Rare Case of Osseus Metaplasia in a Detached Remnant Leiomyoma Following Hysteroscopic Myomectomy.

Uterine leiomyoma is the most common benign tumor of the uterus, affecting reproductive-age women. Although women with uterine fibroids are commonly asymptomatic, in symptomatic patients, hysteroscopic myomectomy is considered the first-line surgical treatment for intracavitary fibroids in women who wish to maintain fertility.  Osseous metaplasia in uterine fibroids is the transformation of fibroids cells into pure mature or immature bone. It is rare, and few case reports present with osseous metaplasia in uterine fibroids. This is the first report in the literature of osseous metaplasia in a remnant fibroid after hysteroscopic myomectomy. Every effort should be attempted to ensure complete retrieval of the detached fibroid remnant after hysteroscopic resection, as this might decrease the risk for subsequent surgeries.

The role of GnRH agonists in the management of large myomas during a pandemic

@#<p style="text-align: justify;">This paper shall present a case of a 42-year-old nulligravid who complained of chronic pelvic pain, vaginal bleeding and palpable abdominal mass secondary to multiple large myomas. Due to the logistical and health restrictions in most hospitals during the peak of the COVID-19 pandemic, elective surgery was postponed and a temporizing medical management was instituted in the form of GnRH agonist, which afforded relief. This paper shall also discuss the mechanism of action of GnRH agonist, and its crucial role as an essential medical treatment option for patients with debilitating conditions such as myoma uteri.</p>

Myomas in uterine rudiments in a patient with Mayer-Rokitansky-Küster-Hauser syndrome.

OBJECTIVE: To describe the case of a patient with Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome and a history of chronic pelvic pain due to myomas in the rudimentary uterine horns. The article highlights a rare origin of gynaecological pain. CASE REPORT: We present the case of 61-year-old woman with MRKH syndrome who has suffered from chronic abdominal pain for more than one year before surgery. Using magnetic resonance imaging and ultrasonography, a suspicion on the tumours of uterine myoma character in the rudimentary horns was suggested. It was confirmed by laparoscopy. Myomas were removed in the endobag and histopathologically confirmed. CONCLUSION: MRKH syndrome is a very rare disease. Approximately ten women are annually born with this congenital anomaly in the Czech Republic. While myoma incidence is extremely rare in this group of women, it must be taken into account in differential dia-gnosis and solved surgically in time.

The effects of menopausal uterine fibroids on the prognosis of endometrium cancer.

OBJECTIVE: This study aimed to evaluate any potential associations between uterine leiomyomas and endometrial cancer. MATERIALS AND METHODS: This is a retrospective study of 153 female patients who have been operated because of endometrial carcinoma in our hospital between 2012 and 2017. Data were collected from hospital records. Study participants were divided into two groups according to the presence and absence of leiomyomas. These two groups were compared in terms of histopathological adenocarcinoma type, nuclear and histological grades, disease stage, para-aortic lymph node involvement, and myometrial invasion. For data analysis, Statistical Package for Social Sciences 15.0 software package was used. Comparison between the two groups was made using the chi-square test, and each variable was tested with the Student's t-test for statistical significance. RESULTS: No statistically significant differences were found between the groups with respect to age, tumor type, myometrial invasion, nuclear grade, or histological grade (p>0.05 for all). A significant difference was found between leiomyomas presence and lymph node metastases. The lymph node metastases were more common in patients without uterine leiomyomas (20.55%) than in those with them (5%; p=0.004). Analysis using the Federation of Obstetrics and Gynecology stages for the presence of leiomyomas indicated that the mean stages were 1A and 1B in patients with and without uterine leiomyomas, respectively (p=0.002). CONCLUSION: Uterine leiomyomas did not adversely affect the prognosis of patients with endometrial carcinoma. Moreover, lymph node involvement was less common, and stages were lower in patients with leiomyomas.

Myomectomy During Cesarean Section: Why Do We Abstain From?

OBJECTIVES: To assess the intra- and postoperative results of cesarean myomectomy. METHODS: A retrospective study was conducted to collect the results of cesarean myomectomy procedures performed in our tertiary center between June 2013 and December 2018. The subjects were 2219 pregnant women undergoing cesarean section at these units. RESULTS: A total of 2219 scheduled patients undergoing CS were included in the present study. Sixty-five patients have undergone intramural myomectomy during CS; 82 patients have had subserosal myomectomy during CS. No statistically significant differences were found between the three groups in changes of preoperative Hb, postoperative Hb, mean Hb and length of hospital stay. Operation times were significantly longer in both intramural and subserosal myomectomy groups (45.23 ± 8.498 vs. 39.02 ± 6.824 vs. 32.14 ± 5.423 min, p 0.01). Only in the intramural myomectomy group, two patients were subjected to blood transfusion (3%). Assessment of intramural myomectomy patients was carried out by taking 5 cm as the cutoff value. No statistical differences were found between the two groups in terms of mean Hb change, operation time, length of hospital stay. In the group with intramural myomectomy larger than 5 cm, two (15.38%) patients needed a blood transfusion. CONCLUSIONS: Cesarean myomectomy operation performed by experienced surgeons has no adverse effects other than lengthening the duration of operation and can be safely implemented.

Decreased expression of LIF mRNA in patients withmyoma uteri.

OBJECTIVE: The aim of this study was to evaluate endometrial receptivity by measuring HOXA-10, HOXA-11, and LIF gene expressions in women with polycystic ovary syndrome. METHODS: A total of 48 women were included in this clinical study. Thepatients were allocated to two groups: study group consisted of 28 patients with myoma uteri and control group consisted of 20 patients without myoma uteri. Endometrial sampling was performed during the proliferative phase. The biopsies obtained from the patients with myoma uteri were taken from the place where the fibroids were localized. HOXA-10, HOXA-11, and LIF expressions were measured in the endometrial sampling material. Demographic data of the patients such as age, obstetric and gynecologic history, medical conditions, medications, surgical history, last menstrual period were recorded. Also, the number, size, localization, and type of the myoma were registered. RESULTS: The mean age of the patients was 42.07 and 38.17, respectively. HOXA-11 levels in the study and control groups were 0.004 ± 0.001 and 0.010 ± 0.001, respectively ( P < 0.90). Paradoxically, HOXA-10 levels were found to be higher in the study group than the control group, but the difference was not statistically significant ( P < 0.25). LIF levels were significantly lower in the study group ( P < 0.05). CONCLUSION: Our results showed that myoma uteri might lead to a decrease in implantation rate by diminishing LIF gene expressions. However, there were no differences between the two groups in terms of HOXA-10 and HOXA-11 levels.

Effect of pregnancy on recurrence of symptomatic uterine myomas in women who underwent myomectomy.

BACKGROUND: There is no consensus in the literature regarding risk factors associated with recurrence of uterine leiomyomas. In this study, we evaluated the factors that affect the recurrence of uterine leiomyomas in women who underwent laparotomic or endoscopic myomectomy. METHODS: This retrospective study included 378 patients that underwent myomectomy. Patient follow-up ranged from two to eight years, and they were classified according to the recurrence of myoma uteri. Age, gravidity, parity, presenting complaints, prior surgery, comorbidity, smoking status, intraoperative and postoperative features, and Ca 125 levels were obtained from the hospital records and patient files. RESULTS: Recurrence was detected in 67 women (17.72 %). No statistically significant differences were observed in the demographic data and past obstetric history between the recurrent and non-recurrent groups. The number of myomas was higher in the recurrence group as compared to the non-recurrence group [2 (range: 1-41) vs 1 (1-19), respectively, p =0.022]. Pregnancy rates were statistically higher in the recurrence group as compared to the non- recurrence group (17.9 % vs 7.1 %, respectively, p =0.005). Pregnancy after myomectomy increased the risk of recurrence by 2.8-fold (odds ratio: 2.87; 95 % confidence interval: 1.34-6.13). No significant differences were observed between the two groups regarding the surgical route, fibroid size, uterine location, and position of the myomas in the uterus. CONCLUSION: Women who had more than two myomas should be informed of the possibility of recurrent myoma uteri. Additionally, pregnancy in women who previously had a myomectomy was found to be a risk factor for recurrence of the uterine myoma. HIPPOKRATIA 2018, 22(3): 122-126.

Endometrial flushing αVß3 integrin, glycodelin and PGF2α levels for evaluating endometrial receptivity in women with polycystic ovary syndrome, myoma uteri and endometrioma.

The aim of this cross-sectional study is to compare endometrial flushing fluid levels of αVß3 integrin, glycodelin and PGF2α during the midluteal phase of the menstrual cycle of women with polycystic ovary syndrome (PCOS, n = 20), myoma uteri (n = 20) and endometrioma (n = 19) with the healthy controls (n = 20). After collecting samples at the midluteal phase of ovulatory volunteers and storing them at -80 °C, αVß3 integrin, glycodelin and PGF2α levels were analyzed using ELISA. The mean ages of the groups were 28.90 ± 5.45, 37.25 ± 2.73, 32.84 ± 6.62 and 32.15 ± 5.18 in PCOS, myoma uteri, endometrioma and control groups, respectively. The αVß3 integrin level (ng/ml) was statistically significantly higher in endometrioma group (9.70 ± 1.72, p < 0.05) as compared to myoma uteri and control groups. Similarly, glycodelin level (ng/ml) was significantly higher in endometrioma group (341.04 ± 93.32) than PCOS (p < 0.01), myoma uteri (p < 0.001) and healthy subjects (p < 0.001). Moreover, PGF2α level (350.04 ± 464.50 ng/ml) was significantly higher in PCOS group relative to myoma uteri (p < 0.001), endometrioma (p < 0.05) and control (p < 0.05) groups. In conclusion, αVß3 integrin level was significantly higher in endometrioma subjects than those with myoma uteri and control groups; glycodelin level was significantly higher in endometrioma group than other three groups, and lastly, PCOS patients had significantly higher PGF2α levels than those patients with myoma uteri, endometrioma and controls.

Subtotal hysterectomy by natural orifice transluminal endoscopic surgery.

STUDY OBJECTIVE: To introduce the innovative surgical procedure of treating benign uterine pathology with subtotal hysterectomy by natural orifice transluminal endoscopic surgery (NOTES). DESIGN: Prospective observational study. SETTING: Tertiary referral medical center. METHODS: From June 2014 to May 2016, three patients with benign uterine diseases who were eligible for laparoscopic subtotal hysterectomy were recruited to undergo transvaginal NOTES at a tertiary referral medical center. Intraoperative and postoperative surgical outcomes were measured. RESULTS: Subtotal hysterectomy by transvaginal NOTES was successfully completed in all patients without any conversion to conventional laparoscopy. The operative time was 144 ± 4.5 (138-149) minutes with an average estimated blood loss of 133 ± 62 (50-200) mL. None of the patients required an intraoperative blood transfusion. The mean specimen weight was 140 ± 59 (56-188) g. The final histology reports were uterine leiomyoma and adenomyosis in these three cases. There were no intraoperative or postoperative complications. No case required intraoperative or postoperative blood transfusion. No cases were converted to traditional laparoscopy or laparotomy. CONCLUSION: Our preliminary results showed the safety and feasibility of subtotal hysterectomy by transvaginal NOTES in selected patients. It is one of the most minimally invasive surgeries and results in invisible scars.

Mioma uterino gigante / Giant myoma uteri

El útero es un órgano del aparato ginecológico, sitio de muchas afecciones benignas y malignas. Las primeras, más frecuentes, y dentro de ellas está el mioma o fibroma uterino. Entre la tercera y quinta décadas de la vida es el tiempo en el que aparece mayormente esta afección en la mujer. Los síntomas son variables, en consecuencia de la localización del mioma (submucoso, intramural o subseroso). El crecimiento del útero es variable, puede ir desde pequeñas tumoraciones hasta grandes masas intraabdominales, que se hacen visibles y llegan a palparse en el mesogastrio. Sus complicaciones son las que la hacen acreedoras de tratamiento quirúrgico. Un gran crecimiento del útero a consecuencia de un mioma puede llegar a convertirlo en un mioma gigante. Se presenta esta paciente con el objetivo de alertar al médico que se encuentre ante la sospecha de un tumor gigante intraabdominal(AU)

Uterus is an organ of the gynecological tract, site of many of them benign and malignant affections. The first ones, more frequent, and including the myoma or uterine fibroma. Between the third and the fifth decades of life is the time in which this affection is more frequent in the woman. Symptoms are variables, as a result of the myoma location (submucous, intramural or subserous). The uterus growth is variable, may go from small tumors until large more evident intra-abdominal masses and to be enough palpable in the mesogastrium. Its complications are the reason for the surgical treatment. A significant growth of uterus caused by a myoma may become it in a giant myoma. The case of this patient is the objective to alert to physician facing the suspicion of a intra-abdominal giant tumor(AU)

Mioma uterino gigante / Giant myoma uteri

El útero es un órgano del aparato ginecológico, sitio de muchas afecciones benignas y malignas. Las primeras, más frecuentes, y dentro de ellas está el mioma o fibroma uterino. Entre la tercera y quinta décadas de la vida es el tiempo en el que aparece mayormente esta afección en la mujer. Los síntomas son variables, en consecuencia de la localización del mioma (submucoso, intramural o subseroso). El crecimiento del útero es variable, puede ir desde pequeñas tumoraciones hasta grandes masas intraabdominales, que se hacen visibles y llegan a palparse en el mesogastrio. Sus complicaciones son las que la hacen acreedoras de tratamiento quirúrgico. Un gran crecimiento del útero a consecuencia de un mioma puede llegar a convertirlo en un mioma gigante. Se presenta esta paciente con el objetivo de alertar al médico que se encuentre ante la sospecha de un tumor gigante intraabdominal(AU)

Uterus is an organ of the gynecological tract, site of many of them benign and malignant affections. The first ones, more frequent, and including the myoma or uterine fibroma. Between the third and the fifth decades of life is the time in which this affection is more frequent in the woman. Symptoms are variables, as a result of the myoma location (submucous, intramural or subserous). The uterus growth is variable, may go from small tumors until large more evident intra-abdominal masses and to be enough palpable in the mesogastrium. Its complications are the reason for the surgical treatment. A significant growth of uterus caused by a myoma may become it in a giant myoma. The case of this patient is the objective to alert to physician facing the suspicion of a intra-abdominal giant tumor(AU)

Pulmonary embolus arising from sloughed off myoma in late puerperium.

Pulmonary embolus is a rare and serious complication of myoma uteri in the puerperium that resulted in late postpartum hysterectomy A 38-year-old, multiparous woman with a large myoma located on the left lateral wall of the uterus underwent emergency cesarean section due to fetal distres at 28 weeks. During the operation, a 15 cm sized intramural myoma was left without any intervention. On the 40(th) day postpartum the patient returned to the clinic with sepsis and pulmonary embolus because of obstruction of lochia drainage by the sloughed off myoma. The patient underwent hysterectomy and medical therapy for pulmonary embolus. We presented an unusual complication of uterine leiomyoma in the late postpartum period after cesarean section. Whatever the mode of sloughing off of the myoma, the results of the obstruction of lochia drainage may be devastating as in our case. To avoid these complications, clinicians must be aware of these symptoms and prompt intervention is essential.

Cortisol secreting adrenal adenoma in a patient with schizophrenia, rheumatic heart disease and myoma uteri: Difficult to find but easy to diagnose

The presence of cortisol - secret ing adenoma concomitantly with rheumatic heart disease, schizophrenia and myoma uteri is rare. This is a case of a 40 year old female with Schizophrenia who gradually developed Cushing's syndrome from an adrenal adenoma. She suffered a cardio-embolic stroke from Rheumatic heart disease which delayed hysterectomy for a bleeding intrauterine myoma. As ide f rom the phys ical f indings of Cushing's syndrome laboratory work up revealed an elevated 24 hour urine free cortisol with loss of normal diurnal cortisol secretion, suppressed 8AM ACTH level and negative suppression after a high dose dexamethasone. The patient underwent laparoscopic adrenalectomy for a 3.8 x 2.4 x 3 cm left adrenocortical adenoma. She required steroid supplementation. Menstrual flow immediately normalized, functional capacity improved and metabolic parameters such as weight, blood pressure and blood sugar were controlled six months after the surgery. Relapse of psychotic symptoms occurred eight months postoperatively because of non-compliance to antipsychotic medications. Cushing's syndrome if untreated can cause significant morbidities such as metabolic, hemodynamic, cardiovascular, bleeding disorder and psychiatric illness. These complications however can also be caused by primary medical illnesses like schizophrenia, rheumatic heart disease and myoma uteri. Treatment of the Cushing's syndrome may resolve some but not all the metabolic and hemodynamic problems and theoretically should also decrease the risk of complications of other primary illnesses concomitantly present. The presence of concomitant primary disease that can cause psychosis, cerebrovascular disease and metrorrhagia should also be investigated in a patient who has Cushing's syndrome. Prompt management of Cushing's syndrome would lessen the risk of complication attributed to schizophrenia, rheumatic heart disease and myoma uteri.

Two cases of cesarean section after laparoscopic radiofrequency myolysis / 대한산부인과학회지

Radiofrequency myolysis is a method for preserving uterus and fecundity, and due to its more non-invasive and simpler operation, it is now carried out to cure the uterine myomas. However, not long time has passed since this operation started, and little studies were conducted on this complications and side effects. Therefore, since the authors experienced the pregnancy after radiofrequency myolysis of uterine myoma, we hereby report the cases.

Uterine abscess after radiofrequency myolysis of uterine myoma: A case report / 대한산부인과학회지

Radiofrequency myolysis is a method for preserving uterus and fecundity, and due to its more non-invasive and simpler operation, it is now frequently carried out to cure the uterine myomas. However, not long time has passed since this operation started, and little studies were conducted on its complications and side effects. Therefore, since the authors experienced the formation of an abscess in uterus after radiofrequency myolysis of uterine myoma, we hereby report the case.

Laparoscopic Myomectomy for Large Myomas

The aim of this study was to assess the feasibility and efficacy of laparoscopic myomectomy (LM) for large myomas. A subpopulation of 51 patients with myomas 8 cm or larger in diameter was selected from 155 patients who underwent LM at Kangbuk Samsung Hospital from July 2003 to November 2006. The mean age of the patients was 34.9+/-5.6 yr, mean parity was 0.6+/-0.9, and 8 patients had a previous operative history. The most common operative indication was a palpable abdominal mass (24 patients, 47%). The mean operating time was 85.6+/-38.9 min, and the mean diameter of the largest myoma was 9.3+/-1.8 cm. The mean change in hemoglobin concentration was 2.1+/-1.2 g/dL. Histopathological diagnosis included 49 patients of leiomyoma (96.1%) and 2 patients of leiomyoma with adenomyosis (3.9%). Postoperatively, a transfusion was done in 7 patients, and a case of subcutaneous emphysema was noted. None of the operations was switched to laparotomy. With the newly-developed screw and the port placement system that was modified from the Choi's 4-trocar method to obtain better surgical vision, LM of large myomas proved to be one of the efficient and feasible methods.

Bilateral Uterine Arterial Embolization for Treatment for Uterine Myoma / 대한산부인과학회지

OBJECTIVE: The purpose of this study is to evaluate the effectiveness and safety of uterine artery embolization for the treatment of symptomatic leiomyomas in the patients who want to preserve uterus, want fertility or feel fear for operation. METHODS: From January 2003 to June 2005, among the patients with symptomatic uterine leiomyoma, fifteen women who wanted to preserve uterus or wanted fertility or had fear for operation were included in this retrospective study. Bilateral Uterine artery embolization (UAE) was performed. At the preprocedure and at 2, 6, and 12 weeks of postprocedure, transvaginal ultrasonography was performed for all patients. Clinical symptoms and follow-up information for each patient were evaluated. RESULTS: 15 leimyomas were treated with UAE. The initial mean volume of leiomyomas was 55.4 (46.3-67.4) cm3. The mean volume decrease was 58.6+/-9.7%, 77.5+/-12.3%, 86.8+/-23.5% at 2, 6, 12 weeks. The outcome of clinical symptoms were as followed; 'much improved' 20% (3/15), 'somewhat improved' 60% (6/15), 'no improvement' 20% (3/15), 'somewhat worsen's 0% (0/15), and 'much worsen' was 0% (0/15). There was no case of hysterectomy or myomectomy after UAE. And also no case of increasement of volume nor worsening of clinical symptoms were found. Lower abdominal pain was the most common symptoms after UAE, but complications were not detected. CONCLUSION: In this study, UAE to treat patients with uterine leiomyoma is proved to be effective not only in volume reduction, but also in symptom improvement. And it is a relatively less-invasive procedure which decreases the risk of side effects of operation. Above all things, it preserves fecundity in young women. Therefore, UAE is very effective and safe procedure in the treatment of symptomatic uterine leiomyoma.

Minimal invasive treatment of uterine myoma: Laparoscopic radiofrequency myolysis / 대한산부인과학회지

OBJECTIVE: To evaluate the feasibility, efficacy and safety of minimal invasive treatment of uterine myoma with laparoscopic radiofrequency (RF) myolysis. METHODS: 69 patients with symptomatic uterine myomas underwent laparoscopy assisted RF myolysis. The accurate targeting and thermal intensity during the procedure were guided by trans-vaginal ultrasound. The measurement of myoma volume and UFS-QOL (Uterine fibroid symptom-quality of life) were obtained once at preoperative period and four times at postoperative period of one week, 1, 3, 6 months. Wilcoxon signed rank test (SPSS 7.5) was used to compare the volume changes of myoma. A significant level of p<0.05 was considered. RESULTS: 107 fibroids were treated with RF myolysis. The mean duration of RF procedure was 15.2+/-18.5 minutes. Mean preoperative volume of treated fibroids was 75.7 cm3 (range: 8.2-367.7) and the mean volume decrease was 12.1+/-10.2%, 32.3+/-40.2%, 48.3+/-33.6%, 53.5+/-18.1% at one week, 1, 3, 6 months. Fifty eight patients had improved symptom severity with UFS-QOL score: symptom severity score 30.8+/-8.2 (mean+/-S.D.), quality of life score 20.3+/-9.2 after RF myolysis. There were 3 cases of RF heat related complication. CONCLUSION: Early experience of laparoscopy assisted RF myolysis in the treatment of uterine fibroids shows that the method is safe and effective under the guidance of trans-vaginal sonification.

Fertility Outcomes after Myomectomy in Infertile Patients with Myoma Uteri / 대한산부인과학회잡지

OBJECTIVE: To investigate the fertility outcomes after abdominal or laparoscopic myomectomy in infertile patients with no other infertility factors except uterine myoma. METHODS: From January, 1992 to December, 1998, abdominal or laparoscopic myomectomy was performed in 76 patients with desire for children and no other recognizable infertility factors. The medical records were reviewed retrospectively. The mean duration of postoperative follow-up was 23.4+/-21.2 months(1~82 months). RESULTS: After myomectomy, 35 patients(46.1%) became pregnant during the follow-up period, especially with 24(68.6%) within 12 months. Excluding 7 cases of spontaneous abortion and 2 cases of intrauterine fetal death, 26 patients(74.3%) had a viable birth. Parity, duration of infertility, number, type and location of myoma, and the proportion of opening the intrauterine cavity during operation were not significantly different between the pregnant and nonpregnant groups. However, the size of uterine myoma was significantly larger in the pregnant group(p<0.05). CONCLUSION: We obtained a reasonable pregnancy rate in infertile patients with uterine myoma as a sole infertility factor. The size of myoma may influence the postmyomectomy pregnancy rate, and this may indicate a more beneficial effect of myomectomy in infertile patients with a relatively larger myoma.