Minimally Invasive Therapy & Allied Technologies

ISSN: 1364-5706 (Print) 1365-2931 (Online) Journal homepage: http://www.tandfonline.com/loi/imit20

Uterus banding with the Osada method effectively

reduces intraoperative blood loss during
myomectomy

Grzegorz Raba, Jan Kotarski, Kamil Szczupak, Beata Obloza & Magdalena
Fudali-Walczak

To cite this article: Grzegorz Raba, Jan Kotarski, Kamil Szczupak, Beata Obloza & Magdalena
Fudali-Walczak (2015): Uterus banding with the Osada method effectively reduces
intraoperative blood loss during myomectomy, Minimally Invasive Therapy & Allied
Technologies

To link to this article: http://dx.doi.org/10.3109/13645706.2015.1075558

Published online: 02 Sep 2015.

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 Minimally Invasive Therapy. 2015; Early Online, 1–5

ORIGINAL ARTICLE

Uterus banding with the Osada method effectively reduces

intraoperative blood loss during myomectomy

GRZEGORZ RABA1, JAN KOTARSKI2, KAMIL SZCZUPAK3, BEATA OBLOZA4,

MAGDALENA FUDALI-WALCZAK5
1
Institute of Obstetrics and Medical Lifesaving of the University of Rzeszow, Rzeszow, Poland, 2Medical University of
Downloaded by [New York University] at 04:50 12 September 2015

Lublin, Lublin, Poland, 3Department of Gynecology and Obstetrics, Provincial Hospital, Przemysl, Poland, 4Institute of
Mother and Child in Warsaw, Poland, and 5Provincial Hospital, Przemysl, Poland

Abstract
Introduction: The surgery of fibroid removal and reconstruction of the uterus is associated with increased blood loss. That is a
significant limitation of surgical myomectomy. There are many methods to decrease blood loss during myomectomy.
However, in women planning to conceive their reversibility is important. The procedure of uterus banding with the Osada
method meets this condition. The objective of this study was a comparison of intraoperative blood loss during the
myomectomy with banding according to the Osada technique with blood loss during a classic myomectomy with the Martin
method. Material and methods: The study group consisted of 140 women with myomatous uterus. In 70 patients
myomectomy was performed with the Osada uterus banding method, for the remaining 70 patients the Martin method
was applied. Results: Myomectomy with banding according to the Osada method versus myomectomy with the Martin
method: intraoperative blood loss (ml): 56 ± 23 vs 378 ± 186, p < 0.05; a drop in hematocrit levels over 24 hours postoperatively
(%): 0.32 ± 0.12 vs 3.42 ± 2.54, p < 0.05; a drop in hemoglobin concentration over 24 hours postoperatively (g/dl): 0.13 ±
0.04 vs 0.79 ± 0.38, p < 0.05. the need for blood transfusion (% of women): 0 vs 4.28, p < 0.05. Conclusion: Myomectomy
performed according to the Osada method of uterus banding is associated with less intraoperative blood loss.

Key words: Myomectomy, uterine fibroids, Martin method

Introduction of arterio-arterial anastomoses in the myometrium

The frequency of occurrence of uterine fibroids
increases with age, in the third and fourth decades
of life (1,2). Social changes have caused more women
to delay childbearing. Thus it can be expected that in
women suffering from fibroids of the uterus the num-
ber of surgeries allowing to preserve the childbearing
function will increase, reducing the frequency of
hysterectomy (3–5). The surgery of fibroid removal
and reconstruction of the uterus is associated with
blood loss resulting from vascularization of the myo-
metrium (6). The blood supply comes mainly from
the uterine arteries and from the ovarian arteries,
through the fallopian tube branch of the ovarian artery
(7). Vascularization by the round and uterosacral
ligaments must also be accounted for. The presence
constitutes an essential element hampering the effect
of haemostasis at the site where fibroids have been
removed. Also individual differences in the vascular-
ization of particular fibroids are important. In some
clinical conditions, e.g., in women after the surgery of
ligation of internal iliac arteries to control bleeding in
childbirth, the leading role of the uterine arteries can
be taken over by the ovarian arteries through reversal
of blood flow in the ovarian branches of the uterine
arteries (8). For years, myomectomy as described by
Martin has been the standard of care for removing
uterine fibroids (9). The main reason for a rare
qualification for myomectomy is the fact that it is a
procedure burdened with the risk of a several times
higher number of complications (9). These complica-
tions result from higher blood loss due to a large

Correspondence: Grzegorz Raba, University of Rzeszow, Zuravica, Poland. E-mail: g.raba@plusnet.pl

ISSN 1364-5706 print/ISSN 1365-2931 online  2015 Informa Healthcare

DOI: 10.3109/13645706.2015.1075558
 2 G. Raba et al.
healing surface of the uterine muscle, no possibility of
immediate haemostasis (closing large vascular trunks)
and disorders in uterine contractility (3,10). In order
to decrease intraoperative blood loss a number of
modifications have been introduced to this surgical
procedure (7). Ravina et al. (11) applied preoperative
uterine artery embolization. Also ligation or coagula-
tion of uterine arteries effectively decreases the
amount of blood loss. Myometrial injection of
vasopressin at the site adjacent to the fibroid is widely
used during laparoscopic myomectomy (12).
However, in women planning to conceive reversibility
of procedures reducing uterine vascularization is
essential. The technique proposed by Osada of the
so called ‘banding’, involving a periodical, atraumatic
Downloaded by [New York University] at 04:50 12 September 2015
clamping of uterine arteries and their branches,
meets this condition. In the available literature there
are no randomized studies which would assess intrao-
perative blood loss during myomectomy following
the classic Martin method or involving uterus
banding.
This study aimed to compare intraoperative blood
loss during the surgery of myomectomy performed
with the Osada uterus banding procedure with blood
loss during myomectomy by means of the Martin
method.
Material and methods
We conducted a prospective cohort study. The study
group consisted of 140 women of child-bearing age
with fibroid uterus desiring to preserve fertility. In
70 patients, myomectomy with the Martin procedure
was used (cohort B), in the remaining 70 patients,
uterus banding was performed during myomectomy
following the procedure presented by Osada in the
‘Comprehensive Manual and Procedures DVD’
(Medical View 2009) (cohort A).
For each cohort patients were qualified according
to the following criteria. Inclusion criteria: Between
Table I. Characteristics of the study group
Cohort A: Osada banding method
Group size 70
Average number of fibroids (items) 2.4
Average uterine volume (cm )3
487
Patient age (years) 32.6
Average preoperative hemoglobin 10.8
concentration (g/dl)
No. of women with 1-2 fibroids 41
No. of women with 3-4 fibroids 29
28 and 37 years of age, number of fibroids from one to
four, uterus volume 400-600 gr. Exclusion criteria:
Patients who underwent laparotomy, BMI >30. The
number of fibroids and the volume of the uterus were
measured using an endovaginal ultrasound and
volumetric software. Patients for cohorts A and B
were randomly assigned – every other patient in the
order of admission for the surgery. Both cohorts were
compared with respect to intraoperative blood loss, a
drop in hematocrit levels and hemoglobin concentra-
tion over 24 hours after the operation, and the
frequency of erythrocyte mass transfusion.
In order to apply a uniform surgical procedure all
the surgeries were performed by the same team using
a single surgical protocol. Intraoperative blood loss
was calculated with a blood collection method with
direct suction of the surgical field from the moment of
uterine incision to its closure and obtaining complete
haemostasis of the uterine wall on visual assessment.
Suction drainage was the only form of visualization of
the operation field. Before starting the measurement,
full haemostasis of the incised abdominal wall was
obtained. The protocol was acknowledged by the
University of Rzeszów Bioethics Committee. The
analysis of the convergence of features was made by
means of the chi-squared test. The level of p <
0.05 was considered statistically significant.
In both cohorts patients did not significantly differ
in age, number of fibroids, average uterus volume or
average concentration of hemoglobin before the
surgery (p > 0.05) (Table I).
Results
Table II shows that intraoperative blood loss, a drop
in hematocrit levels over 24 hours postoperatively, a
drop in hemoglobin concentration and the necessity
for erythrocyte mass transfusion were statistically
significantly lower (p < 0.05) after surgical myomec-
tomy using banding with the Osada technique (cohort
Cohort B: Martin method p
70 >0.05
2.8 >0.05
535 >0.05
35.1 >0.05
11.4 >0.05
37 >0.05
33 >0.05
 Uterus banding for myomectomy reduces blood loss 3

Table II. Intraoperative calculation of blood loss, a drop in hematocrit level and hemoglobin concentration, and the frequency of erythrocyte
mass transfusion in the study group.

Cohort A: Cohort B:
(Osada banding method) (Martin method) p

Intraoperative blood loss (ml) 56 ± 23 378 ± 186 <0.05

A drop in hematocrit level over 24 hours postoperatively (%) 0.32 ± 0.12 3.42 ± 2.54 <0.05
A drop in hemoglobin concentration over 24 hours postoperatively (mg/dl) 0.13 ± 0.04 0.79 ± 0.38 <0.05
Erythrocyte mass transfusion (% of cases) 0 4.28 <0.05

Table III. Comparison of intraoperative blood loss assessment parameters in women with one to two and three to four fibroids in the group
who underwent the surgery by means of banding.

Cohort A (Osada banding method) Number of fibroids: 1-2 Number of fibroids: 3-4 p
Downloaded by [New York University] at 04:50 12 September 2015

Intraoperative blood loss (ml) 52 ± 25 56 ± 19 >0.05

A drop in hematocrit levels over 24 hours postoperatively (%) 0.33 ± 0.14 0.36 ± 0.07 >0.05
A drop in hemoglobin concentration over 24 hours postoperatively 0.11 ± 0.08 0.15 ± 0.06 >0.05
Erythrocyte mass transfusion (% of cases) 0 0 N.A.

A) in comparison to the surgeries performed using the
Martin technique (cohort B).
No statistically significant differences were found to
exist (p > 0.05) in the amount of blood loss (ml), a
drop in hematocrit (%), and concentration of hemo-
globin (mg/dl) in women with one to two and those
with three to four fibroids who underwent the surgery
with uterus banding (Table III).
As shown in Table IV, statistically significant
differences (p < 0.05) were found to exist in the
amount of blood loss (ml), a drop in haematocrit
(%), hemoglobin concentration (mg/dl), and the fre-
quency of erythrocyte mass transfusion between
women with one to two fibroids and those with three
to four fibroids who underwent the surgery by means
of the classic Martin method.
Discussion
Higher intraoperative blood loss and the resulting
complications are a major limitation of myomectomy
with the Martin method. In the study group, the
application of uterus banding with the Osada tech-
nique during myomectomy allowed to substantially
decrease operative blood loss. Today there is a grow-
ing tendency in the frequency of performing myo-
mectomy compared with the frequency of performing
hysterectomy (12). This results from the pressure on
the part of the patients who desire to preserve fertility.
Another serious reason is a growing group of women
for whom retaining the uterus is a value for its own
sake, not directly connected with conception, and its
removal can lead to self-image disorders and lower
self-esteem (13). The tendency for myomectomy
replacing hysterectomy makes surgeons look for
surgical techniques which reduce blood loss during
myomectomy. Cases of decrease in blood loss during
myomectomy with the application of compression in
the cervical area by means of Foley’s catheter have
been reported. In a retrospective study Alptelin et al.
(14) proved the effectiveness of such treatment for
intraoperative blood loss reduction. Our prospective

Table IV. Comparison of intraoperative blood loss assessment parameters in women with one to two and three to four fibroids in the group
who underwent the surgery performed by means of a classic Martin method.

Cohort B (Martin method) Number of fibroids: 1-2 Number of fibroids: 3-4 p

Intraoperative blood loss (ml) 293 ± 127 436 ± 194 <0.05

A drop in hematocrit levels over 24 hours after the operation (%) 2.73 ± 1.77 4.24 ± 2.88 <0.05
A drop in hemoglobin concentration over 24 hours after the 0.55 ± 0.32 0.86 ± 0.41 <0.05
operation (mg/dl)
Erythrocyte mass transfusion (% of cases) 0 9 <0.05
 4 G. Raba et al.
study proves the effectiveness of temporary compres-
sion in the cervical area to control intraoperative
blood loss with a two times larger group of patients.
The achieved level of minimization of haemorrhage is
worth noting. The technique of cervical area com-
pression reported in the study by Alptelin et al.
allowed decrease of bleeding by about 50%. The
technique proposed by Osada, which was applied in
our study, allowed to achieve an over five times
greater reduction of intraoperative blood loss
expressed in millilitres. Also no difference in the
effectiveness of banding in terms of reduction of blood
loss between patients with one to two and three to four
fibroids was found to exist in the study. It is worth
noting that such difference occurred in the group who
Downloaded by [New York University] at 04:50 12 September 2015
underwent the surgery by means of the classic Martin
method, which is indicative of the increase of blood
loss with the number of fibroids. The weakness
of the present study is the methodology of intraopera-
tive blood loss calculation, which is certain to be
burdened with some error. However, at present no
perfect method of calculation of intraoperative
blood loss exists. The other proposed techniques,
e.g. weighing wound dressings, are indirect methods,
thus burdened with even greater measurement
tolerance error. The impossibility to have an exact
measurement of operative blood loss is well known.
The method applied in the study of direct suction of
the surgical field, despite its drawbacks, seems to be
the most precise method of assessment available.
Apart from banding, there exist other methods
decreasing blood loss during removal of fibroids.
Uterine artery embolisation (UAE) results in signif-
icant symptom relief and quality of life improvement
(11). Embolization prior to myomectomy not only
decreases blood loss, but also prevents recurrence of
myomata in the future. However, UAE does not meet
the criterion of reversibility. In women planning to
conceive reversibility of procedures reducing uterine
vascularization is essential. The technique proposed
by Osada, the so called ‘banding’, meets the condition
of reversibility. According to Tinelli et al. (15), blood
loss is substantially reduced during laparoscopic myo-
mectomy. Shokeir et al. (16) obtained good results by
administering intravaginal dinoprostone before the
surgery. Randomized control studies have shown a
similar outcome with preoperative intravaginal
administration of misoprostol (17). The ‘vascular
cut off technique’, thanks to which Alobaid et al.
(18) managed to decrease blood loss during myomec-
tomy in relation to a classic technique, seems to be
another alternative. Thus uterine banding, which was
the subject of our study, is one of several alternative
techniques decreasing blood loss during myomec-
tomy. The advantages of banding include its high
clinical effectiveness, full reversibility, simplicity of
application as well as low cost. Nowadays there exist
several treatment methods, both pharmacological as
well as non-pharmacological, which aim at reducing
fibroid volume and relieving its symptoms. However,
surgical treatment still remains the standard of care
for uterine fibroids (19–22). When planning treat-
ment, in order to minimize intraoperative blood loss,
assessment of fibroid parameters should be made
(size, location, number) to determine the most effi-
cient performance of myomectomy. They are subjec-
tive in character and depend on the centre’s
experience and the surgical procedure protocols
used. Apart from higher blood loss, arguments against
myomectomy include considerable injury to the
uterine muscle in the case when there are more
than four fibroids and a quite high recurrence rate
(about 30% or more, depending on age) (23).
The data made us exclude from the study patients
with more than four fibroids. Also women with a
history of prior laparotomy and with BMI >30 were
excluded from the study. The decision was made
due to the probable technical problems in performing
banding in the above-mentioned group. Myomec-
tomy with uterus banding following the Osada
procedure creates new possibilities and also elimi-
nates major intraoperative complications, i.e., high
blood loss and its consequences. It is worth noting
that the procedure of banding might not be effective in
the above-mentioned women after the surgeries of
internal iliac artery ligation. The cause of failure in
this group of patients might be the presence of
diverted flow of blood in the ovarian branches of
uterine arteries (8). In such clinical cases the main
path of vascularization of the uterus is the flow of
blood through the infundibulopelvic ligaments. The
application of any procedures of compression of ves-
sels in the cervical area will not reduce arterial blood
flow to the myometrium. However, in the cases of
patients with physiologically internal iliac arteries
the procedure of banding makes the surgery of
myomectomy safer, which is why it can be a valuable
alternative during the treatment of fibroids of the
uterus in women who wish to retain their childbearing
ability. Uterus banding following the Osada method
is also operator-friendly, simplifying the surgery
through substantial reduction of intraoperative
bleeding.
Conclusion
Myomectomy performed according to the Osada
method of uterus banding is accompanied by less
intraoperative blood loss.

Declaration of interest
The authors report no conflicts of interest. The
authors alone are responsible for the content and
writing of the paper.
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