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Multiple myomectomy
Multiple myomectomy FRANK
R.
Winston-Salem,
LOCK, North
M.D. Carolina
Although multiple myomectomy is seldom used in current gynecologic practice, it is a procedure that has definite value, especially for young women who desire children. Three case summaries have been presented to show that the operation can be used successfully in patients with numerous large fibroids, even when degeneration of some tumors is present. The technique and applicability of this procedure are then considered in some detail. Pregnancy can be expected in about 40 per cent of the patients who have undergone myomectomy, and in most cases is carried to a successful conclusion.
THE OPERATION of multiple myomectomy was first described by William Alexanderl of Liverpool in 1898. His report on the subject, entitled “Nucleation of Uterine Fibroids,” began with the following statement :
be enucleated through the natural uterine and vaginal passages and some more or less pedunculated subperitoneal fibroids, that may be ligatured and snipped off or enucleated, the
operative
Opinions are divided as to the treatment of uterine fibroids. Some medical men hold that severe operative treatment is very rarely required, and that medicinal treatment and the occasional performance of minor operations, such as dilating the uterine canal, curetting, and electrolysis, will tide most uterine fibroids over the menopause. When this period is reached the tumours may be expected to shrink in size and become innocuous. Others hold that they are not the comparatively harmless growths they are sometimes represented to be, and that they kill their hosts more frequently than many medical men admit and to prevent their harmful and often Fatal effects a severe mutilating operation is not only justifiable, but one to be recommended.
in
a few
cases,
where
the
tumor
From the Department of Obstetrics Gynecology, Bowman Gray School Medicine of Wake Forest University.
of most single is extremely
and of all sweeping
plan is by removal
in
of the
this is not so certain as uterus and fibroids, with the appendages, and this
is not so neat
as removal
tumour through easy or applicable by which tomy,
the
of the uterus vagina; and this is not to all cases as panhysterecall the internal reproductive
and so
organs are removed at one fell swoop. The
medical
references small fibroids, and in young people, and with good results as far as the mortality is concerned. But lessened risk of death from an operation does not necessarily justify an operation. To amputate a limb for a strumous ,joint would be a safe neat method of getting rid of a troublesome disease, but the sufferer has afterward to do without a very useful part of his body. .
to the more
Alexander went on to describe the prevailing therapeutic practices as follows: Except
treatment
multiple uterine fibroids, its extent. The mildest ovaries and tubes, but partial removal of the or without removal of
journals
contain
severe operation,
many
even for
A review of recently published textbooks of gynecology will establish that the dilemma described by Alexander has not yet been resolved. While some writers recommend individualization of therapy for uterine fibroids on the basis of the patient’s needs, age, and desire for subsequent pregnancies, a number of authors arbitrarily lay down guidelines reflecting their convictions and practices-
can
and of
The Annual Guest Lecture, presented at the Thirty-sixth Annual Meeting of the Central Association of Obstetricians and Gynecologists, Oklahoma City, Oklahoma, Sept. 26-28, 1968. 642
Volume 104 Number 5
Multiple
often giving scant consideration to myomectomy or expressing disapproval of this procedure for any except minimal lesions. Skepticism regarding the functional capability of the uterus following myomectomy is implied or specifically stated. Although the diagnosis and management of benign uterine tumors have been discussed extensively in the obstetric and gynecologic literature, it is rather remarkable that only two publications on the subject of myomectomy have appeared in a major national journal related to our specialty in the past 10 years. The textbook presentations do not adequately reflect the experience documented by the pioneers who deveIoped gynecology as a surgical specialty. At the time of Alexander’s report, the problems of hemorrhage and sepsis made myomectomy hazardous. In the 1920’s, however, the enthusiastic reports of Victor Bonney21 3, 4 in England and of Kelly and Noble,5 Mayo,6 and Rubin? in this country won a limited popularity for the procedure. Certainly every qualified surgeon has performed numerous myomectomies, but it is my belief that multiple myomectomy has been largely abandoned in current gynecologic practice. Nearly all of the patients coming to me with marked uterine enlargement and multiple tumors have been told by qualified surgeons that hysterectomy was the only treatment available to them; yet many of these women were desperately anxious for children. Since the statistics regarding myomectomy have been adequately presented in previous publications (Table I), my purpose in this discussion is (1) to emphasize the extreme
Table
I. Experience
with
myomectomy
Author
No.
Bonney4 C&s8 Rubin?
Finn and Mull&2 Brown, Chamberlain, Incersolll”
reported
and
TeLindelO
of patients 403 167 481 432 335 139
myomectomy
643
conditions in which this operation can be applied and (2) to review the techniques in some detail. Three case summaries will serve the first purpose. Case reports Case 1. N. K. E. (NCBH 04 01 49) was seen on May 30, 1945, at 33 years of age. She was anxious to have a child. She complained of a large abdominal mass, disabling dsymenorrhea, and menorrhagia. Examination was normal except for multiple fibroids filling the lower abdomen and pelvis. At laparotomy sponge forceps were applied to occlude the uterine circulation. One pedunculated fibroid, 15 cm. in diameter, was removed, twenty-five additional tumors were enucleated by tunneling through the myometrium, and one submucous tumor measuring 3 x 2 x 1 cm. was removed. After curettement of the polypoid endometrium, all defects in the uterus were closed with continuous sutures of chromic No. 0 catgut and a few mattress sutures. The vesical peritoneum was attached to the anterior uterine wall to cover the suture lines. The patient’s postoperative course was uncomplicated. Three years later the patient was delivered of a normal female infant weighing 8 pounds, 6 ounces by cesarean section. Four fibroids, 2 to 3 cm. in diameter, were palpable in the uterine wall but were not removed. Eight years later the uterus was removed for moderate menorrhagia, diffuse uterine enlargement and small fibroids. Case 2. M. M. B. (NCBH 01 03 48), 29 years of age, complained of acute “stabbing” pain in the left lower abdomen and an abdominal mass. Menstruation on November 16 was 2 weeks late and characterized by excessive bleeding. The patient’s menstrual cycle had previously been normal. The examination was within normal limits
by others Mortality (%I 1.7 0.9 1.9 0 0.3 0
Recurrence (%) 4 10 Rare z* 10
Subsequent pregnancy (%I 39.0 28.0 25.35 48.5 42.5 50.0
644
July 1, 1969 Am. J. C&t. & Gynec.
Lock
except for the presence of an irregular multinodular fibroid mass filling and rising from the pelvis to just above the level of the umbilicus. Since the patient’s pain was subsiding, no treatment was carried out. A subsequent hysterogram showed a moderately enlarged uterine cavity with little distortion, Both Fallopian tubes were patent. At laparotomy, the uterus contained multiple subserous and intramural fibroids. The tubes and ovaries were normal. Sponge clamps were applied to the infundibulopelvic and broad ligaments bilaterally to compress the uterine and ovarian vessels. Through a longitudinal incision in the anterior uterine wall, 18 fibroid tumors were enucleated by sharp and blunt dissection. A number of small incisions were required to remove an additional 10 scattered subserous tumors. The endometrial cavity was not entered. The myometrial defect was closed in layers with continuous No. 0 chromic catgut sutures; the several smaller uterine incisions with figure-ofeight sutures. Gross and microscopic examination showed areas of coagulation necrosis and one tumor with red degeneration. The patient’s postoperative course was complicated by a severe paralytic ileus which responded to treatment with a Miller-Abbott tube. Subsequent to the myomectomies the patient has had a spontaneous abortion, and two normal term infants delivered by cesarean section. Examination 9 years later revealed fibroids and the uterus at the level of the umbilicus. Case 3. L. G. L. (NCBH 40 52 58), 24 years of age, had been operated upon for extensive pelvic endometriosis with impiants throughout the cul-de-sac and a chocolate cyst in the left ovary. The appendix and left ovary were removed and pathologic examination confirmed endometriosis of the ovary. Two years later the patient reported progressive increase of dysmenorrhea and pelvic pain. The pelvis and lower abdomen were filled with a cystic mass that extended 13 cm. above the symphysis. Bimanual examination revealed the cervix displaced downward and posteriorly. The uterus could not be discretely outlined but the cystic character of the lesion led to a diagnosis of recurrent endometriosis of the right ovary. An intravenous pyelogram showed a normal urinary tract and a soft-tissue mass measuring 20 by approximately 25 cm. in maximum diameters. No intrinsic calcification was seen. At laparotomy the mass was found to be a diffusely enlarged soft uterus. The left ovary was absent. The right
ovary appeared normal and no corpus luteum was present. No endometriosis was visible. Sponge forceps were then applied to the infundibulopelvic and broad ligaments on the right to occlude the uterine and ovarian vessels and on the left to occlude the uterine vessels. Through a longitudinal uterine incision a mucoid myometrial loculated mass was removed. The defect in the myometrium was repaired in layers with No. 2-O chromic catgut sutures. A small sessile 2 x 4. cm. nodule on the posterior wall of the uterus was then excised and the defect closed. The pathologic diagnoses were leiomyoma with mutinous degeneration, leiomyoma, and adenomyosis. The patient’s postoperative course was benign and her menstrual cycle became normal and regular. Two years later a normal term infant was delivered by cesarean section. Reasons
for
employing
myomectomy
In his report describing multiple myomectomy, Alexander’ expressed the hope that an additional resource was being placed in the hands of gynecologists whereby small, and even more advanced, fibroids could be removed without destroying the function of the sexual organs, “although retention of that function may not seem to the operator of much importance.” He recognized that time alone would determine whether the uterus and the appendages would “resume their functions of pregnancy and parturition” and whether regrowth of tumors would occur. Bonney2 believed there could be no disputing the fact that, in principle, myornectomy fulfills a higher surgical ideal than hysterectomy, since the restoration and maintenance of physiologic function is, or should be, the ultimute goal of surgical treatment. He had strong feelings against the remov-al of a woman’s womb, especially if the woman had not had any children. He stated that sexuality is a very curious and complicated thing, which in some women centers around the idea of procreation and not merely of conjugation. When such women know that pregnancy is no longer possible, he remarked, “the mainspring of the mechanism is lost.” He also noted that sexuality in men is just as quaint and complex and variable
Volume Number
104 5
as it is in women, and that
there are some who are repelled by the idea that their partner is not whole. Bonney’s principal concern, however, was the preservation of the childbearing function. He was gratified by the fact that conception occurred following myomectomy in 39 per cent of a group of 77 patients of childbearing age. ICn a series reported by Giles,8 pregnancy followed myomectomy in 28 per cent. Rubin? too was primarily concerned with childbearing, although he also believed that femininity, personal health, and general endocrine homeostasis were influenced by presence of the menses. Briggsyg use of multiple myomectomy was dictated by the mores of his patients, who were East Indians and Negroes of South African cultural background. In his patients, and in the current culture of most African nationals, the wife’s childbearing potential, as evidenced by menstruation, is a requirement for the maintenance of most marriages. Although present-day theory is that hysterectomy with preservation of ovarian function does not significantly affect general health, endocrine homeostasis, or sexuality, the patient’s desire for future childbearing must be given serious consideration, irrespective of her age. I agree with Brown, Chamberlain, and TeLinde,‘O that: Even though a patient does not become pregnant and a second operation becomes necessary, it does not always mean that myomectomy was a failure or that hysterectomy shouId have been done. . . . Although patients often fully realized conception was remote, a small ray of hope, which was made possible through the preservation of the uterus, helped to maintain a senseof well-being in their psyche. Even in our modern society, the possibility of childbearing may be a requirement to the maintenance of many marriages-certainly among a large segment of our nonwhite population. The fundamental reason for recommending myomectomy in the treatment of benign fibromyomas is to preserve the uterus for childbearing. The accumulated evidence,
Multiple
myomectomy
645
however, provides support for the belief that the operation has a favorable effect on infertility. When the operation is performed for primary infertility in the absence of other causal factors, between 40 and 50 per cent of the patients subsequently become pregnant.lO* I3 The chances that myomectomy will correct infertility are far greater in young women. There is general agreement that the procedure should be used predominantly for those under 35, although an occasional patient in the early forties may be a candidate for this procedure. Preoperative preparation evaluation of the patient and her husband
and
The ground rules for preoperative evaluation and preparation of the patient and her husband prior to myomectomy are well established. Even in the presence of a relative surgical emergency such as acute necrotizing degeneration of a myoma, the fertility of the husband should be determined. Fortunately, the operative treatment of leiomyomas is seldom an emergency, and in most cases there is sufficient time for a satisfactory evaluation of other factors that might cause infertility. In patients with asymptomatic fibromyomas, operation should rarely be considered until adequate time has been allowed for conception to occur. If this does not take place after a reasonable length of time, complete infertility studies should be done. Hysterosalpingography may give invaluable information concerning the normaIcy of the Fallopian tubes, as well as the size and location of tumors and the degree of distortion of the uterine cavity. In patients with large tumors, particularly if they are in a lateral position, intravenous pyelograms may be of particular value by delineating the position of the ureters. Before they are asked to give their consent to a myomectomy, the couple must be made to understand that no assurance of pregnancy can be given, that myomas often recur, and that, in the event of pregnancy, the probability of delivery by cesarean section is high. Since rupture of myomectomy scars is com-
646
Lock
Fig. 1. Sponge forceps applied to occlude ovarian and uterine arteries and veins. Fallopian (arrow) is not included in the forceps.
paratively rare, the frequent use of the latter method of delivery following myomectomy is probably unjustified. Contraindications No surgeon should promise a couple before operation that hysterectomy will not be done. The presence of advanced adnexal disease or unexpected uterine pathology can make hysterectomy mandatory. Malignant change, which is fortunately rare in the age group under consideration, is an obvious contraindication to a limited operation; in case of doubt at the time of operation, a pathologic consultation and frozen section may be necessary to reach a decision. Degeneration in uterine fibroids is not a contraindication to myomectomy. Advanced myxomatous degeneration of a fibroid \vas present in one of the cases just reported, and carneous degeneration and necrosis were found in another. Some authors believe that myomectomy is contraindicated in patients with many tumors or with very large tumors. However, I have never encountered a situation in which benign uterine tumors could not be removed by myomectomy-----~although in one in-
1
stance I had to amputate the uterine body in order to remove a large cervical fibroid; after removal of the tumor, the uterus was anastomosed to the cervix. A similar case was reported by Counseller. l1 Bonney’s removal of 125 tumors from a sir&z uterus,* Rubin’s removal of 89,7 and Briggs’ removal of 5:3” attest to the feasibilitv of removing large numbers of tuInors. Operative treatment of uterine myomas should be avoided during pregnancy, lvhen possible. In Inost cases such complications as acute dczencration, torsion of peclunculated tumors, and rapid grobvth can bc handled by rest, together with symptomatic and supportive treatment. The major complications of myornectomy in pregnancy are uncontrollable hemorrhage, making hystercctoniy mandatory, and postoperative abortion. When myomectomy is unavoidable during gestation, only the offending myoma or those which are pedunculated should be removed. Technique The technique used for multiple myomectom); today is still much the same as that dc~isecl by William Alexander. He removed all
Volume Number
104 5
Fig. 2. Anterior incision from this incision.
Multiple
into the substance of the presenting
tumors through an anterior uterine incision and controlled bleeding by the use of sutures and caustic packs. Despite devastating criticism of his first report, he persisted in using the operation and reported a series of 11 cases.l His contemporaries rejected the second report also, and the procedure did not gain acceptance until Victor Bonney championed it. Reports of myomectomy appearing in the interim dealt largely with he removal of single tumors. Bonney’s method of controlling hemorrhage during the procedure by means of a special uterine clamp and his meticulous description of multiple enucleations accomplished through a minimum number of uterine incisions did much to eliminate the major complications met by earlier surgeons : hemorrhage, sepsis, and postoperative intestinal obstruction. Control of hemorrhage. Before devising the clamp for temporary occlusion of the uterine and ovarian circulation, Bonney ligated the uterine arteries and applied temporary clamps to the ovarian arteries and veins. Although ligation of these four major vessels produces no adverse effects, temporary hemostasis by means of clamps is much simpler. Rubin used an encircling
fibroid.
myomectomy
647
Note the scant bleeding
elastic tourniquet, leaving the ovarian vessels patent. A practically bloodless field can be accomplished by the bilateral application of ring forceps across the infundibulopelvic ligament and the lower portion of the broad ligament to incorporate the uterine artery and veins (Fig. 1). I have used this technique repeatedly, with completely satisfactory results. There is no necessity for intermittent release of these forceps; although the ovaries and Fallopian tubes usually become congested no apparent damage results. By applying the clamp from a lateral position and, if necessary, using curved forcep clamps, the Fallopian tube can be avoided. It is sometimes necessary to compress the ureters, but there has been no evidence of injury in my experience. On completion of the procedure, the clamps are released for evaluation of hemostasis; additional hemostatic sutures may be needed when the circulation is re-established. Enucleation of tumors. With few exceptions, the abdominal incision should be longitudinal, so that it can be extended as much as necessary to give excellent exposure. Although it is preferable to remove all tumors through a single anterior uterine incision,
648 Lock
multiple widely scattered, small, subserosal and intramural tumors may require additional incisions. The anterior incision should be used for removal of submucous and interstitial tumors of the posterior uterine wall. Opening the endometrial cavity makes it easier to explore the myometrium for small tumors by placing the thumb or fingers in the enucleation cavity or in the uterine cavity if it has been opened. The most accessible tumor should be approached first, and the initial incision should be carried into the stroma of the tumor (Fig. 2) in order to facilitate identification of the cleavage plane between the tumor and the myometrium. When the tumor is exposed, it should be grasped with a tenaculum or some other appropriate instrument and gently enucleated with the handle of a scalpel or with the operator’s finger. If fibrous adherent bands are encountered, sharp dissection may occasionally be necessary. It is extremely important to visualize the interstitial portions of the Fallopian tubes and their relation to the tumors being enu-
Ain
July 1, 1969 J. Obst. &Gym.
cleated (Fig. 3). Little is gained by the procedure if the tubes are damaged in the process of removing a tumor or applying sutures to close a uterine wound. When one or more tumors encroach upon the anatomic position of the interstitial portion of a Fallopian tube, it may be desirable to use additional incisions, including the posterior approach, in order to protect this structure. Closure of wounds. The closure of uterine defects should be deferred until all the tumors have been removed. Interrupted and continuous No. 2-O chromic catgut sutures may be used to accomplish hemostasis and close the uterine wounds, using as many layers as may be required to obliterate all dead space in the uterine wall. In closing the utcrine cavity, particular care should be taken to avoid the incorporation of endometrium into the wall. Uterine fibroids often lead to marked hypertrophy and edema of the normal myometrial tissue. Practically none of this tissue should be removed, since it will undergo involution, similar to that occurring post par-
Fig. 3. An incision in the posterior uterine wall, used because of encroachment of this tumor on the Fallopian tube. Note dissection with finger (arrow) under myometrial flap and direct visualization of the insertion and interstitial area of Fallopian tube. The defect in anterior uterine wall which is from removal of another tumor will be closed when all the tumors have been removed.
Volume Number
104 5
Multiple
Fig. 4. Posterior uterine been removed, hemostasis changes.
wall incision is satisfactory,
on
completion of and the Fallopian
turn, within a few weeks after removal of the tumors. Wide flaps of myometrim and many loose-tissue margins may be present in the enucleation cavities. To restore myometrial continuity, it is essential to incorporate all of the tissue in the closing sutures. Imbrication may be a useful technique. Although the uterus is usually enlarged and irregular in shape at the conclusion of the operation, follow-up examinations show that it becomes remarkably symmetrical within a few months. It is easy to peritonize the uterine wounds by advancing the vesical-uterine reflection of peritoneum onto the anterior wall of the uterus. On the posterior wall a careful approximation of the wound may be satisfactory (Fig. 4) ; if not, the unsatisfactory areas may be covered with the sigmoid. The use of transverse incisions in the uterine wall must be given consideration, particularly in pa-
the
myomectomy
649
procedure. Sponge forceps have tubes and ovaries show no adverse
tients with large tumors of the posterior wall; in such cases, peritonization is improved by use of the “Bonney hood technique” of closure. Management complications
of postoperative
If hemostasis is complete and raw surfaces on the uterus have been covered satisfactorily, the postoperative course following multiple myomectomy should be uncomplicated. Antibiotics are administered only for a definite indication. The increased potential for postoperative adhesions and bowel complications should be kept in mind, especially if multiple incisions, some of them including the posterior uterine wall, have been employed. In such cases it may be wise to feed the patient intravenously for a day or 2. If abdominal distention develops, it should be treated promptly.
REFERENCES
1. 2.
Alexander, 1898. Bonney,
W.: M. Press& Circular 66: 349, V.:
Brit.
M.
J. 1: 278,
1918.
3. 4. 5.
Bonney, V.: Brit. M. J. 11: 951, 1925. Bonney, V.: Lancet 1: 171, 1931. Kelly, Howard, and Noble, Charles P.: Gyne-
650
6.
Lock
cology 1908, Mayo,
and Abdominal W. B. Saunders W. J.: Surg.
Surgery, Company,
Philadelphia, vol. I.
8. 9.
Rubin, I. C.: Ax J. OBST. & GYNEC. 44: 196, 1942. Giles, A. E., Jr.: Obst. & Gynaec. Brit. Emp. 29: 608, 1921-22. Briggs, D. W.: AM. J. OBST. & GYNEC. 95: 769. 1966.
Brown, Linde,
A. R.
B., W.:
Chamberlain,
R..
and
‘I’c
AM. J. OBST. & GYXEC. 71:
759, 1956.
Gynec. & Obst. 34: 548,
1922. 7.
IO.
11.
Counseller,
V. S., and
Bedard,
R. E.: J. A. M.
A. 111: 675, 1938. 12. 13.
Finn, W., and Muller, P. F.: GYNEC. 60: 109, 1950. Jngersoll, F. M.: Fertil. & 1963.
Ax. SteriJ.
J. OBST. 14:
& 596.
R.
Winston-Salem,
LOCK, North
M.D. Carolina
Although multiple myomectomy is seldom used in current gynecologic practice, it is a procedure that has definite value, especially for young women who desire children. Three case summaries have been presented to show that the operation can be used successfully in patients with numerous large fibroids, even when degeneration of some tumors is present. The technique and applicability of this procedure are then considered in some detail. Pregnancy can be expected in about 40 per cent of the patients who have undergone myomectomy, and in most cases is carried to a successful conclusion.
THE OPERATION of multiple myomectomy was first described by William Alexanderl of Liverpool in 1898. His report on the subject, entitled “Nucleation of Uterine Fibroids,” began with the following statement :
be enucleated through the natural uterine and vaginal passages and some more or less pedunculated subperitoneal fibroids, that may be ligatured and snipped off or enucleated, the
operative
Opinions are divided as to the treatment of uterine fibroids. Some medical men hold that severe operative treatment is very rarely required, and that medicinal treatment and the occasional performance of minor operations, such as dilating the uterine canal, curetting, and electrolysis, will tide most uterine fibroids over the menopause. When this period is reached the tumours may be expected to shrink in size and become innocuous. Others hold that they are not the comparatively harmless growths they are sometimes represented to be, and that they kill their hosts more frequently than many medical men admit and to prevent their harmful and often Fatal effects a severe mutilating operation is not only justifiable, but one to be recommended.
in
a few
cases,
where
the
tumor
From the Department of Obstetrics Gynecology, Bowman Gray School Medicine of Wake Forest University.
of most single is extremely
and of all sweeping
plan is by removal
in
of the
this is not so certain as uterus and fibroids, with the appendages, and this
is not so neat
as removal
tumour through easy or applicable by which tomy,
the
of the uterus vagina; and this is not to all cases as panhysterecall the internal reproductive
and so
organs are removed at one fell swoop. The
medical
references small fibroids, and in young people, and with good results as far as the mortality is concerned. But lessened risk of death from an operation does not necessarily justify an operation. To amputate a limb for a strumous ,joint would be a safe neat method of getting rid of a troublesome disease, but the sufferer has afterward to do without a very useful part of his body. .
to the more
Alexander went on to describe the prevailing therapeutic practices as follows: Except
treatment
multiple uterine fibroids, its extent. The mildest ovaries and tubes, but partial removal of the or without removal of
journals
contain
severe operation,
many
even for
A review of recently published textbooks of gynecology will establish that the dilemma described by Alexander has not yet been resolved. While some writers recommend individualization of therapy for uterine fibroids on the basis of the patient’s needs, age, and desire for subsequent pregnancies, a number of authors arbitrarily lay down guidelines reflecting their convictions and practices-
can
and of
The Annual Guest Lecture, presented at the Thirty-sixth Annual Meeting of the Central Association of Obstetricians and Gynecologists, Oklahoma City, Oklahoma, Sept. 26-28, 1968. 642
Volume 104 Number 5
Multiple
often giving scant consideration to myomectomy or expressing disapproval of this procedure for any except minimal lesions. Skepticism regarding the functional capability of the uterus following myomectomy is implied or specifically stated. Although the diagnosis and management of benign uterine tumors have been discussed extensively in the obstetric and gynecologic literature, it is rather remarkable that only two publications on the subject of myomectomy have appeared in a major national journal related to our specialty in the past 10 years. The textbook presentations do not adequately reflect the experience documented by the pioneers who deveIoped gynecology as a surgical specialty. At the time of Alexander’s report, the problems of hemorrhage and sepsis made myomectomy hazardous. In the 1920’s, however, the enthusiastic reports of Victor Bonney21 3, 4 in England and of Kelly and Noble,5 Mayo,6 and Rubin? in this country won a limited popularity for the procedure. Certainly every qualified surgeon has performed numerous myomectomies, but it is my belief that multiple myomectomy has been largely abandoned in current gynecologic practice. Nearly all of the patients coming to me with marked uterine enlargement and multiple tumors have been told by qualified surgeons that hysterectomy was the only treatment available to them; yet many of these women were desperately anxious for children. Since the statistics regarding myomectomy have been adequately presented in previous publications (Table I), my purpose in this discussion is (1) to emphasize the extreme
Table
I. Experience
with
myomectomy
Author
No.
Bonney4 C&s8 Rubin?
Finn and Mull&2 Brown, Chamberlain, Incersolll”
reported
and
TeLindelO
of patients 403 167 481 432 335 139
myomectomy
643
conditions in which this operation can be applied and (2) to review the techniques in some detail. Three case summaries will serve the first purpose. Case reports Case 1. N. K. E. (NCBH 04 01 49) was seen on May 30, 1945, at 33 years of age. She was anxious to have a child. She complained of a large abdominal mass, disabling dsymenorrhea, and menorrhagia. Examination was normal except for multiple fibroids filling the lower abdomen and pelvis. At laparotomy sponge forceps were applied to occlude the uterine circulation. One pedunculated fibroid, 15 cm. in diameter, was removed, twenty-five additional tumors were enucleated by tunneling through the myometrium, and one submucous tumor measuring 3 x 2 x 1 cm. was removed. After curettement of the polypoid endometrium, all defects in the uterus were closed with continuous sutures of chromic No. 0 catgut and a few mattress sutures. The vesical peritoneum was attached to the anterior uterine wall to cover the suture lines. The patient’s postoperative course was uncomplicated. Three years later the patient was delivered of a normal female infant weighing 8 pounds, 6 ounces by cesarean section. Four fibroids, 2 to 3 cm. in diameter, were palpable in the uterine wall but were not removed. Eight years later the uterus was removed for moderate menorrhagia, diffuse uterine enlargement and small fibroids. Case 2. M. M. B. (NCBH 01 03 48), 29 years of age, complained of acute “stabbing” pain in the left lower abdomen and an abdominal mass. Menstruation on November 16 was 2 weeks late and characterized by excessive bleeding. The patient’s menstrual cycle had previously been normal. The examination was within normal limits
by others Mortality (%I 1.7 0.9 1.9 0 0.3 0
Recurrence (%) 4 10 Rare z* 10
Subsequent pregnancy (%I 39.0 28.0 25.35 48.5 42.5 50.0
644
July 1, 1969 Am. J. C&t. & Gynec.
Lock
except for the presence of an irregular multinodular fibroid mass filling and rising from the pelvis to just above the level of the umbilicus. Since the patient’s pain was subsiding, no treatment was carried out. A subsequent hysterogram showed a moderately enlarged uterine cavity with little distortion, Both Fallopian tubes were patent. At laparotomy, the uterus contained multiple subserous and intramural fibroids. The tubes and ovaries were normal. Sponge clamps were applied to the infundibulopelvic and broad ligaments bilaterally to compress the uterine and ovarian vessels. Through a longitudinal incision in the anterior uterine wall, 18 fibroid tumors were enucleated by sharp and blunt dissection. A number of small incisions were required to remove an additional 10 scattered subserous tumors. The endometrial cavity was not entered. The myometrial defect was closed in layers with continuous No. 0 chromic catgut sutures; the several smaller uterine incisions with figure-ofeight sutures. Gross and microscopic examination showed areas of coagulation necrosis and one tumor with red degeneration. The patient’s postoperative course was complicated by a severe paralytic ileus which responded to treatment with a Miller-Abbott tube. Subsequent to the myomectomies the patient has had a spontaneous abortion, and two normal term infants delivered by cesarean section. Examination 9 years later revealed fibroids and the uterus at the level of the umbilicus. Case 3. L. G. L. (NCBH 40 52 58), 24 years of age, had been operated upon for extensive pelvic endometriosis with impiants throughout the cul-de-sac and a chocolate cyst in the left ovary. The appendix and left ovary were removed and pathologic examination confirmed endometriosis of the ovary. Two years later the patient reported progressive increase of dysmenorrhea and pelvic pain. The pelvis and lower abdomen were filled with a cystic mass that extended 13 cm. above the symphysis. Bimanual examination revealed the cervix displaced downward and posteriorly. The uterus could not be discretely outlined but the cystic character of the lesion led to a diagnosis of recurrent endometriosis of the right ovary. An intravenous pyelogram showed a normal urinary tract and a soft-tissue mass measuring 20 by approximately 25 cm. in maximum diameters. No intrinsic calcification was seen. At laparotomy the mass was found to be a diffusely enlarged soft uterus. The left ovary was absent. The right
ovary appeared normal and no corpus luteum was present. No endometriosis was visible. Sponge forceps were then applied to the infundibulopelvic and broad ligaments on the right to occlude the uterine and ovarian vessels and on the left to occlude the uterine vessels. Through a longitudinal uterine incision a mucoid myometrial loculated mass was removed. The defect in the myometrium was repaired in layers with No. 2-O chromic catgut sutures. A small sessile 2 x 4. cm. nodule on the posterior wall of the uterus was then excised and the defect closed. The pathologic diagnoses were leiomyoma with mutinous degeneration, leiomyoma, and adenomyosis. The patient’s postoperative course was benign and her menstrual cycle became normal and regular. Two years later a normal term infant was delivered by cesarean section. Reasons
for
employing
myomectomy
In his report describing multiple myomectomy, Alexander’ expressed the hope that an additional resource was being placed in the hands of gynecologists whereby small, and even more advanced, fibroids could be removed without destroying the function of the sexual organs, “although retention of that function may not seem to the operator of much importance.” He recognized that time alone would determine whether the uterus and the appendages would “resume their functions of pregnancy and parturition” and whether regrowth of tumors would occur. Bonney2 believed there could be no disputing the fact that, in principle, myornectomy fulfills a higher surgical ideal than hysterectomy, since the restoration and maintenance of physiologic function is, or should be, the ultimute goal of surgical treatment. He had strong feelings against the remov-al of a woman’s womb, especially if the woman had not had any children. He stated that sexuality is a very curious and complicated thing, which in some women centers around the idea of procreation and not merely of conjugation. When such women know that pregnancy is no longer possible, he remarked, “the mainspring of the mechanism is lost.” He also noted that sexuality in men is just as quaint and complex and variable
Volume Number
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as it is in women, and that
there are some who are repelled by the idea that their partner is not whole. Bonney’s principal concern, however, was the preservation of the childbearing function. He was gratified by the fact that conception occurred following myomectomy in 39 per cent of a group of 77 patients of childbearing age. ICn a series reported by Giles,8 pregnancy followed myomectomy in 28 per cent. Rubin? too was primarily concerned with childbearing, although he also believed that femininity, personal health, and general endocrine homeostasis were influenced by presence of the menses. Briggsyg use of multiple myomectomy was dictated by the mores of his patients, who were East Indians and Negroes of South African cultural background. In his patients, and in the current culture of most African nationals, the wife’s childbearing potential, as evidenced by menstruation, is a requirement for the maintenance of most marriages. Although present-day theory is that hysterectomy with preservation of ovarian function does not significantly affect general health, endocrine homeostasis, or sexuality, the patient’s desire for future childbearing must be given serious consideration, irrespective of her age. I agree with Brown, Chamberlain, and TeLinde,‘O that: Even though a patient does not become pregnant and a second operation becomes necessary, it does not always mean that myomectomy was a failure or that hysterectomy shouId have been done. . . . Although patients often fully realized conception was remote, a small ray of hope, which was made possible through the preservation of the uterus, helped to maintain a senseof well-being in their psyche. Even in our modern society, the possibility of childbearing may be a requirement to the maintenance of many marriages-certainly among a large segment of our nonwhite population. The fundamental reason for recommending myomectomy in the treatment of benign fibromyomas is to preserve the uterus for childbearing. The accumulated evidence,
Multiple
myomectomy
645
however, provides support for the belief that the operation has a favorable effect on infertility. When the operation is performed for primary infertility in the absence of other causal factors, between 40 and 50 per cent of the patients subsequently become pregnant.lO* I3 The chances that myomectomy will correct infertility are far greater in young women. There is general agreement that the procedure should be used predominantly for those under 35, although an occasional patient in the early forties may be a candidate for this procedure. Preoperative preparation evaluation of the patient and her husband
and
The ground rules for preoperative evaluation and preparation of the patient and her husband prior to myomectomy are well established. Even in the presence of a relative surgical emergency such as acute necrotizing degeneration of a myoma, the fertility of the husband should be determined. Fortunately, the operative treatment of leiomyomas is seldom an emergency, and in most cases there is sufficient time for a satisfactory evaluation of other factors that might cause infertility. In patients with asymptomatic fibromyomas, operation should rarely be considered until adequate time has been allowed for conception to occur. If this does not take place after a reasonable length of time, complete infertility studies should be done. Hysterosalpingography may give invaluable information concerning the normaIcy of the Fallopian tubes, as well as the size and location of tumors and the degree of distortion of the uterine cavity. In patients with large tumors, particularly if they are in a lateral position, intravenous pyelograms may be of particular value by delineating the position of the ureters. Before they are asked to give their consent to a myomectomy, the couple must be made to understand that no assurance of pregnancy can be given, that myomas often recur, and that, in the event of pregnancy, the probability of delivery by cesarean section is high. Since rupture of myomectomy scars is com-
646
Lock
Fig. 1. Sponge forceps applied to occlude ovarian and uterine arteries and veins. Fallopian (arrow) is not included in the forceps.
paratively rare, the frequent use of the latter method of delivery following myomectomy is probably unjustified. Contraindications No surgeon should promise a couple before operation that hysterectomy will not be done. The presence of advanced adnexal disease or unexpected uterine pathology can make hysterectomy mandatory. Malignant change, which is fortunately rare in the age group under consideration, is an obvious contraindication to a limited operation; in case of doubt at the time of operation, a pathologic consultation and frozen section may be necessary to reach a decision. Degeneration in uterine fibroids is not a contraindication to myomectomy. Advanced myxomatous degeneration of a fibroid \vas present in one of the cases just reported, and carneous degeneration and necrosis were found in another. Some authors believe that myomectomy is contraindicated in patients with many tumors or with very large tumors. However, I have never encountered a situation in which benign uterine tumors could not be removed by myomectomy-----~although in one in-
1
stance I had to amputate the uterine body in order to remove a large cervical fibroid; after removal of the tumor, the uterus was anastomosed to the cervix. A similar case was reported by Counseller. l1 Bonney’s removal of 125 tumors from a sir&z uterus,* Rubin’s removal of 89,7 and Briggs’ removal of 5:3” attest to the feasibilitv of removing large numbers of tuInors. Operative treatment of uterine myomas should be avoided during pregnancy, lvhen possible. In Inost cases such complications as acute dczencration, torsion of peclunculated tumors, and rapid grobvth can bc handled by rest, together with symptomatic and supportive treatment. The major complications of myornectomy in pregnancy are uncontrollable hemorrhage, making hystercctoniy mandatory, and postoperative abortion. When myomectomy is unavoidable during gestation, only the offending myoma or those which are pedunculated should be removed. Technique The technique used for multiple myomectom); today is still much the same as that dc~isecl by William Alexander. He removed all
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104 5
Fig. 2. Anterior incision from this incision.
Multiple
into the substance of the presenting
tumors through an anterior uterine incision and controlled bleeding by the use of sutures and caustic packs. Despite devastating criticism of his first report, he persisted in using the operation and reported a series of 11 cases.l His contemporaries rejected the second report also, and the procedure did not gain acceptance until Victor Bonney championed it. Reports of myomectomy appearing in the interim dealt largely with he removal of single tumors. Bonney’s method of controlling hemorrhage during the procedure by means of a special uterine clamp and his meticulous description of multiple enucleations accomplished through a minimum number of uterine incisions did much to eliminate the major complications met by earlier surgeons : hemorrhage, sepsis, and postoperative intestinal obstruction. Control of hemorrhage. Before devising the clamp for temporary occlusion of the uterine and ovarian circulation, Bonney ligated the uterine arteries and applied temporary clamps to the ovarian arteries and veins. Although ligation of these four major vessels produces no adverse effects, temporary hemostasis by means of clamps is much simpler. Rubin used an encircling
fibroid.
myomectomy
647
Note the scant bleeding
elastic tourniquet, leaving the ovarian vessels patent. A practically bloodless field can be accomplished by the bilateral application of ring forceps across the infundibulopelvic ligament and the lower portion of the broad ligament to incorporate the uterine artery and veins (Fig. 1). I have used this technique repeatedly, with completely satisfactory results. There is no necessity for intermittent release of these forceps; although the ovaries and Fallopian tubes usually become congested no apparent damage results. By applying the clamp from a lateral position and, if necessary, using curved forcep clamps, the Fallopian tube can be avoided. It is sometimes necessary to compress the ureters, but there has been no evidence of injury in my experience. On completion of the procedure, the clamps are released for evaluation of hemostasis; additional hemostatic sutures may be needed when the circulation is re-established. Enucleation of tumors. With few exceptions, the abdominal incision should be longitudinal, so that it can be extended as much as necessary to give excellent exposure. Although it is preferable to remove all tumors through a single anterior uterine incision,
648 Lock
multiple widely scattered, small, subserosal and intramural tumors may require additional incisions. The anterior incision should be used for removal of submucous and interstitial tumors of the posterior uterine wall. Opening the endometrial cavity makes it easier to explore the myometrium for small tumors by placing the thumb or fingers in the enucleation cavity or in the uterine cavity if it has been opened. The most accessible tumor should be approached first, and the initial incision should be carried into the stroma of the tumor (Fig. 2) in order to facilitate identification of the cleavage plane between the tumor and the myometrium. When the tumor is exposed, it should be grasped with a tenaculum or some other appropriate instrument and gently enucleated with the handle of a scalpel or with the operator’s finger. If fibrous adherent bands are encountered, sharp dissection may occasionally be necessary. It is extremely important to visualize the interstitial portions of the Fallopian tubes and their relation to the tumors being enu-
Ain
July 1, 1969 J. Obst. &Gym.
cleated (Fig. 3). Little is gained by the procedure if the tubes are damaged in the process of removing a tumor or applying sutures to close a uterine wound. When one or more tumors encroach upon the anatomic position of the interstitial portion of a Fallopian tube, it may be desirable to use additional incisions, including the posterior approach, in order to protect this structure. Closure of wounds. The closure of uterine defects should be deferred until all the tumors have been removed. Interrupted and continuous No. 2-O chromic catgut sutures may be used to accomplish hemostasis and close the uterine wounds, using as many layers as may be required to obliterate all dead space in the uterine wall. In closing the utcrine cavity, particular care should be taken to avoid the incorporation of endometrium into the wall. Uterine fibroids often lead to marked hypertrophy and edema of the normal myometrial tissue. Practically none of this tissue should be removed, since it will undergo involution, similar to that occurring post par-
Fig. 3. An incision in the posterior uterine wall, used because of encroachment of this tumor on the Fallopian tube. Note dissection with finger (arrow) under myometrial flap and direct visualization of the insertion and interstitial area of Fallopian tube. The defect in anterior uterine wall which is from removal of another tumor will be closed when all the tumors have been removed.
Volume Number
104 5
Multiple
Fig. 4. Posterior uterine been removed, hemostasis changes.
wall incision is satisfactory,
on
completion of and the Fallopian
turn, within a few weeks after removal of the tumors. Wide flaps of myometrim and many loose-tissue margins may be present in the enucleation cavities. To restore myometrial continuity, it is essential to incorporate all of the tissue in the closing sutures. Imbrication may be a useful technique. Although the uterus is usually enlarged and irregular in shape at the conclusion of the operation, follow-up examinations show that it becomes remarkably symmetrical within a few months. It is easy to peritonize the uterine wounds by advancing the vesical-uterine reflection of peritoneum onto the anterior wall of the uterus. On the posterior wall a careful approximation of the wound may be satisfactory (Fig. 4) ; if not, the unsatisfactory areas may be covered with the sigmoid. The use of transverse incisions in the uterine wall must be given consideration, particularly in pa-
the
myomectomy
649
procedure. Sponge forceps have tubes and ovaries show no adverse
tients with large tumors of the posterior wall; in such cases, peritonization is improved by use of the “Bonney hood technique” of closure. Management complications
of postoperative
If hemostasis is complete and raw surfaces on the uterus have been covered satisfactorily, the postoperative course following multiple myomectomy should be uncomplicated. Antibiotics are administered only for a definite indication. The increased potential for postoperative adhesions and bowel complications should be kept in mind, especially if multiple incisions, some of them including the posterior uterine wall, have been employed. In such cases it may be wise to feed the patient intravenously for a day or 2. If abdominal distention develops, it should be treated promptly.
REFERENCES
1. 2.
Alexander, 1898. Bonney,
W.: M. Press& Circular 66: 349, V.:
Brit.
M.
J. 1: 278,
1918.
3. 4. 5.
Bonney, V.: Brit. M. J. 11: 951, 1925. Bonney, V.: Lancet 1: 171, 1931. Kelly, Howard, and Noble, Charles P.: Gyne-
650
6.
Lock
cology 1908, Mayo,
and Abdominal W. B. Saunders W. J.: Surg.
Surgery, Company,
Philadelphia, vol. I.
8. 9.
Rubin, I. C.: Ax J. OBST. & GYNEC. 44: 196, 1942. Giles, A. E., Jr.: Obst. & Gynaec. Brit. Emp. 29: 608, 1921-22. Briggs, D. W.: AM. J. OBST. & GYNEC. 95: 769. 1966.
Brown, Linde,
A. R.
B., W.:
Chamberlain,
R..
and
‘I’c
AM. J. OBST. & GYXEC. 71:
759, 1956.
Gynec. & Obst. 34: 548,
1922. 7.
IO.
11.
Counseller,
V. S., and
Bedard,
R. E.: J. A. M.
A. 111: 675, 1938. 12. 13.
Finn, W., and Muller, P. F.: GYNEC. 60: 109, 1950. Jngersoll, F. M.: Fertil. & 1963.
Ax. SteriJ.
J. OBST. 14:
& 596.