Intramyometrial vasopressin as a haemostatic agent during myomectomy. Use of a single preoperative dose of misoprostol is efficacious for patients who undergo abdominal myomectomy. Oxytocin during myomectomy: a randomized study. Oxytocin infusion in laparoscopic myomectomy may decrease operative blood loss. Reducing blood loss at open myomectomy using triple tourniquets: a randomised controlled trial. Bupivacaine plus epinephrine for laparoscopic myomectomy: a randomized placebo-controlled trial. Chemically assisted dissection of tissues: an interesting support in abdominal myomectomy. Intravenous tranexamic acid use in myomectomy: a prospective randomized double-blind placebo controlled study. Laparoscopic myomectomy: enucleation of the myoma by morcellation while it is attached to the uterus. The use of torniquet to reduce blood loss at myomectomy. Reducing blood loss at myomectomy with use of a gelatin-thrombin matrix hemostatic sealant.
To assess the efficacy of intramyometrial vasopressin for minimising bleeding and its sequelae at myomectomy.
                A randomised placebo controlled trial.
                University Hospital of the West Indies, Kingston, Jamaica.
                Twenty women with symptomatic uterine fibroids scheduled for myomectomy who satisfied entry criteria: 10 randomised to the vasopressin group and 10 to the control group.
                Myomectomy was performed after the intramyometrial injection of either 20 units vasopressin diluted to 20 ml in normal saline or placebo (20 ml normal saline).
                The efficacy of vasopressin was measured by comparing pre- and post-operative haemoglobin levels and haematocrit, changes in intra-operative pulse and blood pressure, measured blood loss, need for blood transfusion and post-operative febrile morbidity in the treatment and control groups.
                The use of vasopressin resulted in median blood loss of 225 ml (range 150-400 ml) compared with 675 ml (range 500-800 ml) in the placebo group (P < 0.001). The vasopressin group had a correspondingly lower fall in haemoglobin level (median 1.7 g/dl vs 5.3 g/dl, P < 0.001) and haematocrit (median 5% vs 13%, P < 0.001) compared with the controls. Fifty percent of the placebo group had blood transfusions compared with none in the vasopressin group (P = 0.03). There were no significant differences between the groups in intra-operative pulse and blood pressure or post-operative white blood cell counts or temperature.
                The results indicate that vasopressin is effective in preventing blood loss and reducing the need for blood transfusion during myomectomy. To investigate the effectiveness of a single preoperative dose of misoprostol in abdominal myomectomies.
                Placebo-controlled randomized prospective study.
                Department of obstetrics and gynecology in a university hospital.
                Twenty-five women with symptomatic uterine leiomyomas.
                Among patients undergoing abdominal myomectomies, an hour before the operation women in the study group (n = 13) were given a single dose of vaginal misoprostol (400 microg); those in the control group (n = 12) were given placebo.
                Intraoperative blood loss, duration of operation, duration of postoperative hospitalization, and the need for blood transfusion were compared between the control and study groups.
                Blood loss, operation time, and need for postoperative blood transfusion were significantly reduced in the group given vaginal misoprostol. No difference was observed among patients in terms of the time of hospitalization.
                A single preoperative dose of vaginal misoprostol is a simple, reliable method for reducing intraoperative blood loss and need for postoperative blood transfusion after abdominal myomectomies. To evaluate the influence of oxytocin on peroperative blood loss during myomectomy.
                From October 1998 to May 2002, 94 patients requiring surgical myomectomy by laparotomy or by the vaginal approach were enrolled in a randomized double blind study. Patients were randomized to two groups. In the first group (47 patients) oxytocin was administered during myomectomy and in the second group (47 patients) a placebo was used. The main outcome measures were peroperative blood loss and rates of blood transfusion and autotransfusion.
                Peroperative blood loss was no different between the oxytocin group and the placebo group (508 +/- 558 ml versus 451 +/- 336 ml; P=0.55). Rates of autotransfusion and blood transfusion were also similar in both groups.
                Administration of oxytocin during myomectomy did not reduce peroperative blood loss in our study. The benefits of using oxytocin to prevent hemorrhage during myomectomy seem to be limited. To evaluate the influence of oxytocin on operative blood loss during laparoscopic myomectomy (LM).
                Prospective clinical study (Canadian Task Force classification I).
                Tertiary care university hospital.
                Sixty women scheduled for myomectomy because of symptomatic uterine myomas.
                Two ampules of oxytocin (10 u/mL/amp) were added to 1000 mL of saline solution running at the rate of 40 mU/min during the course of LM.
                Blood loss and blood transfusion rate were significantly greater in the group without oxytocin infusion (group B) than in the group with oxytocin infusion (group A), with 445.0 +/- 268.6 mL (95% CI 344.7-545.3) versus 269.5 +/- 225.8 mL (95% CI 185.2-353.8)/(p <.05), and 36.7% versus 6.7% (p <.05), respectively. There was no significant difference in average age, body weight, or numbers of vaginal delivery and cesarean sections between the 2 groups. There was no significant difference in mean total myoma weight, main myoma size, postoperative stay, and complications between the 2 groups.
                Oxytocin infusion combined with skillful surgical techniques may decrease operative blood loss and blood transfusion during LM. To evaluate triple tourniquets in controlled conditions and for the first time to investigate the hypothesis that leaving a semi-permanent tourniquet around the uterine artery reduces post-operative bleeding from the uterine incisions.
                A randomised controlled trial.
                Two University teaching hospitals.
                Twenty-eight patients with symptomatic fibroids and uterine sizes ranging from 14 to 24 weeks of gestation undergoing open myomectomy.
                A number 1 polyglactin suture was tied around the cervix to occlude the uterine arteries, and polythene tourniquets were tied around the infundibulopelvic ligament to obstruct the ovarian vessels. At the end of the procedure, the ovarian ties were released but the uterine artery suture remained in situ.
                Intra-operative blood loss, post-operative blood loss, blood transfusion rates, operative morbidity, uterine blood flow and ovarian function.
                There was significantly less blood lost in the tourniquet group than in the control group (difference between means 1870 mL, 95% CI 1159-2580 mL, P < 0.0001; transfusion rates of 7% and 79%, P= 0.0003). The volume in the pelvic drain 20 min post-operatively and after 48 hours failed to reach statistical significance between the two groups (P= 0.10 and P= 0.165). There were no differences in uterine artery Doppler resistance indices at five days (P= 0.54), six weeks (P= 0.47), three months (P= 0.49) and at six months (P= 0.18). Day two serum FSH concentrations after surgery were unchanged (P= 0.45), compared with baseline values.
                Triple tourniquets are effective in reducing bleeding and transfusion rates. There appears no obvious adverse effect on uterine perfusion or ovarian function. To evaluate the effectiveness of the injection of bupivacaine plus epinephrine before laparoscopic myomectomy.
                Sixty premenopausal women with uterine leiomyomata were enrolled in a randomized controlled design and intraoperatively treated with injection of bupivacaine plus epinephrine (group A) or saline solution (group B) during laparoscopic myomectomy. Uterine size and volume, number of leiomyomata, hematological parameters, total operative time, enucleation time of each myoma, suturing time of the myomectomy, blood loss, degree of surgical difficulty, and postoperative pain were evaluated. Just before and after the injection of vasoconstrictive or saline solution, systolic and diastolic blood pressure and heart rate were recorded in each subject.
                Blood loss, total operative and enucleation time, and degree of surgical difficulty was significantly (P <.05) lower in group A than in group B. No difference was observed between groups in suturing time of the myomectomy. The number of vials of pain medication used postoperatively was significantly (P <.05) lower in group A than in group B. No differences in systolic and diastolic blood pressure or heart rate was recorded between the 2 groups.
                The injection of bupivacaine plus epinephrine during laparoscopic myomectomy is effective in reducing blood loss, total operative and enucleation time, degree of surgical difficulty, and postoperative pain. The aim of this study was to verify the efficacy of sodium-2-mercaptoethanesulfonate (mesna) in the chemical separation of tissues in abdominal myomectomies when used with the traditional mechanical separation techniques.
                In a prospective, randomized study, 58 women underwent abdominal myomectomy. In 29 of these, we used mesna for highlighting and separating tissues, and in the other 29 we used saline solution for the same purposes. The variables evaluated included the number of myomas removed, the volume of the biggest myoma, and the total volume of the myomas removed in every intervention. We also recorded operating time, the length of hospital stay, the degree of procedure difficulty, perioperative blood loss, operative complications, and cost.
                The operation was significantly shorter in the mesna group (p < 0.05) even though the volume and the number of myomas were larger. The degree of difficulty evaluated by the surgeon at the end of every operation was not significantly different in the two groups. The reduction in hemoglobin 24 hours after operation was significantly less in the patients treated with mesna (p = 0.006), but this difference was probably altered by the increase in hematocrit levels.
                Because of its ability as a chemical dissector, mesna may be a useful aid in this type of benign gynecologic operation. Larger studies to confirm this are needed. To define the effect of tranexamic acid use on perioperative and postoperative bleeding and blood transfusion requirements in women undergoing myomectomy.
                Among the patients that underwent myomectomy a total of 100 cases were included in the study. The patients (n=50) randomized to receive tranexamic acid were defined as Group I and those receiving saline were defined as Group II. Perioperative blood loss was calculated by measuring the volume in the suction apparatus and weighing the swabs. Postoperative blood loss was defined as the blood volume found in the subfascial suction drain. The two groups were compared for age, body mass index, basal hemoglobin and hematocrit, basal parameters of coagulation, the number and the volume of myomas removed, peri- and postoperative and total blood loss, duration of surgery and blood transfusion requirements.
                No significant difference was found between the two groups when compared age, body mass index, preoperative blood analysis, the number and volume of myomas removed. Statistically significant differences were found between the two groups when compared for postoperative and total blood loss and duration of surgery (p<0.01, p=0.03 and p=0.03, respectively). Perioperative blood loss and blood transfusion requirements were similar between the two groups (p=0.12 and p=0.25, respectively). There were no complications in either group.
                Our study is the first in the literature evaluating the effectiveness of tranexamic acid use on peri- and postoperative bleeding in gynecological surgery. No additional benefit of intravenous infusion of tranexamic acid was found. Tranexamic acid does not seem to be a useful adjunct in myomectomy if given according to the described protocol in this study. To evaluate the feasibility, blood loss, length of surgery, mean hospital stay, and complications of enucleation of a myoma by morcellation while it is still attached to the uterus and to compare the technique with the standard technique of laparoscopic myomectomy.
                Randomized study (Canadian Task Force classification II-2).
                Private endoscopy center.
                Forty-four patients with symptomatic myomas confirmed by ultrasound examination were included in the study from January 2000 through December 2001 and were randomized into two groups-A and B. The inclusion criteria were the presence of a uterus larger than 12 weeks (on bimanual examination), ultrasound confirmation of the presence of at least one myoma 7 cm or greater in size, and/or presence of three or more myomas greater than 5 cm in size.
                The technique of laparoscopic myomectomy by enucleation of a myoma by morcellation while it is still attached to the uterus was performed in all patients in Group A. The patients in Group B underwent laparoscopic myomectomy by the conventional technique of complete enucleation of the myoma followed by morcellation.
                Forty-nine myomas were removed in group A and 35 in group B. The mean weight of the myomas removed in each patient was 600.5 +/- 369.1 g in group A (95% CI 452.83-748.17 g) and 584.2 +/- 411.1 g in group B (95% CI 404.05-764.45 g) (p = .706). The mean blood loss was 283.9 +/- 229.3 mL in group A (95% CI 192.20-375.72 mL) and 218.5 +/- 110.7 mL in group B (95% CI 169.96-267.04 mL) (p = .739), the mean hospital stay was 37.91 +/- 5.44 hours in group A (95% CI 35.74-40.10 hours) and 39.5 +/- 3.634 hours in group B (95% CI 37.91-41.09 hours) (p = .236). The mean length of surgery was significantly shorter in group A (97.7 +/- 27.06 min, 95% CI 86.88-108.54 minutes) as compared with that in group B (123 +/- 38.8 min 95% CI 106.93-140.57 minutes), (p = .013).
                Preliminary results suggest that laparoscopic myomectomy employing the technique of enucleation of a myoma by morcellation while it is still attached to the uterus is safe and efficient. It helps to overcome certain technical difficulties inherent in the standard technique of laparoscopic myomectomy. It may help to relax the inclusion criteria of patients with myoma for laparoscopic myomectomy based on the size of the myoma. Fibroids remain the commonest pelvic tumour seen in women with myomectomy being the major form of treatment in our environment. Techniques to minimize blood loss will reduce patient morbidity and the need for blood transfusions. One such technique is the use of a tourniquet during myomectomy operation. This study examines the effectiveness and safety this tourniquet technique.
                A comparative analysis of the blood loss, transfusion rate and the morbidities associated with the use and non-use of a tourniquet during myomectomy operation at Nnamdi Azikiwe University Teaching Hospital, Nnewi Nigeria was undertaken. The Foley's urethral catheter was adapted as a uterine tourniquet and applied as low as possible at the base of the uterus before enucleating the fibroid masses.
                The patients who had their myomectomy performed with application of a tourniquet [tourniquet group] and those without [no-tourniquet group] were evenly matched for age, parity and presenting symptoms. The overall mean age of patients was 35.7 +/- 6.1 years and parity was 0.40 +/- 1.25. The main presenting symptoms of the patients were lower abdominal mass 65.6%, menorrhagia 38.7%, infertility 33.3%, abdominal pain 19.4% and dysmenorrhoea 14.0%. There was a statistically significant difference [P < 0.001] in mean blood loss for the no-tourniquet group [756.4 +/- 285.7] and the tourniquet group [515.7 +/- 292.8] as well as the mean blood transfusion rate in no-tourniquet group [1.0 units +/- 1.14] and the tourniquet group [0.24 units +/- 0.51]. However there was no significant difference between the two groups with respect to complication profile.
                The Foley's catheter form of tourniquet is cheap, safe, effectively reduces blood loss during myomectomy and significantly reduces transfusion rate while not adding to the complications due to the operation. To evaluate the hemostatic efficacy and handling of gelatin-thrombin matrix in abdominal myomectomy.
                Prospective and randomized trial.
                University teaching hospital.
                Women (n = 50) with uterine fibroids with a uterine size equivalent to > or =16 weeks gestation.
                Gelatin-thrombin matrix (FloSeal Matrix; Baxter Healthcare Corp., Fremont, CA) was delivered to the site of the uterine bleeding during myomectomy.
                Patient age, parity, number of myomas, operative time, blood loss, transfusion, intraoperative and postoperative complications, and length of hospitalization were evaluated.
                The average blood loss during surgery was 80 +/- 25.5 mL for the FloSeal group and 625 +/- 120.5 mL for the control group. Intraoperative blood transfusion was necessary in five patients from the control group. Postoperative blood loss was 25 +/- 5 mL for the FloSeal group and 250 +/- 75 mL for the control group. Length of the postoperative hospital stay was 2.5 +/- 1.2 days for FloSeal group and 4.5 +/- 1.3 for the control group. No major immediate or delayed complications were observed in either group.
                Reductions in hemorrhage in FloSeal-treated women undergoing a myomectomy are encouraging, and provide evidence for the ability of gelatin-thrombin matrix to reduce blood loss when applied immediately and directly to bleeding uterine tissue.
There is limited evidence that misoprostol, vasopressin, bupivacaine plus epinephrine, tranexamic acid, gelatin thrombin matrix, peri-cervical tourniquet, and mesna may reduce bleeding during myomectomy. Bupivacaine plus epinephrine has limited clinical importance compared with other interventions as the clinical impact was small. There is no evidence that oxytocin and morcellation reduce blood loss. Further well designed studies are required to establish effectiveness, safety and the costs of different interventions for reducing blood loss during myomectomy.