The Use of ulipristal acetate (Esmya) prior to laparoscopic myomectomy: Help or hindrance?

Abstract

Introduction: The aim of this study was to assess the operative effects, both positive and negative, of pretreatment with ulipristal acetate (UPA) on laparoscopic myomectomy. Materials and Methods: We conducted a retrospective analysis of prospectively collected data from patients who underwent a laparoscopic myomectomy over a 2-year period. Results: A total of 62 patients were included, of which 10 received a 3-month preoperative course of UPA, and 52 patients received no pretreatment. There was no statistically significant difference between the two groups (no pretreatment vs. UPA pretreatment) with regard to blood loss (214.4 [±214.96] vs. 160 [±51.64], P = 0.432), operating time (111.64 [±41.8] vs. 117.5 [±50.4], P = 0.694), and duration of inpatient stay (1.27 [±0.56] vs. 1.11 [±0.33], P = 0.419). There were no complications in either group. In 100% of cases with UPA pretreatment, a distortion of the fibroid capsule with a more technically challenging dissection was noted, compared to 0% in the no pretreatment group. This anatomical distortion may result in more cases of incomplete resection and a potentially higher risk of recurrence. Conclusion: We conclude that UPA confers no operative benefits and should be used with caution in the presurgical treatment of fibroids. The use of UPA may indeed result in a more technically difficult myomectomy with distorted cleavage planes and carry a potential risk of incomplete resection.

Metastatic smooth muscle tumor of uncertain malignant potential after laparoscopic presuming myomectomy

“…[ 2 ] Ulipristal acetate has been introduced as preoperative treatment of patients with large fibroids; however, studies showed that it results in a more technically difficult situation with the potential risk of incomplete resection due to anatomical distortion and unclear cleavage planes. [ 3 ] Although minimally invasive surgery represents the gold standard treatment, laparoscopic myomectomy still requires adequate knowledge of the risk factors for complications, of which the most common is bleeding. The myoma diameter, the number of myomas, and the operative time were found to be significantly associated with blood loss and transfusion rate.…”

90 YEARS OF PROGESTERONE: Selective progesterone receptor modulators in gynaecological therapies

“…Larger welldesigned RCTs are needed before conclusions regarding the use of UPA prior to myomectomy procedures may be drawn. Another recent small (n = 10 UPA; n = 52 no pretreatment) retrospective study in the United Kingdom supported the findings of potentially difficult laparoscopic myomectomy with UPA use (Mallick et al 2019).…”

“…UPA is known to have proapoptotic, antifibrotic and antiproliferative effects on uterine fibroids with myometrial sparing (Gaillard et al 1985, Xu et al 2005, Courtoy et al 2015, Donnez et al 2018b. UPA is thought to also effect the fibroid pseudocapsule, which in turn is proposed to make surgical planes challenging to identify and subsequently result in difficult fibroid enucleation (Mallick et al 2019). The pseudocapsule is a fibro-neurovascular structure surrounding the fibroid and separating it from the surrounding myometrium.…”

“…2018 b ). UPA is thought to also effect the fibroid pseudocapsule, which in turn is proposed to make surgical planes challenging to identify and subsequently result in difficult fibroid enucleation ( Mallick et al . 2019 ).…”

Unusual Leiomyoma Presentations and Management

“…Ulipristal acetate may induce endometrial changes, alter leiomyoma texture, and distort leiomyoma cleavage planes. 19 GnRH agonists too are associated with loss of cleavage planes and incomplete leiomyoma resection. Antiprogesterones (mifepristone/RU486) have also been used but are associated with endometrial changes.…”