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

Podsumowanie

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

Streszczenie

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's diameter at a depth reaching the fibroid's surface; 2) holding the fibroid stably and making rotary cuts on the fibroid at a depth of 0.5–1 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 "shrink", 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.

Wprowadzenie

Uterine fibroids are the most common pelvic tumors observed in gynecologic practice. The incidence is estimated to be about 20–25% 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 women^2,3. 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 recurrence^3,5. 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 fibroids^8,9. 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 LM^12,13. 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'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.

Protokół

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

1. 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.
2. Use the following exclusion criteria: suspected malignancy; suspected fibroid degeneration; pedunculated, cervical, or intra-broad ligamentous fibroids; preoperative use of gonadotrophin-releasing hormone analogues; acute systemic inflammation or pelvic inflammatory disease; patient is currently pregnant, within puerperium, or within three months after abortion; severe coagulation disorders; any other contraindications for general anesthesia or laparoscopy.
3. Conduct a pelvic palpation and ultrasound examination to determine the location, number, and size of the fibroids.
4. Inform the patient of the benefits and risks of surgery and obtain written consent, discussing the risks of excessive bleeding and blood transfusion, conversion to laparotomy, tumor cell dissemination during the operation, and postoperative infection.
5. Perform the surgery under general anesthesia with endotracheal intubation. Administer to each patient a prophylactic antibiotic dosage of 2 g of cefamandole intravenously 30 min before induction of anesthesia.

2. Pre-IRCP Preparation

1. After standard skin sterilization, establish the ports by standard techniques: a 10 mm umbilical port, and 5 mm and 10 mm ancillary ports in the lower abdomen. Connect the 5 mm port with a plastic tube for vacuum drainage, which can suck the smoke during surgery.
2. During the surgery, have an anesthesiologist carefully monitor vital signs of the patient.
3. Maintain the intraabdominal pressure and gas flow rate at 13 kPa and 12 L/min, respectively.

3. Intracapsular Rotary-cut Procedure (IRCP)

1. Inspect the pelvis carefully to confirm the size, number, and location of the fibroids. Inject an ischemic solution (6 U pituitrin and 20 U oxytocin diluted in 10 mL of saline) into the myometrium around the fibroids with a 10 mL syringe.
2. Determine the incision position on the most-protruding site of the fibroid and incise longitudinally by a monopolar hook electrode at low wattage (30 W), ensuring the length is no longer than half of the fibroid diameter. Open the pseudo-capsule by a longitudinal cut to expose the fibroid surface (Figure 1A).
3. Hold the fibroid with the laparoscopic forceps and pull it outward, keeping a certain tension to expose the boundary between the fibroid and the pseudo-capsule (Figure 1B).
4. Perform multiple rotary cuts on the fibroid (Figure 1C1) with a monopolar electrical knife in depths of 5–10 mm, shrinking the diameter of the tumor (Figure 1C2) and ensuring not to cut any pieces of the fibroid off.
   1. Meanwhile, keep pulling outward to facilitate further exposure of the gap between the fibroid and the pseudo-capsule. Remove the smoke by vacuum drainage to keep a clear field.
5. Repeat the cutting-pulling procedures on the fibroid in the manner described above with 10 mm intervals, ensuring that each cut is at a certain distance with the prior cut, until the longest dimension of the fibroid is outside the incision. Then, the fibroid will be squeezed out by contraction of the pseudo-capsule and myometrium (Figure 1D). Avoid pulling too hard and blunt dissection to protect fibers and vessels of the pseudo-capsule.
6. Gently pull the fibroid outward, and the pseudo-capsule should slip off to the base of the fibroid. Continue the cuts on the fibroid until the base of the fibroid is exposed and isolate it from its pseudo-capsule (Figure 1E). Use bipolar electrocautery forceps to coagulate and cut off the blood vessels, always at 30 W. After removal of the fibroid, only a shallow residual cavity is left (Figure 1F).
7. Close the residual cavity in a single layer with a 30 cm 1-0 polyglyconate unidirectional barbed thread. Begin the running suture at 5 mm outside of the incisal edge with 1 cm increments. Make sure that the stitching passes through the bottom of the residual cavity, and leave no dead space.
   NOTE: Generally, a single-layer suture is enough to close the residual cavity (Figures 1G and 1H). Occasionally, the fibroid was over 12 cm in diameter and occupied more than 2/3 of the myometrium. In these cases, a "folding suture" can be adopted, in which the myometrium on one side of the incision can be sutured on top of the other side to close the residual cavity and strengthen the myometrium.
8. After suturing, enlarge the 10 mm port to a 15–20 mm port for the introduction of the morcellator. Morcellate the fibroids with a reusable morcellator.

4. Postoperative Management

1. Document the intra- and post-operative parameters carefully, including the diameters of the fibroids (represented by the diameter of the largest one in cases of multiple fibroids), operation time (from the beginning of incision to the end of suturing), blood loss (calculated by vacuum drainage), and rate of conversion to laparotomy.
2. Follow up patients by pelvic examination and ultrasound as well as phone interviews.
3. Evaluate the outcomes of IRCP by comparison with those of traditional LM around the same period. Perform statistical analysis by SPSS software and consider p < 0.05 as statistically significant.

Wyniki

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 ...

Dyskusje

Uterine fibroids are the most common benign tumors of the female reproductive system, affecting 20–25% of all women¹ and causing abnormal uterine bleeding, recurrent miscarriage, pelvic pain, premature birth, and infertility in 10–30% 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...

Materiały

Name	Company	Catalog Number	Comments
laparoscopy	Stryker Corporation	X 800
morcellator	Kangji Medical	KJ-301A
30 cm 1-0 polyglyconate unidirectional barbed thread	Covidien	V-Loc 180