Transcript Slide 1

Komplikacije laparoskopske
operacije mioma
Magdalena Karadža
3. HRVATSKI KONGRES O REPRODUKCIJSKOM ZDRAVLJU,
KONTRACEPCIJI I IVF-u,
Šibenik, 15.5. – 17. 5. 2014
• Leiomyomas (myomas) are the commonest benign uterine tumors,
with an estimated incidence of 20%–40% in women during their
reproductive years (increase with age)
• Monoclonal tumors of the uterine smooth muscle cells and consist
of large amounts of extracellular matrix that contain collagen,
fibronectin, and proteoglycan.
• Pathogenesis is not clearly known, there is considerable evidence
that estrogens and progestagens proliferate tumor growth
Khan AT et al, Int J Womens Health. 2014
FIGO Leiomyoma Subclassification System
Munroe MG et al. Int J Gynaecol Obstet. 2011
Clinical presentation of uterine leiomyomas
i. Asymptomatic
ii.
Abnormal uterine bleeding
a. Menorrhagia
b. Anemia
iii. Pelvic pressure
a. Urinary frequency
b. Urinary incontinence
c. Difficulty with urination
d. Hydronephrosis
e. Constipation
f. Tenesmus
iv. Pelvic mass
v. Pelvic pain
vi.
vii.
Infertility
Obstetric complications
viii. Pregnancy related
a. Myoma growth
b. Red degeneration and pain
c. Spontaneous miscarriage
ix. Malignancy
x. Rare associations
a. Ascites
b. Polycythemia
c. Familial syndromes, renal cell carcinoma
xi. Benign metastasizing
Sabry M, Al-Hendy A Obstet Gynecol Int. 2012
Management:
•
•
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Medical (Combined oral contraceptive (COC) and progestins, Mirena® IUS , GnRH
analogs, selective estrogen receptor modulators (SERMs), selective progesterone
receptor modulators (SPRMs), ulipristal acetate, aromatase inhibitors …)
Minimally invasive techniques (Uterine artery embolization – UAE, Magnetic
resonance-guided focused ultrasound surgery – MRgFUS, …)
Surgical (Hysteroscopic myomectomy , Laparoscopic myomectomy, Abdominal
myomectomy, Hysterectomy)
The standard treatment for symptomatic uterine fibroids has always
been surgical, either hysterectomy or, in women who wish to preserve
their fertility, the more conservative procedure of myomectomy
Laparoscopic myomectomy, universally accepted indications:
• presence of a submucous or intramural fibroid
that distorts the uterine cavity
• fibroids greater than 3 cm
• multiple fibroids
maximal size must be 8-10 cm and the total number of fibroids should not exceed
four…
It is prudent not to perform laparoscopic myomectomies with more than five to
seven large myomas
Desai, Patel. J Gynecol Endosc Surg. 2011
Complications:
• Minor complications (9.1%)
• Major complications (2.02%)
-Hemorrhages (intra and postoperative reqiring blood transfusion)
-postoperative hematomas
-bowel injury (bladder and ureter injury)
-postoperative acute kidney failure
-unexpected sarcomas
-Failure to complete planned surgery (conversion to laparotomy – hysterectomy)
-spontaneous uterine rupture in pregnancy
-the probability of complications significantly rises with an increase in the number (more
than 3 myomas and with the intramural or the intraligamentous location of myomas
whereas the myoma size seems to influence particularly the risk of major complications
Sizzi et al. J Minim Invasive Gynecol. 2007
Late complications:
• risk of uterine rupture during pregnancy or labor (high rate of
cesarean sections in pregnant patients, who previously
underwent myomectomy,
cesarean section is recommended if more than 50% of the
myometrium has been disrupted)
• Adhesions
• Recurrence (higher compared to laparotomic myomectomy)
• Iatrogenic parasitic myoma?!
Large parasitic myoma arising after
laparoscopic
myomectomy: a case report
Magdalena Karadza*, Barisic Dubravko, Pavicic Baldani Dinka,
Skrgatic Lana
University Hospital Center, Zagreb, Croatia
• Parasitic myomas may occur spontaneously as pedunculated
subserosal myomas lose their uterine blood supply and
parasitize to other organs.
• More parasitic myomas may be iatrogenically created after
surgery, particularly surgery using morcellation techniques.
With increasing rates of laparoscopic procedures, surgeons
should be aware of the potential for iatrogenic parasitic
myoma formation, their likely increasing frequency, and
intraoperative precautions to minimize occurrence
Kho KA, Nezhat C. Parasitic myomas. Obstet Gynecol. 2009 Sep;114(3):611-5
• The incidence of iatrogenic parasitic myomas
associated with the laparoscopic use of
electric tissue morcellation is increasing.
• Morcellation remnants may implant and
grow around the peritoneal cavity
captivating blood supply from adjacent
structure.
•
Leren V, Langebrekke A, Qvigstad E. Parasitic leiomyomas after laparoscopic surgery with morcellation.
Acta Obstet Gynecol Scand. 2012 Oct;91(10):1233-6. (…three patients diagnosed in an eight year period,
representing an incidence of 0.12% after morcellation procedures in our department)
•
Cucinella G, Granese R, Calagna G, Somigliana E, Perino A. Parasitic myomas after laparoscopic surgery:
an emerging complication in the use of morcellator? Description of four cases. Fertil Steril. 2011
Aug;96(2):e90-6 (… four cases of parasitic myomas over the 3-year study period. Two out of the four were
symptomatic. The prevalence of this complication, considering all women with whom the electric
morcellator was used (n = 423) was 0.9%)
•
Takeda A, Mori M, Sakai K, Mitsui T, Nakamura H. Parasitic peritoneal leiomyomatosis diagnosed 6 years
after laparoscopic myomectomy with electric tissue morcellation: report of a case and review of the
literature. J Minim Invasive Gynecol. 2007 Nov-Dec;14(6):770-5.
•
Donnez O, Jadoul P, Squifflet J, Donnez J. Iatrogenic peritoneal adenomyoma after laparoscopic subtotal
hysterectomy and uterine morcellation. Fertil Steril. 2006 Nov;86(5):1511-2 (… Five years after
laparoscopic subtotal hysterectomy and morcellation)
•
Donnez O, Squifflet J, Leconte I, Jadoul P, Donnez J. Posthysterectomy pelvic adenomyotic masses
observed in 8 cases out of a series of 1405 laparoscopic subtotal hysterectomies. J Minim Invasive
Gynecol. 2007 Mar-Apr;14(2):156-60.
•
Bogusiewicz M, Rosińska-Bogusiewicz K, Walczyna B, Drop A, Rechberger T. Leiomyomatosis peritonealis
disseminata with formation of endometrial cysts within tumors arising after supracervical laparoscopic
hysterectomy. Ginekol Pol. 2013 Jan;84(1):68-71.
22nd ESGE Berlin:
• V 04.09 Torsion of a parasitic leiomyoma after laparoscopic
myomectomy:A case report. Yu Kawasaki (Japan)
• P91 Severe postlaparoscopic leiomuomatosis peritonealis disseminata –
a case report and review of the literature. Stefan Hauer
• P153 Parasitic myoma post supracervical laparoscopic hysterectomy: a
new age for iatrogeny caused by morcellation? Mauricio Paulo Angelo
Mieli
• P243 Laparoscopic management of parasitic fibroids – does this
contribute to pulmonary metastases? Ashleigh Simmonds
• P246 Parasytic myomas after laparoscopic supracervical hysterectomy: a
report of case. Zaki Sleiman
Symptoms:
•
•
•
•
no symptoms
suspect pelvic mass
abdominal pain and bloating
deep dyspareunia and pelvic pain
• A 40-year-old nulliparous women underwent
laparoscopic myomectomy with electric tissue
morcellation for subserous myoma with no
intraoperative or postoperative complications.
• Six years later she presented with large pelvic
mass and abdominal discomfort.
• On physical exam a firm mobile mass about 8 cm
in diameter was found in the left pelvis and just
above the uterus.
• Pelvic ultrasound demonstrated a cystic mass
(5x2x2.5cm) with ultrasound appearance similar
to observed in the case of endometriomas.
• Laparoscopy was preformed and a large
clustered vascularised mass firmly attached to
uterine fundus and rectum was found and
excised.
• Cross-section of the tumor revealed multiple
cystic cavities filled with altered blood.
• Hystologically tumor was composed of smooth
muscle cells and multiple cavities covered with
endometrial stroma and endometrial
epithelium.
• All tissue pieces that are morcellated should
be diligently removed and irrigated.
Implantation and regrowth of morcellated
remnants may result with formation of bizarre
appearing tumors.
• Therefore, a parasitic myoma must be
included in the differential diagnosis if a solid
tumor isfound succeeding the use of electric
tissue morcellation.
• Laparoscopic myomectomy performed by an
experienced surgeon is a safe technique, with
an extremely low failure rate and good results
in terms of the outcome of pregnancy