|Year : 2020 | Volume
| Issue : 1 | Page : 1-5
Outcome of laparoscopic uterine artery occlusion for uterine fibroids on ovarian function and complications in patients with uterine fibroid
Guanlan Liu1, Yuan Dong2, Xiuying Zhang2, Ying Liu3
1 Department of Obstetrics and Gynecology, Women and Children Hospital of Siping China and Korea; Departments of Obstetrics and Gynecology, Siping Central Hospital, Siping, Jilin, China
2 Department of Obstetrics and Gynecology, Women and Children Hospital of Siping China and Korea, Siping, Jilin, China
3 Department of Science and Education, Siping Central Hospital, Siping, Jilin, China
|Date of Submission||03-Jan-2020|
|Date of Decision||15-Feb-2020|
|Date of Acceptance||17-Feb-2020|
|Date of Web Publication||30-Mar-2020|
Dr. Ying Liu
Department of Science and Education, Siping Central Hospital, No. 89 Nanyingbin Street, Siping, Jilin 136000
Source of Support: None, Conflict of Interest: None
Objective: The aim of this study is to investigate the outcome of laparoscopic uterine artery occlusion (LUAO) on ovarian function in the treatment of uterine fibroid and its influence on complications.
Materials and Methods: A total of 61 patients with uterine fibroid accept LUAO from January 2013 to December 2015 were selected as the research objects. The changes of ovarian hormone secretion volume, internal blood supply of uterine fibroid, uterine volume, fibroid volume, and the occurrence of complications were observed before and 3, 6, 12, and 24 months after surgery. These results were compared with the outcomes of 63 patients with uterine fibroid accept myomectomy.
Results: Compared with myomectomy treatment, the length of intraoperative blood loss, operation time, and hospitalization time of patients in the LUAO group were shorter (P < 0.05). Menstruation characteristics, uterine volume, and uterine fibroid volume postoperation were better than the prior ones in the LUAO group (P < 0.05). The ovarian secretion of luteinizing hormone, estradiol, and follicle-stimulating hormone levels in patients in the following 24 months after surgery were not statistically different in two groups (P > 0.05), and the pelvic floor function had similar results.
Conclusion: Uterine fibroid treated by LUAO is effective, it can decrease the internal blood supply of uterine fibroid, narrow the volume of uterine fibroid, and little impaction on ovarian function. Hence, this kind of treatment is worthy of promotion.
Keywords: Myomectomy, ovarian function, uterine fibroid
|How to cite this article:|
Liu G, Dong Y, Zhang X, Liu Y. Outcome of laparoscopic uterine artery occlusion for uterine fibroids on ovarian function and complications in patients with uterine fibroid. Vasc Invest Ther 2020;3:1-5
|How to cite this URL:|
Liu G, Dong Y, Zhang X, Liu Y. Outcome of laparoscopic uterine artery occlusion for uterine fibroids on ovarian function and complications in patients with uterine fibroid. Vasc Invest Ther [serial online] 2020 [cited 2020 Nov 30];3:1-5. Available from: https://www.vitonline.org/text.asp?2020/3/1/1/281595
| Introduction|| |
Uterine myomas are the most common benign tumor of the uterus, based on an epidemiological point of view, their clinical signs and symptoms can be found in 25%–40% of patients with fibromas. Clinical manifestations of fibromas usually include abnormal uterine blood, pelvic pressure pain, and subfertility or infertility. Large fibromas can also induce pelvic pain and pelvic pressure symptoms with lower urinary tract symptoms (LUTS) and/or constipation.
Uterus-sparing surgery is the current trend in the treatment of uterine adenomyosis to enable women to preserve future fertility and avoid the impact of a hysterectomy on sexual function and mental discomfort. Several new methods and techniques have been tentatively used in the treatment of adenomyosis, including uterine artery embolism (UAE), high frequency ultrasound, balloon endometrial thermoablation, and hysteroscopic endometrial resection.
Based on the UAE method, researchers have begun performing laparoscopic uterine artery occlusion (LUAO) for uterine fibroids with satisfactory outcomes.,,, From 2013 to 2015, we utilized LUAO combined with partial resection for the treatment of 61 eligible patients with symptomatic adenomyosis. The result showed that the postoperative menstrual quantity was decreased significantly and the uterus volume was reduced by 58.3% in these patients during the 36-month follow-up period. Their health-related quality of life was also improved significantly as compared with that before treatment. Postoperative recurrence occurred in only 3 (1.7%) patients, for which hysterectomy was required. Our preliminary clinical practices have demonstrated that LUAO combined with partial resection for the treatment of adenomyosis is safe and effective, and the overall outcome is superior to that reported in the literature. This technology has been incorporated into the uterus adenomyosis classification treatment as an independent operation.
| Materials and Methods|| |
Between January 2013 and December 2015, 61 patients with who received laparoscopic bilateral uterine artery occlusion (LUAO) combined with partial resection of adenomyosis were recruited in this study. The retrospective study reviewed the patients' clinical data, including patients' general characteristics, the results of preoperative examinations, surgical approach, complications, and outcomes of following up for the uterus-sparing patients. This study was approved by the Ethics Committee of Siping Central Hospital (Registration Number: SPZXYY-2013-S-006; Date: January 5, 2013).
The inclusion criteria are as follows: (1) The symptomatic uterine fibroids were ≥5 cm in size or growing quickly myoma based on ultrasonography examination interval of 3–6 months with the increasing diameter ≥3 cm.; (2) The number of fibroids is not more than seven by B-ultrasonography; (3) The main clinical symptoms are menorrhagia and pelvic occupying lesions (including pelvic mass, compression symptoms, etc.,); (4) The level of serum AFP, CEA, CA125, and CA199 are assessed preoperatively to eliminate potential malignancy. For eliminating cervical cancer, cervical cytology examination is performed as routine; and (5) diagnostic curettage was performed for patients with menorrhagia, irregular menstruation, or endometrial thickness more than 14 cm under ultrasound to rule out endometrial malignant lesions.
The exclusion criteria were patients who were diagnosed with uterine fibroid and subsequently received hormonal therapy within the past 6 months; patients with reproduction tract infections or immune system and endocrine diseases; and patients whose preoperative hysteroscopy excluded the diagnosis of endometrial lesions.
The laparoscopic bilateral occlusion of the uterine arteries was carried out according to the standard technique established by Semm and Mettler. The uterine arteries and the anastomotic sites between uterine and ovarian arteries were occluded using clips or bipolar coagulation. The anterior leaf of the broad ligament was opened with scissors, and then, a Maryland clamp was used to dissect the broad ligament toward its base. The roof of the ureteric canal was dissected, and skeletonization of the uterine artery from the ureter was carried out. The main stem of the uterine artery was occluded using two clips or using bipolar coagulation. Cauterization of the anastomotic sites between uterine and ovarian arteries was then carried out and the procedure repeated on the other side.
An incision was made over the fibroid and carried deeply until fibroid tissue with the unipolar electric knife or ultrasonic knife. Then, the myoma was pulled and stripped with the unipolar electric knife or ultrasonic knife, and the pedicel was coagulated and cut with a PlasmaKinetic knife. The residual cavity was closed with the 2# absorbable suture and knotted directly under laparoscopy. All fibroids are morcellated in the peritoneal cavity and removed through the 10 mm Trocar in the left lower abdomen. At last, drainage tube was put through the 5 mm incision in the right lower abdomen.
The perioperative condition of two groups of patients was observed: the operation time, intraoperative blood loss, postoperative exhaust and out-of-bed time, hospitalization time, postoperative analgesic use rate, and average hospitalization costs.
The serum levels follicle-stimulating hormone (FSH, Labor Diagnostika Nord GmBH and Co. KG, Nordhorn, Germany) and luteinizing hormone (LH, Shanghai Yifeng Biotechnology Co., Ltd. Shanghai, China) were measured on the 2th–4th-day postmenses by commercially available Enzyme-linked Immunosorbent Assay Kits according to the manufacturer's instructions. To evaluate the ovarian's function: Preoperative and 3 and 6 months postoperative serum sex hormone levels were detected, including FSH, LH and estradiol (E2), combined with B-ultrasound detection of ovulation to evaluate ovarian reserve function. FSH ≤10 mIU/ml, E2 ≥60 pg/ml for the basic value, and/or FSH ≤20 mIU/ml on menstrual day 10, E2 was significantly higher than in the menstrual period, two times and above of the basic value; B-ultrasound detection showed the follicle gradually became dominant and matured to be excreted, thus was considered as good ovarian reserve function.
The clinical data were presented as a mean ± standard deviation or percentages. Statistical analysis, including survival curve analysis and regression analysis used to statistical software SPSS 18.0 (SPSS Inc., an IBM Company, Chicago, IL, USA). Continuous variables were compared using the t-test, and categorical variables were compared using the Chi-squared test.
| Results|| |
Preoperative assessment and surgical treatment
The general characteristics of the patients are described in [Table 1], and the data were recorded and compared between the groups of LUAO and hysterectomy.
Clinical symptoms postoperation
All patients had a fever, lower abdominal pain, vaginal bleeding, gastrointestinal reactions, limb fatigue, and other symptoms within 1–3 days after the operation. The symptoms improved or disappeared after 4–6 days without serious complications after treatment. Within 6 months postoperation, 57 patients with prolonged menstruation had shorter menstrual periods than preoperation. Among them, 45 patients had a 1/3 reduction in menstrual volume and 51 patients with anemia had different levels of hemoglobin. With the improvement, 6 patients with urinary urgency, frequency of urination, and lower abdominal distension were alleviated, and two infertile patients were successfully pregnant and delivered in 7 or 9 months postoperation.
Comparison of intraoperative blood loss, operation time, and hospitalization time between two groups in the following 24 months
The intraoperative blood loss, operation time, and hospitalization time of patients in the LUAO combined with myomectomy group were lower than those in the myomectomy group (P < 0.01), as shown in [Table 2].
|Table 2: Comparison of intraoperative blood loss, operation time, and hospitalization time between 2 groups|
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Comparison of menstruation prior and postoperation
The menstrual blood volume before operation was higher than the normal range, and the menstrual volume decreased significantly after 3, 6, 12, and 24 months (P < 0.05). The duration of menstruation gradually returned to normal postoperation, and the menstrual cycle gradually normalized, with a significant difference compared with that before operation (P < 0.05) [Table 3].
|Table 3: Comparison of menstruation prior and postoperation in laparoscopic uterine artery occlusion group (n=61, x±s)|
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Comparison of uterine volume, uterine fibroid volume prior and postoperation
The volume of uterine and uterine leiomyoma of all patients decreased gradually in 3, 6, 12, and 24 months postoperation, which were smaller than those preoperation. The difference was statistically significant [Table 4].
|Table 4: Comparison of uterine volume, uterine fibroid volume prior, and postoperation (x±s) in laparoscopic uterine artery occlusion group|
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Compared with hormone levels prior and postoperation
FSH and LH levels of patients' postoperation had no significant difference compared with those of prior surgery (P > 0.05) [Table 5].
|Table 5: Comparison of ovarian function in two groups (mean±standard deviation)|
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Comparison of postoperative pelvic floor function in each group
The scores of prolapse at the top of the vagina, rectal prolapse, and stress urinary incontinence in the LDH group were lower than those in the other group (P < 0.05) [Table 6].
|Table 6: Comparison of pelvic floor function between the two groups 24 months after surgery|
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| Discussion|| |
The concept of retaining uterus for the patients with uterine myomas has been widely accepted in recent years, while there have been few data to show the changes of this kind of surgical approach. This study analyzed retrospectively 61 patients with uterine myomas accepted LUAO to treat uterine myomas and their changes in the following 2 years. In the current study, we reported that LUAO to treat uterine myomas compared with total abdominal hysterectomy has no significant differences in postoperative risk of complications, including urinary tract injury, bowel obstruction, pain score, or pelvic organ prolapse. Hence, endoscopic surgery appeared to replace gradually traditional laparotomy, the LUAO to treat uterine myomas in the study was greatly promoted the development of laparoscopic uterus-sparing surgery.
Uterine myomas are benign tumors coming from smooth muscle cells of the uterine wall. The incidence of uterine myomas was linked to the patient's age, which is estimated that 60% of reproductive-aged women are affected, and 80% of women suffered of this kind of disease during their lifetime.,,
Clinical manifestations of uterine myomas usually include different kinds of excessive bleeding (menorrhagia and metrorrhagia), and sometimes, clinical symptoms were involved in obstetric disturbances such as infertility and complications during pregnancy. Large uterine myomas also induced pelvic pain and pelvic pressure symptoms with LUTS and/or constipation.,
The surgical management of uterine myomas is individual and associated with the patient's age and desire. Our data showed the probability of uterine retention was correlated with the patient's age. The surgical age was 41 ± 1.23 years in the LUAO group and 49 ± 2.65 years in total abdominal hysterectomy group (P < 0.05). It suggested that younger patients tended to the approach of preserving the uterus, even they were informed of the risk that the symptoms would persist and that the leiomyomas may recur and require further surgery. Hence, it is necessary to follow-up the patients' changes regarding clinical symptoms, in the current study, patients were required to accept the imaging examination at an interval of 3–6 months.
The development of approaches regarding lessen bleeding in the operative field is important. In the current study, less bleeding was observed during laparoscopic operations, which contribute to make the surgery easier and to maintain patients' stability. However, the limitation of this kind of operation cannot be avoided. First, it is difficult to approach both uterine arteries in the presence of a large myoma (y8-cm diameter) in the narrow pelvic space. Second, under the condition of dealing with a large myoma, the uterus could be an obstacle to applying the clip to the uterine artery on the opposite side. Hence, this approach was basically dependent on the experience of the surgeon, and feasibility could be determined in surgical planning.
We also detected the basal level of blood sex hormone before operation, 3 months after operation, and 6 months after operation. It was found that there were no differences in the level of LH, FSH, and E2 between preoperation and postoperation. Compared with the control group that had no amenorrhea, there was no difference in the incidence of amenorrhea, so we inferred that LUAO for uterine fibroids had little interference on the ovary reserve function. Similar results were reported in previous researches,, which performed LUAO combined with myomectomy for symptomatic uterine myomas.
The other changes detected in the following 2 years include: first, 56 patients with excessive menstruation had reduced menstrual volume, shortened menstrual period and normal menstrual cycle. Thirty-two patients with normal menstrual volume had a mild decrease of menstruation volume. Twelve oligomenorrhea patients had normal menstrual volume. Second, the symptoms of clinical compression were improved in 25 patients, including 15 disappeared cases and 10 relieved cases. Finally, the uterine leiomyoma volume and uterine volume at 3, 6, and 12 months after operation were significantly smaller than those before the operation, and uterine leiomyoma volume and uterine volume at 12 months after operation were significantly smaller than those at 3 and 6 months after the operation. Their difference was statistically significant (P < 0.05). The reduction rate of uterine leiomyoma volume at 3, 6, and 12 months after the operation was significantly higher than that of uterine volume, and the difference was statistically significant (P < 0.05) [Table 4].
| Conclusion|| |
LUAO for uterine myomas would have a broad prospect. Although it has a high technical requirement and great difficulty in operation, it will widen the indication of laparoscopic myomectomy. It will improve the clinical symptoms of uterine fibroids and fulfill the demand of patients to retain their uteri. Further study would be focus on how to avoid recurrence.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Lumsden MA, Hamoodi I, Gupta J, Hickey M. Fibroids: Diagnosis and management. BMJ 2015;351:h4887.
Donnez J, Dolmans MM. Uterine fibroid management: From the present to the future. Hum Reprod Update 2016;22:665-86.
Grimbizis GF, Mikos T, Tarlatzis B. Uterus-sparing operative treatment for adenomyosis. Fertil Steril 2014;101:472-87.
Cheng Z, Yang W, Dai H, Hu L, Qu X, Kang L. Laparoscopic uterine artery occlusion combined with myomectomy for uterine myomas. J Minim Invasive Gynecol 2008;15:346-9.
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;75:417-22.
Liu WM. Laparoscopic bipolar coagulation of uterine vessels to treat symptomatic leiomyomas. J Am Assoc Gynecol Laparosc 2000;7:125-9.
Dubuisson J, Ramyead L, Streuli I. The role of preventive uterine artery occlusion during laparoscopic myomectomy: A review of the literature. Arch Gynecol Obstet 2015;291:737-43.
Kang L, Gong J, Cheng Z, Dai H, Liping H. Clinical application and midterm results of laparoscopic partial resection of symptomatic adenomyosis combined with uterine artery occlusion. J Minim Invasive Gynecol 2009;16:169-73.
Liu M, Cheng Z, Dai H, Qu X, Kang L. Long-term efficacy and quality of life associated with laparoscopic bilateral uterine artery occlusion plus partial resection of symptomatic adenomyosis. Eur J Obstet Gynecol Reprod Biol 2014;176:20-4.
Semm K, Mettler L. Technical progress in pelvic surgery via operative laparoscopy. Am J Obstet Gynecol 1980;138:121-7.
Downes E, Sikirica V, Gilabert-Estelles J, Bolge SC, Dodd SL, Maroulis C, et al
. The burden of uterine fibroids in five European Countries. Eur J Obstet Gynecol Reprod Biol 2010;152:96-102.
Myers SL, Baird DD, Olshan AF, Herring AH, Schroeder JC, Nylander-French LA, et al
. Self-report versus ultrasound measurement of uterine fibroid status. J Womens Health (Larchmt) 2012;21:285-93.
Zimmermann A, Bernuit D, Gerlinger C, Schaefers M, Geppert K. Prevalence, symptoms and management of uterine fibroids: An international internet-based survey of 21,746 women. BMC Womens Health 2012;12:6.
Gupta S, Jose J, Manyonda I. Clinical presentation of fibroids. Best Pract Res Clin Obstet Gynaecol 2008;22:615-26.
Qu X, Cheng Z, Yang W, Xu L, Dai H, Hu L. Controlled clinical trial assessing the effect of laparoscopic uterine arterial occlusion on ovarian reserve. J Minim Invasive Gynecol 2010;17:47-52.
Hovsepian DM, Ratts VS, Rodriguez M, Huang JS, Aubuchon MG, Pilgram TK. A prospective comparison of the impact of uterine artery embolization, myomectomy, and hysterectomy on ovarian function. J Vasc Interv Radiol 2006;17:1111-5.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]