Efficacy of combined laparoscopic uterine artery occlusion and myomectomy via minilaparotomy in the treatment of recurrent uterine myomas

Transcription

1 REPRODUCTIVE SURGERY Efficacy of combined laparoscopic uterine artery occlusion and myomectomy via minilaparotomy in the treatment of recurrent uterine myomas Wei-Min Liu, M.D., a Peng-Hui Wang, M.D., Ph.D., b Chun-Shan Chou, M.D., Ph.D., a Wun-Long Tang, M.D., a I-Te Wang, M.D., a and Chii-Ruey Tzeng, M.D. a a Department of Obstetrics and Gynecology, Taipei Medical University Hospital, and Taipei Medical University, Taipei, Taiwan; b Department of Obstetrics and Gynecology, Taipei Veterans General Hospital and National Yang-Ming University School of Medicine, Taipei, Taiwan, Republic of China Objective: To evaluate the therapeutic efficacy of laparoscopic uterine artery occlusion combined with myomectomy through a minilaparotomy in the treatment of recurrent uterine myomas, compared with myomectomy alone. Design: Controlled, nonrandomized clinical study. Setting: University-affiliated tertiary care referral center. Patient(s): Eighty-two women with symptomatic, recurrent myomas warranting surgical treatment, who expressed a strong desire to retain their uterus. Fifty-two patients (63.4%) underwent laparoscopic uterine artery occlusion and subsequent minilaparotomy and myomectomy (group I) and 30 patients (36.6%) underwent myomectomy alone (group II). Intervention(s): Occlusion of the uterine arteries was performed with a laparoscopic approach before minilaparotomy and myomectomy. Main Outcome Measure(s): The efficacy of combined laparoscopic uterine artery occlusion and myomectomy via minilaparotomy in the treatment of recurrent uterine myomas was measured by comparing blood loss, need for blood transfusion, postoperative febrile morbidity, recurrence rate of the uterine myomas, and fertility rate in the treatment (group I) and control (group II) groups. Results: The average blood loss was and ml in groups I and II, respectively. The recurrence rate of uterine myomas was 5.8% (3 of 52) in group I and 36.7% (11 of 30) in group II during an average follow-up period of 42.5 months. Of the sexually active patients who did not use contraception, 19.2% (5 of 26) and 22.4% (4 of 18) became pregnant in groups I and II, respectively (no statistical significance). Conclusion(s): This study has demonstrated the superiority of laparoscopic uterine artery occlusion when combined with repeat myomectomy in treating recurrent symptomatic myomas. (Fertil Steril 2007;87: by American Society for Reproductive Medicine.) Key Words: Laparoscopic uterine artery occlusion, myomectomy, recurrent uterine myomas, fertility Received March 2, 2006; revised and accepted 4 July Supported in part by grants from Taipei Medical University, Taipei Veterans General Hospital (V95ED1-013, and V95B2-003), and National Science Council, Taiwan. No benefit of any kind will be received either directly or indirectly by the authors. Reprint requests: Wei-Min Liu, M.D., Department of Obstetrics and Gynecology, Taipei Medical University and Taipei Medical University Hospital, Taiwan, R.O.C. (FAX: ; weiminliu50@hotmail. com); or Peng-Hui Wang, M.D., Ph.D., Taipei Veterans General Hospital and National Yang-Ming University School of Medicine, 252 Wusing Street,Taipei110,Taiwan,R.O.C.(FAX: ; phwang@ vghtpe.gov.tw). Uterine leiomyomas not only represent the most common tumor of the female reproductive system, but are also the most common indication for hysterectomy. For women who wish to retain childbearing potential, abdominal myomectomy has been the preferred treatment. Alternatives to abdominal myomectomy have also been developed for the purpose of extirpating leiomyomas, namely laparoscopic and hysteroscopic myomectomy. With these different approaches to myomectomy, the risk of recurrent leiomyomas is far greater than reported following abdominal myomectomy (1). The detection of recurrent leiomyomas using transvaginal ultrasonography suggests that up to one-half of women have detectable myomas within 5 years after an abdominal myomectomy (2 4), and the percentage is even higher after laparoscopic myomectomy (5, 6). The need for a repeat myomectomy or hysterectomy after abdominal myomectomy is therefore high and appears to be between 15% and 20% after approximately 10 years (7 9). In the past, the majority of studies pertaining to uterine leiomyomas have focused on primary myomectomy or in- 356 Fertility and Sterility Vol. 87, No. 2, February /07/$32.00 Copyright 2007 American Society for Reproductive Medicine, Published by Elsevier Inc. doi: /j.fertnstert

2 terruption of the uterine blood supply by the abdominal approach (10), laparoscopic myomectomy (5, 6), hysteroscopic resection (11), vaginal excision (12), myolysis (13), arterial embolization (14), and uterine artery occlusion (15 18). Although many factors may influence the possibility of recurrent myomas, including the disparity in surgical procedures (surgeon and technique dependent), the severity of previous myomas, and other possible factors, additional means that further decrease the recurrence rate of uterine myomas are reasonable and acceptable. However, only one study has addressed additional means by which to decrease the recurrence of uterine myomas after myomectomy (17). Another study reported the operative morbidity and reproductive outcome that occur with repeat myomectomy following recurrence of uterine myomas (19). Therefore, the aim of this controlled study was not only to evaluate a new treatment method to alleviate the symptoms of women with recurrent myomas while conserving their uterus and reproductive potential, but also to decrease operative morbidities, such as intraoperative hemorrhage and the frequent recurrence of uterine myomas requiring additional treatment. Fertility outcome was also assessed for those women after repeat myomectomy. MATERIALS AND METHODS Patients and Indications Between January 1999 and January 2004, 123 patients were enrolled in this controlled, clinical study. All patients had undergone a myomectomy between 7 months and 10 years earlier at different hospitals. Twenty-one patients with adenomyosis, 11 patients with endometriosis, and 9 patients with both adenomyosis and endometriosis were excluded from the study by a priori design. Thus, 82 patients, 29 to 48 years of age (mean 39.7 years), who had recurrent symptomatic uterine leiomyomas necessitating surgical intervention and who wished to retain their uterus, remained in the study. These uterine leiomyomas were diagnosed by transvaginal ultrasound (TVS), and recurrence was based on the history of the patients, who had previously been treated with a myomectomy procedure. The phrase symptomatic included either compression syndromes such as frequent lower back pain, constipation, or menstruation problems such as menorrhagia and anemia. No patients had amenorrhea or premenstrual basal FSH levels 30 IU/L. Because combined laparoscopic uterine artery occlusion with minilaparotomy and myomectomy is a novel technique, the postoperative uterine function and fertility statuses were unknown. Those patients unwilling to submit to this new technique following informed consent, but desirous of a repeat myomectomy, comprised the control group (group II; n 30). Patients willing to undergo the combined laparoscopic uterine artery occlusion and minilaparotomy with myomectomy made up the study group (group I; n 52). In addition, the general characteristics of the patients in both groups were similar, using the limited number of evaluated items (age, body mass index, hormone profile, and biochemical and blood data). For example, the mean age of patients in group I and group II was 33.9 years (ranging between 30 and 39 years) and 34.2 years (ranging between 29 and 42 years), respectively. The body mass index was 24.2% (ranging between 21.3% and 28.8%) in group I and 24.9% (ranging between 22.1% and 27.9%) in group II, respectively. However, there may have been some differences, for example, in the educational level, socioeconomic level, surgical procedures (surgeon and technique dependent), severity of previous myomas, or some other etiology, such as desire for future pregnancy, between these individuals. Unfortunately, we did not include these items for analysis. The study subjects were all thoroughly counseled regarding the potential risks, benefits, curative nature, and fertility issues related to the uterine artery occlusion. Institutional review board approval was obtained through the Department of Obstetrics and Gynecology. Written informed consent was obtained from all patients before enrollment in the study. All patients in the study had undergone a previous abdominal or laparoscopic myomectomy. The average interval from the first to the second myomectomy was 4.7 years (ranging between 7 months and 10 years). The exact number and size of myomas removed during the first myomectomy were not consistently available through operative and pathology reports; thus, no attempt was made to accurately predict the risk for repeat surgery. Operative Procedures Dilute vasopressin (1:60) was used in both group I and group II patients to decrease intraoperative bleeding. Group I patients underwent laparoscopic uterine artery occlusion before myomectomy, because it was sometimes difficult to perform the technique through the minilaparotomy wound (data not shown). The precise technique, as previously described (15 19), was followed in all but three patients in this group. Because of the severity of pelvic adhesions present in these three patients, the decision to perform a celiotomy was made intraoperatively. The previously reported procedure (18) was followed; thus, the uterine arteries were doubly ligated with silk suture before myomectomy. In brief for technique, after inducing pneumoperitoneum and obtaining three ports on the abdomen (a 10-mm port through the umbilicus for video laparoscope, one 5-mm port on either side, and one 5-mm port suprapubically), we chose the triangle enclosed by the round ligament, external iliac vessels, and infundibulopelvic ligament to open the broad ligament. After vertical incision of 2 to 3 cm of the broad ligament, we identified the ureter laterally and internal iliac artery medially. We separated them carefully and the uterine artery was seen originating from the internal iliac artery crossing over the ureter. With the aid of the grasper compressing the ureter medially, the Fertility and Sterility 357

3 TABLE 1 Surgical findings. Group Pelvic adhesions No. of myomas Cases with entry into the uterine cavity I 27 (52.9%) 4.2 (2 47) 15 (28.8%) II 14 (46.7%) 4.6 (1 54) 7 (23.3%) Note: Group I laparoscopic uterine artery occlusion and minilaparotomy with myomectomy (n 52); group II myomectomy alone (n 30). Liu. Uterine artery occlusion with myomectomy. Fertil Steril methods during the follow-up period. The number of patients who became pregnant and the outcome of the pregnancies, such as spontaneous abortions, ectopic pregnancies, and the mode of delivery, were recorded. Statistical Analysis SPSS (version 11.5, SPSS Inc. Chicago, IL) statistical software was used to analyze the patient data. Data were presented as the mean standard deviation. A parametricindependent samples t test was used to compare differences between the two groups, and chi-square analysis was used for categorical variables. The level of statistical significance was set at a value of P.05. uterine artery was isolated from the ureter and the internal iliac artery, and was then obliterated using the Kleppinger (Richard Wolf Medical Instruments, Vernon Hills, IL) bipolar forceps and two vascular clips (19). The minilaparotomy and myomectomy was performed in accordance with the technique described before (18), and the tumors were individually removed through a 3- to 6-cm abdominal incision. The uterine incision was then repaired using 1-0 chromic catgut. Pelvic lavage was carried out with warm normal saline solution before the application of a Seprafiilm adhesion barrier (Genzyme Corporation, Cambridge, MA). Blood loss was estimated by calculating the blood volume collected in the suction apparatus and the net weight change of gauze used during surgery. RESULTS Surgical Findings Pelvic adhesions, likely a reflection of the previous myomectomy, were present in 27 (52.9%) patients in group I and 14 (46.7%) patients in group II (Table 1). Lysis of adhesions was performed in all these patients without difficulty. Bilateral tubal occlusions were noted in two patients in group I and one patient in group II, all of whom desired fertility. The average yield of myomas was 4.2 (ranging between 2 and 47) for group I and 4.6 (ranging between 1 and 54) for group II. The uterine cavity was breached during the course of removing suspiciously submucous leiomyomas in 15 (28.8%) of the group I patients and 7 (23.3%) of the group II patients. Accordingly, all these patients were counseled to advise their obstetricians of the need for abdominal delivery should they conceive. Assessments Basal FSH levels were determined at 3-month intervals for 6 months in patients 45 years of age. All patients had postoperative evaluations with TVS every 6 months for a period of 18 months (mean 42.5 months), and were instructed to report all pregnancies. Twenty-six women (50%) in group I and 18 women (60%) in group II did not use any contraceptive Surgical Results No major acute or delayed surgical complications occurred in either group of patients. However, febrile morbidity (temperature 38.5 C) occurred in eight patients, each in groups I and II (15.4% and 26.7%, respectively; Table 2). The average operative time was minutes (ranging between 54 and 128 min) for laparoscopic uterine artery occlusion and TABLE 2 Surgical results. Group Operating time Blood loss Weight of removed myoma Febrile morbidity n (%) Postoperative hospital stay min ml g d I (54 128) (50 450) (96 1,860) 8 (15.4%) (2 4) II (46 124) ( ) (125 2,160) 8 (26.7%) (2 7) P value NS NS.061 Note: Results reported as mean SD (range) unless noted. Febrile morbidity temperature 100 o C; group I laparoscopic uterine artery occlusion and minilaparotomy with myomectomy (n 52); group II myomectomy alone (n 30); NS not statistically significant; SD standard deviation. Liu. Uterine artery occlusion with myomectomy. Fertil Steril Liu et al. Uterine artery occlusion with myomectomy Vol. 87, No. 2, February 2007

4 TABLE 3 Long-term follow-up. Group Recurrence rate Pregnancy rate Delivery rate Spontaneous abortion Ectopic pregnancy I 5.8% (3/52) 19.2% (5/26) 11.5% (3/26) 3.8% (1/26) 3.8% (1/26) II 36.7% (11/30) 22.2% (4/18) 11.18% (2/18) 11.1% (2/18) P value.001 NS (.808) NS (1.026) NS (.344) NS Note: Group I laparoscopic uterine artery occlusion and minilaparotomy with myomectomy (n 52; 26 women without contraception); group II myomectomy alone (n 30; 18 women without contraception); NS not statistically significant. Liu. Uterine artery occlusion with myomectomy. Fertil Steril minilaparotomy with myomectomy, and minutes (ranging between 46 and 124 min) for myomectomy only. On average, 16 additional minutes was required to complete the laparoscopic component of the combined procedure. The average blood loss during surgery was ml (ranging between 50 and 450 ml) for group I, and ml (ranging between 75 and 1,150 ml) for group II patients. During or immediately after surgery, four of the patients in group II required a blood transfusion, but none of the group I patients required one. The average length of the postoperative hospital stay was days (ranging between 2 and 4 days) for group I and days (ranging between 2 and 7 days) for group II patients. healthy infants, and one woman delivered a preterm, but healthy, infant. One (3.8%) woman had a spontaneous abortion and one (3.8%) had an ectopic pregnancy. In group II, of the 18 (60.0 %) women who were sexually active without using contraception or receiving an assisted reproductive technique, 4 (22.2%) had clinical pregnancies. Two (11.1%) women had a live birth and two (11.1%) had a spontaneous abortion. The difference in live-birth rates between the two groups was not statistically significant No basal FSH changes were demonstrated in the seven women from group I and the four women from group II who were 45 years of age. Long-Term Follow-up The average follow-up time for all study participants was 42.5 months (ranging between 18 and 66 months). Secondary recurrence was defined as any uterine myoma diagnosed postoperatively by a transvaginal ultrasonographic examination. In group I, the combined laparoscopic uterine artery occlusion and minilaparotomy with myomectomy group, 3 (5.8%) of 52 patients had recurrent myomas after an average interval of 38 months (ranging between 24 and 54 months), none of whom required further treatment (Table 3). In group II, the myomectomy-only group, 11 (36.7 %) of 30 patients had a myoma recurrence after an average interval of 22 months (ranging between 12 and 60 months). Of these 11 women, 10 did not require treatment and 1 patient underwent a hysterectomy because of refractory menorrhagia. Fibroid size, location, patient age, parity, and postoperative pregnancies had no discernible effect on recurrence in either group. However, recurrence was associated with the number of myomas. In those patients with (n 14) and without (n 68) recurrence, there were an average of 6.3 and 2.1 myomas, respectively. Among the 26 (50.0%) women in group I not using contraception or receiving an assisted reproductive technique, a total of 5 (19.2%) had six clinical pregnancies (Table 3). Three (11.5%) women went on to deliver four DISCUSSION Although the alleviation of symptoms in women with recurrence of leiomyomas can be achieved by performing a repeat myomectomy, repeat myomectomy gives rise to an increase in operative morbidity and a poor fertility outcome (20). Operative morbidity includes postoperative fever ( 38.5 C) or intraoperative hemorrhage (median 700 ml), despite the use of vasopressin as a hemostatic agent. Febrile morbidity in the current study involved 17.3% and 26.7% of the patients in groups I and II, respectively, and was lower than that previously reported (20). Blood clots retained in the abdomen, presumably arising from oozing at the uterine suture sites, were considered to be the main etiology for postoperative febrile morbidity. This complication was unavoidable despite thorough pelvic lavage with normal saline before closure of the abdomen. Uterine artery occlusion may have been useful in decreasing such oozing from the uterus and thereby indirectly reduced the postoperative febrile morbidity observed in patients from group I. The average blood loss in group I patients was ml, which was lower than that in the group II patients ( ml) or the 700 ml reported by Frederick et al. (20). Accordingly, blood transfusion was required in 13% of group II patients and 12% of the patients in the study by Frederick et al. (20), although none of the group I patients Fertility and Sterility 359

5 required blood transfusion. Uterine artery occlusion has been shown to achieve an effective hemostasis during myomectomy procedures (18). Injection of diluted vasopressin does not always prevent massive bleeding during myomectomy (21), even when using a much more concentrated solution, which was reported and showed apparently improved hemostasis (22), but when combined with uterine artery occlusion, it can reduce intraoperative hemorrhage significantly. Indeed, when compared with our previous report (18), the blood loss in the group I patients ( ml) and was still greater than in the patients who underwent uterine artery occlusion and primary myomectomy ( ml). Pelvic adhesions were present in 52.9% of group I patients and 46.7% of group II patients; additional bleeding resulting from adhesiolysis may have accounted for the additional blood loss during secondary myomectomy. Theoretically, there exist at least two reasons for recurrence of leiomyomas following myomectomy, irrespective of the operative method utilized (i.e., abdominal, laparoscopic, or hysteroscopic myomectomy). First, small and inconspicuous myomas were incidentally left in situ by the surgeons at the initial myomectomy; these continued to grow, subsequently becoming clinically detectable and symptomatic leiomyomas. Second, de novo formation of leiomyomas occurred subsequent to the initial myomectomy. In the former instance, occlusion of the uterine arteries may have prevented growth vis-à-vis an inadequate blood supply. Because uterine artery occlusion is durable and preemptive (23), it would seem prudent to treat the entire population of leiomyomas, especially those occult myomas overlooked during myomectomy. Ligation of both uterine arteries results in ischemia and degeneration of those subclinical myomas, thus preventing their continued growth. This hypothesis further supports our previous report (18) in which 234 patients treated with uterine artery occlusion and myomectomy had no recurrences versus a 19.4% recurrent rate for patients undergoing myomectomy alone after a mean follow-up of 25.4 months. A myoma recurrence rate of 5.8% (3 of 52) occurred in group I patients, which was lower than the 36.7% rate (11 of 30), which occurred in the group II patients. This result may imply that uterine artery occlusion does reduce the recurrence rate of occult leiomyomas present at the time of initial myomectomy, possibly through necrosis. In contrast, a possible reason that the three patients in group I had recurrent small myomas at an average follow-up time of 42.5 months was that de novo formation of leiomyomas after secondary myomectomy still occurred in some potentially high-risk patients. Most studies have reported successful pregnancy outcomes in between 20% and 50% of patients following primary myomectomy (24 26). Only one study has reported on the natural pregnancy outcome following secondary myomectomy (20). In that study, the spontaneous pregnancy rate of 15% was significantly lower than that in most reported series after primary myomectomy. In our patient groups, there was an older mean age (39.7 vs years) compared with the study from Frederick et al. (20), and one-half of our patients underwent secondary myomectomy based on a strong desire for uterine preservation while using a method of contraception. The remaining one-half of our patients either had desired fertility or chose not to use contraception on a regular basis. The 19.2% and 22.2% pregnancy rates in group I and group II, respectively, were comparable to those of Frederick et al. (20). A possible reason for these poor fertility outcomes in both series may be the severe pelvic adhesions resulting from primary myomectomy (20). There were no differences between group I and group II patients in pregnancy rates or healthy infant delivery rates. The same result was also noted in our previous study (18) in which 50% of patients underwent myomectomy alone, and 37.5% of those who had uterine artery occlusion with myomectomy had a live birth, with no significant differences between the two groups. Pregnancy remains possible after surgical occlusion of both the internal iliac and ovarian arteries (27). Twelve successful pregnancies have been reported after bilateral uterine artery ligation for post-cesarean section hemorrhage (28). Uterine artery ligation has been widely utilized by obstetricians attempting to treat postpartum hemorrhage before resorting to definitive hysterectomy. In addition, our recent research showed promising results in reducing postpartum blood loss and minimizing the need for future surgery using uterine artery ligation for the treatment of pregnant women with uterine leiomyomas who are undergoing Cesarean section (29). The rationale for the option of such conservative treatment is a serious commitment to preserve future fertility. If fertility is compromised by this procedure or any maternal complication or fetal abnormality is reported in the literature, obstetricians should be prohibited from using uterine artery ligation to treat postpartum hemorrhage. However, the potential complications of laparoscopic uterine artery occlusion, including ureter injury, intestinal injury, and others, cannot be discounted completely, although the incidence was low in two reports (30, 31), and no major acute or delayed surgical complications occurred in either group of patients in this study. Uterine artery occlusion will have a different impact on the uterus and on the leiomyomas. When the uterine arteries are occluded, collateral arteries supply the uterus but not the leiomyomas, so the uterus can reestablish its perfusion within hours or days, whereas necrosis of the leiomyomas ultimately occurs (32). These theoretical implications provide the rationale for using uterine artery occlusion to treat leiomyomas without consideration of uterine function and future fertility. The question remains regarding how hormonal function is altered following uterine artery occlusion. No patients with elevated basal FSH levels were detected in this study. However, for patients aged 45 years who have undergone uterine artery embolization in the treatment of leiomyomas, 360 Liu et al. Uterine artery occlusion with myomectomy Vol. 87, No. 2, February 2007

6 there is an approximately 15% likelihood of an increase in basal FSH into the perimenopausal range (33). It has been reported that a 9.0% (2 of 22) rate of hormonal change results from laparoscopic occlusion of uterine vessels in the treatment of symptomatic myomas (34). Our previous study also showed a 3.5% (3 of 85) increase in FSH levels ( 30 IU/L) in patients treated by laparoscopic bipolar coagulation of uterine vessels (16). The difference between the present study and the aforementioned two series was that we occluded the uterine arteries only before myomectomy, and did not obliterate the collateral circulation between the ovaries and uterus, thereby explaining why the hormonal status and uterine and ovarian function were not influenced. In conclusion, combined laparoscopic uterine artery occlusion and minilaparotomy with myomectomy for the treatment of symptomatic leiomyomas is an accepted alternative to hysterectomy or repeat myomectomy alone in patients with recurrent myomas, who require further surgical intervention. Nevertheless, repeat myomectomy is still a difficult procedure with the attendant risks of surgical complications and a lower pregnancy rate. Uterine artery occlusion before myomectomy significantly reduces intraoperative blood loss and the secondary recurrence of leiomyomas. However, a high level of skill is needed for laparoscopic uterine artery occlusion, and consequently, uterine artery ligation should not be performed until familiarity with the anatomical site of the origin of the uterine artery from the internal iliac artery and facility with the technique is acquired. In this small series, fertility was apparently not compromised by the incorporation of laparoscopic uterine artery occlusion into the repeat myomectomy procedure. Acknowledgments: The authors thank Yuan-Chii Lee, Ph.D., of Taipei Medical University for her assistance in statistical analysis. REFERENCES 1. Stewart EA, Faur AV, Wise LA, Reilly RJ, Harlow BL. Predictors of subsequent surgery for uterine leiomyomata after abdominal myomectomy. Obstet Gynecol 2002;99: Candiani GB, Fedele L, Parazzini F, Villa L. Risk of recurrence after myomectomy. Br J Obstet Gynaecol 1991;98: Fedele L, Vercellini P, Bianchi S, Brioschi D, Dorta M. Treatment with GnRH agonists before myomectomy and the risk of short-term myoma recurrence. Br J Obstet Gynaecol 1990;97: Fedele L, Parazzini F, Luchini L, Mezzopane R, Tosí L, Villa L. Recurrence of fibroids after myomectomy: a transvaginal ultrasonographic study. Hum Reprod 1995;10: Nezhat FR, Roemisch M, Nezhat CH, Seidman DS, Nezhat CR. Recurrence rate after laparoscopic myomectomy. J Am Assoc Gynecol Laparosc 1998;5: Dubuisson JB, Fauconnier A, Babaki-Fard K, et al. Laparoscopic myomectomy: a current view. Hum Reprod Update 2000;6: Buttram VC Jr, Reiter RC. Uterine leiomyomata: etiology, symptomatology, and management. Fertil Steril 1981;36: Malone LJ. Myomectomy: recurrence after removal of solitary and multiple myomas. Obstet Gynecol 1969;34: Acien P, Quereda F. Abdominal myomectomy: results of a simple operative technique. Fertil Steril 1996;65: Fletcher H, Frederick J, Hardie M, Simeon D. Vasopressin versus tourniquet. Am J Obstet Gynecol 1996;87: Hallez JP. Single-stage total hysteroscopic myomectomies: indications, techniques and results. Fertil Steril 1995;63: Magos AL, Bournas N, Sinha R, Richardson RE, O Connor H. Vaginal myomectomy. Br J Obstet Gynecol 1994;101: Dubuisson JB, Chapron C, Morice P. Laparoscopic myomectomy and myolysis. Bailliere s Clin Obstet Gynaecol 1995;9: Spies JB, Ascher SA, Roth AR, Kim J, Levy EB, Gomez-Jorge J. Leiomyomata treated with uterine artery embolization: factors associated with successful symptom and imaging outcome. Radiology 2002;1: Liu WM. Laparoscopic bipolar coagulation of uterine vessels to treat symptomatic leiomyomas. J Am Assoc Gynecol Laparosc 2000;7: Liu WM, Ng HT, Wu YC, Yen YK, Yuan CC. Laparoscopic bipolar coagulation of uterine vessels: a new method for treating symptomatic fibroids. Fertil Steril 2001;75: Liu WM, Yen YK, Wu YC, Yuan CC, Ng HT. Vaginal expulsion of submucous myomas after laparoscopic-assisted uterine depletion of the myomas. J Am Assoc Gynecol Laparosc 2001;8: Liu WM, Tzeng CR, Yi-Jen C, Wang PH. Combining the uterine depletion procedure and myomectomy may be useful for treating symptomatic fibroids. Fertil Steril 2004;82: Chou YC, Wang PH, Yuan CC, Yen YK, Liu WM. Laparoscopic bipolar coagulation of uterine vessels to managing delayed postpartum hemorrhage. Am Assoc Gynecol Laparosc 2002;9: Frederick J, Hardie M, Reid M, Fletcher H, Wynter S, Frederick C. Operative morbidity and reproductive outcome in secondary myomectomy: a prospective cohort study. Hum Reprod 2002;17: Ginsburg ES, Benson CB, Garfield JM, Gleason RE, Friedman AJ. The effect of operative technique and uterine size on blood loss during myomectomy: a prospective randomized study. Fertil Steril 1993;60: Frederick J, Fletcher H, Simeon D, Mullings A, Hardie M. Intramyometrial vasopressin as a haemostatic agent during myomectomy. Br J Obstet Gynaecol 1994;101: Burbank F, Hutchins FL. Uterine artery occlusion by embolization or surgery for the treatment of fibroids: a unifying hypothesis-transient uterine ischemia. J Am Assoc Gynecol Laparosc 2000;7(4 Suppl):S Rosenfield DL. Abdominal myomectomy for otherwise unexplained infertility. Fertil Steril 1986;46: Solitt S, Issa A. Reproductive outcome after abdominal myomectomy. J Obstet Gynecol 2000;29: Li TC, Mortimer R, Cooke ID. Myomectomy: a retrospective study to examine reproductive performance before and after surgery. Hum Reprod 1999;14: Mengert WF, Burchell RC, Blumstein RW. Pregnancy after bilateral ligation of the internal iliac and ovarian arteries. Obstet Gynecol 1969; 34: Oleary JA. Pregnancy following uterine artery ligation. Obstet Gynecol 1980;55: Liu WM, Wang PH, Tang WL, Wang IT, Tzeng CR. Uterine artery ligation for treatment of pregnant women with uterine leiomyomas who are undergoing Cesarean section. Fertil Steril 2006;86: Wang PH, Lee WL, Yuan CC, Chao HT, Liu WM, Yu KJ, et al. Major complications of operative and diagnostic laparoscopy for gynecologic disease. J Am Assoc Gynecol Laparosc 2001;8: Zdenek Holub Z, Eim J, Jabor A, Hendl A, Lukac J, Kliment L. Complications and myoma recurrence after laparoscopic uterine artery occlusion for symptomatic myomas. J Obstet Gynaecol Res 2006;32: Lichtinger M, Burbank F, Hallson L, Herbert S, Uyeno J, Jones M. The time course of myometrial ischemia and reperfusion after laparoscopic uterine artery occlusion theoretical implications. J Am Assoc Gynecol Laparosc 2003;10: Roth AR, Spies JB, Walsh SM, Wood BJ, Gomez-Jorge J, Levy EB. Pain after uterine artery embolization for leiomyomata: can its severity be predicted and does severity predict outcome? J Vasc Interv Radiol 2002;11: Hald K, Langebrekke A, Know NE, Noreng HJ, Berge AB, Istre O. Laparoscopic occlusion of uterine vessels for the treatment of symptomatic fibroids: initial experience and comparison to uterine artery embolization. Am J Obstet Gynecol 2004;190: Fertility and Sterility 361