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Objective: To review the mechanism of action, pharmacology, dosing, and complications of tranexamic acid (TXA) and consolidate current evidence for TXA in gynecologic surgery.Methods: A literature search of PubMed, Ovid (MEDLINE), Google Scholar, and Elsevier was performed, in addition to a targeted search of cited references involving TXA and gynecologic surgery. Preference was given to systematic reviews and randomized control trials (RCTs).Results: TXA reversibly binds to plasminogen, preventing clot degradation. RCTs on hysterectomy, myomectomy, cervical conisation, hysteroscopy, and surgery for cervical and ovarian cancer were identified, as were case reports on TXA use for ectopic pregnancy. During hysterectomy, TXA reduces blood loss (two RCTs, n = 432, mean difference -66.0 mL and 180 mL), blood transfusion (1 RCT, n = 100, 12% vs. 42%, p < .00001). For myomectomy, a systematic review and meta-analysis showed a statistically significant decrease in blood loss with TXA (two RCTs, mean difference -213.1 mL, 95% CI: -242.4 mL to -183.7 mL). Following cervical conisation, TXA decreased the risk of delayed hemorrhage (four RCTs, RR 0.23, 95% CI: 0.11-0.50). A single RCT for cervical and ovarian cancer surgery demonstrated a decrease mean blood loss of 120 mL-135 mL and 210 mL, respectively, and fewer blood transfusions for the latter (OR 0.44, upper 95% CI: 0.97, p = .02). Less robust data suggest a possible benefit from TXA during hysteroscopy and surgery for ectopic pregnancies. Most commonly, 1 g of intravenous TXA is given intraoperatively.Conclusion: TXA is a safe adjunct that can be considered in a variety of gynecologic surgeries to decrease blood loss and risk of blood transfusion.
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Antifibrinolíticos/administración & dosificación , Procedimientos Quirúrgicos Ginecológicos/métodos , Ácido Tranexámico/administración & dosificación , Administración Intravenosa , Pérdida de Sangre Quirúrgica/prevención & control , Transfusión Sanguínea , Femenino , Humanos , Embarazo , Ensayos Clínicos Controlados Aleatorios como AsuntoRESUMEN
STUDY OBJECTIVE: To compare surgical experience of laparoscopic/robotic myomectomy in premenopausal patients pretreated with ulipristal acetate (UPA) with women not hormonally pretreated. DESIGN: A retrospective, multicenter cohort study of laparoscopic/robotic myomectomy procedure videos (Canadian Task Force Classification III). SETTING: Multiple university-affiliated tertiary care hospitals. PATIENTS: Fifty-five premenopausal women who underwent laparoscopic/robotic myomectomy for intramural myomas and were either pretreated with 3 months of UPA or had no hormonal pretreatment. INTERVENTIONS: Laparoscopic/robotic myomectomy surgical videos were independently reviewed by 2 gynecologists blinded to whether or not patients received pretreatment with UPA. Each procedure was scored using a novel 22-point surgical global rating tool containing 6 subscales: depth of myometrial incision, ease of myoma-myometrium cleavage plane identification, ease of myoma detachment, blood loss during myoma detachment, myometrial blood loss after myoma detachment, and myoma consistency. MEASUREMENTS AND MAIN RESULTS: Participating surgeons submitted 55 videos of laparoscopic/robotic myomectomy procedures recorded over a 3-year period (2012-2015). Fifty met the inclusion criteria (25 UPA-treated patients and 25 patients without hormonal pretreatment). Patients treated with UPA were more likely to be older than patients with no medical pretreatment (mean age = 33.5 vs 38.3 years, p = .002). There were no statistically significant differences regarding other baseline characteristics such as the largest diameter of myoma removed, the number of myomas removed, or the estimated blood loss. There was no difference in the physician assessors' mean global rating score for patients with UPA pretreatment versus no pretreatment (12.4 vs 13.4, p = .23). Within the 6 subscales, no differences were observed between the 2 groups. Each video was graded independently by 2 assessors, and there was high inter-rater agreement for the total score and each subscale. CONCLUSION: There was no difference in surgical experience for myomectomies of patients pretreated with UPA versus those without medical pretreatment.
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Competencia Clínica , Laparoscopía/métodos , Leiomioma/cirugía , Norpregnadienos/uso terapéutico , Miomectomía Uterina/métodos , Neoplasias Uterinas/cirugía , Adulto , Competencia Clínica/estadística & datos numéricos , Escolaridad , Femenino , Ginecología/educación , Humanos , Laparoscopía/estadística & datos numéricos , Leiomioma/tratamiento farmacológico , Cuidados Preoperatorios/métodos , Estudios Retrospectivos , Resultado del Tratamiento , Miomectomía Uterina/estadística & datos numéricos , Neoplasias Uterinas/tratamiento farmacológico , Grabación en Video , Recursos HumanosRESUMEN
Incidental adnexal masses occur with relatively high frequency in post-menopausal women, with a prevalence rate of 3.3-18% in asymptomatic patients. Unilocular, benign-appearing ovarian cysts represent the vast majority of abnormal findings at transvaginal ultrasonography. As many as 80% will resolve over a period of several months; if persistent, unchanged, less than 10 cm, and with normal CA-125 values, the likelihood of an invasive cancer is sufficiently low that observation should be offered. More recent investigations support the use of secondary imaging modalities such as MRI, which may help differentiate benign from malignant masses. Surgical management plays a key role when patients are symptomatic regardless of age, menopausal and have documented changes in cyst characteristics, experience elevations in tumor markers or have symptoms suggestive of a hormone-producing neoplasm. High level, evidence-based screening guidelines have yet to be developed.
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Enfermedades de los Anexos/diagnóstico , Hallazgos Incidentales , Quistes Ováricos/diagnóstico , Neoplasias Ováricas/diagnóstico , Enfermedades de los Anexos/diagnóstico por imagen , Enfermedades de los Anexos/cirugía , Adulto , Biomarcadores de Tumor/análisis , Antígeno Ca-125/sangre , Endometriosis/diagnóstico , Estradiol/sangre , Femenino , Humanos , Imagen por Resonancia Magnética , Tamizaje Masivo , Ciclo Menstrual , Persona de Mediana Edad , Quistes Ováricos/diagnóstico por imagen , Neoplasias Ováricas/diagnóstico por imagen , Posmenopausia , Valor Predictivo de las Pruebas , UltrasonografíaRESUMEN
PURPOSE OF REVIEW: This review will provide a detailed account of chronic pelvic pain and endometriosis, two conditions that frequently occur in adolescents. Current approaches used to evaluate and treat these patients will be addressed. RECENT FINDINGS: Although previous investigations have established relative rates of disease and basic treatment algorithms for endometriosis in adolescents, its pathogenesis is yet to be explained. Recent scientific works have focused on the interplay of specific genes and the role of host immune response. Despite such progress, we have not yet learned how to apply this knowledge to clinical use. Most innovative treatment strategies are based on algorithms generated primarily for adults, with only a small percentage focusing on adolescents. SUMMARY: Treating pain associated with endometriosis may be facilitated by early intervention. Future study should focus on identifying adolescents with progressive disease and introducing less invasive therapies that could reverse inflammatory pathways and minimize subsequent morbidity.