- Email: [email protected]
Endoscopic management of fibromyomata
Reviews in Gynaecological Practice 3 (2003) 41–45
Endoscopic management of fibromyomata Peter J. Maher∗ University of Melbourne, Endosurgery Unit, Mercy Hospital for Women and Melbourne Fibroid Clinic, Cliveden Hill Private Hospital, East Melbourne, Vic., Australia Received 30 January 2003; accepted 13 February 2003
Abstract Surgical endoscopy has been successfully utilised in most gynaecological conditions with reported benefits which include small scars, reduced hospital stay and early return to normal duties. Myomectomy with uterine conservation has been popularised since the 1930s. The relationship between symptoms, such as menorrhagia and the presence of uterine myomata, has still not been fully evaluated although it appears that there is a causal relationship when sub-mucous fibroids are present. In recent years, laparoscopy has been proposed as the access of choice to remove fibroids up to 10 cm in diameter. Concern and debate continue over the integrity of the scar produced and its strength in a future pregnancy. Pre-operative investigation to assess myoma position within the uterus varies from simple pelvic ultrasound, saline infusion sonography to magnetic resonance imaging (MRI). The technique of laparoscopic myomectomy also varies and different approaches are discussed here-in. Newer non-surgical techniques, such as uterine artery embolisation (UAE), are addressed. The true value of this approach is yet to be assessed as there are no randomised control trials (RCTs) comparing it with myomectomy. Hysteroscopic resection of sub-mucous fibroids is associated with a decrease in menstrual loss. A recent publication using truly evidenced-based medicine questions the accepted surgical tradition of treating fibroids even greater than 16-gestational weeks in size [Aust. N.Z. J. Obstet. Gynaecol. 2001 (41) 125]. © 2003 Elsevier Science B.V. All rights reserved. Keywords: Myoma; Laparoscopy; Myomectomy; Hysteroscopy; Complications
1. Introduction Endoscopic surgery in gynaecology has been shown to be effective in most diseases, including fibromyomata, endometriosis, adnexal pathology, ectopic pregnancy and some types of malignancy. Semm and Mettler [1] first reported the laparoscopic approach to myomas in the late 1970s at a time when they were exploring the application of laparoscopy to a variety of pathologies. Almost 10 years passed before laparoscopic myomectomy was performed for myomas that were more intra-mural than sub-serosal [2,3]. The indications for myoma removal include heavy menstrual bleeding, infertility associated with uterine cavity or fallopian tube distortion, pain and pressure on the bladder or rectum. The association between uterine fibroids and menorrhagia remains unclear. Vollenhoven et al. [4] reported that 30% of women known to have fibroids have symptoms. On the ∗ Tel.:
+61-3-92702760; fax: +61-3-92702769. E-mail address: [email protected] (P.J. Maher).
other hand, in a prospective study of women undergoing hysterectomy for reasons not including menorrhagia, 40% were noted to have fibroids. There is some evidence to suggest that women with a higher volume of menstrual blood loss have an increased incidence of fibroids. Rybo et al. [5] reported a 40% incidence of fibroids when blood loss was greater than 200 ml compared to only a 10% incidence when blood loss was less than 100 ml. Sub-mucous fibroids have been implicated more so than sub-serous and intra-mural tumours as a cause of menorrhagia, presumably due to distortion of the cavity and an increase in the bleeding surface of the endometrium. However, in a study of women undergoing hysterectomy for the symptom of menorrhagia and known fibroids, sub-mucous fibroids were present in only 40% [6]. Farrer-Brown et al. [7] performed radiographic studies to demonstrate that myomas cause compression on the veins of the adjacent myometrium with resultant formation of venous lakes in the endometrium which in turn could contribute to abnormal bleeding. This may explain why heavy bleeding can be associated with fibroids anywhere in the uterine wall.
1471-7697/03/$ – see front matter © 2003 Elsevier Science B.V. All rights reserved. doi:10.1016/S1471-7697(03)00006-6
42
P.J. Maher / Reviews in Gynaecological Practice 3 (2003) 41–45
Table 1 Indication for myomectomy 1 2 3 4 5
Menorrhagia associated with sub-mucous or intra-mural fibroids Infertility associated with uterine cavity distortion after all other avenues have been investigated Recurrent miscarriage associated with sub-mucous fibroids Pregnancy complications associated with malpresentation—other causes excluded Pressure symptoms on bowel/bladder
Menorrhagia is the most common cause of anaemia (Hb < 10 gm/l). Friseur et al. [8] reported that anaemia is more common in women with fibroid-associated menorrhagia than menorrhagia from other causes. The conventional treatment for symptomatic fibroids in a woman who has completed her family is hysterectomy. Although hysterectomy has a low mortality, it does have considerable associated morbidity. The crude mortality rate varies between 5 and 8 per 10,000 non-neoplastic hysterectomy procedures [9,10]. The combined major and minor morbidity associated with this procedure has been reported to vary between 18 and 47% [9,11,12]. The increased use of minimally invasive surgery, together with increased interest in uterine conservation, may decrease the incidence of the more common complications associated with hysterectomy for fibroids. If hysterectomy is the preferred option, it may be performed by the open, vaginal or laparoscopic technique. The route will depend on the size of the uterus, the degree of vaginal access and the laparoscopic skill of the surgeon. The use of pre-operative GnRH analogues will in some instances allow an abdominal operation to be converted into a laparoscopic or vaginal procedure. If a woman wishes to retain her uterus for either fertility or “personal” reasons, then myomectomy is the treatment of choice. There are also a variety of other treatments using minimally invasive techniques to treat fibroids. These include myolysis, uterine artery embolisation (UAE), uterine artery ligation, hysterectomy, including sub-total and hysteroscopic myoma resection. Table 1 lists the accepted indications for myomectomy. In a recent article, Farquhar et al. [12] published evidence-based guidelines for the management of uterine fibroids. In the summary, they recommended no intervention in an asymptomatic woman with fibroids equivalent to a 16-week gestation in the absence of symptoms. The purpose of this paper is to review the recent advances in minimal access interventions in the management of uterine fibromyomata.
2. Pre-surgical assessment of myomas The surgical approach will be dependant on the anatomical site of the fibroids, their number and, most importantly, their size. Several methods of investigations which include transvaginal ultrasound with or without saline infusion into
the uterine cavity, computerised sonography (CT), magnetic resonance imaging (MRI), hysteroscopy and laparoscopy are available. Abdominal ultrasound should be reserved for women with large fibroids or pedunculated fibroids combined with transvaginal ultrasound [13]. Hysteroscopy compares favourably with both transvaginal ultrasound alone or with saline infusion in the diagnosis of sub-mucous fibroids [14]. Precise pre-operative assessment assists in counselling patients as to the correct surgical approach in the management of their myomas.
3. Laparoscopic myomectomy Due to the expertise required to perform laparoscopic suturing, this procedure is technically difficult. Precise closure of the defect left following removal of the myoma is essential, particularly in women wishing to achieve pregnancy. In Farquhar et al.’s review [12], they recommend that the laparoscopic approach not be undertaken in women who wish to become pregnant because of case reports which suggest an increased incidence of rupture. Dubuisson et al. [15] reported 1.0% (95% CI: 0.0–5.5%) uterine rupture rate among 100 deliveries. Other small series reported no ruptures [16–18]. Technical problems associated with suture closure may explain the rupture following myomectomy. For this reason, myomas >6 cm are generally not suitable for the laparoscopic approach except in the case of pedunculated tumours [16,19,20]. MRI or colour Doppler ultrasound may be used after surgery to check the thickness of the scar in the uterine wall. Fibroids can be excised if intra-operative bleeding is not excessive, their size does not make removal technically difficult and the myoma bed can be safely and effectively closed. If the fibroids are large and the laparoscopic approach is preferred, it is possible to perform a laparoscopic-assisted mini-laparotomy. The advantages of this procedure are threefold: 1. reduce operating time, 2. allow digital manipulation and 3. effective closure of the myoma bed using long handled laparotomy needle holders. To perform gasless laparoscopy, some form of abdominal elevation is necessary [21]. Adhesions may occur in 40% of patients undergoing myomectomy. These adhesions can cause post-operative pain and infertility [22]. Anti-adhesion agents, including Interceed® , Gortex® , Intergel® and Spray Gel® , have been proposed but, at present, there is insufficient evidence to support their routine use [12]. Careful microsurgical techniques using fine grasping forceps, minimal use of power which produces necrosis of adjacent tissues, continuous irrigation combined with minimal handling of normal tissues will go a long way towards minimising post-operative adhesions.
P.J. Maher / Reviews in Gynaecological Practice 3 (2003) 41–45
4. Surgical approach An effective uterine manipulator is essential. It is the author’s preference to make a transverse incision through the myoma capsule. This minimises the amount of bleeding as the main blood supply arises from radial vessels which in turn come from the ascending uterine vessels. In the case of large fibroids, ligation of the uterine arteries before commencement of the myomectomy may reduce blood loss. This can be performed laparoscopically by entering the broad ligament in the space bordered by the round ligament anteriorly, the external iliac artery laterally, and the infundibulo-pelvic ligament medially. Once the peritoneum is opened, the pneumo-peritoneum will create a space within the ligament. The umbilical ligament placed under tension will aid in the identification of the terminal portion of the internal iliac artery, anterior branch. The uterine artery is then identified as it leaves the anterior branch. The ureter is identified on the medical leaf of the broad ligament. A clip or ligature can be used to close the vessel. A spoon electrode is preferred using 80 W cutting current. It is important to remember that the depth of the incision through the pseudo-capsule to expose the fibroid is often deeper than first thought. It is essential to establish the plane of cleavage between the myoma and compressed myometrium. Limited use of the electro-coagulation will minimise damage to the adjacent normal myometrium. It has been suggested that overzealous use of electro-coagulation has resulted in weakness or breakdown in the surrounding myometrium predisposing to uterine rupture [23,24]. As soon as the myoma is evident through the pseudo-capsule, a myoma screw is inserted. Counter-traction is obtained with a counter movement of the intra-uterine manipulator in the opposite direction to the position of the screw. The author uses two blunt probes to develop the avascular plane. Any bleeding that is encountered is treated with bipolar coagulation remembering again to minimise damage to the normal myometrium. Once the myoma is removed, it is stored usually in the Pouch of Douglas, and others removed. Some authors suggest limiting the number of myomas to two or three [25]. This has not been the practice in this Unit and up to five myomas have been removed at the one surgery. The principle of a single incision and multiple fibroids being removed through it is not possible using a laparoscopic approach. Each myoma is approached through a separate incision which, at the completion of removal of the myoma, require careful suturing. On most occasions, a single layer full thickness interrupted suture (Monocryl® ) is used to close the defect. If there is concern that a dead space exists which will predispose to haematoma formation, a single deep layer of suture is inserted and then the superficial layer closed. Dead space with or without haematoma formation will predispose to rupture of the gravid uterus—a similar circumstance visited in early reports when the defects were not sutured [26]. If there is concern about the integrity of the
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sutured cavity, then laparoscopic mini-laparotomy should be considered [27]. Following successful laparoscopic myomectomy, it may be necessary to perform a mini-laparotomy to remove large myomas. Alternatively, they can be removed through an extended umbilical incision, posterior colpotomy [28] or with the aid of a manual or electronic morsellator. Myomectomy has been reported to be associated with an average blood loss of 500 ml and the need for blood transfusion (41%) or the need for hysterectomy for uncontrollable bleeding [29]. In another prospective non-randomised control trial (RCT), Landi et al. [30] reported a mean decrease in haemoglobin of only 1.38 ± 0.93 g/100 ml. The use of a vasoconstrictor agent or a tourniquet to temporarily occlude the uterine vessels has been reported to reduce the amount of blood loss during the procedure [31,32]. The use of GnRH analogues in the pre-operative period has also been shown to be effective in reduction of intra-operative blood loss [33], although their use has been associated with difficulty in finding the plane of cleavage of myomectomy and an increase in the recurrence rate of myomas post-operatively [34].
5. UAE UAE involves injection of polyvinyl alcohol particles into the terminal branches of the uterine artery via a catheter inserted through the femoral artery [35]. In a large prospective observational study involving 400 patients, menstrual bleeding was improved in 84% and menstrual pain in 79%. Fibroid volume was shown to be reduced by up to 67%. Similar results have been reported by other authors [36]. There are no reported RCTs comparing outcomes of UAE versus surgery, although they have been proposed. It would be difficult to run such a trial, as women choose UAE to specifically avoid surgery and, the author believes this group would be very reluctant to be randomly allocated to undergo surgery.
6. Hysteroscopic surgery There is an association between heavy bleeding and sub-mucous fibroid myomata. Neuwirth and Assin [37] first described hysteroscopic fibroid resection in 1976. This approach is now the gold standard for sub-mucous fibroids less than 5 cm in diameter. GnRH analogues have been reported to decrease the fibroid size by up to 60%, thus facilitating quicker and safer resection. The most common solution used for resection of both fibroids and endometrium is 1% glycine. Fluid absorption with resultant hyponatraemic encephalopathy, which may lead to death, is the most serious complication of this procedure. The incidence of fluid overload varies between 1 and 5% [38]. Fluid absorption occurs through the open veins of the myoma and possibly through transperitoneal absorption from retrograde flow through the fallopian tubes. In an earlier report, Maher and Hill [39]
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P.J. Maher / Reviews in Gynaecological Practice 3 (2003) 41–45
showed that there was little retrograde flow through the fallopian tubes in 100 patients undergoing simultaneous endometrial resection and laparoscopy. The amount of fluid absorbed is directly related to the size of the myoma and hence the duration of surgery. It is safer to perform hysteroscopic surgery under local or regional anaesthesia compared with general anaesthesia, as this allows ongoing assessment of the patient’s mental state throughout surgery and the post-operative phase. Early symptoms of hyponatraemic encephalopathy, i.e. nausea, headache, vomiting and weakness, will alert the surgeon and anaesthetist to impending serious complications and allow commencement of corrective measures together with the cessation of the surgery. In a series of 122 patients, Hart et al. [40] reported fluid absorption of >2000 ml in three patients. They reported a successful outcome in 79% patients as measured by the absence of further surgery for 4 years. Patient satisfaction was 90% in this series. In another prospective study, Wamsteker et al. [41] reported that, in a series of 51 patients, up to three procedures were necessary to control symptoms of heavy bleeding. Other complications associated with sub-mucous myoma resection include perforation haemorrhage and infection. Perforation rates vary from 1 to 3% [42]. The most serious complication arising from perforation is burning of bowel overlying the uterus. If a perforation is suspected, then the procedure should be terminated immediately and further surgery scheduled 6–8 weeks later. Perforation may also create an area of weakness in the uterine wall which may have adverse consequences in a subsequent pregnancy. Haemorrhage is uncommon. Vasoconstrictor agents inserted into the base of the myoma can minimise blood loss. Similarly, cautery of large vessels traversing the myoma will have a positive impact on haemorrhage rates. If haemorrhage does occur, a Foley catheter can be inserted into the uterine cavity to tamponade the bleeding vessels. In our Unit, this has only been necessary in four cases over the last 10 years.
7. Conclusion The endoscopic approach to many gynaecological surgeries has been shown to be associated with less postoperative pain, shorter time in hospital and quicker return to normal activities. Fibromyomata is associated with heavy bleeding, pregnancy complications, infertility, pressure and pain. Newer techniques that avoid surgery, i.e. UAE, may have a place in the future although its efficacy has not been fully assessed with RCTs. Using evidence-based medicine, it is reported that there is no reason to treat asymptomatic fibroids less than 16 weeks in gestational size [12]. Asymptomatic women with fibroids >16 weeks should be assessed by a specialist gynaecologist to discuss treatment options which include observation. The author believes, however, that most clinicians will continue to counsel patients with fibroids using the indicators
in Table 1 and in consultation with them decide whether it is appropriate to proceed to surgery.
References [1] Semm K, Mettler L. Technical progress in pelvic surgery via operative laparoscopy. Am J Obstet Gynecol 1980;138:121–7. [2] Dubuisson JB, Lecuru F, Foulot H, et al. Myomectomy by laparoscopy: a preliminary report of 43 cases. Fertil Steril 1991;56:827–30. [3] Nezhat C, Nezhat F, Silfen SL, et al. Laparoscopic myomectomy. Int J Fertil 1991;36:275–80. [4] Vollenhoven BJ, Lawrence AS, Healey DL. Uterine fibroids. A clinical review. Br J Obstet Gynaecol 1990;97:285–98. [5] Rybo G, Leman J, Tibbin R. Epidemiology of menstrual blood loss. In: Baird DT, Michiea P, editors. Mechanisms of menstrual bleeding. New York: Raven Press; 1985. p. 181–93. [6] Lumsden MA. Fibroids and menorrhagia. In: Shaw RW, editor. Uterine fibroids: time for review. UK: Parthenon Publishing; 1992. p. 57–68. [7] Farrer-Brown G, Bobbeilby JOW, Tarbit NH. Venous changes in the endometrium of myomatas uterine. Obstet Gynecol 1971;82:97–101. [8] Friseur I, Mecca G, Markham R, et al. Measured menstrual blood loss in women with menorrhagia associated with pelvic disease or coagulation disorder. Obstet Gynecol 1986;9:630–3. [9] Opit LJ, Gadiel D. Hysterectomy in NSW, an evaluation of its use and outcome. Sydney: Office of Health Care Finance; 1982. [10] Greenberg MD, Kazamel TIG. Medical and socio economic impact of uterine fibroids. Obstet Gynecol Clin North Am 1995;22:625–36. [11] Dicker RC, Greenspan JR, Strauss LT, et al. Complications of abdominal and vaginal hysterectomy among women of reproductive age in the United States. Am J Obstet Gynecol 1982;144:841–8. [12] Farquhar C, Arroll B, Ekeroma A, et al. An evidence based guideline for the management of uterine fibroids. Aust NZ J Obstet Gynaecol 2001;41(2):125–40. [13] Leibman AJ, Kruse B, McSweeney MB. Transvaginal sonography: comparison with transabdominal sonography in the diagnosis of pelvic masses. AMJ Roentgenol 1988;151:89–92. [14] Vercellini P, Cortesi I, Oldani S, et al. The role of transvaginal ultrasonography and outpatient diagnostic hysteroscopy in the evaluation of patients with menorrhagia. Hum Reprod 1997;12:1768–71. [15] Dubuisson JB, Faucconier A, Deffarges JV, et al. Pregnancy outcome and deliveries following laparoscopic myomectomy. Hum Reprod 2000;15:869–73. [16] Darai E, Dichaud H, Benifla JL, et al. Fertility after laparoscopic myomectomy: preliminary results. Hum Reprod 1997;12:1931–4. [17] Miller CE, Johnson M, Rundell M. Laparoscopic myomectomy in the infertile woman. J Am Assoc Gynecol Laparosc 1966;3:525–32. [18] Nezhat CH, Nezhat F, Roenisch M, et al. Pregnancy following laparoscopic myomectomy: preliminary results. Hum Reprod 1999;14:1219–21. [19] Dubuisson JB, Chapron C, Chavet X, Gregorakis SS. Fertility after laparoscopic myomectomy of large intramural myomas: preliminary results. Hum Reprod 1996;11:518–22. [20] Mais V, Ajorsa S, Guerriero S, et al. Laparoscopic versus abdominal myomectomy. A prospective randomised trial to evaluate benefits in early outcome. AMJ Obstet Gynecol 1996;174:654–8. [21] Maher P, Wood C, Hill D. Endoscopic mini laparotomy. Aust NZ J Obstet Gynaecol 1995;35:76–8. [22] Buttram VC, Reiter R. Uterine leiomyomata: aetiology, symptomatology and management. Fertil Steril 1981;36:433–45. [23] Pelosi M, Pelosi MA. Spontaneous uterine rupture at thirty five weeks subsequent to previous superficial laparoscopic myomectomy. Am J Obstet Gynecol 1997;177:1547–9.
P.J. Maher / Reviews in Gynaecological Practice 3 (2003) 41–45 [24] Vilos G, Daly LJ, Tse BM. Pregnancy outcome after laparoscopic electromyolysis. J Am Assoc Gynecol Laparosc 1998;5:289–92. [25] Dubuisson JB, Chapron C, Levy L. Difficulties and complications of laparoscopic myomectomy. J Gynecol Surg 1996;12:159–65. [26] Hasson HM. Laparoscopic myomectomy. Infertil Reprod Med Clin North Am 1996;7:143–59. [27] Wood C, Maher P. Laparoscopic mini laparotomy: a suitable addition to major gynaecological surgery. Gynecol Endosc 1996;5:83–8. [28] Mangeshikar PR. New instrumentation and technique for laparoscopic myomectomy. J Am Assoc Gynecol Laparosc 1995;2:529. [29] Gardner RL, Shaw RL. GNRH agonists and blood loss at surgery. In: Shaw R, editor. Uterine fibroids: a time for review. Carnforth: Pathenon Publishing; 1991. p. 123–4. [30] Landi S, Zacoletti R, Ferrari L, Minelli L. Laparoscopic myomectomy technique, complication and ultrasound scan evaluation. J Am Assoc Gynecol Laparosc 2001;8:231–40. [31] Frederick J, Fletcher H, Simeon D, et al. Intramyometrial vasopressin as a haemostatic agent during myomectomy. Br J Obstet Gynecol 1994;101:435–7. [32] Ginsberg ES, Benson CB, Garfield JM, et al. The effect of operative technique and uterine size on blood loss during myomectomy: a prospective randomised study. Fertil Steril 1993;60:956–62. [33] Zullo F, Pellicano M, DiStefano R, et al. A prospective randomised study to evaluate leuprolide acetate treatment before laparoscopic myomectomy: efficacy and ultrasonographic predictors. Am J Obstet Gynecol 1998;178:108–12.
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[34] Fedele L, Vercellini P, Branchi S, et al. Treatment with GnRH agonists before myomectomy and the risk of short term myoma recurrence. Br J Obstet Gynaecol 1990;97:393–6. [35] Ravina JH, Herbreteau D, Ciraru-Vigneron N, et al. Arterial embolisation to treat uterine myomata. Lancet 1995;346:671–2. [36] Franquart F, Bruncreau L, Cottier JP, et al. Prospective sonographic assessment of uterine artery embolisation for the treatment of fibroids. Ultrasound Obstet Gynecol 2002;19:81–7. [37] Neuwirth RS, Assin HK. Excision of sub mucous fibroids with hysteroscopic control. Am J Obstet Gynecol 1976;126:95–9. [38] Varol N, Maher P, Vancaillie T, et al. A literature review and update on the prevention and management of fluid overload in endometrial resection and hysteroscopic surgery. Gynaecol Endosc 2002;11:19– 26. [39] Maher PJ, Hill DJ. Transcervical endometrial resection for abnormal uterine bleeding. Aust NZ J Obstet Gynaecol 1990;35:76–8. [40] Hart R, Molnar BG, Magos A. A long term follow up of hysteroscopic myomectomy assessed by survival analysis. Br J Obstet Gynaecol 1999;106:700–5. [41] Wamsteker K, Emanuel MH, de Kruif JH. Transcervical hysteroscopic resection of sub mucous fibroids for abnormal uterine bleeding: results regarding degree of intramural extension. Obstet Gynecol 1993;82:736–40. [42] Holt E, Gilmer MD. Endometrial resection. Baillieres Clin Obstet Gynecol 1995;9(2):279–97.
Endoscopic management of fibromyomata Peter J. Maher∗ University of Melbourne, Endosurgery Unit, Mercy Hospital for Women and Melbourne Fibroid Clinic, Cliveden Hill Private Hospital, East Melbourne, Vic., Australia Received 30 January 2003; accepted 13 February 2003
Abstract Surgical endoscopy has been successfully utilised in most gynaecological conditions with reported benefits which include small scars, reduced hospital stay and early return to normal duties. Myomectomy with uterine conservation has been popularised since the 1930s. The relationship between symptoms, such as menorrhagia and the presence of uterine myomata, has still not been fully evaluated although it appears that there is a causal relationship when sub-mucous fibroids are present. In recent years, laparoscopy has been proposed as the access of choice to remove fibroids up to 10 cm in diameter. Concern and debate continue over the integrity of the scar produced and its strength in a future pregnancy. Pre-operative investigation to assess myoma position within the uterus varies from simple pelvic ultrasound, saline infusion sonography to magnetic resonance imaging (MRI). The technique of laparoscopic myomectomy also varies and different approaches are discussed here-in. Newer non-surgical techniques, such as uterine artery embolisation (UAE), are addressed. The true value of this approach is yet to be assessed as there are no randomised control trials (RCTs) comparing it with myomectomy. Hysteroscopic resection of sub-mucous fibroids is associated with a decrease in menstrual loss. A recent publication using truly evidenced-based medicine questions the accepted surgical tradition of treating fibroids even greater than 16-gestational weeks in size [Aust. N.Z. J. Obstet. Gynaecol. 2001 (41) 125]. © 2003 Elsevier Science B.V. All rights reserved. Keywords: Myoma; Laparoscopy; Myomectomy; Hysteroscopy; Complications
1. Introduction Endoscopic surgery in gynaecology has been shown to be effective in most diseases, including fibromyomata, endometriosis, adnexal pathology, ectopic pregnancy and some types of malignancy. Semm and Mettler [1] first reported the laparoscopic approach to myomas in the late 1970s at a time when they were exploring the application of laparoscopy to a variety of pathologies. Almost 10 years passed before laparoscopic myomectomy was performed for myomas that were more intra-mural than sub-serosal [2,3]. The indications for myoma removal include heavy menstrual bleeding, infertility associated with uterine cavity or fallopian tube distortion, pain and pressure on the bladder or rectum. The association between uterine fibroids and menorrhagia remains unclear. Vollenhoven et al. [4] reported that 30% of women known to have fibroids have symptoms. On the ∗ Tel.:
+61-3-92702760; fax: +61-3-92702769. E-mail address: [email protected] (P.J. Maher).
other hand, in a prospective study of women undergoing hysterectomy for reasons not including menorrhagia, 40% were noted to have fibroids. There is some evidence to suggest that women with a higher volume of menstrual blood loss have an increased incidence of fibroids. Rybo et al. [5] reported a 40% incidence of fibroids when blood loss was greater than 200 ml compared to only a 10% incidence when blood loss was less than 100 ml. Sub-mucous fibroids have been implicated more so than sub-serous and intra-mural tumours as a cause of menorrhagia, presumably due to distortion of the cavity and an increase in the bleeding surface of the endometrium. However, in a study of women undergoing hysterectomy for the symptom of menorrhagia and known fibroids, sub-mucous fibroids were present in only 40% [6]. Farrer-Brown et al. [7] performed radiographic studies to demonstrate that myomas cause compression on the veins of the adjacent myometrium with resultant formation of venous lakes in the endometrium which in turn could contribute to abnormal bleeding. This may explain why heavy bleeding can be associated with fibroids anywhere in the uterine wall.
1471-7697/03/$ – see front matter © 2003 Elsevier Science B.V. All rights reserved. doi:10.1016/S1471-7697(03)00006-6
42
P.J. Maher / Reviews in Gynaecological Practice 3 (2003) 41–45
Table 1 Indication for myomectomy 1 2 3 4 5
Menorrhagia associated with sub-mucous or intra-mural fibroids Infertility associated with uterine cavity distortion after all other avenues have been investigated Recurrent miscarriage associated with sub-mucous fibroids Pregnancy complications associated with malpresentation—other causes excluded Pressure symptoms on bowel/bladder
Menorrhagia is the most common cause of anaemia (Hb < 10 gm/l). Friseur et al. [8] reported that anaemia is more common in women with fibroid-associated menorrhagia than menorrhagia from other causes. The conventional treatment for symptomatic fibroids in a woman who has completed her family is hysterectomy. Although hysterectomy has a low mortality, it does have considerable associated morbidity. The crude mortality rate varies between 5 and 8 per 10,000 non-neoplastic hysterectomy procedures [9,10]. The combined major and minor morbidity associated with this procedure has been reported to vary between 18 and 47% [9,11,12]. The increased use of minimally invasive surgery, together with increased interest in uterine conservation, may decrease the incidence of the more common complications associated with hysterectomy for fibroids. If hysterectomy is the preferred option, it may be performed by the open, vaginal or laparoscopic technique. The route will depend on the size of the uterus, the degree of vaginal access and the laparoscopic skill of the surgeon. The use of pre-operative GnRH analogues will in some instances allow an abdominal operation to be converted into a laparoscopic or vaginal procedure. If a woman wishes to retain her uterus for either fertility or “personal” reasons, then myomectomy is the treatment of choice. There are also a variety of other treatments using minimally invasive techniques to treat fibroids. These include myolysis, uterine artery embolisation (UAE), uterine artery ligation, hysterectomy, including sub-total and hysteroscopic myoma resection. Table 1 lists the accepted indications for myomectomy. In a recent article, Farquhar et al. [12] published evidence-based guidelines for the management of uterine fibroids. In the summary, they recommended no intervention in an asymptomatic woman with fibroids equivalent to a 16-week gestation in the absence of symptoms. The purpose of this paper is to review the recent advances in minimal access interventions in the management of uterine fibromyomata.
2. Pre-surgical assessment of myomas The surgical approach will be dependant on the anatomical site of the fibroids, their number and, most importantly, their size. Several methods of investigations which include transvaginal ultrasound with or without saline infusion into
the uterine cavity, computerised sonography (CT), magnetic resonance imaging (MRI), hysteroscopy and laparoscopy are available. Abdominal ultrasound should be reserved for women with large fibroids or pedunculated fibroids combined with transvaginal ultrasound [13]. Hysteroscopy compares favourably with both transvaginal ultrasound alone or with saline infusion in the diagnosis of sub-mucous fibroids [14]. Precise pre-operative assessment assists in counselling patients as to the correct surgical approach in the management of their myomas.
3. Laparoscopic myomectomy Due to the expertise required to perform laparoscopic suturing, this procedure is technically difficult. Precise closure of the defect left following removal of the myoma is essential, particularly in women wishing to achieve pregnancy. In Farquhar et al.’s review [12], they recommend that the laparoscopic approach not be undertaken in women who wish to become pregnant because of case reports which suggest an increased incidence of rupture. Dubuisson et al. [15] reported 1.0% (95% CI: 0.0–5.5%) uterine rupture rate among 100 deliveries. Other small series reported no ruptures [16–18]. Technical problems associated with suture closure may explain the rupture following myomectomy. For this reason, myomas >6 cm are generally not suitable for the laparoscopic approach except in the case of pedunculated tumours [16,19,20]. MRI or colour Doppler ultrasound may be used after surgery to check the thickness of the scar in the uterine wall. Fibroids can be excised if intra-operative bleeding is not excessive, their size does not make removal technically difficult and the myoma bed can be safely and effectively closed. If the fibroids are large and the laparoscopic approach is preferred, it is possible to perform a laparoscopic-assisted mini-laparotomy. The advantages of this procedure are threefold: 1. reduce operating time, 2. allow digital manipulation and 3. effective closure of the myoma bed using long handled laparotomy needle holders. To perform gasless laparoscopy, some form of abdominal elevation is necessary [21]. Adhesions may occur in 40% of patients undergoing myomectomy. These adhesions can cause post-operative pain and infertility [22]. Anti-adhesion agents, including Interceed® , Gortex® , Intergel® and Spray Gel® , have been proposed but, at present, there is insufficient evidence to support their routine use [12]. Careful microsurgical techniques using fine grasping forceps, minimal use of power which produces necrosis of adjacent tissues, continuous irrigation combined with minimal handling of normal tissues will go a long way towards minimising post-operative adhesions.
P.J. Maher / Reviews in Gynaecological Practice 3 (2003) 41–45
4. Surgical approach An effective uterine manipulator is essential. It is the author’s preference to make a transverse incision through the myoma capsule. This minimises the amount of bleeding as the main blood supply arises from radial vessels which in turn come from the ascending uterine vessels. In the case of large fibroids, ligation of the uterine arteries before commencement of the myomectomy may reduce blood loss. This can be performed laparoscopically by entering the broad ligament in the space bordered by the round ligament anteriorly, the external iliac artery laterally, and the infundibulo-pelvic ligament medially. Once the peritoneum is opened, the pneumo-peritoneum will create a space within the ligament. The umbilical ligament placed under tension will aid in the identification of the terminal portion of the internal iliac artery, anterior branch. The uterine artery is then identified as it leaves the anterior branch. The ureter is identified on the medical leaf of the broad ligament. A clip or ligature can be used to close the vessel. A spoon electrode is preferred using 80 W cutting current. It is important to remember that the depth of the incision through the pseudo-capsule to expose the fibroid is often deeper than first thought. It is essential to establish the plane of cleavage between the myoma and compressed myometrium. Limited use of the electro-coagulation will minimise damage to the adjacent normal myometrium. It has been suggested that overzealous use of electro-coagulation has resulted in weakness or breakdown in the surrounding myometrium predisposing to uterine rupture [23,24]. As soon as the myoma is evident through the pseudo-capsule, a myoma screw is inserted. Counter-traction is obtained with a counter movement of the intra-uterine manipulator in the opposite direction to the position of the screw. The author uses two blunt probes to develop the avascular plane. Any bleeding that is encountered is treated with bipolar coagulation remembering again to minimise damage to the normal myometrium. Once the myoma is removed, it is stored usually in the Pouch of Douglas, and others removed. Some authors suggest limiting the number of myomas to two or three [25]. This has not been the practice in this Unit and up to five myomas have been removed at the one surgery. The principle of a single incision and multiple fibroids being removed through it is not possible using a laparoscopic approach. Each myoma is approached through a separate incision which, at the completion of removal of the myoma, require careful suturing. On most occasions, a single layer full thickness interrupted suture (Monocryl® ) is used to close the defect. If there is concern that a dead space exists which will predispose to haematoma formation, a single deep layer of suture is inserted and then the superficial layer closed. Dead space with or without haematoma formation will predispose to rupture of the gravid uterus—a similar circumstance visited in early reports when the defects were not sutured [26]. If there is concern about the integrity of the
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sutured cavity, then laparoscopic mini-laparotomy should be considered [27]. Following successful laparoscopic myomectomy, it may be necessary to perform a mini-laparotomy to remove large myomas. Alternatively, they can be removed through an extended umbilical incision, posterior colpotomy [28] or with the aid of a manual or electronic morsellator. Myomectomy has been reported to be associated with an average blood loss of 500 ml and the need for blood transfusion (41%) or the need for hysterectomy for uncontrollable bleeding [29]. In another prospective non-randomised control trial (RCT), Landi et al. [30] reported a mean decrease in haemoglobin of only 1.38 ± 0.93 g/100 ml. The use of a vasoconstrictor agent or a tourniquet to temporarily occlude the uterine vessels has been reported to reduce the amount of blood loss during the procedure [31,32]. The use of GnRH analogues in the pre-operative period has also been shown to be effective in reduction of intra-operative blood loss [33], although their use has been associated with difficulty in finding the plane of cleavage of myomectomy and an increase in the recurrence rate of myomas post-operatively [34].
5. UAE UAE involves injection of polyvinyl alcohol particles into the terminal branches of the uterine artery via a catheter inserted through the femoral artery [35]. In a large prospective observational study involving 400 patients, menstrual bleeding was improved in 84% and menstrual pain in 79%. Fibroid volume was shown to be reduced by up to 67%. Similar results have been reported by other authors [36]. There are no reported RCTs comparing outcomes of UAE versus surgery, although they have been proposed. It would be difficult to run such a trial, as women choose UAE to specifically avoid surgery and, the author believes this group would be very reluctant to be randomly allocated to undergo surgery.
6. Hysteroscopic surgery There is an association between heavy bleeding and sub-mucous fibroid myomata. Neuwirth and Assin [37] first described hysteroscopic fibroid resection in 1976. This approach is now the gold standard for sub-mucous fibroids less than 5 cm in diameter. GnRH analogues have been reported to decrease the fibroid size by up to 60%, thus facilitating quicker and safer resection. The most common solution used for resection of both fibroids and endometrium is 1% glycine. Fluid absorption with resultant hyponatraemic encephalopathy, which may lead to death, is the most serious complication of this procedure. The incidence of fluid overload varies between 1 and 5% [38]. Fluid absorption occurs through the open veins of the myoma and possibly through transperitoneal absorption from retrograde flow through the fallopian tubes. In an earlier report, Maher and Hill [39]
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showed that there was little retrograde flow through the fallopian tubes in 100 patients undergoing simultaneous endometrial resection and laparoscopy. The amount of fluid absorbed is directly related to the size of the myoma and hence the duration of surgery. It is safer to perform hysteroscopic surgery under local or regional anaesthesia compared with general anaesthesia, as this allows ongoing assessment of the patient’s mental state throughout surgery and the post-operative phase. Early symptoms of hyponatraemic encephalopathy, i.e. nausea, headache, vomiting and weakness, will alert the surgeon and anaesthetist to impending serious complications and allow commencement of corrective measures together with the cessation of the surgery. In a series of 122 patients, Hart et al. [40] reported fluid absorption of >2000 ml in three patients. They reported a successful outcome in 79% patients as measured by the absence of further surgery for 4 years. Patient satisfaction was 90% in this series. In another prospective study, Wamsteker et al. [41] reported that, in a series of 51 patients, up to three procedures were necessary to control symptoms of heavy bleeding. Other complications associated with sub-mucous myoma resection include perforation haemorrhage and infection. Perforation rates vary from 1 to 3% [42]. The most serious complication arising from perforation is burning of bowel overlying the uterus. If a perforation is suspected, then the procedure should be terminated immediately and further surgery scheduled 6–8 weeks later. Perforation may also create an area of weakness in the uterine wall which may have adverse consequences in a subsequent pregnancy. Haemorrhage is uncommon. Vasoconstrictor agents inserted into the base of the myoma can minimise blood loss. Similarly, cautery of large vessels traversing the myoma will have a positive impact on haemorrhage rates. If haemorrhage does occur, a Foley catheter can be inserted into the uterine cavity to tamponade the bleeding vessels. In our Unit, this has only been necessary in four cases over the last 10 years.
7. Conclusion The endoscopic approach to many gynaecological surgeries has been shown to be associated with less postoperative pain, shorter time in hospital and quicker return to normal activities. Fibromyomata is associated with heavy bleeding, pregnancy complications, infertility, pressure and pain. Newer techniques that avoid surgery, i.e. UAE, may have a place in the future although its efficacy has not been fully assessed with RCTs. Using evidence-based medicine, it is reported that there is no reason to treat asymptomatic fibroids less than 16 weeks in gestational size [12]. Asymptomatic women with fibroids >16 weeks should be assessed by a specialist gynaecologist to discuss treatment options which include observation. The author believes, however, that most clinicians will continue to counsel patients with fibroids using the indicators
in Table 1 and in consultation with them decide whether it is appropriate to proceed to surgery.
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