Faculty Bibliography

Introduction: We have previously shown sex-specific effects of placental gross features on birth weight in the Collaborative Perinatal Project, a cohort of university-based births >50 years ago. We search to confirm these findings in a modern community-based cohort of low-risk term births.
Method(s): A community hospital based sample with universal placental examination was searched for those births followed to at least age 2 years at our institution. Gross placental examination was performed according to a protocol that recorded trimmed placental weight (PW), major and minor disk axes, minimum and maximum disk thickness and cord eccentricity. Infant sex, and centiles for weight and length/height at birth and ages 1 and 2 years were extracted from medical records. Gross measures and centiles of growth were both analyzed with nonparametric tests due to non-normal distributions.
Result(s): 1631 infants met inclusion criteria. Placental measures of disk thickness (minimum and variance), chorionic disk ellipsivity, and eccentricity of cord insertion relative to the mean chorionic surface radius were significantly reduced in males (p=0.02, p=0.003, p=0.01. p=0.02, respectively) compared to females. While PW and chorionic plate area (CPA) were significantly related to birth weight and length centiles in both sexes, disk thickness was related to birth centiles in females only (e.g., p=0.01 v. p=0.10). PW and CPA) showed effects on growth centiles at years 1 and 2 in both sexes (each p<0.01), while the effects of disk thickness in females did not persist to years 1 and 2.
Conclusion(s): Placental measures show significant relationships to weight and length centiles at birth, with disk thickness associated with growth only in female infants. The unique effect of disk thickness on female birth centiles was lost by age 1. Disk thickness represents the placental villous arborization and parallels the nutrient exchange surface area available to the fetus. The different impacts of such villous branching on male and female fetal growth may contribute to differential fetal programming and account for divergent lifelong health risks

STUDY OBJECTIVE: To evaluate the efficacy of laparoscopic uterine artery ligation (LUAL) before in situ morcellation (ISM) compared with ISM alone. DESIGN: Prospective study (Canadian Task Force classification II-1). SETTING: University-affiliated hospital. PATIENTS: One hundred forty-four women with symptomatic uterine myomas, of whom 45 underwent LUAL and ISM and 99 underwent ISM only, from August 2007 through August 2009. INTERVENTIONS: Ligation or no ligation of the uterine arteries before ISM. MEASUREMENTS AND MAIN RESULTS: In the LUAL+ISM group compared with the ISM group, mean (SD) operative time was significantly longer (107 [34] minutes vs 93 [35] minutes; p = .03), and there was less intraoperative blood loss (84 [53] mL vs 137 [166] mL; p < .001). Eight patients in the ISM group (8.1%) required a blood transfusion, including 4 (4.0%) with excessive intraoperative bleeding and 4 (4.0%) with postoperative hematomas. Although myomas in the LUAL+ISM group weighed more (p < .001), none of the patients in that group had excessive intraoperative bleeding, postoperative hematomas, or required blood transfusion (p = .046). At 2 years of follow-up, in the LUAL+ISM group compared with the ISM group, the myoma recurrence rate was 7% vs 24%, and symptom improvement was reported by 98% of patients vs 86% (statistically significant). CONCLUSION: Laparoscopic myomectomy using an ISM technique with or without simultaneous LUAL may be used in the management of symptomatic uterine myomas; however, LUAL+ISM may result in a better surgical outcome.

BACKGROUND: To determine the optimal surgical approach for laparoscopic uterine artery ligation (LUAL) combined with myomectomy in the management of women with symptomatic uterine fibroids. METHODS: This is a prospective study. One hundred and six women with symptomatic uterine myomas underwent LUAL + laparoscopic morcellation after enucleation (enucleation group) (n = 51) or LUAL + laparoscopic in situ morcellation (ISM group) (n = 55). The outcome was measured by comparing surgical techniques, symptom control, recurrence and pregnancy during a 3-year follow-up in both groups. RESULTS: General characteristics of the patients were similar in both groups, except the myomas were larger in the ISM group. The operative time (mean +/- SD) was significantly shorter in the ISM group than the enucleation group (107 +/- 30 min versus 128 +/- 49 min, P = 0.009). There were no differences in the therapeutic outcomes of the two groups at the 3-year follow-up, with low recurrence rates and good symptom control rates. Of the sexually active patients without contraception, the pregnancy and live birth rates were 87.5 and 100% in the ISM group and 66.7 and 83.3% in the enucleation group (all NS). CONCLUSIONS: The LUAL + myomectomy, either by enucleation or ISM, is acceptable in the management of symptomatic uterine fibroids. However, the LUAL + ISM technique might be more feasible, as it requires less operative time.

OBJECTIVE: To evaluate a strategy of laparoscopic excision of a cervical myoma (CM). DESIGN: Prospective study. SETTING: University-affiliated hospital. PATIENT(S): Twenty-eight patients with CM underwent laparoscopic myomectomy. These cases were classified into five types according to the location: [1] anterior cervical myoma (ACM); [2] posterior cervical myoma (PCM); [3] central cervical myoma (CCM); [4] lateral cervical myoma [LCM]; and [5] deep-rooted cervical myoma (DCM). INTERVENTION(S): After preoperative assessment, patients underwent laparoscopic myomectomy. Ligation of the uterine artery and diluted vasopressin injection were performed to decrease bleeding during laparoscopy. MAIN OUTCOME MEASURE(S): Myoma numbers, myoma weight, operative time, estimated blood loss, hospital stay, complication rate. RESULT(S): Most of the lesions were ACM (43%) and PCM (32%). The mean operative time was 121 minutes, mean blood loss was 99 mL, and mean myoma weight was 287 g. The mean hospital stay was 2.2 days. There were no complications. Histopathologic examination showed that all lesions were leiomyoma. Hypermenorrhea, dysmenorrhea, and symptoms of compression improved after the operation. Two infertile patients conceived spontaneously at 1 and 7 months postoperatively, and successfully delivered infants by cesarean section at term. CONCLUSION(S): Surgical treatment of CM is empirically difficult. It is important that the approach be changed according to the location and size of the myoma.

OBJECTIVE: To evaluate the outcome of myoma enucleation by morcellation while it is attached to the uterus (in situ morcellation) in laparoscopic myomectomy. MATERIALS AND METHODS: A total of 82 patients diagnosed with myoma or adenomyosis in 2007 were enrolled. The patients were divided into three groups according to the myoma weight. The operative time, myoma weight, blood loss, duration of hospital stay, and complication experienced were recorded for analysis. RESULTS: The mean myoma weight was 265 +/- 240 g and the mean operative time was 93 +/- 30 minutes. The patients were divided into three groups: group A with myomas less than 150 g; group B with myomas 150-349 g; and group C with myomas greater than 350 g. The mean myoma weights were 73 +/- 34 g, 214 +/- 52 g, and 571 +/- 218 g for groups A, B, and C, respectively; the mean operative times were 79 +/- 17 minutes, 84 +/- 22 minutes, and 121 +/- 32 minutes, respectively. The operative time increased with myoma weight. Two patients (8%) in group C had excessive intraoperative hemorrhage and one (4%) required a blood transfusion. There was no conversion to laparotomy. CONCLUSION: In situ morcellation was an efficient and safe procedure for removal of large uterine myoma during laparoscopic myomectomy.

OBJECTIVE: To evaluate vascular perfusion and uterine healing after laparoscopic myomectomy using three-dimensional power Doppler ultrasound (3D-PDU). DESIGN: Prospective study. SETTING: University-affiliated hospital. PATIENT(S): Ninety-seven women with symptomatic myomas warranting laparoscopic myomectomy. INTERVENTION(S): Three-dimensional PDU obtained preoperatively and 1 week and 3 months postoperatively. MAIN OUTCOME MEASURE(S): Resistance index, pulsatility index, and peak systolic velocity of the uterine artery; vascularization index, flow index, and vascularization flow index of the uterine tissue, nonoperative area, and healing myometrial area. RESULT(S): The median age was 39 years. More than half of the patients were nulliparous, and one third desired fertility. The median myoma size was 8 cm, and median weight of the extirpated myomas was 250 g. The median myoma volume was 262 cm(3), and median uterine volume was 380 cm(3). On the 7th postoperative day all laparoscopic myomectomy healing sites appeared as highly echogenic areas with profuse blood flow at the periphery and reduced resistance index and pulsatility index of the uterine artery. Nonoperated areas had significantly more blood flow than healing areas. Two patients had hematomas, which appeared as hypoechoic areas that were almost avascular. By the 3rd postoperative month the blood flow and uterine volume decreased significantly. However, an 11-cm(3) hypoechoic hematoma with poor tissue perfusion was still seen in 1 patient with a 720-cm(3) myoma. CONCLUSION(S): Healing of a laparoscopic myomectomy scar can be evaluated by 3D-PDU. Adequate perfusion demonstrated by 3D-PDU might suggest good wound healing and dissolving of hematomas.

BACKGROUND: Laparoscopic myomectomy (LM) is technically difficult and time consuming procedure that requires surgical skill and modifications. The aim of this study was to assess factors which affect operative times in LM. METHODS: From March 2003 to June 2007, 174 women, who underwent LM for symptomatic myomas, were enrolled. Standard LM was performed in the first 4 years and simultaneous morcellation in situ (SMI) method was applied in the fifth year. RESULTS: The mean myoma weight was 213.5 +/- 190.4 g and the mean operative time was 117.0 +/- 39.6 min. No laparoconversions occurred and there was a 2.3% rate of complications. Total myoma weight increased and operative time declined significantly over time. The surgeon's learning curve and the effect of SMI on operative time were identified by establishing a nonlinear multiple regression model. Model assumptions showed little violation by residual plots. Slopes of the average myoma weight (total myoma weight/number of myoma operated) for describing the operative time declined along with the study year, suggesting that operative experience is a major factor influencing operative time. SMI showed a further 19 min reduction in the predicted operative time. CONCLUSIONS: Operative time in LM is dependent on a multitude of factors including surgical experience. Applying SMI during LM is an efficient way to further reduce operative time.