Dipartimento Materno-Infantile Direttore : Paolo Puggina. Miomectomia laparoscopica indicazioni e limiti Giuseppe De Francesco

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1 Dipartimento Materno-Infantile Direttore : Paolo Puggina Miomectomia laparoscopica indicazioni e limiti Giuseppe De Francesco

2 The clinical dilemma is whether we treat all symptomatic uterine leiomyomas as cancer until proved otherwise.

3 Abandonment of morcellation (zero reduction) Patient triage (probable risk reduction) In bag morcellation ( unproven safety) 2015

4 Suzanne George, MD, Center for Sarcoma and Bone Oncology, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston

5 ; Cancer October 15, 2014

6 Whether electromechanical morcellation poses a unique danger to the patient with occult leiomyosarcoma is an unanswered question..

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8 Morcellation During Uterine Tissue Extraction Nezhat C. President of AAGL,2014

9 Morcellation During Uterine Tissue Extraction Conclusion It is the opinion of the AAGL that all existing methods of tissue extraction have benefits and risks, which must be balanced. At this time, we do not believe there is a single method that can protect all patients; therefore, all current methods of tissue extraction should remain available. We believe that an understanding of the issues reviewed in this document will allow surgeons and hospitals to make the most appropriate, informed choices regarding utilization of tissue extraction in individual patients undergoing uterine surgery. C Nezhat C. President of AAGL,2014

10 MEMBER UPDATE #5: AAGL Response to FDA Guidance onuse of Power Morcellation during Tissue Extraction for Uterine Fibroid November 25, 2014 In summary, abandoning power morcellation technology for many patients undergoing minimally invasive myomectomy, supracervical hysterectomy, or hysterectomy for a large uterus will be a setback in the care of patients with gynecologic conditions. With meticulous adherence to preoperative patient selection guidelines and informed consent, the AAGL believes appropriately performed power morcellation outweighs the risk of laparotomy in low-risk patients and is an option to be carefully considered by patients and their gynecologists."

11 Culdotomy Vaginal outlet

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29 2010 Surgical treatment of fibroids for subfertility (Review) Griffiths AN, D Angelo A, Amso NN Objectives To determine the efficacy and safety of the removal of uterine fibroids in subfertile women by laparotomy, laparoscopy or hysteroscopy when compared with expectant management or each other. The review will include also new surgical approaches as and when they are trialed. Authors conclusions There is limited evidence to suggest that there is no difference in fertility efficacy outcome if fibroids are removed via laparotomy when compared to laparoscopy. There is no good randomised controlled evidence to support hysteroscopic removal of fibroids compared to other surgical modalities for fertility efficacy.

30 2012 Surgical treatment of fibroids for subfertility (Review) Metwally M, Cheong YC, Horne AW Objectives To examine the effect of myomectomy on fertility outcomes and to compare different surgical approaches Authors conclusions There is currently insufficient evidence from randomised controlled trials to evaluate the role of myomectomy to improve fertility. Regarding the surgical approach to myomectomy there is no significant difference between the laparoscopic and open approach regarding fertility performance..

31 2014 Objectives To determine the benefits and harms of laparoscopic or hysteroscopic myomectomy compared with open myomectomy Authors conclusions Laparoscopic myomectomy is a procedure associated with less subjectively reported postoperative pain, lower postoperative fever and shorter hospital stay compared with all types of open myomectomy. No evidence suggested a difference in recurrence risk between laparoscopic and open myomectomy. More studies are needed to assess rates of uterine rupture, occurrence of thromboembolism, need for repeat myomectomy and hysterectomy at a later stage.

32 The mechanisms by which myomas may adversely affect fertility are several: Displacement of the cervix that may reduce exposure to sperm Enlargement or deformity of the uterine cavity that may interfere with sperm migration and transport Obstruction of the proximal fallopian tubes Altered tubo-ovarian anatomy, interfering with ovum capture Increased or disordered uterine contractility that may hinder sperm or embryo transport or nidation Distortion or disruption of the endometrium and implantation due to atrophy or venous ectasia over or opposite a submucous myoma Impaired endometrial blood flow Endometrial inflammation or secretion of vasoactive substances Fertil Steril, 2008 American Society for Reproductive Medicine

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35 «.In relazione all aumentato rischio assoluto di rottura d utero, la possibilità di un parto vaginale dopo taglio cesareo è controindicata in caso di pregressa rottura d utero, pregressa incisione uterina longitudinale e in caso di tre o più tagli cesarei precedenti» (BPC)

36 .There is insufficient and conflicting information on whether the risk of uterine rupture is increased in women with previous myomectomy

37 The log rank test was used comparing the pregnancy rate in two groups: no significant differences were found

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41 2010 AAGL

42 Since nearly complete suturing is possible in Laparoscopic Myomectomy (LM) as in laparotomy, vaginal delivery can be accomplished safely without uterine rupture even after LM (VBALM), provided that delivery is managed as in vaginal birth after cesarean section(vbac) AAGL

43 Conclusion With the widespread adoption of LM as conservative surgery for uterine myoma, the number of patients desiring to become pregnant and deliver vaginally after LM is likely to increase. The results of the current study suggest that the risk of uterine rupture in pregnancy or delivery subsequent to LM is extremely low if the myomectomy wounds are sutured appropriately during the LM, and that a vaginal birth under strict delivery management can be safely chosen for selected patients after LM AAGL

44 Fertility, obstetric and delivery outcome after laparoscopic myomectomy in the patient with unexplained infertility Pregnancyandfertility rate after LM To confirm the validity of the Laparoscopic approach: quality of the uterine scar Delivery outcome: vaginal deliveryorcesarean section?

45 Setting:Evangelical Hospital of Naples - Villa Betania -Department of Obstetrics and Gynaecology January December 2014 Patient(s): 168 womenwith diagnosis of unexplained infertility and presumed uterine myoma Intervention(s): Laparoscopic Myomectomy. In our study, myomectomy was performed exclusively by laparoscopy. LM, as well as other laparoscopic procedures, has less morbidity, rapid recovery, and potentially less risk for adhesion formation

46 Patients characteristics Laparoscopic Myomectomy N of patients(%) 168 Age (years) 30+/-6,2 Parity 0 Infertility period(months) 24+/-7 Indication for myomectomy(n) Unexplained infertility 168 Uterine and leiomyoma characteristics Leiomyoma diameter(cm) 6,5 (3,5-10) Number of leiomyomas 1,5 (1-3) Localization of leiomyomas(n) Intramural 168

47 Laparoscopic Myomectomy Waiting Period after LM (mounth) 8 (6-10) Pregnancy rate (%) 82 (48,8%) Abortion rate (%) 23 (28%) Pregnancy in progress 4 Ectopic pregnancy 2 Deliveries 59 (71.9%) Preterm deliveries (%) 2 (3,38%) Vaginal birth (%) 41 (69,49%) Caesarean section(%) 16 (27,1%) Uterine rupture 0

48 Ulipristal Acetate for Fibroid Treatment before Surgery UPA optimizes operative conditions and thus the postoperative outcome by: Control of uterine bleeding (reducing anemia) Down-sizing of fibroids Post-operative treatment of recurrent In cases of large fibroids, UPA administration can probably avoid hysterectomy and laparotomy in favour of laparoscopic or hysteroscopic enucleation of fibroids

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