Name: introduction of intracapsular rotary-cut procedures (ircp): a modified hysteromyomectomy procedures facilitating fertility preservation
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Description: Watch this Scientific Journal Video about Introduction of Intracapsular Rotary-cut Procedures IRCP: A Modified Hysteromyomectomy Procedures Facilitating Fertility Preservation at JoVE.com

All the procedures in the following protocol were reviewed and approved by the Institutional Review Board of Peking University Shenzhen Hospital for application on patients on December, 15, 2012.
1. Patient Preparation
<ol>
	<li>Use the following inclusion criteria: abnormal uterine bleeding; fibroids compressing surrounding organs and causing urinary, digestive, or sexual symptoms; infertility; fibroid is larger than 4 cm while the patient is preparing for pregnancy.</li>
	<li>Use the follo...

<ol>
	<li>Drayer, S. M., Catherino, W. H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Prevalence,+morbidity,+and+current+medical+management+of+uterine+leiomyomas.">Prevalence, morbidity, and current medical management of uterine leiomyomas.</a> International Journal of Gynecology &amp; Obstetrics. 131 (2), 117-122 (2015).</li><li>Wu, J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Prevalence+and+clinical+significance+of+mediator+complex+subunit+12+mutations+in+362+Han+Chinese+samples+with+uterine+leiomyoma.">Prevalence and clinical significance of mediator complex subunit 12 mutations in 362 Han Chinese samples with uterine leiomyoma.</a> Oncology Letters. 14 (1), 47-54 (2017).</li><li>Falcone, T., Parker, W. H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Surgical+management+of+leiomyomas+for+fertility+or+uterine+preservation.">Surgical management of leiomyomas for fertility or uterine preservation.</a> Obstetrics &amp; Gynecology. 121 (4), 856-868 (2013).</li><li>Donnez, J., Dolmans, M. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Uterine+fibroid+management:+from+the+present+to+the+future.">Uterine fibroid management: from the present to the future.</a> Human Reproduction Update. 22 (6), 665-686 (2016).</li><li>Gu, Y., Zhu, L., Liu, A., Ma, J., Lang, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Analysis+of+hysterectomies+for+patients+with+uterine+leiomyomas+in+China+in+2010.">Analysis of hysterectomies for patients with uterine leiomyomas in China in 2010.</a> International Journal of Gynecology &amp; Obstetrics. 129 (1), 71-74 (2015).</li><li>Cheng, P. J., Duan, T. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=China's+new+two-child+policy:+maternity+care+in+the+new+multiparous+era.">China's new two-child policy: maternity care in the new multiparous era.</a> BJOG. 123, 7-9 (2016).</li><li>Tinelli, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+myomectomy+focusing+on+the+myoma+pseudocapsule:+technical+and+outcome+reports.">Laparoscopic myomectomy focusing on the myoma pseudocapsule: technical and outcome reports.</a> Human Reproduction. 27 (2), 427-435 (2012).</li><li>Agdi, M., Tulandi, T. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Minimally+invasive+approach+for+myomectomy.">Minimally invasive approach for myomectomy.</a> Seminars in Reproductive Medicine. 28 (3), 228-234 (2010).</li><li>Al-Talib, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Factors+contributing+to+failure+of+laparoscopic+myomectomy.">Factors contributing to failure of laparoscopic myomectomy.</a> Surgical Technology International. 23, 149-151 (2013).</li><li>Saccardi, C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Limits+and+complications+of+laparoscopic+myomectomy:+which+are+the+best+predictors?+A+large+cohort+single-center+experience.">Limits and complications of laparoscopic myomectomy: which are the best predictors? A large cohort single-center experience.</a> Archives of Gynecology and Obstetrics. 290 (5), 951-956 (2014).</li><li>Sizzi, O., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Italian+multicenter+study+on+complications+of+laparoscopic+myomectomy.">Italian multicenter study on complications of laparoscopic myomectomy.</a> Journal of Minimally Invasive Gynecology. 14 (4), 453-462 (2007).</li><li>Buckley, V. A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+myomectomy:+clinical+outcomes+and+comparative+evidence.">Laparoscopic myomectomy: clinical outcomes and comparative evidence.</a> Journal of Minimally Invasive Gynecology. 22 (1), 11-25 (2015).</li><li>Glaser, L. M., Friedman, J., Tsai, S., Chaudhari, A., Milad, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+myomectomy+and+morcellation:+A+review+of+techniques,+outcomes,+and+practice+guidelines.">Laparoscopic myomectomy and morcellation: A review of techniques, outcomes, and practice guidelines.</a> Best Practice &amp; Research: Clinical Obstetrics &amp; Gynaecology. 46, 99-112 (2018).</li><li>Kelly, B. A., Bright, P., Mackenzie, I. Z. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Does+the+surgical+approach+used+for+myomectomy+influence+the+morbidity+in+subsequent+pregnancy.">Does the surgical approach used for myomectomy influence the morbidity in subsequent pregnancy.</a> Journal of Obstetrics &amp; Gynaecology. 28 (1), 77-81 (2008).</li><li>Tian, Y. C., Long, T. F., Dai, Y. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Pregnancy+outcomes+following+different+surgical+approaches+of+myomectomy.">Pregnancy outcomes following different surgical approaches of myomectomy.</a> Journal of Obstetrics and Gynaecological Research. 41 (3), 350-357 (2015).</li><li>Zhong, S. L., Zeng, L. P., Li, H., Wu, R. F. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Development+and+evaluation+of+an+improved+laparoscopic+myomectomy+adopting+intracapsular+rotary-cut+procedures.">Development and evaluation of an improved laparoscopic myomectomy adopting intracapsular rotary-cut procedures.</a> European Journal of Obstetrics &amp; Gynecology and Reproductive Biology. 221, 5-11 (2018).</li><li>Vilos, G. A., Allaire, C., Laberge, P. Y., Leyland, N., Special, C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+management+of+uterine+leiomyomas.">The management of uterine leiomyomas.</a> Journal of Obstetrics and Gynaecology Canada. 37 (2), 157-178 (2015).</li><li>Lethaby, A., Vollenhoven, B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Fibroids+(uterine+myomatosis,+leiomyomas).">Fibroids (uterine myomatosis, leiomyomas).</a> BMJ Clinical Evidence. , (2011).</li><li>Liu, F., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+epidemiological+profile+of+hysterectomy+in+rural+Chinese+women:+a+population-based+study.">The epidemiological profile of hysterectomy in rural Chinese women: a population-based study.</a> BMJ Open. 7 (6), e015351 (2017).</li><li>Bhave Chittawar, P., Franik, S., Pouwer, A. W., Farquhar, C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Minimally+invasive+surgical+techniques+versus+open+myomectomy+for+uterine+fibroids.">Minimally invasive surgical techniques versus open myomectomy for uterine fibroids.</a> Cochrane Database of Systematic Reviews. (10), CD004638 (2014).</li><li>Tinelli, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Angiogenesis+and+Vascularization+of+Uterine+Leiomyoma:+Clinical+Value+of+Pseudocapsule+Containing+Peptides+and+Neurotransmitters.">Angiogenesis and Vascularization of Uterine Leiomyoma: Clinical Value of Pseudocapsule Containing Peptides and Neurotransmitters.</a> Current Protein and Peptide Science. 18 (2), 129-139 (2017).</li><li>Tinelli, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Surgical+management+of+neurovascular+bundle+in+uterine+fibroid+pseudocapsule.">Surgical management of neurovascular bundle in uterine fibroid pseudocapsule.</a> Journal of the Society of Laparoendscopic Surgeons. 16 (1), 119-129 (2012).</li><li>Fagherazzi, S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Pregnancy+outcome+after+laparoscopic+myomectomy.">Pregnancy outcome after laparoscopic myomectomy.</a> Clinical and Experimental Obstetrics and Gynecology. 41 (4), 375-379 (2014).</li><li>Liu, Y., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+descriptive+analysis+of+the+indications+for+caesarean+section+in+mainland+China.">A descriptive analysis of the indications for caesarean section in mainland China.</a> BMC Pregnancy Childbirth. 14, 410 (2014).</li><li>Weibel, H. 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Uterine fibroids are the most common benign tumors of the female reproductive system, affecting 20&#8211;25% of all women1 and causing abnormal uterine bleeding, recurrent miscarriage, pelvic pain, premature birth, and infertility in 10&#8211;30% cases2. As most patients with uterine fibroids are asymptomatic, the actual incidence may be higher than recognized1. Management of uterine fibroids are generally based on various factors including the age a...

Uterine fibroids are the most common pelvic tumors observed in gynecologic practice. The incidence is estimated to be about 20&#8211;25% worldwide1. Most uterine fibroids are asymptomatic but sometimes cause abnormal uterine bleeding, pelvic pressure, pelvic pain, and adverse reproductive outcomes, thus diminishing the quality of life of women2,3. Management of fibroids depends on individual situations and includes options such as surgery, medication, and revisit observation4. A hysterectomy is an important method to treat uterine fibroids and is a radical surgery that can prevent recurrence3,5. Myomectomy, however, is becoming popular as doctors are paying more attention to the fertility preservation of patients at reproductive ages, especially during the era of the two-child policy in China6.
As Tinelli and his colleagues have described, in the procedure of laparoscopic myomectomy (LM)7, the visceral peritoneum is incised in the midline longitudinally by monopolar scissors or a crochet needle electrode, proceeding at a certain depth into the myometrium to identify the pseudo-capsule. The pseudo-capsule is opened longitudinally by monopolar scissors or a hook electrode at a low wattage (30 W) to expose the fibroid. Then, the fibroid is hooked by a myoma screw for gentle enucleation with help from an irrigator cannula that is inserted in the space between the pseudo-capsule and fibroid. Hemostasis of the small vessels is made to free the base of the myoma and connective bridges from the pseudo-capsule. The myometrium is then closed in a single layer for subserous fibroids and as double layers for intramural fibroids.
Although LM is widely applied around the world, there are still some limitations of this procedure. Since LM is more technically demanding than laparotomy, it should be applied to selected cases with relatively smaller sizes and numbers of fibroids8,9. It remains a great challenge to remove intramural fibroids greater than 8 cm or subserous ones greater than 12 cm with laparoscopy10. Published data have shown that transfusion-requiring bleeding and postoperative hematomas significantly increased when applying LM to removal of intra-broad ligamentous fibroids11. Other researchers believe that excessive bleeding, prolonged operation time, and potential dissemination of cells when applying morcellation are concerning problems with LM12,13. The risk of during-pregnancy uterine rupture after LM is reported to be higher than abdominal myomectomy due to the technical difficulties of suturing14. The safety of pregnancy succeeding LM remains controversial15. As postoperative healing of the myometrium is very important for patients who need to maintain fertility either clinically or by request, LM procedures need to be more applicable, which can be accomplished by reducing the technical difficulties and promoting uterine healing after the surgery.
In order to minimize the damage to the patient&#39;s fertility, here we present a modified myomectomy procedure, the intracapsular rotary-cut procedure (IRCP)16. This procedure shortens the incision on uterine wall as much as possible and reduces the technical difficulties of LM. Also, it helps to protect fibers and blood vessels of the pseudo-capsule that plays an important role in uterine healing after myomectomy, ultimately reducing the risk of postoperative hematoma and uterine rupture in subsequent pregnancy. After being reviewed and approved by the Institutional Review Board of Peking University Shenzhen Hospital on December 15, 2012, we began the application of IRCP and evaluation of the outcomes of IRCP by comparison with traditional LM.

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			<td height="42" style="height:42px;width:231px;">laparoscopy</td>
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			<td height="42" style="height:42px;width:231px;">morcellator</td>
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			<td height="42" style="height:42px;width:231px;">30-cm 1-0 polyglyconate unidirectional barbed thread</td>
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introduction of intracapsular rotary-cut procedures (ircp): a modified hysteromyomectomy procedures facilitating fertility preservation

Uterine fibroids are common benign tumors in the female reproductive system. A hysterectomy is the most effective treatment for symptomatic fibroids. For patients desiring pregnancy, laparoscopic intracapsular myomectomy (LM) is an alternative surgery option. Although LM is widely accepted to treat fibroids, it is technically demanding with risk of excessive bleeding and difficult suturing, especially in cases with large fibroids or tumors in unusual locations. Therefore, we developed an intracapsular rotary-cut procedure (IRCP) as a modification of laparoscopic intracapsular myomectomy, with the intention to minimize risks of LM and help uterine healing. A summary of the improvements to the IRCP is described: 1) making an incision at the site of the fibroid with a length of one-third to one-half of the fibroid&#39;s diameter at a depth reaching the fibroid&#39;s surface; 2) holding the fibroid stably and making rotary cuts on the fibroid at a depth of 0.5&#8211;1 cm within its pseudo-capsule while pulling it outward slightly, making sure not to cut off any pieces of the fibroid; and 3) repeating the cutting-and-pulling until the longest dimension of the fibroid is outside the incision. The multiple cuts are to minimize the diameter and extend the length of the fibroid. When the multiple cuts cause half of the fibroid body to &#34;shrink&#34;, the fibroid is squeezed out by contraction of the surrounding myometrium. Evaluation of the outcomes of IRCP showed that the time of enucleation and suturing, intraoperative bleeding, and decline of hemoglobin were significantly lower in the IRCP group than the LM group. As for reproductive outcomes, the full-term live birth rate of the IRCP group was significantly higher than that of LM group. However, there was no difference in delivery modes between the two groups. In conclusion, IRCP significantly benefits fertility preservation by minimizing damage to the uterus, protecting myofibers of the pseudo-capsule, and resulting in a shallower residual cavity, which eases stitching and causes less bleeding. It is worthwhile to adopt IRCP in younger patients who desire preservation of their fertility.

IRCP was performed on 41 patients with uterine fibroids and traditional LM was performed on 72 patients from 2013 to 2016. 9 cases (12.5%) in the LM group were converted to laparotomy because of massive bleeding, difficulty in enucleation, or suturing, while laparoscopy was performed successfully in all cases in the IRCP group. The percentage of conversion to laparotomy was significantly higher in the LM group (p = 0.025). Excluding the 9 cases converted to laparotomy, the average age of ...

Watch this Scientific Journal Video about Introduction of Intracapsular Rotary-cut Procedures IRCP: A Modified Hysteromyomectomy Procedures Facilitating Fertility Preservation at JoVE.com

Introduction of Intracapsular Rotary-cut Procedures IRCP: A Modified Hysteromyomectomy Procedures Facilitating Fertility Preservation

Here, we present a protocol for performing an intracapsular rotary-cut procedure (IRCP), a modified laparoscopic intracapsular myomectomy that promotes fertility preservation.

Introduction of Intracapsular Rotary-cut Procedures (IRCP): A Modified Hysteromyomectomy Procedures Facilitating Fertility Preservation

Uterine fibroids are common benign tumors in the female reproductive system. A hysterectomy is the most effective treatment for symptomatic fibroids. For ...

This procedure was developed to protect patient fertility by preventing the possibility of uterine rupture in post-myomectomy pregnancies induced by large, barely closed, residual cavities and pulling healed myometrium. The key advantage of this procedure is that it minimizes the surgical injury to the myometrium on the outside of pseudo-capsular, and the vascular tissue inside of the pseudo-capsule. This intracapsular rotary-cut procedure requires patients and care for needs, especially of the beginning of the procedure and during the application of the electrical monopolar knife.Before beginning the procedure, use standard techniques to establish a 10 millimeter umbilical port and two five millimeter ports, and one 10 millimeter ancillary port in the lower and middle abdomen in the anesthetized patient. When all of the ports have been placed, carefully inspect the pelvis to confirm the size, number and location of the fibroids and use a 10 millimeter syringe to inject an ischemic solution into the myometrium around the fibroids. Determine the incision position on the most protruding side of the fibroid and use a monopolar hook electrode at 30 watts to make a longitudinal incision, taking care the length is no longer than half of the fibroid diameter.After exposing the fibroid surface, use laparoscopic forceps to pull the fibroid outward to expose the boundary between the fibroid and pseudo-capsule. Use a monopolar electrical knife to make the first cut on the exposed part of the fibroid, then hold the edge of the first cut with the forceps to pull the fibroid outward. Next, make multiple long rotary cuts on all sides of the fibroid that have been isolated from the capsule, at different levels of the fibroid, partially overlapping with the prior cuts to shirt the diameter of the tumor.While the cuts are being made, switch the forceps from the previous cut to the next cut, to keep pulling the tissue outward to facilitate further exposure of the gap between the fibroid and pseudo-capsule. Use vacuum drainage to remove the smoke to maintain a clear viewing field as necessary. When more than half of the fibroid is outside of the incision, the pseudo-capsule in the myometrium will contract, squeezing the fibroid out of the cavity.The pseudo-capsule should slip to the base of the fibroid. Continue making the incisions until the base of the fibroid is exposed and can be isolated from its pseudo-capsule. Then use electrocautery forceps to coagulate and cut off the blood vessels, to completely remove the fibroid, leaving only a shallow residual cavity.Starting at five millimeters outside of the incisal edge, close the empty fibroid cavity in a single layer with a running 30 centimeter 1-O polyglyconate, unidirectional barbed suture, in one centimeter increments, taking care that the stitching passes through the bottom of the residual cavity. Then enlarge the 10 millimeter port to 15 to 20 millimeters, and morcellate the fibroid with a reusable morcellator. There is only a little bleeding in the whole procedure.In this clinical study, after excluding the nine laparoscopic myomectomy cases that were converted to laparotomy, the average age of patients in the two groups was statistically similar, as were the mean diameters of the fibroids. However, the time of enucleation and suturing, intraoperative bleeding, and decline of hemoglobin were all significantly lower in the intracapsular rotary-cut procedure group than in the laparoscopic myomectomy group. The intracapsular rotary-cut procedure significantly minimizes the damage to the uterus, protects the myofibers of pseudo-capsule, and leaves a shallower residual cavity for easier stitching and healing of the myometrium.Our outreach have to preserve to preserve patient fertility.

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