Chiou Chung Yuan

Laparoscopic bipolar coagulation of uterine vessels: a new method for treating symptomatic fibroids.

OBJECTIVEnTo evaluate the effects of laparoscopic bipolar coagulation of uterine vessels in treating symptomatic fibroids.nnnDESIGNnProspective clinical study.nnnSETTINGnUniversity-affiliated tertiary referral center.nnnPATIENT(S)nEighty-seven women with symptomatic fibroids warranting surgical treatment and wanting to retain their uteri.nnnINTERVENTION(S)nLaparoscopic bipolar coagulation of uterine arteries and anastomotic sites of uterine arteries with ovarian arteries.nnnMAIN OUTCOME MEASURE(S)nPercentage reduction in the dominant fibroid size and clinical response evaluation.nnnRESULT(S)nEighty-five (97.7%) of 87 patients underwent technically successful laparoscopic coagulation of uterine vessels without intraoperative complications. The mean follow-up time was 10.2 months. Symptomatic improvement was reported in 76 (89.4%) of 85 patients, including 18 (21.2%) with complete resolution of symptoms. Significant reductions in the dominant fibroid size (average, 76%) and the uterine volume (average, 46%) were sonographically demonstrated. Two patients conceived 4 and 9 months, respectively, after treatment. Three (3.5%) premenopausal women became postmenopausal postoperatively.nnnCONCLUSION(S)nLaparoscopic bipolar coagulation of uterine vessels appears to be a promising new method for treating fibroid-related menorrhagia and pelvic pain.

Major Complications of Operative and Diagnostic Laparoscopy for Gynecologic Disease

STUDY OBJECTIVEnTo compare complication rates of diagnostic and operative laparoscopy. Design. Retrospective study (Canadian Task Force classification II-2).nnnSETTINGnOne medical center and three teaching hospitals.nnnPATIENTSnSix thousand four hundred fifty-one women with various indications for laparoscopic diagnosis and/or laparoscopic surgery from January 1994 through June 1999.nnnINTERVENTIONnDiagnostic and operative laparoscopies.nnnMEASUREMENTS AND MAIN RESULTSnForty-two major complications occurred that directly resulted in one death. One patient had stomach injury, 3 had major vessel injuries, 5 had ureter injuries, 10 had intestinal injuries, and 23 had bladder injuries. The overall complication rate for all laparoscopies was 0.65% (42/6451); however, it rose to 0.80% (39/4865) for operative laparoscopy compared with 0.19% for diagnostic laparoscopy (3/1586; p <0.001, Fishers exact test).nnnCONCLUSIONnLaparoscopic surgery is appropriate for managing various gynecologic diseases and has an acceptable complication rate. However, operative laparoscopy should be performed carefully because its rate of complications is significantly higher than that of diagnostic laparoscopy, especially for laparoscopic-assisted vaginal hysterectomy. (J Am Assoc Gynecol Laparosc 8(1):68-73, 2001)

Successful treatment of symptomatic arteriovenous malformation of the uterus using laparoscopic bipolar coagulation of uterine vessels.

OBJECTIVEnTo report a case of symptomatic arteriovenous malformation (AVM) of the uterus that was successfully treated with laparoscopic bipolar coagulation of uterine vessels.nnnDESIGNnCase report.nnnSETTINGnUniversity-affiliated tertiary referral center.nnnPATIENT(S)nA 66-year-old woman with symptomatic AVM of the uterus.nnnINTERVENTION(S)nLaparoscopic bipolar coagulation of uterine vessels.nnnMAIN OUTCOME MEASURE(S)nClinical symptoms, color Doppler sonographic examination, and pelvic magnetic resonance imaging.nnnRESULT(S)nRemarkable shrinkage of the lesion size, obvious decrease in all of the impedance measurements (pulsatility, resistance, velocity indexes [systolic/diastolic]), and freedom from symptoms.nnnCONCLUSION(S)nThis modality is a new alternative method for the management of patients with symptomatic AVM of the uterus who do not respond to conservative treatment.

Symptomatic myoma treated with laparoscopic uterine vessel occlusion and subsequent immediate myomectomy: which is the optimal surgical approach?

OBJECTIVEnTo determine the optimal surgical approach when patients are treated with laparoscopic uterine vessel occlusion (LUVO) combined with myomectomy in the management of women with symptomatic uterine fibroids.nnnDESIGNnAn observational study.nnnSETTINGnMedical centers.nnnPATIENT(S)nOne hundred thirty-one patients with symptomatic myomas underwent LUVO plus laparoscopic myomectomy (LM; LUVO+LM) (n = 49) or LUVO plus ultra-mini laparotomy UMLT-M (LUVO+UMLT-M) (n = 82).nnnINTERVENTION(S)nMyomectomy through laparoscopy or UMLT access.nnnMAIN OUTCOME MEASURE(S)nThe outcome was measured by comparing surgical techniques, and 3-year follow-up, including symptom control and reintervention (hysterectomy or myomectomy), in both groups.nnnRESULT(S)nGeneral characteristics of the patients were similar in both groups, except the number of myomas. Surgical techniques seemed to be easier in the LUVO+UMLT-M group than in LUVO+LM group, because of less operation time (56.1 +/- 16.9 minutes vs. 73.4 +/- 26.9 minutes; P=.009) and a higher success rate (100% vs. 91.8%; P=.018). There were no differences in the 3-year follow-up of the therapeutic outcomes of the LUVO+UMLT-M and LUVO+LM groups, with low reintervention rates (1.2% vs. 0) and good symptom control rates in both groups.nnnCONCLUSION(S)nThe LUVO+LM, either through laparoscopy or UMLT, was acceptable in the management of symptomatic uterine fibroids. However, the LUVO+UMLT-M technique might be more feasible, as it required less operative time and had a higher success rate.

Comparison of ultraminilaparotomy for myomectomy through midline vertical incision or modified Pfannenstiel incision—a prospective short-term follow-up

OBJECTIVEnTo evaluate the short-term therapeutic outcome of myomectomy using ultraminilaparotomy (UMLT) through a midline vertical incision (MVI) or a modified Pfannenstiel incision (MPI) in the treatment of myomas.nnnDESIGNnControlled, nonrandomized clinical study.nnnSETTINGnUniversity-affiliated medical center.nnnPATIENT(S)nNinety-eight patients with symptomatic, uncomplicated myomas warranting myomectomy. Forty-three patients underwent UMLT myomectomy by MVI and 55 by MPI.nnnINTERVENTION(S)nUMLT myomectomy through MI or MPI access.nnnMAIN OUTCOME MEASURE(S)nThe outcome was measured by comparing incision length, blood loss, operative time, postoperative pain, complications, success rate, postoperative recovery, and the return to work capability in both groups.nnnRESULT(S)nGeneral characteristics of the patients were similar in both groups. There were no statistical differences in postoperative recovery, complications, and success rate between the two groups. However, the operative technique seemed to be easier and more acceptable in the MVI group compared with that in the MPI group, because of the smaller incision wound, less operation time, and less blood loss. By contrast, less postoperative pain and an earlier return to work capability were noted in the MPI group.nnnCONCLUSION(S)nThis study has demonstrated that UMLT myomectomy using either a MVI or MPI can be applied in the successful management of uncomplicated myomas. The MPI technique was more complicated, but yielded less wound pain and earlier postoperative recovery for the women during this 1-year short-term follow-up.

Laparoscopic Bipolar Coagulation of Uterine Vessels to Treat Symptomatic Myomas in Women with Elevated CA 125

STUDY OBJECTIVEnTo assess laparoscopic bipolar coagulation of uterine vessels (LBCUV) for symptomatic myomas in women with elevated CA 125 (>35 U/ml).nnnDESIGNnProspective, longitudinal study (Canadian Task Force classification II-1).nnnSETTINGnPrivate practice, university-affiliated hospital.nnnPATIENTSnForty-six women (age 30-50 yrs) with symptomatic myomas and elevated CA 125 level.nnnINTERVENTIONnLaparoscopic bipolar coagulation of uterine vessels performed over 10 months.nnnMEASUREMENTS AND MAIN RESULTSnAll patients underwent successful LBCUV and coagulation of anastomotic site of uterine arteries with ovarian arteries without intraoperative complication. One, 3, and 6 months after treatment, respectively, 52.2%, 65.2%, and 71.7% of women reported improvement in menorrhagia, 19.6%, 45.7%, and 56.5% noted improvement in dysmenorrhea, and 6.5%, 16.1%, and 38.7% had improvement in bulk-related symptoms. Average reduction in uterine volume was 9.1%, 16.9%, and 38.3% and average reduction in dominant myoma was 12.1%, 23.9%, and 59.1% at those times; the average reduction of CA 125 in all patients was 39.8, 75.4, and 126.1U/ml.nnnCONCLUSIONnSymptoms were improved and uterine volume and dominant myoma were reduced by LBCUV. The CA 125 level fell during follow-up in 40 patients (87.0%). Improvement in symptoms, especially menorrhagia, and shrinkage of uterine volume and dominant myoma seemed to be more pronounced in women with decreased than in those without decreased CA 125 after treatment (p = 0.045). The CA 125 level may be a valuable indicator for monitoring the efficacy of LBCUV.

Vaginal Expulsion of Submucous Myomas after Laparoscopic-Assisted Uterine Depletion of the Myomas

STUDY OBJECTIVEnTo determine the safety and side effects that may be caused by laparoscopic-assisted uterine depletion (LAUD) of submucous myomas.nnnDESIGNnRetrospective chart review and follow-up (Canadian Task Force classification II-2).nnnSETTINGnUniversity-affiliated tertiary referral center.nnnPATIENTSnFive hundred twenty women with symptomatic myomas warranting surgical treatment, who wished to retain their uteri.nnnINTERVENTIONnLaparoscopic bipolar coagulation of uterine arteries and anastomotic sites of uterine arteries with ovarian arteries.nnnMEASUREMENTS AND MAIN RESULTSnPostoperative sonographs showed submucous myomas in 53 (10.2%) women. During follow-up for a mean of 8.6 months very few complications occurred; however, nine women (1.7%) experienced vaginal expulsion of myomas from 2 weeks to 5 months postoperatively. Four of them were readmitted within 43 days with high fever and fetid discharge, and cervical cultures revealed heavy growth of Escherichia coli in three. Vaginal myomectomy was performed in six patients, and one woman passed the myoma spontaneously. Histopathologic studies of these nine specimens showed that two had infarction, three had coagulative necrosis, and four had degeneration. After treatment, all nine women had normal menstruation and their symptoms resolved during follow-up of at least 3 months.nnnCONCLUSIONnIn our experience LAUD led to satisfactory symptomatic improvement and reduction in myoma volume and few complications. If vaginal expulsion of submucous fibroids can be viewed as a side effect, we should pay close attention to women with submucous myomas, especially within 2 months of LAUD. Otherwise, more dangerous complications could occur.

Ureteral injury after laparoscopic surgery

Ureteral injuries are uncommon but serious complications of laparoscopic pelvic surgery. When unrecognized, patients experience fever, abdominal pain, signs of peritonitis, and leukocytosis usually 48 to 72 hours after the surgical procedure. A 48-year-old woman underwent laparoscopic-assisted vaginal hysterectomy, bilateral salpingo-oophorectomy, and anterior and posterior colporrhapy due to a large, symptomatic uterine myoma. Postoperatively, she suffered from progressive left lower quadrant pain, with drainage of yellowish fluid from the subumbilical puncture wound 5 days after the operation. Significant urinary ascites was present. Intravenous pyelogram revealed injury to the lower third of the left ureter about 3 cm away from the ureterovesical junction. Left-sided percutaneous nephrostomy was performed after transurethral placement of a ureteral stent failed. Reanastomosis of the ureter was performed successfully 3 months later, and the patient fully recovered without compromise of the genitourinary tract.

Successful pregnancy in a woman with symptomatic fibroids who underwent laparoscopic bipolar coagulation of uterine vessels

OBJECTIVEnTo report a case of successful pregnancy after laparoscopic bipolar coagulation of uterine vessels (LBCUV).nnnDESIGNnCase report.nnnSETTINGnUniversity-affiliated tertiary referral center.nnnPATIENT(S)nOne woman, treated with LBCUV for symptomatic fibroids, who subsequently had a successful pregnancy.nnnINTERVENTION(S)nLaparoscopic bipolar coagulation of uterine arteries and anastomotic sites of uterine arteries with ovarian arteries.nnnMAIN OUTCOME MEASURE(S)nPatient evaluation by physical and ultrasound examinations.nnnRESULT(S)nComplete resolution of menorrhagia and dysmenorrhea was found after LBCUV. Reduction in fibroid size was seen by ultrasound. Two months later, the patient conceived a singleton pregnancy without the use of assisted reproductive technologies. The woman delivered by cesarean section. Neither myoma recurrence nor abnormality in uterine function was observed.nnnCONCLUSION(S)nAlthough fecundity- and pregnancy-related complications after LBCUV for managing uterine fibroids are still unclear, this first case report of successful pregnancy after LBCUV is promising. LBCUV might be a safe and effective alternative to myomectomy and hysterectomy.

Comparison of Two Procedures for Laparoscopic-Assisted Vaginal Hysterectomy of Large Myomatous Uteri

STUDY OBJECTIVEnTo evaluate whether laparoscopic bipolar coagulation of uterine vessels (LBCUV) and supracervical amputation improve laparoscopic-assisted vaginal hysterectomy (LAVH).nnnDESIGNnProspective, randomized, longitudinal study (Canadian Task Force classification II-1).nnnSETTINGnPrivate practice, university-affiliated hospital.nnnPATIENTSnSixty-four women (age 31-52 yrs) with symptomatic myomatous uteri larger than 12 weeks on bimanual examination.nnnINTERVENTIONSnLAVH with or without LBCUV and laparoscopic supracervical amputation followed by trachelectomy.nnnMEASUREMENTS AND MAIN RESULTSnLBCUV and laparoscopic supracervical amputation followed by trachelectomy and removal of the specimen vaginally were performed successfully in 29 women (group A). Hysterectomy was performed successfully in 32 comparable patients (group B) with severing of the round ligament, ovarian ligament, or infundibulopelvic ligament, and preparation of the bladder flap in the laparoscopic phase, and severing of uterine vessels and cardinal-uterosacral ligament complex through the vagina. Average blood loss was 169.8 and 308.7 ml in groups A and B, respectively (p <0.05); average operating time was 126.4 and 152.8 minutes, respectively (p <0.05); hemoglobin decreased on average 0.9 and 1.7 g/100 ml, respectively (p <0.05). Conclusion. LBCUV and laparoscopic supracervical amputation followed by trachelectomy reduce operating time and blood loss in LAVH, and allow conversion of many abdominal procedures to laparoscopy.