Fibroids
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Uterine Artery Occlusion at Myomectomy

Uterine Artery Occlusion at Myomectomy
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Video Description

In this video, we demonstrate three approaches to uterine artery occlusion at time of laparoscopic myomectomy as a blood-sparing intra-operative technique. A step-wise approach is applied prior to beginning the myomectomy which includes the following:

1) Selecting the appropriate approach to uterine artery occlusion (lateral vs. posterior vs. anterior) based on individual anatomy;

2) identification of relevant anatomy and important landmarks for the procedure

3) isolating the uterine artery and identifying the ureter;

4) occluding the uterine artery.

As illustrated in this video, uterine artery occlusion can be performed by three different approaches, depending on both surgeon preference and unique patient anatomy. A systematic review and meta-analysis of the literature supports the efficacy of this procedure in terms of limiting blood loss, blood transfusion, and fibroid recurrence, albeit at slightly longer operative times.

Presented By

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Dr. Andrew Zakhari
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Dr. Ari Sanders
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Dr. Ally Murji

Affiliations

University of Toronto

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What is Uterine Artery Occlusion at Myomectomy?

Uterine artery occlusion at myomectomy is a surgical technique used to reduce blood loss during the removal of uterine fibroids, or myomas, which are benign tumors in the uterus. This procedure involves temporarily blocking the blood flow to the uterus to decrease bleeding while the fibroids are surgically excised. This can be particularly beneficial in managing large or multiple fibroids, where significant blood loss might otherwise occur. The occlusion can be achieved through various methods:

  1. Surgical Clamping: Temporary clamps are placed on the uterine arteries during the myomectomy to stop the blood flow.
  2. Radiological Embolization: Uterine artery embolization (UAE) can be performed before the myomectomy to reduce the size and vascularity of the fibroids, thus minimizing intraoperative blood loss.
  3. Laparoscopic Clips or Coils: In laparoscopic or robotic myomectomy, clips or coils may be used to occlude the uterine arteries.

The main advantage of this approach is the significant reduction in blood loss during surgery, which can lead to a safer procedure and quicker recovery. It also reduces the likelihood of needing a blood transfusion and may help preserve more of the healthy uterine tissue.

While uterine artery occlusion can make myomectomy safer by reducing bleeding, it requires careful consideration of the patient’s overall health, fertility goals, and specific characteristics of the fibroids. The procedure’s success largely depends on the surgeon’s expertise and the chosen method of occlusion. After the procedure, monitoring for potential complications, such as postoperative pain or transient amenorrhea, is essential.

What are the Risks of Uterine Artery Occlusion at Myomectomy?

Uterine artery occlusion at myomectomy is a procedure aimed at reducing blood loss during the removal of uterine fibroids by temporarily blocking the blood supply to the uterus. While effective in minimizing intraoperative bleeding, there are several risks and potential complications associated with this procedure:

  • Uterine Ischemia: By blocking the blood supply to the uterus, there is a risk of ischemia or insufficient blood flow to the uterine tissues. This can lead to tissue damage or necrosis if the occlusion is prolonged or not carefully monitored.
  • Postoperative Pain: Some patients may experience increased postoperative pain following uterine artery occlusion. This pain is thought to be due to the decreased blood flow and the potential for ischemic tissue damage.
  • Impact on Fertility: There are concerns about the potential impact on fertility, as the procedure may affect the blood flow to the ovaries as well as the uterus. Reduced blood flow could potentially impair ovarian function or decrease the viability of the endometrium for implantation.
  • Reperfusion Injury: When blood flow is restored after being temporarily blocked, the sudden influx of blood can cause inflammation and oxidative stress in the tissues, known as reperfusion injury. This could potentially lead to additional damage.
  • Embolization Risks: If the occlusion is performed using embolization techniques, there are risks associated with the migration of embolic materials to unintended sites, which could cause blockages in other areas.
  • Incomplete Occlusion or Recurrence: There is also the risk that the occlusion might not be completely effective in reducing blood flow, leading to continued or excessive bleeding. Additionally, the fibroids may recur, necessitating further treatment.
  • General Surgical Risks: As with any surgical procedure, there are general risks such as infection, bleeding, and reactions to anesthesia.

Patients considering uterine artery occlusion at myomectomy should discuss these potential risks with their healthcare provider to weigh the benefits against the possible complications. This discussion can help ensure that the treatment plan aligns with the patient’s health needs and reproductive goals.

Video Transcript: Uterine Artery Occlusion at Myomectomy

In this video, we will review three approaches to uterine artery occlusion at the time of laparoscopic myomectomy.

Excessive blood loss is one of the major morbidities associated with myomectomy, and uterine artery occlusion is one technique to decrease the amount of intraoperative bleeding. Uterine artery occlusion results in decreased pulse pressure, decreased blood flow towards the uterus, improved coagulation and improved haemostasis.

Uterine artery occlusion was first described in Fertility and Sterility in 2001 by Liu, who accessed the uterine artery through the lateral triangle formed by the round ligament anteriorly, the infundibulopelvic ligament medially and the external iliac vessels laterally.

In 2009, Alborzi published in Fertility and Sterility on a posterior approach in which the uterine artery is accessed through the ovarian fossa. Aust, in 2011, described an anterior approach in which the uterine artery is accessed from the paravesical space near the obliterated umbilical ligament.

We will now go through the lateral, posterior and anterior approaches. In clinical practice, the approach chosen will be individualised, based on anatomical considerations and surgeon preference.

The lateral approach. In this case of laparoscopic myomectomy, we note a large, mobile, fibroid uterus. We begin by identifying the triangle bounded by the round ligament anteriorly, the external iliac vessels laterally and the infundibulopelvic ligament in continuity with the fallopian tube medially.

The peritoneum in this triangle is linearly incised. Traction on the obliterated umbilical ligament in the anterior abdominal wall allows identification of this important landmark in the space. The obliterated umbilical ligament can be traced to its origin to identify the uterine artery.

Careful dissection medially reveals the pulsating uterine artery, shown here. Once the vessel has been adequately skeletonised and the ureter has been identified inferiorly, surgical clips are applied. Apart from permanent surgical clips, other methods of uterine artery occlusion include temporary clips, suture ligation and coagulation. The ureter is seen here, coursing inferior to the occluded uterine artery.

The posterior approach. In this example, easy access to the right pelvic side wall favours a posterior approach. The ureter and the obliterated umbilical ligament are important landmarks for this approach. The ureter can easily be seen, coursing retroperitoneally along the pelvic side wall. The peritoneum is incised linearly above the uterine and caudal to the obliterated umbilical ligament. Gas assists with pneumodissection.

Medial traction is essential to assist with dissection, visualisation and also medialising the ureter during uterine artery occlusion. The ureter is identified here, coursing along the medial leaf of the broad ligament. Further dissection lateral to the ureter reveals the uterine artery, shown here. Once adequately isolated, two surgical clips are applied to occlude the vessel.

The anterior approach. In this case, limited access posteriorly due to a large fibroid favours an anterior approach. We begin by identifying our landmarks, which include the bladder, the obliterated umbilical ligaments, the round ligaments and the paravesical spaces bilaterally.

In this patient, the anterior approach is accessed via the left paravesical space. The peritoneum is incised over the obliterated umbilical ligament. Traction on this structure assists with retroperitoneal dissection along its course. This dissection will lead to the origin of the uterine artery, seen here. The ureter can be seen vermiculating medially and inferiorly to the uterine artery. Once isolated, two surgical clips are used to occlude the uterine artery.

A systematic review and meta-analysis submitted for peer review in 2018 evaluated surgical outcomes following uterine artery occlusion at time of myomectomy compared to myomectomy alone. 25 studies, including 2,871 patients, were included, comprised of observational and randomised controlled trials.

Results showed that UAO at time of myomectomy was associated with a statistically significant reduction in estimated blood loss, a reduction in perioperative blood transfusions, but an increase in operative time, with a mean difference of approximately 11 minutes. Importantly, there were no significant differences between the two groups in terms of total complications.

Uterine blood supply is largely preserved following UAO due to an extensive network of pelvic collateral circulation. Indeed, pregnancies have been reported following bilateral internal iliac artery ligation, which speaks to the extent of pelvic vascular anastomoses. Observational studies describe successful pregnancy outcomes following UAO. However, prospective randomised data is lacking.

A Cochrane review of randomised controlled trials published in 2014 evaluated interventions to reduce excessive blood loss during myomectomy. Misoprostol, vasopressin, tranexamic acid and the use of a peri-cervical tourniquet, in addition to other less common interventions, were all shown, with low to moderate quality evidence, to decrease intraoperative blood loss.

In this video, we have reviewed three different approaches to uterine artery occlusion, the lateral, posterior and anterior approaches. Uterine artery occlusion at time of myomectomy is an effective technique to reduce intraoperative blood loss.