

Developments in techniques for laparoscopic myomectomy.

OBJECTIVES: Conflicting opinions about laparoscopic myomectomy (LM) are still present regarding indications and risks related to reproductive outcome. We reviewed our 13-year experience (1) to identify risk factors or changes in methods that have improved our myomectomy technique and (2) to evaluate how the learning curve and improved surgical devices influenced our procedures, and (3) to study the myomectomy scar with a power color Doppler ultrasound (US). METHODS: From January 1991 to December 2003, we studied 332 patients who underwent laparoscopic myomectomy. We analyzed, as the learning curve, how the introduction of the Steiner morcellator, the use of vasoconstrictive agents, and different techniques of suturing have influenced parameters such as operating time and blood loss. RESULTS: We performed 332 single or multiple myomectomies for symptomatic myomas. Most patients (47%) had more than one myoma, with a maximum of 8 per patient (average myomas removed for patients: 2.23, range 1 to 8). Myoma size ranged from 1cm to 20 cm (mean, 60.20+/-SD27.1 mm). Myomas <4cm were removed during myomectomy for larger ones. The conversion rate to laparotomy was 1.51%. The average drop in hemoglobin concentration was 1.06+/-SD0.86 g/100 mL (range, 0.7 to 2.2 g/100 mL). No blood transfusions were required. No major intraoperative complications occurred. The duration of the procedure ranged from 30 minutes to 360 minutes (mean, 124+/-SD52.6). The dimensions of the myomas removed increased with experience (4.91+/-SD2.2 cm of the earlier cases to 6.76+/-SD2.7 of the latest group, P<0.000). The learning curve positively influenced the length of the procedures in the first cases. The introduction of electromechanical morcellation in 1996 reduced the procedure time. Data showed significantly reduced Hb drop after the introduction in 1998 of vasoconstrictive agents (DeltaHb 1.62 g/100 mL versus 0.95; P<0.001). The running suture offered few advantages in terms of procedure time. However, the drop in hemoglobin was advantageous (DeltaHb 1.1 g/100mL vs 0.61, P<0.01). The overall rate of intrauterine pregnancy following LM was 65.5%. No uterine ruptures occurred. We had 2 serious postoperative complications. CONCLUSION: With increased experience, the technical improvements and clinical results have changed our approach and decision making regarding laparoscopic myomectomy. Our results and extremely low conversion rate suggest that laparoscopic myomectomy is a safe and reliable procedure even in the presence of multiple or enlarged myomas.

Italian multicenter study on complications of laparoscopic myomectomy.

STUDY OBJECTIVE: To study intraoperative and postoperative complications of laparoscopic myomectomy and patients' characteristics influencing this risk. DESIGN: Prospective study, with a review of the patient records by the first author (Canadian Task Force classification II-2). SETTING: Four Italian referral centers. PATIENTS: The incidence and type of complications occurring in 2050 laparoscopic myomectomies undertaken from January 1998 through December 2004 were recorded. INTERVENTIONS: The surgical technique, as well as the expertise of the operators, was the same for the 4 centers. Injection of vasoconstrictive agents was used in 37%. The serosa was always incised in a vertical fashion; mechanical enucleation of the myoma was completed whenever possible; suture was performed in 1 or 2 layers with deep and large stitches swaged to 1 or 0 polyglactin sutures that were tied intracorporeally or extracorporeally. MEASUREMENTS AND MAIN RESULTS: Single or multiple myomectomies (n = 2050) for symptomatic myomas measuring at least 4 cm in diameter were performed. Most patients (48%) had more than 1 myoma, with a maximum of 15 per patient (myomas removed for patients: 2.26 +/- 1.8, mean +/- SD). Myoma size ranged from 1 to 20 cm (mean 6.40 +/- 2.6 SD). Myomas smaller than 4 cm were removed during myomectomy for larger ones. Total complication rate was 11.1% (225/2050 cases). Minor complications accounted for 9.1% (187/2050 cases) and major complications for 2.02% (38/2050 cases). The most serious events were hemorrhages (14 cases, 0.68%) requiring blood transfusions in 3 cases (0.14%); 10 postoperative hematomas (0.48%, one in the broad ligament and 9 in the myomectomy scar); 1 bowel injury (0.04%); 1 postoperative acute kidney failure (0.04%); and 2 unexpected sarcomas (0.09%). Failure to complete planned surgery occurred in 7 cases (0.34%). Two patients were readmitted for surgery (0.09%): 1 had a laparoscopic hysterectomy because of a severe blood loss, and the other had drainage of a hematoma in the broad ligament. After a follow-up period of 41.70 +/- 23.03 months (mean +/- SD), 386 (22.9%) patients conceived, with a pregnancy rate in patients wishing pregnancy of 69.8%; among them, 1 (0.26%) recorded spontaneous uterine rupture at 33 weeks gestation. Odds ratio computed to estimate the risk of complications in relation to the patient characteristics showed that the probability of complications significantly rises with an increase in the number (more than 3 myomas OR: 4.46, p <.001) and with the intramural (OR: 1.48, p <.05) or the intraligamentous location of myomas (OR: 2.36, p <.01) whereas the myoma size seems to influence particularly the risk of major complications (OR: 6.88, p <.001). CONCLUSIONS: This is one of the largest series reported of laparoscopic myomectomy and the first focused on complications. The complication rate appears to be better than acceptable in comparison with complication rates reported after laparotomic myomectomies. Laparoscopic myomectomy, when performed by an experienced surgeon, can be considered a safe technique with an extremely low failure rate and good results in terms of pregnancy outcome.

Laparoscopic myomectomy: a report of 982 procedures.

We have reported the experience of two referral laparoscopic gynecologic centers in Italy considering the results of almost 1000 laparoscopic myomectomies, including complication rate and fertility outcome. From January 1991 to December 2003, a total of 982 single or multiple laparoscopic myomectomies (LM) were performed. Indications were infertility, recent and significant uterine enlargement, and other symptoms such as pelvic pain, menometrorrhagia, and abnormal bleeding. All surgical procedures were performed by three surgeons in two different endoscopic centers. Surgery outcome and information about subsequent fertility and obstetric outcome were reported. Myomectomies were performed using a standard technique with three ancillary suprapubic ports. In cases of deep intramural myomas, we injected the myomas with vasoconstrictive agents. A vertical incision of the serosa was made and mechanical enucleation of the myomas was performed whenever possible. A suture in one or two layers with large, curved needles (CT 1, 30 mm) swaged to polyglactin 1 or 0 sutures was performed. Extraction of the removed myomas took place with electric morcellation. Most patients (47%) had more than one myoma, with a maximum of eight per patient (average myomas removed for patients: 2.23). Myoma size ranged from 1 cm to 20 cm (average 67.20 mm +/- 27.1 mm). Most of the myomas (75%) were intramural. The average drop in hemoglobin concentration was 1.06 g +/- 0.86 g/100 ml. The duration of the entire procedure ranged from 30 min to 360 min with a mean of 104.5 min. The conversion rate to laparotomy was 1.29% and no major intraoperative complications occurred. The mean postoperative hospital stay was 2.02 days +/- 0.61 days and we had three serious postoperative complications. The overall rate of intrauterine pregnancy following LM was 62.53% and the abortion rate was 15.9%. Data suggest that laparoscopic myomectomy is a safe and reliable procedure, even in the presence of multiple or very enlarged myomas, with a low complication rate and satisfying long-term results.

Laparoscopic assistance after vaginal hysterectomy and unsuccessful access to the ovaries or failed uterine mobilization: changing trends.

OBJECTIVES: We conducted retrospective and prospective clinical studies at the Columbus Hospital of Rome to point out changes in choosing the route for performing hysterectomy; to evaluate the feasibility of vaginal hysterectomy (VH) and oophorectomy, even in commonly considered contraindications to the vaginal route; to describe a method of laparoscopic oophorectomy following vaginal hysterectomy; and laparoscopic assistance in impossible vaginal hysterectomies. METHODS: From November 1999 to November 2001, 226 patients (age 46.1+/-4.6 years, range 35 to 58) underwent hysterectomy for benign pathologies: 22 (9.7%) underwent total laparoscopic hysterectomy for the presence of severe endometriosis, limited access to the fornices, or immobile uterus with no lateral mobilization; 204 (90.3%) underwent vaginal hysterectomy. Patients with uterine prolapse were excluded. Uterine size, previous cesarean deliveries, pelvic surgeries and the requirement of prophylactic oophorectomy were not considered contraindications to the vaginal approach. We retrospectively analyzed 509 hysterectomies performed in the previous 2 years from 1997 through 1998. RESULTS: During vaginal hysterectomy, adnexectomy was possible in 90.6% of the cases in which it was indicated (unilateral in 21.8% because of adnexal pathology) and was technically impossible in 9.3%. In 4 patients (1.9%), it was not possible to complete a vaginal hysterectomy, owing to the presence of thick adhesions obliterating the cul-de-sac, to severe endometriosis, or to other unforeseen circumstances. In these few patients with difficult access to the ovaries (2.9% of all VH) or with difficulties in mobilizing the uterus, we resorted to laparoscopy. The pneumoperitoneum was achieved with an insufflation tube inserted via the vagina into the abdominal cavity and packing the vagina. Thus, the risks associated with the insertion of the Veress needle were avoided. In all but 2 patients in whom conversion to laparotomy was necessary, laparoscopy was successfully completed. No major complications occurred. In the retrospective analysis of 509 hysterectomies, we determined that 29% were vaginal, 43% abdominal, and 28% laparoscopic (mostly LAVH). In the following years, LAVH allowed the conversion of a significant number of abdominal or laparoscopic hysterectomies to a vaginal route, showing that the vaginal approach was possible in most of cases. CONCLUSIONS: The vaginal approach is feasible in more than 90% of cases even if oophorectomy is required. In the few cases with difficult access to ovaries or difficulties in mobilizing the uterus, the laparoscopic route can easily be adapted by packing the vagina and obtaining a pneumoperitoneum without the risk and loss of time of the insertion of the Veress needle. In this way, it is possible to avoid a great number of LAVH, reducing operating time and the risks of a concomitant procedure.

Vaginal hysterectomy in generally considered contraindications to vaginal surgery.

OBJECTIVE: The objective was to evaluate the feasibility and complication rate of vaginal hysterectomy with or without adnexectomy in women with enlarged uteri and/or other considered contraindications to the vaginal route. STUDY DESIGN: Over a period of 2 years, a total of 204 women underwent vaginal hysterectomy for benign pathology. Normally considered contraindications to the vaginal route were: moderate to excessive uterine enlargement, nulliparity or no prior vaginal delivery, previous cesarean or pelvic surgeries and adnexal pathologies. Laparoscopy was used only if it became necessary. Patients with uterine prolapse were excluded. The clinical outcomes and complication rate were analyzed even with regards to the type of contraindication. RESULTS: The mean age of the patients was 46.96+/-4.8 years (range: 38-68). The mean uterine weight was 427.74+/-254.75 g (range: 150-2,000). The operative time ranged from 30 to 140 min (mean: 61.59+/-21.80 SD) for vaginal hysterectomy alone, increasing up to 170 min (mean: 83.6+/-38.28 SD) in case of adnexectomy or laparoscopic assistance. The patient characteristics, the uterine weight and the postoperative results and clinical outcome did not differ among the groups of contraindications. Overall, the complication rate was 9.8%. No patient required a transfusion for surgical blood loss, a return to the operating room or readmission to the hospital. During vaginal hysterectomy, adnexectomy was possible in 90.6% of the cases in which it was indicated (unilateral in 21.8% because of adnexal pathology) and was technically impossible in 9.3%. In 4 cases (1.9%) it was not possible to complete vaginal hysterectomy owing to the presence of thick adhesions obliterating the cul-de-sac, of severe endometriosis or other unforeseen circumstances. In these few cases with a difficult access to the ovaries (2.9% of all VH) or with difficulties in mobilizing the uterus, we resorted to laparoscopy. The pneumoperitoneum was achieved by means of an insufflation tube inserted via the vagina into the abdominal cavity and packing the vagina. Thus, the risks associated to the insertion of the Veress needle were avoided. In all but two cases in which conversion to laparotomy was necessary, laparoscopy was successfully completed. CONCLUSIONS: Vaginal hysterectomy appears to be feasible in about 97% of cases in which this approach would have been judged unsuitable. This figure decreases to 94.2% when oophorectomy is indicated.