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Pre-treatment with GnRHa or ulipristal acetate prior to laparoscopic and laparotomic myomectomy: A systematic review and meta-analysis.

ABSTRACT: Myomectomy has potential risks of complications. To reduce these risks, medical pre-treatment can be applied to reduce fibroid size and thereby potentially decrease intra-operative blood loss, the need for blood transfusion and emergency hysterectomy. The aim of this systematic review and meta-analysis is to study the effectiveness of medical pre-treatment with Gonadotropin-releasing hormone agonists (GnRHa) or ulipristal acetate prior to laparoscopic or laparotomic myomectomy on intra-operative and post-operative outcomes.We performed an extensive search in Embase.com, Wiley/Cochrane Library and PubMed in accordance with the Prisma guidelines. All studies published as full papers in peer reviewed journals using GnRHa or ulipristal acetate as medical pre-treatment independent of route of administration or dosage before laparotomic or laparoscopic myomectomy were included. The primary outcome was duration of surgery. Secondary outcomes were duration of enucleation, blood loss, degree of difficulty of surgery, identification of cleavage planes, proportion of vertical incisions, conversion rate, frequency of blood transfusions, post-operative complications, duration of hospital stay, frequency of recurrence of fibroids, frequency of uterine adhesions, recovery time and quality of life. No language restrictions were applied. Meta-analysis were performed where possible.Twenty-three studies were included. In laparotomic myomectomy, pre-treatment with GnRHa decreases intra-operative blood loss with 97.39ml (95% CI -111.80 to -82.97) compared to no pre-treatment or placebo. Pre-treatment with GnRHa before laparoscopic myomectomies also shows a reduction in intra-operative blood loss by 23.03ml (95% CI -40.79 to -5.27) and in the frequency of blood transfusions (OR 0.17, 95% CI 0.05 to 0.55) compared to no pre-treatment. Only two retrospective cohort studies reported on pre-treatment with ulipristal acetate compared to no pre-treatment before laparoscopic myomectomy showing a statistically significant reduction in intra-operative blood loss, duration of surgery and frequency of blood transfusions after pre-treatment with ulipristal acetate.Administration of GnRHa prior to laparotomic myomectomy reduces blood loss and might decrease uterine adhesion formation. Pre-treatment with GnRHa before laparoscopic myomectomy reduces blood loss, the frequency of blood transfusions and might increase recurrence rate of fibroids, however it should be taken into account that some results are mainly based on cohort studies. Other pre-treatment agent ulipristal acetate has not been investigated sufficiently for relevant surgical outcomes.

SUBMITTER: de Milliano I

PROVIDER: S-EPMC5643155 | biostudies-literature | 2017

REPOSITORIES: biostudies-literature

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Pre-treatment with GnRHa or ulipristal acetate prior to laparoscopic and laparotomic myomectomy: A systematic review and meta-analysis.

de Milliano Inge I Twisk Moniek M Ket Johannes C JC Huirne Judith A JA Hehenkamp Wouter J WJ

PloS one 20171016 10

<h4>Background</h4>Myomectomy has potential risks of complications. To reduce these risks, medical pre-treatment can be applied to reduce fibroid size and thereby potentially decrease intra-operative blood loss, the need for blood transfusion and emergency hysterectomy. The aim of this systematic review and meta-analysis is to study the effectiveness of medical pre-treatment with Gonadotropin-releasing hormone agonists (GnRHa) or ulipristal acetate prior to laparoscopic or laparotomic myomectomy ...[more]

PMID: 29036173

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Project description:INTRODUCTION:Laparoscopic myomectomy can be difficult when fibroids are large and numerous. This may result in extensive intraoperative bleeding and the need for a conversion to a laparotomy. Medical pretreatment prior to surgery might reduce these risks by decreasing fibroid size and vascularization of the fibroid. We compared pretreatment with ulipristal acetate (UPA) vs gonadotropin-releasing hormone agonists (GnRHa) prior to laparoscopic myomectomy on several intra- and postoperative outcomes. MATERIAL AND METHODS:We performed a non-inferiority double-blind randomized controlled trial in nine hospitals in the Netherlands. Women were randomized between daily oral UPA for 12 weeks and single placebo injection or single intramuscular injection with leuprolide acetate and daily placebo tablets for 12 weeks. The primary outcome was intraoperative blood loss. Secondary outcomes were reduction of fibroid volume, suturing time, total surgery time and surgical ease. RESULTS:Thirty women received UPA and 25 women leuprolide acetate. Non-inferiority of UPA regarding intraoperative blood loss was not demonstrated. When pretreated with UPA, median intraoperative blood loss was statistically significantly higher (525 mL [348-1025] vs 280 mL[100-500]; P = 0.011) and suturing time of the first fibroid was statistically significantly longer (40 minutes [28-48] vs 22 minutes [14-33]; P = 0.003) compared with GnRHa. Pretreatment with UPA showed smaller reduction in fibroid volume preoperatively compared with GnRHa (-7.2% [-35.5 to 54.1] vs -38.4% [-71.5 to -19.3]; P = 0.001). Laparoscopic myomectomies in women pretreated with UPA were subjectively judged more difficult than in women pretreated with GnRHa. CONCLUSIONS:Non-inferiority of UPA in terms of intraoperative blood loss could not be established, possibly due to the preliminary termination of the study. Pretreatment with GnRHa was more favorable than UPA in terms of fibroid volume reduction, intraoperative blood loss, hemoglobin drop directly postoperatively, suturing time of the first fibroid and several subjective surgical ease parameters.

Project description:AimIt is commonly thought that laparoscopic surgery leads to faster postoperative recovery for its low invasiveness. We evaluated postoperative quality of life (QOL) after laparoscopic myomectomy (LM) by using the Euro-QOL 5 dimension (EQ-5D) score and analyzed its relationship to surgical factors.MethodsBetween 2014 and 2016, 541 patients underwent LM at our institution. We included 86 patients in the final analysis (16% response rate) who replied to the EQ-5D questionnaire, in order to investigate postoperative QOL. We evaluated patients' EQ-5D score before the operation and on the 3rd, 7th, 14th, 21st and 28th postoperative day (POD). We investigated the degree of correlation between the EQ-5D score and four surgical characteristics (operation time, intraoperative bleeding, number of resected myomas and weight of specimen). We examined correlation between EQ-5D scores and chief complaints such as hypermenorrhea, dysmenorrhea, other pain, myoma enlargement, palpable tumor and desire for childbearing. We also examined correlation between EQ-5D scores and other factors such as patient's age, infertility, history of abdominal surgery, marriage and body mass index.ResultsFull recovery, defined as an EQ-5D score of 1.0, was reported 2.3% of patients by POD3, 18.6% by POD7, 58.1% by POD14, 73.3% by POD21 and 86.0% by POD28. Longer duration of operation correlated weakly with poor recovery on POD3. Intraoperative bleeding, number of resected myomas and weight of the specimen did not significantly influence EQ-5D score. There was no correlation between chief complaints or other factors mentioned above and EQ-5D score.ConclusionsMore than a half of the patients undergoing LM included in our study reported full recovery of QOL after 2 weeks. The time to recover QOL was slightly influenced by the operation time. However, when LM was finished without any complications, postoperative QOL eventually seemed to improve regardless of the surgical characteristics such as operation time, intraoperative bleeding, number of resected myomas and weight of specimen.

Dataset Information

Pre-treatment with GnRHa or ulipristal acetate prior to laparoscopic and laparotomic myomectomy: A systematic review and meta-analysis.

Publications

Pre-treatment with GnRHa or ulipristal acetate prior to laparoscopic and laparotomic myomectomy: A systematic review and meta-analysis.

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