Hôpitaux Universitaires de Genève, Service de gynécologie 1206 Geneva SwitzerlandRekrutierend» Google-Maps Ansprechpartner: Lauriane Ramyead, Dr E-Mail: lauriane.ramyead@hcuge.ch» Ansprechpartner anzeigen
1. To assess the effect of preventive uterine artery occlusion during laparoscopic
myomectomy on ovarian reserve parameters;
2. To evaluate the effect of preventive uterine artery occlusion during laparoscopic
myomectomy on intra- and postoperative blood loss, operative time, clinical symptoms
improvement, long-term recurrence of myomas and fertility.
Materials and methods:
Design: This is a prospective randomized single blind trial, including 60 women undergoing a
laparoscopic myomectomy for symptomatic uterine myomas. Patients are randomized into two
groups: a control group "myomectomy alone" and an experimental group "myomectomy with
preventive uterine arteries occlusion".
Setting: The duration of the study will normally be 5 years and will take place at the
University Hospitals of Geneva. The study will include about 20 women per year and follow-up
will last 2 years. Inclusion criteria are: women of childbearing age, wishing to retain their
uterus, having symptomatic uterine myomas and who are eligible for a laparoscopic myomectomy.
The parameters that will be intraoperatively evaluated are the operation time, blood loss and
the complications of the surgical technique. Postoperative complications, improving clinical
symptoms, myomas recurrence and fertility are discussed at short and long term follow-up.
The ovarian reserve will be evaluated pre- and postoperatively for each patient. It will be
determined by plasmatic AMH (anti-Mullerian Hormone) and ultrasound antral follicle count.
Women with undetectable preoperative plasmatic AMH will be excluded from the study. Plasmatic
AMH and antral follicle count will be measured at 1, 3, 6, 12 and 24 months during the
postoperative follow-up.
Limitations:
The sample size is calculated in order to demonstrate a significant difference in plasmatic
AMH before and after myomectomy. Small differences are not highlighted in this study, but
they probably would not have any impact in clinical practice.
Impact of the study:
The results of this study could have a real impact on daily surgical practice. In case of
persistent alteration of ovarian reserve in the experimental group compared to the control
group, preventive uterine arteries occlusion during a laparoscopic myomectomy should only be
indicated in patients who do not wish pregnancy. If there is no significant impact on ovarian
reserve and a beneficial effect on reducing intraoperative blood loss and long-term
improvement of symptoms, it should be systematically proposed in all patients undergoing a
laparoscopic myomectomy.
- capable of discernment understanding and accepting the risks and benefits of the
operation
- symptomatic : menorrhagia, breakthrough bleeding and / or pelvic pain and / or
infertility and / or repeated spontaneous abortions.
- uterine myoma or more, including at least one type of myoma FIGO 2-6 (International
Federation of Gynecology and Obstetrics) objectified by ultrasound and / or pelvic MRI
- laparoscopic approach is technically feasible (as recommended by the National College
of Obstetrics and Gynecology French published in 2011): myoma single lower or equal to
9 cm or sum of the size of myomas in centimeters or less equal to 13 and number of
myomas inferior to four.
- Female patients of childbearing age younger than 45 years and having a plasma AMH
(anti-Mullerian hormone) than 3 pmol / l.
- Patients who accept a postoperative follow-up of 2 years
Exclusion Criteria:
- pregnant patients.
- who underwent radiological uterine artery embolization.
- who have an undetectable AMH levels (<3 pmol / l).
1. Evolution of ovarian reserve markers after myomectomy (Time Frame - Evaluation of the ovarian reserve at several times: on preoperative, 1, 3, 6, 12 and 24 months postoperative): It will be determined by plasmatic AMH and ultrasound antral follicle count
Secondary outcome:
1. Intra-and post-operative blood loss (Time Frame - peroperative): Blood loss will be estimated during the operation, and will be followed for the duration of hospital stay, an expected average of 3 days. furthermore, we will dose the hemoglobin before and after the intervention.
2. operative time (Time Frame - peroperative): Time needed to realise the intervention from the incision to the cutaneous stitches
3. peroperative complications (Time Frame - peroperative): it will be noticed the conversion in laparotomy, the blood transfusion, the organic and vessels lesions
4. Clinical symptoms improvement: hypermenorrhea (Time Frame - 1, 3, 6, 12 and 24 months postoperative): Evaluation of quantity of blood during menstruation with the PBAC scale (Pictorial Blood Assessment Chart) before and after the intervention
5. Clinical symptoms improvement: dysmenorrhea (Time Frame - 1, 3, 6, 12 and 24 months postoperative): Evaluation of improvement of dysmenorrhea by asking patients the pain they have from 0 to 10 and their consumption of pain killers (NSAIDs and paracetamol) during menstruation.
6. Clinical symptoms improvement: occuring of pregnancy (Time Frame - 12 and 24 months postoperative): Evaluation of the occurence of pregnancy by asking women the number of pregnancy, of miscarriage, of abortion, of term pregnancy since the intervention
7. long-term recurrence of myomas (Time Frame - 2 years): An US will be made at 1, 3, 6, 12 and 24 months to estimate the recidive of myoma. It will be considered a recidive when the myoma will be bigger than 20 mm