Nazli Hameed, M Asghar Ali

Combined Military Hospital, Peshawer

Recently there is an increasing trend for minimal access surgery (MAS) for treatment of uterine myomas. Laparoscopic myomectomy has provided minimal invasive alternative to laparotomy for subserosa and intramural myomas. It is associated with faster postoperative recovery and potentially less postoperative adhesions. Main concerns are however subsequent fertility, reproductive outcome and long-term recurrence. Other alternatives are laparoscopic assisted myomectomy, laparoscopic ultraminilaparotomic embolised myomectomy, laparoscopically assisted transvaginal myomectomy, myolysis and cryosurgery. Hysteroscopic access is required for sub mucous myomas. The idea of this review is to analyse recent techniques which are used to treat uterine myomas. Recent evidence favours safety and reliability of laparoscopic myomectomy. Prospective randomised controlled trials comparing laparoscopic myomectomy with laparotomy myomectomy will clarify the status further.

Keywords: Laparoscopic myomectomy, uterine myomas.


Uterine myomas are the commonest pelvic tumours found in at least 20% of the females over thirty years of age.  The incidence rises further with age until the time of menopause.  Fibroids can be identified in as many as 50% of nulliparous women at the age of fifty1. There is a spectrum of presentations but a large proportion (1/4) are asymptomatic.2    Surgical management include hysterectomy and myomectomy for women who wish to retain their uterus for enhancing their reproductive potential. Recently, there has been a renewed interest in this procedure, perhaps owing to the postponement of pregnancy until later age when myoma tends to be found.Myomectomy by any route is still a controversial subject.  According to the available evidence based on a comprehensive review, slightly less than two thirds of the women with uterine leiomyomas and otherwise unexplained infertility conceived after myomectomy 3. Laparoscopy is presently the gold standard of treatment for benign adnexal pathologies, although the evaluation of other techniques as myomectomy, through laparoscopic route remains to be made 4.    The surgeon’s experience in laparoscopic suturing is a crucial requirement for laparoscopic myomectomy5.


Myomectomy is indicated in women:

*       Who wish to preserve their fertility for child bearing or personal reasons, or

*       Who are symptomatic, and are not expected to go into menopause soon and want to retain their uterus.

The commonest symptoms are excessive uterine bleeding, pelvic pressure and pain, recurrent pregnancy losses and occasionally infertility2.  The last two symptoms are particularly related to sub mucous or intramural myomas distorting the uterine cavity5. For conservative myomectomy by laparoscopy, usually the myoma should be about 6 centimetres in its largest diameter, although this depends much on surgeon’s experience 6,7. Myomas causing ureteric obstruction also necessitate removal8.


Contraindications to laparoscopic myomectomy include the following:

*       Any medical conditions that are worsened with abdominal distension and a Trendelenburgh position for a prolonged period.

*       Diffuse leiomyomata.

*       More than three myomas equal to or more than five centimetres.

*       Uterine size more than sixteen weeks gestation.

*       A myoma more than fifteen cms in diameter.


Laparoscopic myomectomy is associated with:

*       Shorter hospitalization. 

*       Faster postoperative recovery.

*       Decreased incidence of postoperative pain

*       Decreased incidence of ileus and thrombo-embolic phenomenon 9.


Laparoscopic myomectomy requires a greater degree of skill and should only be performed by experienced laparoscopists with sound laparoscopic suturing skills. The number of instruments and various angles of insertion to approach the surgical site are limited and therefore certain myomas may be technically difficult to handle.  The flexibility in planning the surgical technique and removal of myoma from the abdominal cavity is often limited and there is difficulty in obtaining the accurate apposition of the edges of uterine wound10, 6.   This is particularly important in cases where future fertility is a concern, as incorrect approximation can predispose to rupture during subsequent pregnancy.There is concern regarding operation time.  Depending on the surgeon’s experience, closure of the uterine incision can be time consuming 11.  In a study, the reported operation time ranged from 25-400 minutes.  This wide range reflects relative lack of predictability in procedure times, meaning that efficient utilization of fixed theatre sessions can be difficult 12The automatic morcellator provides significant savings in operating room time and is a cost effective application of a new technology from this point of view 13,14.


For all the listed indications, other possible causes should be thoroughly excluded.  When no other correctable findings are identified, the patient must decide if her symptoms are sufficiently severe to warrant surgery 15. In women who complain of menorrhagia, the haematocrit is used to assess the degree of anaemia.  For anaemic patients, preoperative Gonadotrophin releasing hormone agonists (GnRHa) treatment may enable restoration of a normal haematocrit, decrease the size of myoma and reduce the need for transfusion.  While some studies show a decrease in intraoperative blood loss after a course of GnRHa therapy 16. GnRHa therapy is associated with hypo estrogenic side effects and an increased incidence of tumour recurrence 8.  About ten percent of the myomas do not respond to GnRHa. Presence of underlying chromosomal aberration t(12;14) has also been suggested as a cause of resistance to GnRHa.17   Some surgeons have also found that pre-treatment with LHRHa is associated with loss of cleavage planes as there is hydropic degeneration of myoma. This may make dissection difficult in some patients.  Others, however, don’t share this experience 18.   Ultrasonography provides information about the site, size and number of fibroids.  Fluid contrast ultrasonography determines endometrial distortion by sub mucous fibroids 15.  Periodic pelvic ultrasound examinations help monitor the growth rate of asymptomatic myomas.  Sub mucous tumours can be detected by pelvic ultrasound, a hysterogram, or hysteroscopy.  The presence of large broad ligament myoma emphasizes the need for an intravenous urography to look for ureteral obstruction8. 



The myoma is grasped and held in a position to allow bipolar cautery paddles to be placed across the pedicle.  If the myoma stalk is thin, an endoloop can be placed and secured at the base.  For a thicker stalk, a suture placed through the base of the stalk, tied fore and aft will ensure haemostasis.  The bipolar instrument is then passed through the incision opposite the retracting instrument and placed over the entire pedicle.  Alternatively, base can be coagulated in two or more sections. The bipolar cautery is activated until coagulation has stopped and there is no current flow.  The stalk is then sharply resected.  Alternatively, monopolar cutting current can be used to divide the pedicle between two secured ligatures on the stalk.  Any subsequent bleeding points are secured with bipolar coagulation 15.  Use of dilute vasopressin injection (0.2-1 U in 100 millilitres lactated Ringer’s solution) helps control uterine bleeding as recommended by Nezhat et al 8.A fibroid less than one centimetre in diameter can be pulled directly through the 10 mm trocar with a grasping forceps or a myoma screw.  For a larger myoma sharp morcellation can be attempted.  Alternatively, myoma can be grasped with one instrument and progressively cut into smaller pieces with a monopolar cautery or scissors.  Shaving should be performed in the anterior cul-de-sac to reduce the possibility of injury to the bowel.  Fragments can be removed through the 10 mm laparoscope channel.  Other options include removal through a colpotomy or an abdominal incision15.


For intramural myomas, dilute vasopressin is injected in multiple sites between the myometrium and the fibroid capsule.  An incision is made in the serosa overlying myoma, using the CO2 laser (superpulse or ultrapulse mode), a monopolar electrode, a fibre laser or a harmonic scalpel.  The incision is extended until it reaches the myoma capsule. Two grasping, toothed forceps are used to hold the edges of the myometrium/fibroid capsule. The suction irrigator is used as a blunt probe to shell the leiomyoma from its capsule; sharp scissors may be used as required.  A myoma screw is inserted into the tumour to apply traction while the dissection is being carried out.   If there are multiple myomas, efforts should be made as far as possible to remove them through one incision.  4-0 Polydioxanone for superficial suturing approximates the edges of the uterine defect.  If the myometrial defect is deep or large, it is repaired with 1-0 or 2-0 Polygalactin suture followed by serosal repair with 4-0 Polydioxanone.  Though difficult, at times myometrium is required to be sutured in two layers.  The sutures are applied at 1 cm increments using extracorporeal19 or intracorporeal knot tying.8 The use of vasopressin has been reported to be associated with severe cardiopulmonary complications20.  There are also some specific procedural difficulties.19 The location of uterine incision is very important as it affects the whole of the operation. Preoperative ultrasonography is invaluable in planning the incision accurately on the uterine wall. The second difficulty lies in planning the type of myometrial incision.  The standard approach is a vertical incision in the uterus.  The third practical difficulty is proper uterine repair. Stringer et al have reported the Endostitch to be the best instrument for laparoscopic closure of uterine defects.21 Recently a continuous spiralling suture for uterine wall reconstruction after laparoscopic myomectomy has been reported. Long term safety however is yet to be proved.22 Removal of myoma from abdomen is time consuming and no method is ideal. Growth of myomas in the trocar incision has been reported.23


In general, laparoscopic myomectomy is associated with a shorter hospital stay, faster recovery and less blood loss that is be explained in part by the tamponade effect of the pnuemoperitoneum. The results of some of studies are shown in the table.


This is an important consideration for those women desiring pregnancy.  Although uterine ruptures during pregnancy have been reported after myomectomies via laparotomy, these are usually sporadic  24,25.

Risk factors for uterine rupture after laparoscopic myomectomy can be :

*       An intramural haematoma at the point of incision

*       Tissue necrosis because of thermal damage, leading to defective scar formation

*       Incorrect approximation of incision edges leading to healing by secondary intention.

Uterine rupture and fistula formation after laparoscopic myomectomy have been reported. However, none of these investigators closed the uterine defect in layers 11, 26,27,28,29. In a recent series reported by Nezhat et al 30, no case of uterine rupture has been reported following pregnancies after laparoscopic myomectomies.  The authors have emphasized the importance of avoiding excessive thermal damage and of adequate uterine repair using multiple layer suturing techniques.  In cases of deeply embedded myomas, larger than six to seven centimetres in size, laparoscopic myomectomy may be replaced with laparoscopic assisted myomectomy.31 Suturing the myometrium in layers during a laparoscopic myomectomy is also necessary to prevent iatrogenic adenomyosis.32


Various modalities have been suggested which include:


Ultrasonography is used to detect the haematoma formation along the uterine scar. Doppler studies can be used to assess the uterine scar, possibly recognizing the irregularities in the vascular patterns and haematoma formation , which  depict  poor  quality  uterine scar. Velocimetric findings at 30th postoperative day may be able to assess the healing process.  A high resistance index may suggest abnormal healing and an area of fibrosis.33,34


Hysterosalpingography may be performed to detect the presence of any fistulae.27The test however, is non-specific.


This is carried out between four to eight weeks postoperatively and a methylene blue test is carried out to check any uterine fistula.  The place of second look laparoscopy has been particularly emphasized in relation to assessment of any postoperative adhesions and its treatment.35,36


Bulleti and co-workers37 compared postoperative adhesions after laparoscopic versus laparotomy myomectomy in a prospective case control study.  At the time of second look laparoscopy, adhesions were found less frequently and were less extensive in patients who had laparoscopic myomectomy.  The critical risk factors being the posterior location of the myoma and the number of uterine incisions.38 High CO2 pneumoperitoneum insufflation's pressure is a cofactor in adhesion formation.  Adequate humidification of CO2 , especially at high flow rates is being emphasized.39 Although several substances have been used in an attempt to decrease adhesion formation, none of these have been found to be unequivocally effective  Most data to date describe the use of oxidized regenerative cellulose (TC 7, Interceed) and expanded Polytetrafluoroethylene (Preclude, Gortex).40,41 Several investigators have recommended second and even third look laparoscopy to diagnose and treat postoperative adhesions.    Minilaparoscopy performed with the patient under conscious sedation may overcome the drawback of repeated anaesthesia.11, 42


Patients having resection of a pedunculated myoma can be discharged the same day.  However, a patient who has undergone successful subserous or intramural laparoscopic myomectomy needs an inpatient observation for at least twenty-four hours, with vital signs recording and serial haemoglobin assessment.  Early ambulation is allowed if vital signs are stable.  Delayed complications like secondary haemorrhage may occur necessitating a probable re-operation, laparoscopy or possibly a laparotomy.15 Myomectomy has been found to be an independent risk factor (after controlling for confounding variables) for fever in the first forty-eight hours after the operation 43.Gastrointestinal injuries may go unsuspected intraoperatively necessitating a later laparotomy 44.  There is also a risk of recurrence.  The cumulative risk increases with the observation period45, and decreased with the parity after myomectomy 46. A recent study by Rossetti A et al concluded that the recurrence rate was similar to that seen after abdominal myomectomy47.


Despite the risk of adhesion formation, myomectomy seems to enhance the reproductive outcome48. The quoted conception rates for abdominal myomectomy in infertile patients have been up to 40% in one series2, and 58% in another 49.After laparoscopic myomectomy, conception rates have been quoted to be 71% and 75% respectively in two different series 50, 51. Provided no other associated factor for infertility is found, laproscopic myomectomy enhances fertility rate52.      In a series reported by Seinera et al 53, 65 pregnancies were achieved in 54 patients with no case of uterine rupture.  In another study by Dubuisson  et al54 the estimated risk of uterine rupture has been reported to be 1.0% (95% CI  0.0-5.5%).  However, particular care however must be given to the uterine closure. The patient satisfaction with operative scar after laparoscopic myomectomy is good55 and as well as fertility satisfaction and reproductive outcome56.


It involves a combination of laparoscopy, with 2-4 centimetres abdominal incision and is usually done for myoma of more than eight centimetres, many myoma requiring extensive morcellation and large, deep intramural myoma that require uterine repair in multiple layers.  Laparoscopically assisted myomectomy, with morcellation and conventional suturing reduces the duration of the exposure and the need for more extensive laparoscopic experience.5,8 Laparoscopic ultraminilaparotomic myomectomy and laparoscopic ultra minilaparotomic embolised myomectomy are some recently adopted surgical alternative with abdominal incision as small as 2.5 cms to apply suture on uterine incision. They may be used to remove myomas >9cms58.


Pelosi MA et al59 and Wang CJ et al60 reported a review of twenty one and thirty one cases of combined laparovaginal myomectomies for extensive and deep infiltrating fundal and posterior wall leiomyomata.  Laparoscopy confirms the size, number and the location of myomas.  Intramyometrial vasopressin is then injected. This is followed by posterior colpotomy allowing delivery of myomata and uterus.  Uterine reconstruction is then performed by conventional suturing performed transvagin-ally. The uterus is then replaced in its anatomical position and colpotomy repaired.  A final laparoscopic survey and lavage is performed. This technique can be especially applicable for posterior and fundal myomas.


Myoma size can be reduced by coagulation of its blood supply with the neodymium: yttrium aluminium garnet (ND: YAG) laser or with a long bipolar needle electrode.  . The long-term effects of the procedure are still unknown.  The procedure seems to be effective and regrowth of the myoma doesn’t occur61.However, there has been a report that three patients who conceived three months postoperatively developed a uterine rupture in the third trimester 62.A newer technique that is currently under investigation is laparoscopic treatment of myoma by cryosurgery (cryomyolysis).   The myoma is frozen with liquid nitrogen delivered with a special probe.  The efficacy of this technique remains to be determined 63.



Table 1: Summary of the results of various studies on Laparoscopic myomectomies


Nezhat et al, 1991

Hasson et al50

Miller et al51

Dubisson et al52

Stringer et al21

Tulandi et al11

No. of patients







Tumour size (cms)







Duration of Procedure (min.)




30-300 (130)




Estimated blood loss (ml)




Postop drop in Hb 1.4±1.1gm/100ml


Postop. Drop of Hb 1.38±.93gm/100ml

Length of average hospital stay (days)








*       Laparoscopic myomectomy is a very recent advance in the field of gynaecological surgery.  It requires proper patient selection, meticulous technique, manual dexterity and experience in laparoscopic suturing skills.  If strict criteria are used laparoscopic myomectomy is as effective as abdominal myomectomy.  The procedure should involve multilayered uterine closure to avoid a weaker scar and subsequent rupture. 

*       Women with diffuse and large leiomyomatous uterus are best treated with conventional laparotomy. 

*       The safety and efficacy of newer procedures including myoma coagulation and cryosurgery needs to be determined.

*       For women with completed family hysterectomy should be offered.

*       Women with sub mucous myomas are best treated by hysteroscopic myomectomy.


We are grateful to Dr. F H Loh, Associate Professor, National University Hospital (NUH) Singapore, for his guidance in preparation of this review article.


1.        Hillard  PA. Benign diseases of female reproductive system: symptoms and sign. In: Berek JS ,Adashi EY, Hillard PA. (eds) Novak’s Gynaecology,12th edn.Baltimore: Williams &Wilkins,1996;331-397

2.        Buttram VC,Rieter RC .Uterine leiomyomata: etiology, symptomatology and management .Fertil Steril 1981;XX:433-445

3.        Vercelleni P, Maddalena S, Giorgi OD, Aimi G, Crosignani PG.   Abdominal myomectomy for infertility: a comprehensive review.   Human Reprod. 1998;13(4):873-9

4.        Phillips DR: Laparoscopic leiomyoma coagulation (myolysis)   Gynaecol Endosc. 1995;4:5-11.

5.        Vashisht A, Studd J, Carey A, Burn P.  Fatal septicaemia after fibroid embolisation.  Lancet 1999; 354 (9175):307-8

6.        Dubuisson JB, Chapron C.  Laparoscopic myomectomy today: a good technique when correctly indicated.   Human Reprod 1996;13(8):2102-6

7.        Nezhat FR, Roemisch M, Nezhat CH, Seidman DS,Nezhat CR  Recurrence rate after laparoscopic myomectomy   J Am Assoc Gynecol Laparosc 1998; 5(3):237-40.

8.        Nezhat C, Siegler A, Nezhat F. Laparoscopic operations on the uterus. In Operative Gynaecologic Laparoscopy. principles and techniques.  2nd ed. McGraw-Hill 2000:261-99.

9.        Valerio M, Silvia A.  Laparoscopic versus abdominal myomectomy: A prospective randomized trial to evaluate benefits in early outcome.  Am J Obstet Gynecol  1996;174(2):654-8.

10.     Dicker D, Dekei A,Orvieto R,Bar-Hava I,Peleg D,Ben-Rafael Z.  The controversy of laparoscopic myomectomy.  Human Reprod 1996;11(5):935-7.

11.     Tulandi T, Al-Took S. Endoscopic myomectomy. Laparoscopy and Hysteroscopy.  Obstet Gynecol Clin North Am  1999; 26(1):135-48

12.     Shushan A, Mohamed H and Magos AL.  How long does laparoscopic surgery really take? Lessons learned from 1000  operative laparoscopies   Human Reprod   1999;14(1):39-43.

13.     Carter JE, McCarus S, Baginiski L, Bailey TS  Lapa-roscopic outpatient treatment of large myomas.  J Am Assoc Gynecol Laparosc  1996;3(4,Supplement): S6

14.     Carter JE, McCarus SD. Laparoscopic myom-ectomy.Time and cost analysis of power vs manual morcellation. J Reprod Med   1997; 42(7): 383-8

15.     Bradley S Hurst.  Laparoscopic myomectomy.  In  Ricardo Azziz, Anna Alvarez. Murphy,  eds.   Practical manual of operative Laparoscopy and Hysteroscopy.  2nd ed   NewYork: Springer; 1997:163-72

16.     Zullo F, Pellicano M, Dicarlo C ,De Stefano R,Marconi D,Zupi E  Ultrasonographic prediction of the efficacy of GnRH agonist therapy before laparoscopic myomectomy.  J Am Assoc Gynecol Laparosc  1998; 5(4):361-6

17.     Takahashi K, Kawamura N, Ishiko O, Ogita S. Shrinkage effect of gonadotropin releasing hormone agonist treatment on uterine leiomyomas and t(12;14). Int J Oncol 2002;20(2):279-83

18.     Deligdisch L, Hirschmann S, Altchek A:   Pathologic changes in Gonadotrophin releasing hormone agonist analogue treated uterine leiomyomata.  Fertil Steril 1997;67:837-41

19.     Dubuisson JB, Chapron C, Chavet X,Gregorakis SS.  Fertility after laparoscopy of large intramural myomas: Preliminary results.  Human Reprod 1996;11(3):518-22

20.     Tulandi T, Beique F, Kimi M. Pulmonary oedema. A complication of local injection of vasopressin at laparoscopy.  Fertil Steril 1996;66(3):478-80

21.     Stringer NH, McMillen MA, Jones RL, Nezhat A, Park E   Uterine closure with endostitch 10 mm laparoscopic suturing device-a review of 50 laparoscopic myomectomies.  Int J Fertil Womens Med  1997; 42(5):288-96

22.     Barisic D, Bagovic D. A single continuous spiraling suture for uterine wall reconstruction after laparoscopic enucleation of intramural myomas.  J Am Assoc Gynecol Laparosc 2001;8(3):409-11

23.     Ostrazenski A:  Uterine leiomyoma particle growing in an abdominal wall incision after laparoscopic retrieval.  Obstet Gynecol 1997;89:853-4

24.     Golan A, Sandbank O, Rubin A. Rupture of the pregnant uterus.  Obstet Gynecol 1980;56:549-54

25.     Pelerme GR, Friedman EA.   Rupture of the gravid uterus in the third trimester.   Am J Obstet Gynecol  1996;94:571-6

26.     Acrangeli S, Pasquarette MM.  Gravid uterine rupture after myolysis.  Obstet Gyneco. 1997;89:857

27.     Dubuisson JB, Chapron C, Chavet C, Gregoakis SS,Morice P  Uterine rupture during pregnancy after laparoscopic myomectomy.   Human Reprod  1995;6(10):1475-7

28.     Harris,WJ.  Uterine dehiscence following laparoscopic myomectomy.  Obstet Gynecol 1992;80:545-6

29.     Pelosi MA III, Pelosi MA.   Spontaneous uterine rupture at thirty three weeks subsequent to superficial laparoscopic myomectomy.  Am J Obstet Gynecol 1997;177:1547-9

30.     Nezhat HC, Nezhat F, Rroemisch M, Seidman DS,Tazuke SI, Nezhat CR  Pregnancy following laparoscopic myomectomy: preliminary results. Hum Reprod   1999;14(5):1219-21

31.     Nezhat C,Nezhat F, Bess O, Nezhat CH,Mashiach R.  Laparoscopically assisted myomectomy: a report of a new technique in 57 cases.  Int J Fertil   1994;39:39-44

32.     Ostrazenski A: Extensive iatrogenic adenomyosis after laparoscopic myomectomy.  Fertil Steril 1998;69(1):143-5

33.     Pun TC, Chau MT, Lam C, Tang G, Leong L.  Sonographic evaluation of the myomectomy “scars”  .Acta Obstet Gynecol Scand  1998;77(2):218-21

34.     Seinera P, Gaglioti P, Volpi E, Cau MA, Todras T  Ultrasound evaluation of uterine wound healing following laparoscopic myomectomy:preliminary results.  Human Reprod 1999;14(10):2460-3

35.     Dubuisson JB, Fauconnier A, Chapron C, Kreiker G,Norgaard C.  Second look after laparoscopic myomectomy.   Human Reprod  1998;13(8):2102-6

36.     Keckstein J, Karageorgieva E, Darwish A, Grab D,Paulus W,Tuttlies F. Laparoscopic Myomectomy:Sonographic follow up and second look laparoscopy for the evaluation of a new technique.  J Am Assoc Gynecol Laparos 1994;1(4,Part 2):S16

37.     Bulletti C, Polli V, Glacomucci ,Flamigni C Adhesion formation after laparoscopic myomectomy   J Am Gynecol Laparosc  1996;3(4): 533-6

38.     Tulandi T, Murray C, Guralnick M. Adhesion formation and reproductive outcome after myomectomy and second-look laparoscopy. Obstet Gynecol 1993;82:123-6

39.     Yesidagler N, Koninckx PR.  Adhesion formation in intubated rabbits increases with high insufflation pressures during endoscopic surgery.  Human Reprod. 2000;15(3); 687-91

40.     Li TC, Cooke ID: The value of an absorbable adhesion barrier, Interceed, in the prevention of adhesion reformation following microsurgical adhesiolysis.  Br J Obstet Gynecol  1996;174:645-8

41.     Murray C, Tulandi T. Prevention of post myomectomy adhesion. Infertil Reprod Med Clin North Am 1996;7:169-77

42.     Takeuchi H, Kinoshita K.Evaluation of adhesion formation after laparoscopic myomectomy by systematic second-look micro laparoscopy. J Am Assoc Gynecol Laparosc 2002;9(4):442-6.

43.     Iversion RE Jr, Chelmow D, Strohbehn K, Waldman L, Evantash EG, Aronson MP.   Myomectomy fever: testing the dogma.  Fertil Steril 1999;72(1):104-8

44.     Chapron C, Pierre F,Harchaoui Y, Larcoix S,Beguin S,Querleu D, et al. Gasrointestinal injuries during gynaecological laparoscopy.   Human Reprod 1999;14(2):333-7

45.     Candiani GB, Fedele L, Parazzini F, Villa.  Risk of recurrence after myomectomy  J Obstet Gynecol   1991;98(4):385-9

46.     Fedele F, Parazzani F, Luchini L et al.  Recurrence of fibroids after myomectomy: a transvaginal ultrasonographic study. Human Reprod  1995;10(7):1795-6

47.     Rossetti A, Sizzi O, Soranna L, Cucinelli F, Mancuso S, Lanzone A. Long-term results of laparoscopic myome-ctomy: recurrence rate in comparison with abdominal myomectomy.Hum Reprod 2001;16(4):770-4

48.     Li TC, Mortimer R, Cook ID.  Myomectomy: a retrospective study to examine reproductive performance before and after surgery.  Human Reprod 1999;14(7):1735-40

49.     Verkauf BS: Myomectomy for fertility enhancement and preservation.  Fertil Steril 1992;58:1-15

50.     Hasson HM, Rotman C, Rana N, Sistos F, Dmowski WP.  Laparoscopic myomectomy.  Obstet Gynecol  1992;80:884-8

51.     Miller CE, Johnston M, Rundell M: Laparoscopic myomectomy in infertile women.  J Am Assoc Gynecol Laparoscop 1996;3:525-9

52.     Dubuisson JB, Chapron C, Fauconnier A, Babaki-Fard K: Laparoscopic myomectomy fertility results: Ann N Y Acad Sci 2001;943:269-75

53.     Seinera P, Farina C, Todros T.  Laparoscopic myomectomy and subsequent pregnancy:result in 54 patients.  Human Reprod 2000;15(9):993-6

54.     Dubuisson JB, Fauconnier A, Deffarges JV, Norgaard C, Kreiker G, Chapron C. Pregnancy outcome and deliveries following laparoscopic myomectomy.  Human Reprod 2000;15(4):869-73

55.     Whittaker MD, Garry R. Patient satisfaction with laparoscopic-assisted removal of large myomas.  J Am Assoc Gynecol Laparosc 1996; 3(4,supplement):S55

56.     Rossetti A, Sizzi O, Soranna L, Mancuso S, Lanzone A. Fertility outcome: long-term results after laparoscopic myomectomyGynecol Endocrinol 2001;15(2):129-34

57.     Seidman DS, Nezhat CH, Nezhat F, Nezhat C. The role of laparoscopic-assisted myomectomy (LAM) : JSLS 2001;5(4):299-303

58.     Signorile Laparoscopic ultraminilaparotomic myomec-tomy (LUM)-laparoscopic ultraminilaparotomic embol-ized myomectomy (LUEM). Surgical techniques. Clin Exp Obstet Gynecol 2002;29(4):277-80

59.     Pelosi MA III and Pelosi MA.  Laparoscopic assisted transvaginal myomectomy. J Am Assoc Gynecol Laparosc  1997;4(2):241-6

60.     Wang CJ, Yen CF, Lee CL, Soong YK. Laparoscopic-assisted vaginal myomectomy. J Am Assoc Gynecol Laparosc 2000;7(4):510-4

61.     Phillips DR: Laparoscopic leiomyoma coagulation (myolysis)   Gynaecol Endosc 1995;4:5-11

62.     Vilos GA, Daly LJ, Tse BM.  Pregnancy outcome after laparoscpic electromyolysis.  J Am Assoc Gynecol Laparosc 1998;5:289

63.     Zreik TG, Ruherford TJ, Palter SF, Troiano RN,William E,Brown JM,Olive DL. Cryomyolysis, a new procedure for conservative treatment of uterine fibroids. J Am Assoc Gynaecol Laaprosc 1998;5:33-38.


Address for Correspondence       

Major Nazli Hameed, Consultant Gynaecologist, Combined Military Hospital, , Peshawer

Tel. off: 91-2016142, Res: 91-2026143