{"paper_id":"832fdc22-2b09-495d-ac0e-c93f8a083483","body_text":"Gynecol Surg (2006) 3: 61 –63\nDOI 10.1007/s10397-006-0175-3\nCASE REPORT\nJenny S. Y. Lo . Andrew Pickersgill\nSuccessful treatment of dysfunctional uterine bleeding using\nlaparoscopic bilateral uterine artery ligation\nReceived: 29 August 2005 / Accepted: 23 December 2005 / Published online: 21 February 2006\n# Springer-V erlag Berlin / Heidelberg 2006\nAbstract We present a case of dysfunctional uterine\nbleeding in a woman who wished to retain her fertility\nbut found conventional treatment neither suitable nor\nsuccessful. Her condition was successfully treated with\nlaparoscopic bilateral ligation of the uterine artery.\nKeywords Dysfunctional uterine bleeding .\nMenorrhagia . Bilateral uterine artery ligation . Anaemia\nIntroduction\nMenorrhagia accounts for about 15-30% of referrals to\ngynaecologists. Most women have no detectable pelvic\npathology and are diagnosed as suffering with dysfunc-\ntional uterine bleeding (DUB). The condition often impacts\nthe sufferer ’s quality of life, and it can occasionally be\nassociated with significant morbidity. Its aetiology is\npoorly understood, and there are medical, surgical, and\ncombined methods of treating it. The treatment choice\ndepends on the severity of bleeding, the woman ’s repro-\nductive desire, and the treatment options available at the\ncare site. The mainstays of conservative treatment are\ndrugs, often contraceptives, and the Mirena coil. The drugs\ncan be poorly tolerated because of their side effects and are\nof little use in patients trying to become pregnant.\nHysterectomy remains the most curative treatment for\nDUB, although more endometrial ablations are now being\ndone. The most commonly performed surgical options are\nalso not fertility sparing, although they are not necessarily\nsterilising. Therefore, current treatment modalities have\nlittle to offer those women with DUB who wish to\nconcurrently conceive.\nWe report a patient in whom none of the conventional\ntreatments was suitable or successful. Her condition was\nsuccessfully treated by ligating both uterine arteries. This is\nthe first case in which the procedure was performed\nlaparoscopically for dysfunctional uterine bleeding and had\na successful outcome.\nCase report\nCH was a 34-year-old woman referred for a second\nopinion. She had had debilitating menorrhagia and\ndysmenorrhoea for several years and had been advised\nthat she required a hysterectomy. She had started her\nperiods at the age of 11 and had subsequently suffered with\nanaemia. This was chronic and responded poorly to iron\nsupplements, which she had taken since she was 15 years\nold. Her periods were also extremely painful; she suffered\nfrom severe central menstrual cramps. The combination of\nthe dysmenorrhoea and menorrhagia was debilitating.\nAfter 12 years of managing her condition in primary\ncare, she was finally referred to her local gynaecologist.\nShe was investigated, including having a diagnostic\nlaparoscopy, and was diagnosed as suffering with DUB.\nShe was then treated with continuous combined oral\ncontraceptive pills for the next 3 years. At the age of 30 she\ndecided to start a family and stopped taking the oral\ncontraceptives. Not surprisingly, her dysmenorrhoea, men-\norrhagia, and coexisting anaemia promptly returned. Her\ngeneral practitioner suggested a course of tranexamic acid,\nwith no apparent benefit. She was reviewed by her\ngynaecologist, and an abdominal hysterectomy was\nadvised. At that point she asked for a second opinion.\nAt the time of referral for her second opinion, she was\nhaving a regular menstrual cycle, bleeding heavily for 8\ndays every month. Her haemoglobin was 10.6 g/dl, with a\nmean cell volume of 78.8 fl and serum ferritin of 1 ug/l. Her\nluteal-phase progesterone levels suggested ovulation.\nClinical examination was normal. Because she was also\ntrying to conceive, the options of further contraception\npills, progestogens, the Mirena coil, endometrial ablation,\nJ. S. Y . Lo ( *) . A. Pickersgill\nWomen’s Unit, Stepping Hill Hospital,\nPoplar Grove,\nStockport, SK2 7JE, UK\ne-mail: jennylo@doctors.org.uk\nTel.: +44-161-4195534\nFax: +44-161-4195582\n\nand hysterectomy were excluded. It was suggested that\nbilateral uterine artery ligation might be a solution to treat\nher menorrhagia and preserve her fertility, and it was\nproposed that this be done laparoscopically. After due\nconsideration, she opted for the surgery.\nTherefore, bilateral uterine artery ligation was performed\nlaparoscopically. The procedure was performed under\ngeneral anaesthesia with the patient in the dorsolithotomy\nTrendelenburg position. A uterine manipulator was\nintroduced, and videolaparoscopy was performed using a\n10-mm 0-degree laparoscope inserted using the open\ntechnique through an umbilical incision. Two 5-mm side\nports were inserted under direct vision lateral to the inferior\nepigastric vessels. Using monopolar diathermy (90 W\ncutting current and 60 W coagulation) with microscissors\nand graspers, the peritoneum of the anterior leaf of the right\nbroad ligament, between the round ligament and the\ninfundibulopelvic ligament, was incised. The lateral um-\nbilical ligament was recognised. Following this upwards,\nthe uterine artery was identified crossing the ureter. After\nsharp and blunt dissection, the ureter was dissected\nlaterally, away from the uterine artery, which was isolated\nand occluded with Ligaclips and then coagulated. The\nprocedure was then repeated on the left side. The\nperitoneum was left open, and no antiadhesive preparations\nwere available for use. The patient ’s postoperative progress\nwas uneventful.\nWhen she was reviewed a year later, her menorrhagia\nwas subjectively cured, and she was satisfied with the\nprocedure. She was no longer anaemic or taking iron\nsupplementation. Her haemoglobin was 11.7 g/dl with a\nmean cell volume of 83.9 fl. However, the procedure had\ndone nothing for her dysmenorrhoea, which persisted and\nrequired multiple analgaesics. Further treatment options\nwere discussed, and she subsequently had a laparoscopic\npresacral neurectomy that finally relieved her dysmenor-\nrhoea. No adhesions were identified at this laparoscopy,\nand her peritoneum had healed as normal.\nDiscussion\nThe main blood supply to the uterus is derived from both of\nthe uterine arteries, with the vaginal and ovarian vessels\nsupplying approximately 58%. Uterine artery embolisation\nis now an established and successful treatment for uterine\nfibroids, though it can be associated with complications\nand is currently not recommended as a treatment for\nwomen wishing to preserve their fertility. However,\nsuccessful pregnancies have been reported following it.\nThe effect of surgical ligation of the uterine vessels may\nnot be equivalent to embolisation, where more diffuse\ndamage to the uterine vasculature is thought to occur [ 1].\nAs a result of embolisation, there appears to be an abrupt\nand severe cell ischaemia, with a slow and gradual cell\nischaemia following ligation. Some authors recommend\ndestroying the anastomotic vessels between the uterine and\novarian arteries to diminish the development of collateral\ncirculation that could render the surgery less effective [ 2].\nHowever, most authors who have described laparoscopic\ncoagulation or ligation of the uterine vessels had selected\npatients not desiring further pregnancies.\nBilateral uterine artery ligation was first described as a\ntreatment for postpartum haemorrhage in 1952 by Waters\nin a series of eight patients [ 3]. The largest series was\ninitially reported in 1966 [ 4], with further additions\nincreasing the numbers to 90 by 1974 [ 5]. In these cases,\nbilateral uterine artery ligation was used successfully to\ntreat severe haemorrhage at the time of caesarean section.\nMore recently, it has been effectively used to manage\ndelayed postpartum haemorrhage [ 6] and in caesarean\nmyomectomy [ 7].\nThe procedure was first described in gynaecological\npractice in 1964 to treat menorrhagia arising in association\nwith fibroids and also with DUB [ 8]. Furthermore, it has\nbeen advocated to be of value in conjunction with\nmyomectomy, both as an aid to reduce intraoperative\nbleeding and then to prevent the recurrence of heavy\nperiods. Early case series reported substantial relief of\nsymptoms following the procedure. Despite these reports,\nthe practice of uterine artery ligation at laparotomy has\nbeen adopted by only a few gynaecological surgeons, and it\nhas never been recognised as a mainstay treatment.\nIn recent times with the advent of better optics and\ninstrumentation, laparoscopic techniques have flourished,\nand techniques of occluding the uterine vessels have been\nsuccessfully adapted to this approach. To perform laparo-\nscopic uterine artery ligation, the surgeon must be equipped\nwith the necessary laparoscopic skills and should be able to\nprecisely locate the uterine artery. The exact site at which\nthe uterine artery is exposed and occluded is generally near\nits origin from the internal iliac artery [ 8–10]. It can also be\ntaken nearer the uterus, although technically this is thought\nto be a more difficult site for isolating it [ 11]. How best to\nocclude or ligate the vessel is a matter of conjecture.\nSutures were originally used, and recanalisation was later\nnoted [ 4]. Similar findings occurred after bipolar desic-\ncation [10], so some authors recommend Ligaclips, often in\ncombination with bipolar coagulation [ 9, 10, 12, 13].\nLaparoscopic bilateral uterine artery ligation has been\nused prior to laparoscopic myomectomy in various centres.\nA recent study by Liu et al. [ 10] has shown laparoscopic\nbipolar coagulation of uterine vessels alone, without\nmyomectomy, to be an effective method for treating\npatients with fibroid-related menorrhagia and pelvic pain.\nIt is safe and effective even in the presence of altered pelvic\nanatomy. The combination of laparoscopic bilateral artery\nligation and intraamniotic methotrexate injection appears\nto be effective in preventing unexpected massive uterine\nbleeding in patients with cervical pregnancy, and it does\nnot compromise future fertility [ 14]. However, this method\nhas been shown to result in poor satisfaction when used to\ntreat symptomatic adenomyosis [ 9].\nMean operating times have been reported as 20 –56 min\n[9] with a hospital stay of 1–2 days [9, 12]. In Wang’s series\nof women with menorrhagia and adenomyosis, the proce-\ndure resulted in 31% eumenorrhoea or hypomenorrhoea,\n62\n\nand 81% achieved a reduction in menstrual loss by 30% or\nmore.\nComplications following this operation include postop-\nerative pain. It has been reported that 24 out of 85 women\nwho underwent uterine vessel ligation for the treatment of\nfibroids experienced lower abdominal pain postoperatively,\nwhich persisted for 2 weeks and mostly developed 5 –6\ndays after surgery [ 10]. Another study also reported that\nprocedure-related pain occurred in most women within the\nfirst 24 h of surgery, and up to 40.7% patients had\nnonmenstrual pain afterwards. This may be associated with\ntarget-tissue ischaemia [ 9]. Our patient did not experience\ndebilitating postoperative pain.\nImpaired ovarian function (transient amenorrhoea, men-\nstrual irregularities) and premature ovarian failure after the\nprocedure have been reported, especially in women older\nthan 45 years. It is not known whether uterine vessel\nligation alters the age at which ovarian activity ceases or\nwhat the long-term effect on the uterine blood supply is.\nThis is a cause of concern, especially in women in whom\nthere is the possibility of compromising subsequent\nfertility. However, successful pregnancies have been\nreported following uterine artery ligation, initially with\nlaparotomy and more recently laparoscopy [ 10, 11]. Our\npatient was counselled that there was no guarantee of a\npregnancy following the surgery and that the long-term\nrisks and benefits of the procedure are hard to predict.\nA laparoscopic presacral neurectomy was not performed\nsimultaneously at the time of the first procedure. It was\nthought that impairing the uterine perfusion could have had\na beneficial effect on prostaglandin production. Likewise,\nsome women experience uterine cramping as they pass\nclots, and it was postulated that if the procedure resulted in\nless bleeding it could have reduced the production of clots.\nWang et al. [9] showed a positive effect on dysmenorrhoea,\nwith 75% of their patients achieving “control” of it and\n37.5% being free of analgaesia.\nLaparoscopic bilateral uterine artery ligation in experi-\nenced hands is associated with low morbidity and has the\npotential to avoid the need for hysterectomy. The postop-\nerative recovery is within days rather than weeks, which\nimparts considerable cost savings. We believe there is a\nplace for laparoscopic uterine vessel ligation in the\ntreatment of dysfunctional uterine bleeding. However, the\nlong-term effects on symptomatic relief and the possible\nside effects of this technique must be fully assessed.\nReferences\n1. Bradley EA, Reidy JF, Forman RG, et al (1998) Transcatheter\nuterine artery embolisation to treat large uterine fibroids. Br\nJ Obstet Gynaecol 105(2):235 –240\n2. Chen YJ, Wang PH, Y uan CC et al (2002) Successful\npregnancy in a woman with symptomatic fibroids who\nunderwent laparoscopic bipolar coagulation of uterine vessels.\nFertil Steril 77(4):838 –840\n3. Waters EG (1952) Surgical management of postpartum hem-\norrhage with particular reference to ligation of uterine arteries.\nAm J Obstet Gynecol 64:1143\n4. O ’Leary JL, O ’Leary JA (1966) Uterine artery ligation in the\ncontrol of intractable postpartum hemorrhage. Am J Obstet\nGynecol 94:920 –924\n5. O ’Leary JL, O ’Leary JA (1974) Uterine artery ligation for\ncontrol of postcesarean section hemorrhage. Obstet Gynecol\n43:849–853\n6. Chou YC, Wang PH, Y uan CC et al (2002) Laparoscopic\nbipolar coagulation of uterine vessels to manage delayed\npostpartum hemorrhage. J Am Assoc Gynecol Laparosc 9\n(4):541–544\n7. 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Park KH, Kim JY , Shin JS et al (2003) Treatment outcomes of\nuterine artery embolization and laparoscopic uterine artery\nligation for uterine myoma. Yonsei Med J (Korea (South)) 44\n(4):694–702\n14. Lin H, Kung FT (2003) Combination of laparoscopic bilateral\nuterine artery ligation and intraamniotic methotrexate injection\nfor conservative management of cervical pregnancy. J Am\nAssoc Gynecol Laparosc 10(2):215 –218\n63","source_license":"CC0","license_restricted":false}