Peng Hui Wang

Comparison of surgery alone and combined surgical-medical treatment in the management of symptomatic uterine adenomyoma

OBJECTIVE To compare the efficacy of surgical-medical treatment and surgery alone in the treatment of uterine symptomatic adenomyoma. DESIGN Prospective nonrandomized study. SETTING Medical centers. PATIENT(S) One hundred sixty-five women treated with conservative adenomyomectomy. INTERVENTION(S) Surgery followed by six-course treatment (n = 114, surgical-medical group) or no treatment (n = 51, surgery-alone group) with a gonadotropin-releasing hormone (GnRH) agonist regimen. MAIN OUTCOME MEASURE(S) Symptom relief (scale: 0, no symptoms, to 5, worst symptoms) and relapse (when any one scale was > or =2 after treatment) during the 2-year follow-up period. RESULT(S) The general characteristics of the patients were similar in both groups, except for the diameter of the adenomyoma and age. Patients in both groups had statistically significant symptom relief, and all symptom scores declined from a mean of 3 or 4 to a mean of 1 or less at the end of the 2-year follow-up period. The symptom-relapse rates in the surgical-medical group were statistically significantly lower than those in the surgery alone group (n = 32, 28.1% vs. n = 25, 49.0%, respectively). CONCLUSION(S) Conservative surgery, regardless of GnRH agonist treatment, may be acceptable for management of a selected population with severe symptomatic adenomyoma. However, surgical-medical treatment provided more effective symptom control (a lower symptom relapse rate) than surgery alone during the 2-year follow-up period.

Major Complications of Operative and Diagnostic Laparoscopy for Gynecologic Disease

STUDY OBJECTIVE To compare complication rates of diagnostic and operative laparoscopy. Design. Retrospective study (Canadian Task Force classification II-2). SETTING One medical center and three teaching hospitals. PATIENTS Six thousand four hundred fifty-one women with various indications for laparoscopic diagnosis and/or laparoscopic surgery from January 1994 through June 1999. INTERVENTION Diagnostic and operative laparoscopies. MEASUREMENTS AND MAIN RESULTS Forty-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). CONCLUSION Laparoscopic 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)

A prospective short-term evaluation of uterine leiomyomas treated by myomectomy through conventional laparotomy or ultraminilaparotomy

OBJECTIVE To evaluate the short-term therapeutic outcome of myomectomy through conventional laparotomy in the treatment of uncomplicated uterine myomas compared with myomectomy through ultraminilaparotomy. DESIGN Controlled, nonrandomized clinical study. SETTING University-affiliated tertiary care referral center. PATIENT(S) One hundred thirteen patients with symptomatic and uncomplicated uterine myomas warranting surgical treatment, who expressed a strong desire to retain their uterus. Seventy-two patients underwent myomectomy by laparotomy and 41 by ultraminilaparotomy. INTERVENTION(S) Myomectomy through laparotomy or ultraminilaparotomy access. MAIN OUTCOME MEASURE(S) The outcome was measured by comparing blood loss, need for blood transfusion, operative time, postoperative febrile morbidity, time of flatus passage after operation, and postoperative pain (visual analogue scale score and anesthesia use) in both groups. RESULT(S) General characteristics of the patients were similar in both groups. There were no statistical differences in mean operative time, blood loss, febrile morbidity, insurance pay, and therapeutic efficacy (symptom relief) between the two groups. However, postoperative recovery seemed to be better and more rapid in the ultraminilaparotomy group compared with that in the laparotomy group, including rapid and early bowel movement, lower scores on the visual analogue scale, and shortened postoperative hospital stay. CONCLUSION(S) This study demonstrates the superiority of ultraminilaparotomy in treating uncomplicated uterine myomas, compared with laparotomy, during this 1-year short-term follow-up.

Adenomyosis and its variance: adenomyoma and female fertility.

Extensive adenomyosis (adenomyosis) or its variance, localized adenomyosis (adenomyoma) of the uterus, is often described as scattered, widely-distributed endometrial glands or stromal tissue found throughout the myometrium layer of the uterus. By definition, adenomyosis consists of epithelial as well as stromal elements, and is situated at least 2.5 mm below the endometrialmyometrial junction. However, the diagnosis and clinical significance of uterine adenomyosis and/or adenomyoma remain somewhat enigmatic. The relationship between infertility and uterine adenomyosis and/or adenomyoma is still uncertain, but severe endometriosis impairs the chances of successful pregnancy when using artificial reproductive techniques. To date, there is no uniform agreement on the most appropriate therapeutic methods for managing women with uterine adenomyosis and/or adenomyoma who want to preserve their fertility. Fertility has been restored after successful treatment of adenomyosis using multiple modalities, including hormonal therapy and conservative surgical therapy via laparoscopy or exploratory laparotomy, uterine artery embolization, and other methods, including a potential but under-investigated procedure, magnetic resonance-guided focused ultrasound. This review will explore recent publications that have addressed the use of different approaches in the management of subfertile women with uterine adenomyosis and adenomyoma.

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

OBJECTIVE To 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. DESIGN An observational study. SETTING Medical centers. PATIENT(S) One 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). INTERVENTION(S) Myomectomy through laparoscopy or UMLT access. MAIN OUTCOME MEASURE(S) The outcome was measured by comparing surgical techniques, and 3-year follow-up, including symptom control and reintervention (hysterectomy or myomectomy), in both groups. RESULT(S) General 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. CONCLUSION(S) The 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

OBJECTIVE To 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. DESIGN Controlled, nonrandomized clinical study. SETTING University-affiliated medical center. PATIENT(S) Ninety-eight patients with symptomatic, uncomplicated myomas warranting myomectomy. Forty-three patients underwent UMLT myomectomy by MVI and 55 by MPI. INTERVENTION(S) UMLT myomectomy through MI or MPI access. MAIN OUTCOME MEASURE(S) The 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. RESULT(S) General 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. CONCLUSION(S) This 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.

Use of uterine vessel occlusion in the management of uterine myomas: two different approaches

OBJECTIVE To evaluate the difference between uterine artery occlusion alone (UAO) and combined (UVO) with simultaneous blockage of anastomosis between the uterine and ovarian vessels in the management of women with myomas in a 3-year follow-up. DESIGN Case-control study. SETTING University-associated hospital. PATIENT(S) One hundred ten patients with uterine fibroids. INTERVENTION(S) Forty-four patients underwent UAO and 66 patients UVO; patients were matched using a statistically generated selection of all UVOs performed during the same period. MAIN OUTCOME MEASURE(S) Outcomes were assessed by comparing surgical parameters, immediate postoperative recovery, and therapeutic outcomes. RESULT(S) During the 3-year follow-up, the majority of patients in both groups reported symptom relief (ranging from 61.5% to 84.6% in the UVO group and 31.6% to 77.3% in the UAO group, on the basis of different kinds of symptoms). However, symptom control seemed to be different between the two groups when the follow-up time was prolonged; for example, symptom control was better in the UVO group at the end of 3 years, especially for menorrhagia (76.5% vs. 34.5%). The fibroid size was smaller in the UVO group, resulting in a lower reintervention rate, compared with the UAO group (13.6% vs. 36.4%). CONCLUSION(S) If UVO is used for uterine fibroids, the 3-year efficacy might be better than that with UAO. This finding is worthy of further investigation.

Basal FSH level changes after different types of uterine vessel occlusion in the management of uterine fibroids.

OBJECTIVE To assess the effect on FSH of the application of different types of uterine vessel blockage (uterine artery occlusion alone [UAO] or with blockage of vessel anastomosis [UVO]) in the management of women with fibroids. DESIGN Case-control study. SETTING Medical center. PATIENT(S) One hundred ten women with uterine fibroids. INTERVENTION(S) Forty-four consecutive patients undergoing UAO were compared with 66 matched subjects who underwent UVO during the same period. MAIN OUTCOME MEASURE(S) Surgery types and FSH levels were compared. RESULT(S) At the first month after surgery, FSH levels were elevated from 5.5 mIU/mL to 14.2 and 8.7 mIU/mL in the UVO and UAO groups, respectively. The difference between the 2 groups continued up to 6 months and disappeared thereafter. More patients (38%) in the UVO group had an increased FSH level of >10 mIU/mL, compared with 5% in the UAO group at the first month after surgery, which contributed to the high percentage of women with irregular menstruation. CONCLUSION(S) Women treated with UVO were associated with a greater risk of a significant increase in FSH level at the first month after operation than those treated with UAO, which may be a reflection of diminished ovarian function. The long-term effect was uncertain, because of the lack of difference in the FSH levels between the two groups.

Laparoscopic Uterine Vessel Occlusion in the Treatment of Women with Symptomatic Uterine Myomas with and without Adding Laparoscopic Myomectomy: 4-Year Results

STUDY OBJECTIVE To estimate the necessity of laparoscopic myomectomy (LM) in the treatment of women with symptomatic uterine myomas who are undergoing laparoscopic uterine vessel occlusion (LUVO). DESIGN A comparative observational study (Canadian Task Force classification II-3). SETTING Medical center. PATIENTS In all, 163 patients with symptomatic, uncomplicated myomas warranting myomectomy. A total of 95 patients underwent LUVO and 68 underwent LUVO with LM. INTERVENTIONS Symptomatic myomas treated by LUVO with or without LM. MEASUREMENTS AND MAIN RESULTS The outcome was measured by comparing surgical parameters, immediate postoperative parameters, 4-year evaluations of symptom control, and reintervention (hysterectomy or myomectomy) in both groups. The general characteristics of the patients were similar in both groups. No statistical differences existed in complications, success rate, or immediate satisfaction rate between the 2 groups. Compared with LUVO+LM, LUVO had advantages in surgical and immediate postoperative parameters, including less operative time, minimal blood loss, and rapid postoperative recovery; however, LUVO+LM was superior to LUVO in terms of a better and longer duration of symptom relief, a higher level of satisfaction, and avoidance of reintervention. Of the sexually active patients who did not use contraception, 58.8% (10/17) and 66.7% (4/6) became pregnant in groups I and II, respectively (no statistical significance). CONCLUSION Although LUVO is a less invasive procedure in the treatment of most women with symptomatic myomas, it is also less effective for symptom control and has shorter durable symptom relief compared with LUVO+LM. Reoperation can be avoided in most patients who are treated with LUVO+LM.

Successful treatment of ovarian pregnancy with laparoscopy-assisted local injection of etoposide

OBJECTIVE To present a case of ovarian ectopic pregnancy successfully treated with laparoscopy-assisted local injection of etoposide. DESIGN Case report. SETTING University-affiliated teaching hospital. PATIENT(S) A 33-year-old woman with the diagnosis of an ovarian pregnancy. INTERVENTION(S) Laparoscopically assisted local injection of etoposide. MAIN OUTCOME MEASURE(S) Successful treatment of the ovarian ectopic pregnancy, with preservation of the ovary. RESULT(S) The patient was successfully treated, and she had normal menstruation after surgery. CONCLUSION(S) Treatment of ovarian ectopic pregnancy with a laparoscopy-assisted local injection of etoposide might be a less invasive choice that can circumvent the systemic side effects of the medication.