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Background: Our aim was to assess surgical complaints and reproductive outcomes of laparoscopic intracapsular myomectomies by a prospective observational study run in University affiliated hospitals., Methods: Between 2005 and 2010, 235 women underwent subserous and intramural laparoscopic myomectomy of fibroids (4-10 cm in diameter) for indications of pelvic pain, menstrual disorders, a large growing myoma or infertility. The main outcome measures were post-surgical parameters, including complications, the need for subsequent surgery or symptomatic relief, resumption of normal life and reproductive outcome., Results: Pelvic pain occurred in 27%, menorrhagia or metorrhagia in 21%, a large growing myoma in 10% and infertility in 42% of women. Single fibroids occurred in 51.9% of patients while 48.1% had multiple myomas. Of all patients, 58.2% had subserosal and 41.8% had intramural myomas. No laparoscopies were converted to laparotomy. In 3 years, 1.2% of patients had a second laparoscopic myomectomy for recurrent fibroids. The mean total operative laparoscopic time was 84 min (range 25-126 min), with mean blood loss of 118 ± 27.9 ml. By 48 h after surgery, 86.3% were discharged with no major post-operative complications. No late complications, such as bleeding, urinary tract infections or bowel lesions, occurred. Of the women who underwent myomectomy for infertility, 74% finally conceived. At term, 32.9% of patients underwent Caesarean section, 24.8% delivered by vacuum extractor and 42.2% had spontaneous deliveries. No case of uterine rupture occurred., Conclusions: Intracapsular subserous and intramural myomectomy saving the fibroid pseudocapsule showed few early and no late surgical complications, enhanced healing by preserving myometrial integrity and allowed a good fertility rate and delivery outcome. In young patients suffering fibroids, laparoscopic intracapsular myomectomy is a potential recommended surgical treatment.

The uterine fibroid pseudocapsule is a fibro-neurovascular structure surrounding a leiomyoma, separating it from normal peripheral myometrium. The fibroid pseudocapsule is composed of a neurovascular network rich in neurofibers similar to the neurovascular bundle surrounding a prostate. The nerve-sparing radical prostatectomy has several intriguing parallels to myomectomy. It may serve either as a useful model in modern fibroid surgical removal, or it may accelerate our understanding of the role of the fibrovascular bundle and neurotransmitters in the healing and restoration of reproductive potential after intracapsular myomectomy. Surgical innovations, such as laparoscopic or robotic myomectomy applied to the intracapsular technique with magnification of the fibroid pseudocapsule surrounding a leiomyoma, originated from the radical prostatectomy method that highlighted a careful dissection of the neurovascular bundle to preserve sexual functioning after prostatectomy. Gentle uterine leiomyoma detachment from the pseudocapsule neurovascular bundle has allowed a reduction in uterine bleeding and uterine musculature trauma with sparing of the pseudocapsule neuropeptide fibers. This technique has had a favorable impact on functionality in reproduction and has improved fertility outcomes. Further research should determine the role of the myoma pseudocapsule neurovascular bundle in the formation, growth, and pathophysiological consequences of fibroids, including pain, infertility, and reproductive outcomes.

The ultimate goal is to develop a safe vaginal ultrasound-directed myolysis needle to treat uterine myomas. The specific preclinical study objective was to determine the optimal power to coagulate myomas in hysterectomy specimens with a prototype needle in a prospective preclinical study with an echogenic insulated needle electrode. In phase I of the study, myolysis was performed with ultrasound guidance at various powers and times. In phase II, a 20-W coagulating current was applied at defined distances from the serosa and surface temperatures measured. Myolysis with 10 to 20 W applied 5 to 10 seconds was optimal, because tissue popping occurred at 30 W or more when the needle was 5 mm or less from the serosa. The serosal temperature was never elevated above physiological ranges at any distance at this setting. Ultrasound-directed transvaginal myolysis may provide another option for women with uterine myomas if it is proven safe and effective in future clinical studies. On the basis of the observations in these preclinical studies, myolysis with 20 W for 10 seconds should be a safe parameter for clinical research, because there is no increased serosal temperature at these settings.

Objective: To determine if the addition of fibrin sealant to incision closure in a rabbit uterine horn myomectomy model affects adhesion formation or strength of incision closure., Design: Prospective randomized controlled trial., Setting: Academic research center., Animal(s): New Zealand white female rabbits., Intervention(s): A pilot study revealed that the time interval for maximal uterine incision healing was eight weeks. Thirty New Zealand white rabbits underwent a 1-cm standardized myotomy incision on both uterine horns. A single interrupted stitch of 3-0 polygalactin suture was placed to reapproximate each incision. Fibrin sealant was then applied to one of each rabbit's horns (randomized). After eight weeks, the rabbits were killed, and the strength of myotomy closure was determined by measurement of maximal burst pressure for each uterine horn. Adhesion presence was recorded., Main Outcome Measure(s): Uterine burst pressure, adhesion presence., Result(s): The mean burst pressure was 267.8 (+/-75.8) mm Hg in the suture only group and 247.8 (+/-92.3) mm Hg in the suture and fibrin sealant group. There was no statistical difference in the presence of adhesions., Conclusion(s): Fibrin sealant did not strengthen myotomy repair nor did it reduce postoperative adhesion formation. There is no apparent advantage to fibrin sealant in this myomectomy model.

Laparoscopic myomectomy (LM) is an increasingly accepted method of treatment for symptomatic uterine leiomyomas. It affords patients a minimally invasive surgery compared to the more traditional abdominal approach. Studies have shown the benefits of decreased blood loss, shorter hospital stay and recovery period, as well as decreased postoperative pain and fever in comparison to abdominal myomectomy (AM). Even myomas larger than 5 cm can be laparoscopically resected safely in the hands of an experienced surgeon. To date, studies indicate a decreased adhesion rate with the laparoscopic approach compared to the abdominal procedure. The use of adhesion barriers may decrease this rate further. In infertile women with myomas, pregnancy and live-birth rates improve following LM, and appear to be comparable with those rates achieved following AM. The data regarding the risk of uterine rupture in pregnancy following LM is limited. However, small studies show safe outcomes when patients are managed with the same degree of caution one might employ with post-abdominal myomectomy patients. In performing LM, a precise and diligent technique should be exercised to ensure a secure, multilayer closure.