Incidence and risk factors of parasitic myoma after laparoscopic myomectomy using uncontained power morcellation: Retrospective analysis of 87 patients who had a subsequent second laparoscopic surgery.

Murakami K ，Kitade M ，Kumakiri J ，Takeuchi S ，Kawasaki Y ，Ochiai A ，Yanagihara Y ，Itakura A ... -  《-》

In-bag manual versus uncontained power morcellation for laparoscopic myomectomy.

Uterine leiomyomas, also referred to as myomas or fibroids, are benign tumours arising from the smooth muscle cells of the myometrium. They are the most common pelvic tumour in women. The estimated rate of leiomyosarcoma, found during surgery for presumed benign leiomyomas, is about 0.51 per 1000 procedures, or approximately 1 in 2000. Treatment options for symptomatic uterine leiomyomas include medical, surgical, and radiologically-guided interventions. Laparoscopic myomectomy is the gold standard surgical approach for women who want offspring, or otherwise wish to retain their uterus. A limitation of laparoscopy is the inability to remove large specimens from the abdominal cavity through the laparoscope. To overcome this challenge, the morcellation approach was developed, during which larger specimens are broken into smaller pieces in order to remove them from the abdominal cavity via the port site. However, intracorporeal power morcellation may lead to scattering of benign tissues, with the risk of spreading leiomyoma or endometriosis. In cases of unsuspected malignancy, power morcellation can cause unintentional dissemination of malignant cells, and lead to a poorer prognosis by upstaging the occult cancer. A strategy to optimise women's safety is to morcellate the specimens inside a bag. In-bag morcellation may avoid the dissemination of tissue fragments. To evaluate the effectiveness and safety of protected in-bag extracorporeal manual morcellation during laparoscopic myomectomy compared to intra-abdominal uncontained power morcellation. On 1 July 2019, we searched; the Cochrane Gynaecology and Fertility Group Specialized Register of Controlled Trials, CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL, LILACS, PubMed, Google Scholar, and two trials registers. We reviewed the reference lists of all retrieved full-text articles, and contacted experts in the field for additional and ongoing trials. We included all randomised controlled trials comparing in-bag extracorporeal manual morcellation versus intracorporeal uncontained power morcellation during laparoscopic myomectomy in premenopausal women. We followed standard Cochrane methods. Two review authors independently reviewed the eligibility of trials, extracted data, and evaluated the risk of bias. Data were checked for accuracy. The summary measures were reported as risk ratios (RR) or mean differences (MD) with 95% confidence interval (CI). The outcomes of interest were a composite of intraoperative and postoperative complications, operative times, ease of morcellation, length of hospital stay, postoperative pain, conversion to laparotomy, and postoperative diagnosis of leiomyosarcoma. Results for the five main outcomes follow. We included two trials, enrolling 176 premenopausal women with fibroids, who underwent laparoscopic myomectomy. The experimental group received in-bag manual morcellation, during which each enucleated myoma was placed into a specimen retrieval bag, and manually morcellated with scalpel or scissors. In the control group, intracorporeal uncontained power morcellation was used to reduce the size of the myomas. No intraoperative complications, including accidental morcellation of the liver, conversion to laparotomy, endoscopic bag disruption, bowel injury, bleeding, accidental injury to any viscus or vessel, were reported in either group in either trial. We found very low-quality evidence of inconclusive results for total operative time (MD 9.93 minutes, 95% CI -1.35 to 21.20; 2 studies, 176 participants; I² = 35%), and ease of morcellation (MD -0.73 points, 95% CI -1.64 to 0.18; 1 study, 104 participants). The morcellation operative time was a little longer for the in-bag manual morcellation group, however the quality of the evidence was very low (MD 2.59 minutes, 95% CI 0.45 to 4.72; 2 studies, 176 participants; I² = 0%). There were no postoperative diagnoses of leiomyosarcoma made in either group in either trial. We are very uncertain of any of these results. We downgraded the quality of the evidence due to indirectness and imprecision, because of limited sites in high-income settings and countries, small sample sizes, wide confidence intervals, and few events. There are limited data on the effectiveness and safety of in-bag morcellation at the time of laparoscopic myomectomy compared to uncontained power morcellation. We were unable to determine the effects of in-bag morcellation on intraoperative complications as no events were reported in either group. We are uncertain if in-bag morcellation improves total operative time or ease of morcellation compared to control. Regarding morcellation operative time, the quality of the evidence was also very low and we cannot be certain of the effect of in-bag morcellation compared to uncontained morcellation. No cases of postoperative diagnosis of leiomyosarcoma occurred in either group. We found only two trials comparing in-bag extracorporeal manual morcellation to intracorporeal uncontained power morcellation at the time of laparoscopic myomectomy. Both trials had morcellation operative time as primary outcome and were not powered for uncommon outcomes such as intraoperative complications, and postoperative diagnosis of leiomyosarcoma. Large, well-planned and executed trials are needed.

Zullo F ，Venturella R ，Raffone A ，Saccone G ... -  《-》

Parasitic myoma after laparoscopic morcellation: a systematic review of the literature.

Laparoscopic morcellation is frequently used for tissue removal after laparoscopic hysterectomy or myomectomy and may result in parasitic myomas, due to seeding of remained tissue fragments in the abdominal cavity. However, little is known about the incidence and risk factors of this phenomenon. To identify the incidence and risk factors for the development of parasitic myoma after laparoscopic morcellation. A systematic review of the literature in Pubmed (MEDLINE) and Embase was conducted. Reference lists of identified relevant articles were checked for missing case reports. Studies reporting on incidence or cases of parasitic myoma diagnosed after laparoscopic morcellation were selected. Studies were excluded when history of laparoscopic morcellation was lacking or final pathology demonstrated a malignancy or endometriosis. Data were extracted and analysed on incidence of parasitic myomas and characteristics of case reports. Fourty-four studies were included. Sixty-nine women diagnosed with parasitic myomas after laparoscopic morcellation were identified. Mean age was 40.8 (± 7.5) years (range 24-57), median time between surgery and diagnosis was 48.0 months (range 1-192) and mean number of parasitic myomas was 2.9 (± 3.3) (range 1-16). The overall incidence of parasitic myomas after laparoscopic morcellation was 0.12-0.95%. Although the incidence is relatively low, it is important to discuss the risk of parasitic myoma after laparoscopic morcellation with women and balance towards alternative treatment options. The duration of steroid exposure after laparoscopic morcellation might be a risk factor for development of parasitic myomas. Systematic review on the incidence and risk factors for parasitic myoma after laparoscopic morcellation.

Van der Meulen JF ，Pijnenborg JM ，Boomsma CM ，Verberg MF ，Geomini PM ，Bongers MY ... -  《-》

In-Bag Manual Extraction of Excised Myomas by Surgical Scalpel through Suprapubic Mini-Laparotomic Incision in Laparoscopic-Assisted Myomectomy.

To evaluate the safety and feasibility of in-bag manual extraction for the retrieval of excised myomas through a suprapubic mini-laparotomic incision in 2-port laparoscopic-assisted myomectomy. Retrospective comparative study (Canadian Task Force classification II-2). Departments of obstetrics and gynecology and diagnostic pathology at a general hospital. Twenty-six patients undergoing open manual extraction and 26 patients undergoing in-bag manual extraction by surgical scalpel for the retrieval of excised myomas through a suprapubic mini-laparotomic incision in 2-port laparoscopic-assisted myomectomy. In patients with open manual extraction, myoma tissues were directly morcellated in an uncontained setting, whereas in patients managed by in-bag manual extraction, enucleated myomas were put into a retriever bag and then were morcellated by a surgical scalpel while monitoring bag damage by the leakage of indigo carmine dye filled in a bag. The patient demographics and surgical outcome measures were compared between the 2 groups. In the initial 15 patients with in-bag manual extraction, the macroscopic myoma fragments retained in the bag were collected and removed after completion of myoma extraction. Then, the bag contents were washed with normal saline and spilled microscopic tissues salvaged by centrifugation. A histologic examination was performed for collected tissue materials to identify the microscopic myoma fragments. In patient demographics and surgical outcomes, which include excised tissue weight, surgical duration, and estimated intraoperative blood loss, no significant differences could be identified between the 2 groups. Bag rupture as monitored by the leakage of indigo carmine dye in vivo and ex vivo was not observed. In all patients managed by in-bag manual extraction, spilled macroscopic myoma fragments were identified in the bag. Furthermore, histologic examinations of collected bag contents detected microscopic myoma tissues in 53.3% of patients. These results suggest that without closed conditions, these microscopic myoma particles, which could be difficult to completely remove even by rigorous washing of the peritoneal cavity under laparoscopic vision, might be dispersed in the peritoneal cavity and potentially form iatrogenic peritoneal parasitic myomas if they survive and grow. In-bag manual extraction of myoma tissues through a suprapubic mini-laparotomic incision by a surgical scalpel is a feasible alternative to prevent the dispersion of microscopic myoma fragments and to avoid the potential risk of spreading occult malignancy in 2-port laparoscopic-assisted myomectomy.

Takeda A ，Watanabe K ，Hayashi S ，Imoto S ，Nakamura H ... -  《-》

Multimodal imaging for diagnosis and management of parasitic peritoneal myoma with myxoid degeneration after laparoscopic-assisted myomectomy with electric power morcellation.

A 45-year-old multipara woman was referred due to the rapid enlargement of an asymptomatic pelvic mass that was detected during a regular check up. She had undergone laparoscopic-assisted myomectomy 15 years previously. At the time, the uncontained extraction of an intraligamental myoma with electric power morcellation had been performed. Multimodal imaging revealed a heterogeneous mass in the vesicouterine pouch that was found to be supplied by the left gastro-omental and superior vesical arteries. Although malignancy could not be completely denied, parasitic peritoneal myoma with myxoid degeneration was the most probable diagnosis. Single-port laparoscopic excision of the peritoneal mass was performed along with laparoscopic-assisted vaginal hysterectomy and bilateral salpingo-oophorectomy. The excised peritoneal mass was placed into a retrieval bag and extracted through the vagina. The pathological diagnosis was a parasitic peritoneal myoma with myxoid degeneration. The postoperative course was uneventful, and there was no recurrence of parasitic myoma in the 1-year follow up after surgery.

Takeda A ，Koike W ，Watanabe K 《-》