Yuan Kuei Yen

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

OBJECTIVE To evaluate the effects of laparoscopic bipolar coagulation of uterine vessels in treating symptomatic fibroids. DESIGN Prospective clinical study. SETTING University-affiliated tertiary referral center. PATIENT(S) Eighty-seven women with symptomatic fibroids warranting surgical treatment and wanting to retain their uteri. INTERVENTION(S) Laparoscopic bipolar coagulation of uterine arteries and anastomotic sites of uterine arteries with ovarian arteries. MAIN OUTCOME MEASURE(S) Percentage reduction in the dominant fibroid size and clinical response evaluation. RESULT(S) Eighty-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. CONCLUSION(S) Laparoscopic bipolar coagulation of uterine vessels appears to be a promising new method for treating fibroid-related menorrhagia and pelvic pain.

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

STUDY OBJECTIVE To assess laparoscopic bipolar coagulation of uterine vessels (LBCUV) for symptomatic myomas in women with elevated CA 125 (>35 U/ml). DESIGN Prospective, longitudinal study (Canadian Task Force classification II-1). SETTING Private practice, university-affiliated hospital. PATIENTS Forty-six women (age 30-50 yrs) with symptomatic myomas and elevated CA 125 level. INTERVENTION Laparoscopic bipolar coagulation of uterine vessels performed over 10 months. MEASUREMENTS AND MAIN RESULTS All 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. CONCLUSION Symptoms 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 OBJECTIVE To determine the safety and side effects that may be caused by laparoscopic-assisted uterine depletion (LAUD) of submucous myomas. DESIGN Retrospective chart review and follow-up (Canadian Task Force classification II-2). SETTING University-affiliated tertiary referral center. PATIENTS Five hundred twenty women with symptomatic myomas warranting surgical treatment, who wished to retain their uteri. INTERVENTION Laparoscopic bipolar coagulation of uterine arteries and anastomotic sites of uterine arteries with ovarian arteries. MEASUREMENTS AND MAIN RESULTS Postoperative 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. CONCLUSION In 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.

Comparing robotic surgery with conventional laparoscopy and laparotomy for cervical cancer management.

Objective The aim of this study was to compare the outcomes of robotic surgery, laparoscopy, and laparotomy for the surgical treatment of stage IA to IIB cervical cancer. Methods This retrospective study was carried out in a university-affiliated teaching hospital. A total of 100 women with an initial diagnosis of stage IA to IIB cervical cancer, without preoperative brachytherapy or chemotherapy, were included in this study. With selection of the cases, 44 patients received laparotomy surgery, 32 patients received laparoscopic surgery, and 24 patients received robotic surgery. The perioperative parameters measured included operation time, blood loss, transfusion rate, lymph node yield, adhesion score, laparotomy conversion rate, postoperative and 24-hour pain scores, time to full diet resumption, and hospital stay. The perioperative complication and disease-free survival were also evaluated. Results The robotic group showed a shorter operation time, less blood loss, lower transfusion rate, and lower laparotomy conversion rate than the laparoscopic or laparotomy group. As for the postoperative parameters, the robotic group showed reduced postoperative and 24-hour pain scores, shortened length of hospital stay, and decreased time to full diet resumption compared with the other 2 surgical groups. No significant differences were found between the groups in perioperative complication rate or disease-free survival. Conclusions The data suggested that robotic surgery is a feasible and potentially optimal option for the treatment of stage IA to IIB cervical cancer with favorable short-term surgical outcomes.

Comparison of robotic surgery and laparoscopy to perform total hysterectomy with pelvic adhesions or large uterus.

Background: Currently, benefits of robotic surgery in patients with benign gynecological conditions remain unclear. In this study, we compared the surgical outcome of robotic and laparoscopic total hysterectomies and evaluated the feasibility of robotic surgery in cases with pelvic adhesions or large uterus. Materials and Methods: A total of 216 patients receiving total hysterectomy via robotic or laparoscopic approach were included in this study. Of all 216 patients, 88 underwent robotic total hysterectomy and 128 underwent laparoscopic total hysterectomy. All cases were grouped by surgical type, adhesion score, and uterine weight to evaluate the interaction or individual effect to the surgical outcomes. The perioperative parameters, including operation time, blood loss, postoperative pain score, time to full diet resumption, length of hospital stay, conversion rate, and surgery-related complications were compared between the groups. Results: Operation time and blood loss were affected by both surgical type and adhesion score. For cases with severe adhesions (adhesion score greater than 4), robotic surgery was associated with a shortened operation time (113.9 ± 38.4 min versus 164.3 ± 81.4 min, P = 0.007) and reduced blood loss (187.5 ± 148.7 mL versus 385.7 ± 482.6, P=0.044) compared with laparoscopy. Moreover, robotic group showed a lower postoperative pain score than laparoscopic group, as the effect was found to be independent of adhesion score or uterine weight. The grade-II complication rate was also found to be lower in the robotic group. Conclusions: Comparing to laparoscopic approach, robotic surgery is a feasible and potential alternative for performing total hysterectomy with severe adhesions.

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

OBJECTIVE To report a case of successful pregnancy after laparoscopic bipolar coagulation of uterine vessels (LBCUV). DESIGN Case report. SETTING University-affiliated tertiary referral center. PATIENT(S) One woman, treated with LBCUV for symptomatic fibroids, who subsequently had a successful pregnancy. INTERVENTION(S) Laparoscopic bipolar coagulation of uterine arteries and anastomotic sites of uterine arteries with ovarian arteries. MAIN OUTCOME MEASURE(S) Patient evaluation by physical and ultrasound examinations. RESULT(S) Complete 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. CONCLUSION(S) Although 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 OBJECTIVE To evaluate whether laparoscopic bipolar coagulation of uterine vessels (LBCUV) and supracervical amputation improve laparoscopic-assisted vaginal hysterectomy (LAVH). DESIGN Prospective, randomized, longitudinal study (Canadian Task Force classification II-1). SETTING Private practice, university-affiliated hospital. PATIENTS Sixty-four women (age 31-52 yrs) with symptomatic myomatous uteri larger than 12 weeks on bimanual examination. INTERVENTIONS LAVH with or without LBCUV and laparoscopic supracervical amputation followed by trachelectomy. MEASUREMENTS AND MAIN RESULTS LBCUV 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.

Addition of laparoscopic uterine nerve ablation to laparoscopic bipolar coagulation of uterine vessels for women with uterine myomas and dysmenorrhea.

STUDY OBJECTIVE To assess the effectiveness of laparoscopic uterine nerve ablation (LUNA) in women with dysmenorrhea caused by uterine myomas treated by laparoscopic bipolar coagulation of uterine vessels (LBCUV). DESIGN Prospective, randomized, longitudinal study (Canadian Task Force classification II-1). SETTING Private practice, university-affiliated hospital. PATIENTS Eighty-five women with uterine leiomyomas and associated dysmenorrhea. INTERVENTION Laparoscopic bipolar coagulation of uterine vessels with or without LUNA. MEASUREMENTS AND MAIN RESULTS Of 85 patients who entered the study, 41 were assigned to undergo LBCUV-LUNA (group A), which was successful in 40 (97.6%). In 44 women assigned to have LBCUV only (group B), 43 (97.7%) underwent successful surgery. Eighty women completed 1-, 3-, and 6-month follow-up (38 group A, 42 group B). The groups did not differ significantly in age, history of abdominopelvic surgery, intraperitoneal adhesions, endometriosis, concomitant surgery, and operating time. Seven (18.4%) of 38 women in group A and 12 (28.6%) of 42 in group B experienced lower abdominal pain postoperatively. Acceptable pain was defined as a score of zero or 1: 31 and 30 women in groups A and B reported scores of zero; 3 and 2 reported scores of 1; 4 and 8 reported scores of 2; zero and 2 reported scores of 3; and no patients reported scores of 4. The frequency and severity of postoperative pain were less in group A than in group B (both p <0.05). The efficacy of both methods was almost equal in shrinking the uterus and dominant myoma, and in improving menorrhagia and bulk-related symptoms. Dysmenorrhea improvement was 84.2% and 61.9% in groups A and B at 3 months and 92.1% and 73.8% at 6 months, respectively. This was more significant in group A than in group B (p <0.05). CONCLUSION Our results suggest that LUNA may decrease postoperative ischemic pain and improve dysmenorrhea associated with uterine myomas treated by LBCUV.

Laparoscopic bipolar coagulation of uterine vessels to manage delayed postpartum hemorrhage

Postpartum hemorrhage (PPH) is a big challenge for obstetricians. Fertility-preserving procedures are encouraged, especially in young women. Bilateral hypogastric (internal iliac) artery ligation, bilateral uterine artery ligation after vaginal delivery or after cesarean delivery, and uterine artery embolization are well documented vascular occlusive methods for treating PPH. To our knowledge, the laparoscopic approach to uterine artery ligation has not been reported. A 29-year-old woman experienced delayed PPH. Although curettage of the uterine cavity to remove retained placenta was performed, bleeding did not stop. We successfully performed a relatively new method--laparoscopic bipolar coagulation of uterine vessels--to stop bleeding and preserve the uterus.

Rapid Enlargement of Uterine Myomas after Laparoscopic Bipolar Coagulation of Uterine Vessels

Degenerative changes occur relatively frequently in uterine leiomyomas. Morphologic changes such as necrosis, hyalinization, and alterations in cellularity are described after uterine artery embolization. A modified method to interrupt the uterine blood supply is laparoscopic bipolar coagulation of uterine vessels (LBCUV). Although the success rate is good, occasional patients require hysterectomy because of complications or continuing symptoms. A woman with symptomatic myomas underwent LBCUV, but required hysterectomy due to rapid enlargement of myomas and intractable symptoms including pelvic pain and pressure, and acute urinary retention. The combination of degenerative and iatrogenic changes resulted in a histologic appearance resembling diffuse hyalinization and hydropic degeneration of the leiomyomas.