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Myomectomy as a reproductive procedure
Myomectomy as a reproductive procedure Donald C. Smith, MD, and Jane K. Uhlir, MD Seattle, Waskington This series of 64 myomectomies describes the indications, technique, and efficacy of the procedure; the majority of operations were performed on large multinodular uteri. Indications included enlarging pelvic mass, menorrhagia, anemia, and pregnancy wastage in women who wished to preserve reproductive capability. Although infertility was not the primary indication in any case, 32 patients were nulligravid. Only 10 patients were parous and 14 had a history of spontaneous abortion or pregnancy wastage. The average age of the patients was 35.8 years (range, 27 to 47 years). There were no major complications and no patients received blood transfusions. Follow-up revealed three patients with recurrent tumors necessitating repeat procedures. Successful pregnancies have occurred in 40% of those attempting pregnancy. It is concluded that successful myomectomy can be performed in most patients regardless of uterine size, thereby preserving reproductive potential. (AM J OSSTET GYNECOL 1990;162:1476-82.)
Key words: Myomectomy, fertility, fibroids
Although myomectomy was introduced to gynecologic surgery nearly 150 years ago, it has been during recent years that it has become an increasingly important procedure performed with greater frequency. This increased use of myomectomy rather than hysterectomy results from the desire and necessity of patients to retain or improve reproductive potential. There are several reasons for this, the most important of which follow. Today there are generally fewer adoptive infants available to the infertile couple or patient after hysterectomy than in the past. Delaying attempts at pregnancy until a later maternal age has exposed many women to the increased prevalence of uterine myomas before conception. Finally, there is no current medical treatment to accomplish the permanent removal or resolution of uterine leiomyomas. In addition to these reasons, many women (whether they plan to attempt pregnancy or not), for various psychologic, emotional, or cultural reasons, are reluctant to proceed with hysterectomy and wish to preserve the uterus. Despite the reason, and limiting discussion primarily to the groups wishing to attempt subsequent pregnancy, the role of myomectomy as a reproductiveenhancing or -preserving procedure is clearly established.
From the Department of Obstetrics-Gynecology, Swedish Hospital Medical Center. Presented at the Fifty-sixth Annual Meeting of the Pacific Coast Obstetrical and Gynecological Society, Coronado, California, September 17-21,1989. Reprint requests: Donald C. Smith, MD, 1229 Madison (1050), Seattle, WA 98104. 616119932
1476
Material and techniques This article reports the experience of 64 myomectomies performed in 63 patients by the authors between Jan. 1, 1981, and Nov. 30, 1988 (Table I). The age range for the group was between 27 and 47 years, (average age, 35.8 years). Table II shows the number of procedures performed in 5-year age groupings. Indications for myomectomy are shown in Table III. All patients were first seen with a pelvic mass, and the size of the uterus or a recent enlargement was the primary indication for surgery in 58 cases (uterine size, 12 weeks' gestational size or larger). In 37 patients, uterine size or recent continued growth was the only indication. These were instances in which the uterine size was usually significantly larger than 12 weeks' gestational size, and delay of myomectomy would result in a more difficult procedure, or in which the clinical setting suggested that subsequent attempts at achieving a successful pregnancy outcome would be jeopardized (e.g., cavity distortion, advanced maternal age, rapid growth of myomas), Ten patients had experienced 14 spontaneous abortions but only in four patients were the fibroid tumors thought to be directly related to the early pregnancy loss. Infertility was not the primary indication in any patient, although 35 patients were nulligravid. The remaining 28 patients had been pregnant a total of 46 times, and 11 patients had been delivered 15 infants. There was a total of IS spontaneous abortions; 11 occurred in 10 nulliparous women. Table IV shows the comparative previous reproductive histories between those patients who attempted pregnancy after operation and those who did not. The
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Volume 162 Number 6
Table I. Myomectomies performed by year Year
No. performed
1981 1982 1983 1984 1985 1986 1987 1988
1 5 5 8 9 16 9 11
Table II. Myomectomy (N Patient age (yr)
=
25-29 30-34 35-39 40-44 ::::45
Table III. Indications for surgery myomectomy No.
Pelvic mass Menorrhagia Anemia Pregnancy wastage Spontaneous abortion Pelvic inflammatory disease Endometriosis Previous sterilization Septate uterus
64 (58*) 4 8 4 10 9 3 1 1
*Primary indication.
64)
I
1477
No.
4 21 26 12 1
Age range 27-47 years; average 35.8 years.
only significant difference was that there were more patients with accompanying pelvic inflammatory disease or endometriosis in the group attempting pregnancy. Operative techniques
Although myomectomy is a procedure that has been performed by gynecologic surgeons for many years, a few comments on preoperative preparation and operative techniques are appropriate. Because most of the operations in this series were performed before gonadotropin-releasing hormone agonists were readily available to most clinicians, they were not used preoperatively in any case to induce shrinkage of tumors before operation as has been suggested. 1 Preoperative hysterosalpingography is desirable in nearly all cases. This allows definition of cavitary involvement and identification of interstitial obstruction of the fallopian tubes or associated distal tubal disease if it is present. If intracavitary fibroid tumors are present, or if it is likely that the uterine cavity will be entered, a dark solution of indigo carmine or methylene blue should be instilled into the uterine cavity before incision. This is most easily accomplished by a transcervical cannula or catheter. This greatly aids in determining when the cavity has been entered and assists in avoiding undue damage to the endometrial surfaces. It has been our belief that vigorous attention must be paid to hemostasis to allow the surgeon to carefully and accurately remove all tumors, reconstruct the myometrial defects, and obtain meticulous closure of the
Table IV. Pre myomectomy reproductive performance No.
Patients attempting pregnancy (n = 32) N ulligravid Gravid Parous Spontaneous abortion Pelvic inflammatory disease or endometriosis Patients not attempting pregnancy (n = 27) Nulligravid Gravid Parous Sontaneous abortion Pelvic inflammatory disease or endometriosis
16 16 4
7
11
18 9 5 4 1
uterine inCISIOns. Therefore whenever possible we place a circumferential lower uterine segment tourniquet consisting of a size l2-Fr red rubber catheter cinched tight with hemostats. This is not released until the uterine incisions are being closed or are closed. There have been no cases of postoperative shock as a result of accumulation of a histamine-like substance as suggested by Rubin 2 and Ranney and Frederick,' and we do not think that it is a potential cause of ischemic damage, as mentioned by Buttram and Reiter! We also employ the liberal use of a vasoconstrictive agent (vasopressin, 20 units in 200 ml of sterile saline solution), injected into the myometrium surrounding the fibroid tumors. Use ofthes ancillary procedures allows the surgeon to work in a nearly bloodless field. Careful thoughts should be given to the placement of the uterine incisions. Midline uterine incisions are generally less vascular, but incision placement should be made so that as many tumors as possible can be removed through a single incision while avoiding the uterotubal junction. The greater concern of posterior uterine incisions, which may cause complicating adhesions more frequently, is not as important with the ac-
1478 Smith and Uhlir
June 1990 Am J Obstet Gynecol
Table V. Number and weight of fibroids removed
I
No. of fibroids
I
Weight of fibroids (gm)
100-765 1-29 (Average 5.0) (Average 284) 110-765 1-10 Patients wtih uterine size as only indication (n = 37) (Average 4.1) (Average 345.5)
Total series (n
=
64)
Table VI. Postmyomectomy reproductive performance: pregnancies per age group Patient's age (yr)
25-29 30-34 35-39 40-44 245
No. of pregnancies
o
8 (E, E, Ab) 3 5 (G, G, Ab)
o
E, Ectopic; Ab, spontaneous abortion; G, gamete intrafallopian transfer pregnancy.
complishment of meticulous closure of the serosal inClSlOn.
Our choice of suture material for the myometrial reconstruction is 2-0 or 4-0 Vicryl (Ethicon, Inc., Somerville, N.].) for the deeper layers and 4-0 or occasional 6-0 Vicryl for the uterine serosa. In general, as small a suture as possible is used, but the suture should be large enough to avoid breaking or cutting through the tissue if placed under significant tension. Procedures for actual removal of the myomas use familiar techniques of blunt and sharp dissection with conventional instruments. We use loupe lens magnification in many instances, because it emphasizes careful dissection. Vigorous traction on the tumors should be avoided, particularly when they are located close to the endometrial cavity or interstitial tube. During the course of the procedure the pelvis is irrigated with Ringer's lactated heparin solution, and before closure of the peritoneum, 100 ml of dextran 70 (Hyskon, Pharmacia Laboratories, Piscataway, N.].) is instilled in the cul-de-sac. Routine antibiotics or corticosteroids or other agents to prevent adhesions were not used.
Results During the interval of the study, myomectomy was successfully performed in all patients for whom it was scheduled. Hysterectomy, hypogastric artery ligation, or other procedures to control bleeding was not necessary in any case. The average length of hospital stay was 4 days (range, 2 to 7 days); this is consistent with most laparotomies. There were no major complications, such as pelvic abscesses or bowel obstructions, that necessitated additional lengths of stay. Only three of the
64 procedures necessitated a hospital stay of over 5 days. The range of operating time of 55 minutes to 3 hours 50 minutes (average, 2 hours) generally correlated with the number of tumors removed or with ancillary procedures performed. Because of strict attention to hemostasis, no patient required blood transfusion. Estimated blood loss ranged between 200 and 400 ml, and the average drop in hematocrit 24-hours after operation was six points. There was a wide range in the total number and total weight of myomas removed (Table V). Larger tumors were removed from the group of patients in whom uterine size was the sole preoperative indication. Thirty-two of the patients have attempted to become pregnant after operation. For a variety of reasons, 27 of the women have elected not to attempt pregnancy at this time; the most common reason is that they were unmarried. Two patients have had subsequent hysterectomies, and current information is not available for two patients. Of the 32 patients who attempted pregnancy, sixteen have achieved a single pregnancy. Twelve of these have resulted in term viable infants (40%). There have been two ectopic pregnancies (both in patients with associated pelvic inflammatory disease), and two pregnancies that ended in spontaneous abortions. The sixteen pregnancies that occurred are shown related to maternal age at time of delivery in Table VI. Half the patients who were delivered were age 35 years of age or older and five were age 40 or older. Two patients became pregnant by gamete intrafallopian transfer. There was no correlation between the total weight of fibroid tumors removed and the likelihood of becoming pregnant. The average fibroid tumor weight of those who subsequently conceived was 224 gm, and in those who did not conceive average tumor weight was 190 gm. Of the 62 patients for whom follow-up data are available, recurrent myomas have been detected in four (6.4%). The reappearance of tumors occurred after 5 years in three patients and after 4 years in one patient. These have resulted in hysterectomies in two cases and repeat myomectomy in one patient. The remaining case is currently being followed up.
Comment This series of myomectomies was collected and presented to illustrate several points. Sixty-one of the 63 patients in the study were either attempting pregnancy or wished to preserve childbearing potential for the future. Within this group, we estimate that 20% to 25% of the cases were either referred or sought second opinions because other physicians recommended hysterectomy as a first choice or told them that there was no alternative. To the contrary, if subsequent pregnancy
Myomectomy 1479
Volume 162 Number 6
is even a consideration, hysterectomy is not an alternative. Even with the advanced degree of sophistication of assisted reproductive technologies allowing pregnancies to occur without fallopian tubes or even ovaries, a successful pregnancy is not possible without a uterus. In view of this, myomectomy must be offered to this large segment of patients, and should be performed with the same principles of atraumatic technique used in other fertility operations. This implies careful hemostasis, accurate closure and reapproximation of uterine incisions, and magnification when necessary to avoid damage to delicate uterotubal structures and to minimize postoperative adhesion formation. This point cannot be overemphasized; Berkely et al. s concluded that myomectomy itself may decrease fertility, probably as a result of adhesion formation. The question of whether fibroid tumors cause infe rtility was not addressed directly in this series, although subsequent reproductive function is of primary interest. After operation 50% of the patients who attempted pregnancy have succeeded (16 of 32). This figure may be somewhat decreased by the fact that six of the 16 patients who did not become pregnant in this group had either chronic pelvic inflammatory disease or endometriosis in addition to leiomyomas. Infertility alone was not the primary indication for operation in any case, but it is likely that some of the patients were indeed infertile. Although disagreement exists regarding the extent of the relationship between fibroid tumors and infertility, several recent studies s-s have reported on myomectomy as treatment for infertility, with pregnancy rates ranging between 50% and 65.2%, similar to those reported here. Berkely et al. 5 reported only seven of 21 patients over the age of 30 who achieved pregnancy after myomectomy, whereas 18 of 29 patients under age 30 conceived; Babaknia et al. 6 reported that they had no pregnancy successes in women over the age of 35. However, in our half of the patients who became pregnant were 35 years of age or older, and 32% (5 of 16) were 40 years of age or older. These findings are similar to those of Rosenfeld s who reported that five of eight patients over age 35 and two of four patients over age 40 became pregnant. We found no significant difference in the total weight of fibroid tumors removed and achievement in pregnancy, which differs from the findings of Berkely et al.,5 who found average total weight of fibroid tumors in those who ultimately conceived to be 194 gm compared with 384 gm in those who did not. The possibility of recurrence of leiomyomas is a clinical consideration, especially when myomectomies are performed in younger women. In an extensive review by Buttram and Reiter: 493 (15%) of2554 patients had recurrent myomas, with 330 (10%) requiring subsequent treatment. In 62 patients for whom we have ac-
curate follow-up data, four patients (6.4%) have had recurrent tumors and operation was required in three (4.8%). A rather short length of follow-up may account for these lower rates, but we attempt to remove all tumors encountered regardless of size. In summary, the importance of the role of myomectomy in preserving reproductive capacity is emphasized. This implies that the procedure be available to every patient desiring it, and that it be performed in a manner that minimizes postoperative complications that could decrease desired results. Sixteen of 32 patients who attempted pregnancy succeeded, and half were aged 35 or older. The total weight of tumors removed did not correlate with pregnancy success. It is our conclusion that virtually any patient in the reproductive age range, regardless of uterine size, is an appropriate candidate for consideration for myomectomy. REFERENCES 1. Kessel B, LiuJ, MortolaJ, Berga S, Yen SC. Treatment of uterine fibroids with agonist analogs of gonadotrophinreleasing hormone. Ferti! Steril 1988;49:538. 2. Rubin Ie. Progress in myomectomy. AMJ OSSTET GYNECOL 1942;44:196. 3. Ranney B, Frederick 1. The occasional need for myomectomy. Obstet Gynecol 1979;53:437. 4. Buttram VC, Reiter RC. Uterine leiomyomata: etiology, symptomatology, and management. Fertil Steril 1981 ;36: 433. 5. Berkely AS, DeCherney AB, Polan ML. Abdominal myomectomy and subsequent fertility. Surg Gynecol Obstet 1983;156:319. 6. Babaknia A, Rock JA, Jones BW Jr. Pregnancy success following abdominal myomectomy for infertility. Fertil Steril 1978;30:644. 7. Garcia CR, Turock RW. Submucosalleiomyomas and infertility. Ferti! Steril 1984;42: 16. 8. Rosenfeld DL. Abdominal myomectomy for otherwise unexplained infertility. Ferti! Steril 1986;46:328.
Editors' note: This manuscript was revised after the dis-
cussions were presented. Discussion
DR. HOWARD A. BLANCHETI'E, Berkeley, California. Drs. Smith and Uhlir addressed a clinical problem that we as gynecologists confront daily in our practices. The challenge to preserve reproductive potential of women in the childbearing age group who are afflicted with leiomyomas necessitates myomectomy in any woman desirous of retaining her childbearing potential, or wishing to preserve her uterus for personal or cultural reasons. The authors have emphasized the necessity to use the principles of infertility microsurgery in performance of myomectomy. They include preoperative evaluation with a hysterosalpingogram to allow definition of cavitary involvement and identification of interstitial obstruction of the fallopian tubves, or associ-
1480 Smith and Uhlir
ated distal tubal disease. They also recommend instillation of indigo carmine or methylene blue into the uterine cavity before incision, to help in determining when the cavity has been entered. Intraoperatively a tourniquet is used circumferentially around the lower uterine segment and vasopressin, 20 units in 200 ml of sterile saline solution, is used liberally. Loupe lens magnification is also used. Fine suture material, ranging from 2-0 to 6-0 Vicryl, and meticulous attention to hemostasis is emphasized. Incisions are made in such a manner as to remove as many tumors as possible through a single incision, and serosal incisions are neatly closed. Intraoperatively the pelvis is irrigated with Ringer's lactated heparin solution; 100 ml of Hyskon is instilled in the cul-de-sac before closure of the peritoneum. Drs. Smith and Uhlir do not use routine antibiotics, corticosteroids, or other agents to prevent adhesions, nor do they use gonadotropin-releasing hormone agonist preoperatively to decrease vascularity and size of the uterus. The results are impressive: 64 myomectomies over a time span of 7 years with no m~or complications, no blood transfusions, no intraoperative hysterectomies, average length of hospitalization of 4 days, 6.4% incidence of recurrent tumors, and, in those patients who attempt pregnancy, a 50% pregnancy rate with a 40% live-birth rate. Half of the pregnancies were in women over the age of 35. Comparative results from my three-person private practice in obstetrics and gynecology in Berkeley substantiate these findings. Sixty-nine myomectomies were performed in a lO-year period from 1979 through 1989. There was little difference between the authors' patients and our patients with regard to previous reproductive performance, average age, indications for surgery, length of hospitalization, preoperative and postoperative hematocrit levels, numbers of tumors removed, and the weight of tumors removed. However, differences were evident between the two groups in the use of hemostatic adjuncts. The authors routinely used a tourniquet and vasopressin, whereas in my group over a third did not have any hemostatic adjunct. This may have explained why three of our patients required intraoperative transfusion. Fourteen of our patients, contrasted with three of the authors' patients, had a length of stay greater than 5 days. The authors had no major complications, and we had two. One patient had postoperative endometritis that necessitated use of parenteral antibiotics, and another patient required intraoperative hysterectomy, not because of bleeding, but because the myomatous process was so extensive that meticulous excision would not preserve her childbearing potential. Four of our patients had excision of tumors that weighed more than 765 gm, which was the authors' upper limit; of interest is the one patient who had a 30-week size uterus, nine fibroids, with accumulative weight of 2640 gm. Sixteen percent of our patients had recurrent tumors, contrasted with 6.4% of the authors' cases. The postmyomectomy reproductive performance in
June 1990 Am J Obstet Gynecol
those patients who attempted pregnancy was similar in both groups; their group achieved a 50% pregnancy rate, and a 40% live birth rate, and our group achieved a 52% pregnancy rate with the same live birth rate. Half of their patients and one third of our patients who achieved pregnancy were over the age of 35. The authors have stated emphatically that if a subsequent pregnancy is even a consideration in any woman with uterine leiomyomas, hysterectomy is not an alternative. They concluded that virtually any patient in the reproductive age range, regardless of uterine size, is an appropriate candidate for consideration for myomectomy. Recent studies in the literature addressing the enhancement of preoperative assessment and intraoperative management to improve the reproductive outcome of myomectomy include: (1) the preoperative use of magnetic resonance imaging to assess size and location of the fibroids, (2) the use of a gonadotropin-releasing hormone agonist preoperatively to reduce vascularity and size of the leiomyomas, (3) the use of the laser intraoperatively to improve hemostasis, reduce postoperative adhesion formation, remove myomas from previously inaccessible areas, and effect direct vaporization of smaller myomas, and (4) the judicious use of prophylactic antibiotics in instances when it is anticipated that the uterine cavity may be entered during the performance of myomectomy. Controversy does abound in the literature regarding leiomyomas, infertility, and the role of myomectomy. I will outline the controversy by asking Dr. Smith the three following questions. (1) Should myomectomy precede attempts at conception if a documented submucous fibroid tumor is present? (2) At what uterine size should myomectomy precede attempts at conception? (3) In instances when a leiomyoma is the only finding in a couple's infertility evaluation, should myomectomy be performed? DR. ROBERT ISRAEL, Los Angeles, California. In May 1935, Victor Bonney, consulting gynecologic and obstetric surgeon to the Middlesex Hospital, London, England, was the invited guest at the American Gynecological Society'S annual meeting in Hot Springs, Virginia. In 1946 he thanked the fellows of that Society by dedicating to them his new book, The Technical Minutiae of Extended Myomectomy and Ovarian Cystectomy.l On the basis of his experience with over 800 myomectomies, the focus of the book is directed toward the various operative approaches that can be used depending on the location and size of the myomas encountered. If Victor Bonney were alive today, he would be delighted with this paper that not only espouses myomectomy, but clearly demonstrates that this operation can be performed with precision and attention to detail that will yield very low complication and recurrence rates. Recent years have seen a great improvement but radical operations on the womb are still being carried out where conservatism would be equally feasible and safe; the surgeons who perform them being either timid of new ways or too confirmed
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in the old, to change. I have no message for the suture-bound, nor for those whose capacity is already stretched to its utmost, but to those others I would say that surgery thus shorn of what should be its chief adornment, mercy, is a mean goal to aim at. l
Having praised the authors' study for its vision and excellent results, I would like to raise some questions and review some concepts that, hopefully, will make this an even stronger paper. As noted by the authors, all 64 patients who had myomectomies presented with a pelvic mass, and in 58 uterine size or a recent enlargement were the primary indications for operation. How many of the 58 cases were in each of these categories? Additionally, when does size become an indication? Although the authors discuss tumor weight, they did not mention what is clinically important preoperatively: uterine size. What was the breakdown of these cases by uterine size and how was "recent enlargement" evaluated? This information would seem to be relevant since none of the patients apparently presented with clinically important pain, pressure symptoms, or excessive bleeding. Because combined surgical procedures often yield poorer results, one wonders whether the patient who underwent myomectomy with reversal of tubal sterilization maintained tubal patency and conceived? In the patient who underwent transabdominal myomectomy and metroplasty, where was the myoma(s) located, and, if it did not involve the uterine cavity, was consideration given to a hysteroscopic metroplasty to prevent the future need for cesarean section? With no major complications, no blood transfusions, and the normal postoperative length of stay, it is obvious that we cannot quarrel with the authors' meticulously thorough operative technique. Bonney would be proud. I have often thought how wonderfully perfect the surgery of the abdominal cavity would become, if we could send a team of trained Lilliputians down a ladder through the abdominal wound with instructions to get on with the job. What gentleness! What absolute hemostasis! What meticulous neatness of adjustment and suture! How little after-pain; not worse than a mild toothache. What safety! Gentleness is of great importance in myomectomy, for the hurried wrenching out of deeply-imbedded tumours shocks the patient and mauls the tissues. l
Drs. Smith and Uhlir for Lilliputians-of-the-Year! The average drop in the postoperative hematocrit was 6 points. With the hemodilution usually observed after operation when 100 ml of dextran 70 are left in the pelvis, this hematocrit fall is not unusual. When was the postoperative hematocrit sample drawn? Were the 12 infants who were born after myomectomy delivered vaginally or by cesarean section? If there were any cesarean sections, were they performed because the uterine cavity had been entered, or a significant portion of the myometrium violated, at the time of myomectomy? All the myomectomies were performed between 1981 and 1988. With the low rate of myoma recurrence, how many patients were followed
1481
up for how long (i.e., how many have been followed up 8 years, how many 7 years, etc?). Although all of the authors' cases involved uterine myomata, they were fortunate that on occasion they did not encounter an enlarged adenomyomatous uterus rather than an enlarged myomatous uterus. If the planned operation is a hysterectomy, differentiating between the two is unimportant. However, if the planned operation is a myomectomy, finding adenomyosis when the uterine wall is incised leaves only one conservative alternative: Back out, closing the abdominal incision as you go. Fortunately, today we have magnetic resonance imaging that can differentiate between adenomyosis and myomas before operation. With use of a high index of suspicion, especially with a globularly enlarged uterus, preoperative magnetic resonance imaging, with even just a few sagittal views, will prevent you from starting a "myomectomy" on an adenomyomatous uterus. Could the authors explain their nonmagnetic resonance imaging "skills" and could they also give their opinion on magnetic resonance imaging use? Given the lack of any significant cases of menorrhagia, one wonders whether the Seattle weather does not permit the development of submucous myomas or, in actuality, there were no submucous lesions? The difficult myoma cases involve a combination of submucous myoma(s), menorrhagia, and anemia. With the clinical availability of at least one gonadotropin-releasing hormone agonist, the bleeding can be stopped, thus allowing the anemia to be corrected with iron therapy, and the myoma(s) can be reduced to a size that can be handled hysteroscopically or through a Pfannenstiel skin incision, in contrast to the authors' midline vertical approach. Although no blood transfusions were necessary in this study, they are potentially necessary in all myomectomies. Autologous blood use is the preferred method of intraoperative and postoperative blood replacement. Even in the patient with menorrhagia, the use of a gonadotropin-releasing hormone agonist can create an amenorrheic state and allow restoration of a normal hemoglobin level and the ability to self-donate blood. In 1946, Victor Bonneyl wrote: "Very few cases of fibroids are now beyond the technical range of myomectomy. There is a pleasure, a pride, and a satisfaction in these conservative operations which cannot be appreciated save by those who have performed them, and I want to see them in the repertory of every surgeon called upon to operate on the womb."l Forty-three years later, Bonney would revel in Smith and Uhlir's last sentence: "It is our conclusion that virtually any patient in the reproductive age range, regardless of uterine size, is an appropriate candidate for consideration for myomectomy." REFERENCE 1. Bonney V. The technical minutiae of extended myomectomy and ovarian cystectomy. London: Hoeber, 1946.
1482
Smith and Uhlir
DR. SMITH (Closing). All questions posed by Drs. Israel and Blanchette are important and appropriate; however, time constraints preclude addressing most of them. I will comment briefly on a few of their questions. To clarify Dr. Israel's comments, we do not use vertical abdominal incisions. The incisions I alluded to are vertical uterine incisions. In regard to the use of magnetic resonance imaging for the definition of myoma as opposed to adenomyosis, I believe that use of ultrasonography and pelvic examination, together with presenting complaints, is sufficient to differentiate between the two disease entities and is more economical. In our series we have encountered adenofibromas but no frank cases of adenomyosis. With regard to Dr. Blanchette's three questions, I have no definite answers to these clinical dilemmas. In a patient with a submucous myoma, unless it marked distorts the cavity, an attempt at pregnancy is probably justified before myomectomy. Although the age of the
June 1990 Am J Obstet Gynecol
patient, size of the fibroid tumor, and the total clinical setting must be considered, I have seen patients with prominent lower-segment fibroids carry pregnancies to term. At what uterine size do we choose to intervene? There is no definite answer. I believe that uterine sizes larger than 12 to 14 weeks' gestational size begin to be more technically difficult, and allowing the uterus to grow beyond this point may produce a more difficult procedure. I would perform a myomectomy at that time, even if the patient was going to defer pregnancy attempts to some later date. The last question regards the infertile patient and fibroid tumors. If you think your evaluation is complete, no other cause has been uncovered, and more conservative therapeutic approaches have been unsuccessful, then, and only then, should myomectomy be considered.
Key words: Myomectomy, fertility, fibroids
Although myomectomy was introduced to gynecologic surgery nearly 150 years ago, it has been during recent years that it has become an increasingly important procedure performed with greater frequency. This increased use of myomectomy rather than hysterectomy results from the desire and necessity of patients to retain or improve reproductive potential. There are several reasons for this, the most important of which follow. Today there are generally fewer adoptive infants available to the infertile couple or patient after hysterectomy than in the past. Delaying attempts at pregnancy until a later maternal age has exposed many women to the increased prevalence of uterine myomas before conception. Finally, there is no current medical treatment to accomplish the permanent removal or resolution of uterine leiomyomas. In addition to these reasons, many women (whether they plan to attempt pregnancy or not), for various psychologic, emotional, or cultural reasons, are reluctant to proceed with hysterectomy and wish to preserve the uterus. Despite the reason, and limiting discussion primarily to the groups wishing to attempt subsequent pregnancy, the role of myomectomy as a reproductiveenhancing or -preserving procedure is clearly established.
From the Department of Obstetrics-Gynecology, Swedish Hospital Medical Center. Presented at the Fifty-sixth Annual Meeting of the Pacific Coast Obstetrical and Gynecological Society, Coronado, California, September 17-21,1989. Reprint requests: Donald C. Smith, MD, 1229 Madison (1050), Seattle, WA 98104. 616119932
1476
Material and techniques This article reports the experience of 64 myomectomies performed in 63 patients by the authors between Jan. 1, 1981, and Nov. 30, 1988 (Table I). The age range for the group was between 27 and 47 years, (average age, 35.8 years). Table II shows the number of procedures performed in 5-year age groupings. Indications for myomectomy are shown in Table III. All patients were first seen with a pelvic mass, and the size of the uterus or a recent enlargement was the primary indication for surgery in 58 cases (uterine size, 12 weeks' gestational size or larger). In 37 patients, uterine size or recent continued growth was the only indication. These were instances in which the uterine size was usually significantly larger than 12 weeks' gestational size, and delay of myomectomy would result in a more difficult procedure, or in which the clinical setting suggested that subsequent attempts at achieving a successful pregnancy outcome would be jeopardized (e.g., cavity distortion, advanced maternal age, rapid growth of myomas), Ten patients had experienced 14 spontaneous abortions but only in four patients were the fibroid tumors thought to be directly related to the early pregnancy loss. Infertility was not the primary indication in any patient, although 35 patients were nulligravid. The remaining 28 patients had been pregnant a total of 46 times, and 11 patients had been delivered 15 infants. There was a total of IS spontaneous abortions; 11 occurred in 10 nulliparous women. Table IV shows the comparative previous reproductive histories between those patients who attempted pregnancy after operation and those who did not. The
Myomectomy
Volume 162 Number 6
Table I. Myomectomies performed by year Year
No. performed
1981 1982 1983 1984 1985 1986 1987 1988
1 5 5 8 9 16 9 11
Table II. Myomectomy (N Patient age (yr)
=
25-29 30-34 35-39 40-44 ::::45
Table III. Indications for surgery myomectomy No.
Pelvic mass Menorrhagia Anemia Pregnancy wastage Spontaneous abortion Pelvic inflammatory disease Endometriosis Previous sterilization Septate uterus
64 (58*) 4 8 4 10 9 3 1 1
*Primary indication.
64)
I
1477
No.
4 21 26 12 1
Age range 27-47 years; average 35.8 years.
only significant difference was that there were more patients with accompanying pelvic inflammatory disease or endometriosis in the group attempting pregnancy. Operative techniques
Although myomectomy is a procedure that has been performed by gynecologic surgeons for many years, a few comments on preoperative preparation and operative techniques are appropriate. Because most of the operations in this series were performed before gonadotropin-releasing hormone agonists were readily available to most clinicians, they were not used preoperatively in any case to induce shrinkage of tumors before operation as has been suggested. 1 Preoperative hysterosalpingography is desirable in nearly all cases. This allows definition of cavitary involvement and identification of interstitial obstruction of the fallopian tubes or associated distal tubal disease if it is present. If intracavitary fibroid tumors are present, or if it is likely that the uterine cavity will be entered, a dark solution of indigo carmine or methylene blue should be instilled into the uterine cavity before incision. This is most easily accomplished by a transcervical cannula or catheter. This greatly aids in determining when the cavity has been entered and assists in avoiding undue damage to the endometrial surfaces. It has been our belief that vigorous attention must be paid to hemostasis to allow the surgeon to carefully and accurately remove all tumors, reconstruct the myometrial defects, and obtain meticulous closure of the
Table IV. Pre myomectomy reproductive performance No.
Patients attempting pregnancy (n = 32) N ulligravid Gravid Parous Spontaneous abortion Pelvic inflammatory disease or endometriosis Patients not attempting pregnancy (n = 27) Nulligravid Gravid Parous Sontaneous abortion Pelvic inflammatory disease or endometriosis
16 16 4
7
11
18 9 5 4 1
uterine inCISIOns. Therefore whenever possible we place a circumferential lower uterine segment tourniquet consisting of a size l2-Fr red rubber catheter cinched tight with hemostats. This is not released until the uterine incisions are being closed or are closed. There have been no cases of postoperative shock as a result of accumulation of a histamine-like substance as suggested by Rubin 2 and Ranney and Frederick,' and we do not think that it is a potential cause of ischemic damage, as mentioned by Buttram and Reiter! We also employ the liberal use of a vasoconstrictive agent (vasopressin, 20 units in 200 ml of sterile saline solution), injected into the myometrium surrounding the fibroid tumors. Use ofthes ancillary procedures allows the surgeon to work in a nearly bloodless field. Careful thoughts should be given to the placement of the uterine incisions. Midline uterine incisions are generally less vascular, but incision placement should be made so that as many tumors as possible can be removed through a single incision while avoiding the uterotubal junction. The greater concern of posterior uterine incisions, which may cause complicating adhesions more frequently, is not as important with the ac-
1478 Smith and Uhlir
June 1990 Am J Obstet Gynecol
Table V. Number and weight of fibroids removed
I
No. of fibroids
I
Weight of fibroids (gm)
100-765 1-29 (Average 5.0) (Average 284) 110-765 1-10 Patients wtih uterine size as only indication (n = 37) (Average 4.1) (Average 345.5)
Total series (n
=
64)
Table VI. Postmyomectomy reproductive performance: pregnancies per age group Patient's age (yr)
25-29 30-34 35-39 40-44 245
No. of pregnancies
o
8 (E, E, Ab) 3 5 (G, G, Ab)
o
E, Ectopic; Ab, spontaneous abortion; G, gamete intrafallopian transfer pregnancy.
complishment of meticulous closure of the serosal inClSlOn.
Our choice of suture material for the myometrial reconstruction is 2-0 or 4-0 Vicryl (Ethicon, Inc., Somerville, N.].) for the deeper layers and 4-0 or occasional 6-0 Vicryl for the uterine serosa. In general, as small a suture as possible is used, but the suture should be large enough to avoid breaking or cutting through the tissue if placed under significant tension. Procedures for actual removal of the myomas use familiar techniques of blunt and sharp dissection with conventional instruments. We use loupe lens magnification in many instances, because it emphasizes careful dissection. Vigorous traction on the tumors should be avoided, particularly when they are located close to the endometrial cavity or interstitial tube. During the course of the procedure the pelvis is irrigated with Ringer's lactated heparin solution, and before closure of the peritoneum, 100 ml of dextran 70 (Hyskon, Pharmacia Laboratories, Piscataway, N.].) is instilled in the cul-de-sac. Routine antibiotics or corticosteroids or other agents to prevent adhesions were not used.
Results During the interval of the study, myomectomy was successfully performed in all patients for whom it was scheduled. Hysterectomy, hypogastric artery ligation, or other procedures to control bleeding was not necessary in any case. The average length of hospital stay was 4 days (range, 2 to 7 days); this is consistent with most laparotomies. There were no major complications, such as pelvic abscesses or bowel obstructions, that necessitated additional lengths of stay. Only three of the
64 procedures necessitated a hospital stay of over 5 days. The range of operating time of 55 minutes to 3 hours 50 minutes (average, 2 hours) generally correlated with the number of tumors removed or with ancillary procedures performed. Because of strict attention to hemostasis, no patient required blood transfusion. Estimated blood loss ranged between 200 and 400 ml, and the average drop in hematocrit 24-hours after operation was six points. There was a wide range in the total number and total weight of myomas removed (Table V). Larger tumors were removed from the group of patients in whom uterine size was the sole preoperative indication. Thirty-two of the patients have attempted to become pregnant after operation. For a variety of reasons, 27 of the women have elected not to attempt pregnancy at this time; the most common reason is that they were unmarried. Two patients have had subsequent hysterectomies, and current information is not available for two patients. Of the 32 patients who attempted pregnancy, sixteen have achieved a single pregnancy. Twelve of these have resulted in term viable infants (40%). There have been two ectopic pregnancies (both in patients with associated pelvic inflammatory disease), and two pregnancies that ended in spontaneous abortions. The sixteen pregnancies that occurred are shown related to maternal age at time of delivery in Table VI. Half the patients who were delivered were age 35 years of age or older and five were age 40 or older. Two patients became pregnant by gamete intrafallopian transfer. There was no correlation between the total weight of fibroid tumors removed and the likelihood of becoming pregnant. The average fibroid tumor weight of those who subsequently conceived was 224 gm, and in those who did not conceive average tumor weight was 190 gm. Of the 62 patients for whom follow-up data are available, recurrent myomas have been detected in four (6.4%). The reappearance of tumors occurred after 5 years in three patients and after 4 years in one patient. These have resulted in hysterectomies in two cases and repeat myomectomy in one patient. The remaining case is currently being followed up.
Comment This series of myomectomies was collected and presented to illustrate several points. Sixty-one of the 63 patients in the study were either attempting pregnancy or wished to preserve childbearing potential for the future. Within this group, we estimate that 20% to 25% of the cases were either referred or sought second opinions because other physicians recommended hysterectomy as a first choice or told them that there was no alternative. To the contrary, if subsequent pregnancy
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is even a consideration, hysterectomy is not an alternative. Even with the advanced degree of sophistication of assisted reproductive technologies allowing pregnancies to occur without fallopian tubes or even ovaries, a successful pregnancy is not possible without a uterus. In view of this, myomectomy must be offered to this large segment of patients, and should be performed with the same principles of atraumatic technique used in other fertility operations. This implies careful hemostasis, accurate closure and reapproximation of uterine incisions, and magnification when necessary to avoid damage to delicate uterotubal structures and to minimize postoperative adhesion formation. This point cannot be overemphasized; Berkely et al. s concluded that myomectomy itself may decrease fertility, probably as a result of adhesion formation. The question of whether fibroid tumors cause infe rtility was not addressed directly in this series, although subsequent reproductive function is of primary interest. After operation 50% of the patients who attempted pregnancy have succeeded (16 of 32). This figure may be somewhat decreased by the fact that six of the 16 patients who did not become pregnant in this group had either chronic pelvic inflammatory disease or endometriosis in addition to leiomyomas. Infertility alone was not the primary indication for operation in any case, but it is likely that some of the patients were indeed infertile. Although disagreement exists regarding the extent of the relationship between fibroid tumors and infertility, several recent studies s-s have reported on myomectomy as treatment for infertility, with pregnancy rates ranging between 50% and 65.2%, similar to those reported here. Berkely et al. 5 reported only seven of 21 patients over the age of 30 who achieved pregnancy after myomectomy, whereas 18 of 29 patients under age 30 conceived; Babaknia et al. 6 reported that they had no pregnancy successes in women over the age of 35. However, in our half of the patients who became pregnant were 35 years of age or older, and 32% (5 of 16) were 40 years of age or older. These findings are similar to those of Rosenfeld s who reported that five of eight patients over age 35 and two of four patients over age 40 became pregnant. We found no significant difference in the total weight of fibroid tumors removed and achievement in pregnancy, which differs from the findings of Berkely et al.,5 who found average total weight of fibroid tumors in those who ultimately conceived to be 194 gm compared with 384 gm in those who did not. The possibility of recurrence of leiomyomas is a clinical consideration, especially when myomectomies are performed in younger women. In an extensive review by Buttram and Reiter: 493 (15%) of2554 patients had recurrent myomas, with 330 (10%) requiring subsequent treatment. In 62 patients for whom we have ac-
curate follow-up data, four patients (6.4%) have had recurrent tumors and operation was required in three (4.8%). A rather short length of follow-up may account for these lower rates, but we attempt to remove all tumors encountered regardless of size. In summary, the importance of the role of myomectomy in preserving reproductive capacity is emphasized. This implies that the procedure be available to every patient desiring it, and that it be performed in a manner that minimizes postoperative complications that could decrease desired results. Sixteen of 32 patients who attempted pregnancy succeeded, and half were aged 35 or older. The total weight of tumors removed did not correlate with pregnancy success. It is our conclusion that virtually any patient in the reproductive age range, regardless of uterine size, is an appropriate candidate for consideration for myomectomy. REFERENCES 1. Kessel B, LiuJ, MortolaJ, Berga S, Yen SC. Treatment of uterine fibroids with agonist analogs of gonadotrophinreleasing hormone. Ferti! Steril 1988;49:538. 2. Rubin Ie. Progress in myomectomy. AMJ OSSTET GYNECOL 1942;44:196. 3. Ranney B, Frederick 1. The occasional need for myomectomy. Obstet Gynecol 1979;53:437. 4. Buttram VC, Reiter RC. Uterine leiomyomata: etiology, symptomatology, and management. Fertil Steril 1981 ;36: 433. 5. Berkely AS, DeCherney AB, Polan ML. Abdominal myomectomy and subsequent fertility. Surg Gynecol Obstet 1983;156:319. 6. Babaknia A, Rock JA, Jones BW Jr. Pregnancy success following abdominal myomectomy for infertility. Fertil Steril 1978;30:644. 7. Garcia CR, Turock RW. Submucosalleiomyomas and infertility. Ferti! Steril 1984;42: 16. 8. Rosenfeld DL. Abdominal myomectomy for otherwise unexplained infertility. Ferti! Steril 1986;46:328.
Editors' note: This manuscript was revised after the dis-
cussions were presented. Discussion
DR. HOWARD A. BLANCHETI'E, Berkeley, California. Drs. Smith and Uhlir addressed a clinical problem that we as gynecologists confront daily in our practices. The challenge to preserve reproductive potential of women in the childbearing age group who are afflicted with leiomyomas necessitates myomectomy in any woman desirous of retaining her childbearing potential, or wishing to preserve her uterus for personal or cultural reasons. The authors have emphasized the necessity to use the principles of infertility microsurgery in performance of myomectomy. They include preoperative evaluation with a hysterosalpingogram to allow definition of cavitary involvement and identification of interstitial obstruction of the fallopian tubves, or associ-
1480 Smith and Uhlir
ated distal tubal disease. They also recommend instillation of indigo carmine or methylene blue into the uterine cavity before incision, to help in determining when the cavity has been entered. Intraoperatively a tourniquet is used circumferentially around the lower uterine segment and vasopressin, 20 units in 200 ml of sterile saline solution, is used liberally. Loupe lens magnification is also used. Fine suture material, ranging from 2-0 to 6-0 Vicryl, and meticulous attention to hemostasis is emphasized. Incisions are made in such a manner as to remove as many tumors as possible through a single incision, and serosal incisions are neatly closed. Intraoperatively the pelvis is irrigated with Ringer's lactated heparin solution; 100 ml of Hyskon is instilled in the cul-de-sac before closure of the peritoneum. Drs. Smith and Uhlir do not use routine antibiotics, corticosteroids, or other agents to prevent adhesions, nor do they use gonadotropin-releasing hormone agonist preoperatively to decrease vascularity and size of the uterus. The results are impressive: 64 myomectomies over a time span of 7 years with no m~or complications, no blood transfusions, no intraoperative hysterectomies, average length of hospitalization of 4 days, 6.4% incidence of recurrent tumors, and, in those patients who attempt pregnancy, a 50% pregnancy rate with a 40% live-birth rate. Half of the pregnancies were in women over the age of 35. Comparative results from my three-person private practice in obstetrics and gynecology in Berkeley substantiate these findings. Sixty-nine myomectomies were performed in a lO-year period from 1979 through 1989. There was little difference between the authors' patients and our patients with regard to previous reproductive performance, average age, indications for surgery, length of hospitalization, preoperative and postoperative hematocrit levels, numbers of tumors removed, and the weight of tumors removed. However, differences were evident between the two groups in the use of hemostatic adjuncts. The authors routinely used a tourniquet and vasopressin, whereas in my group over a third did not have any hemostatic adjunct. This may have explained why three of our patients required intraoperative transfusion. Fourteen of our patients, contrasted with three of the authors' patients, had a length of stay greater than 5 days. The authors had no major complications, and we had two. One patient had postoperative endometritis that necessitated use of parenteral antibiotics, and another patient required intraoperative hysterectomy, not because of bleeding, but because the myomatous process was so extensive that meticulous excision would not preserve her childbearing potential. Four of our patients had excision of tumors that weighed more than 765 gm, which was the authors' upper limit; of interest is the one patient who had a 30-week size uterus, nine fibroids, with accumulative weight of 2640 gm. Sixteen percent of our patients had recurrent tumors, contrasted with 6.4% of the authors' cases. The postmyomectomy reproductive performance in
June 1990 Am J Obstet Gynecol
those patients who attempted pregnancy was similar in both groups; their group achieved a 50% pregnancy rate, and a 40% live birth rate, and our group achieved a 52% pregnancy rate with the same live birth rate. Half of their patients and one third of our patients who achieved pregnancy were over the age of 35. The authors have stated emphatically that if a subsequent pregnancy is even a consideration in any woman with uterine leiomyomas, hysterectomy is not an alternative. They concluded that virtually any patient in the reproductive age range, regardless of uterine size, is an appropriate candidate for consideration for myomectomy. Recent studies in the literature addressing the enhancement of preoperative assessment and intraoperative management to improve the reproductive outcome of myomectomy include: (1) the preoperative use of magnetic resonance imaging to assess size and location of the fibroids, (2) the use of a gonadotropin-releasing hormone agonist preoperatively to reduce vascularity and size of the leiomyomas, (3) the use of the laser intraoperatively to improve hemostasis, reduce postoperative adhesion formation, remove myomas from previously inaccessible areas, and effect direct vaporization of smaller myomas, and (4) the judicious use of prophylactic antibiotics in instances when it is anticipated that the uterine cavity may be entered during the performance of myomectomy. Controversy does abound in the literature regarding leiomyomas, infertility, and the role of myomectomy. I will outline the controversy by asking Dr. Smith the three following questions. (1) Should myomectomy precede attempts at conception if a documented submucous fibroid tumor is present? (2) At what uterine size should myomectomy precede attempts at conception? (3) In instances when a leiomyoma is the only finding in a couple's infertility evaluation, should myomectomy be performed? DR. ROBERT ISRAEL, Los Angeles, California. In May 1935, Victor Bonney, consulting gynecologic and obstetric surgeon to the Middlesex Hospital, London, England, was the invited guest at the American Gynecological Society'S annual meeting in Hot Springs, Virginia. In 1946 he thanked the fellows of that Society by dedicating to them his new book, The Technical Minutiae of Extended Myomectomy and Ovarian Cystectomy.l On the basis of his experience with over 800 myomectomies, the focus of the book is directed toward the various operative approaches that can be used depending on the location and size of the myomas encountered. If Victor Bonney were alive today, he would be delighted with this paper that not only espouses myomectomy, but clearly demonstrates that this operation can be performed with precision and attention to detail that will yield very low complication and recurrence rates. Recent years have seen a great improvement but radical operations on the womb are still being carried out where conservatism would be equally feasible and safe; the surgeons who perform them being either timid of new ways or too confirmed
Myomectomy
Volume 162 Number 6
in the old, to change. I have no message for the suture-bound, nor for those whose capacity is already stretched to its utmost, but to those others I would say that surgery thus shorn of what should be its chief adornment, mercy, is a mean goal to aim at. l
Having praised the authors' study for its vision and excellent results, I would like to raise some questions and review some concepts that, hopefully, will make this an even stronger paper. As noted by the authors, all 64 patients who had myomectomies presented with a pelvic mass, and in 58 uterine size or a recent enlargement were the primary indications for operation. How many of the 58 cases were in each of these categories? Additionally, when does size become an indication? Although the authors discuss tumor weight, they did not mention what is clinically important preoperatively: uterine size. What was the breakdown of these cases by uterine size and how was "recent enlargement" evaluated? This information would seem to be relevant since none of the patients apparently presented with clinically important pain, pressure symptoms, or excessive bleeding. Because combined surgical procedures often yield poorer results, one wonders whether the patient who underwent myomectomy with reversal of tubal sterilization maintained tubal patency and conceived? In the patient who underwent transabdominal myomectomy and metroplasty, where was the myoma(s) located, and, if it did not involve the uterine cavity, was consideration given to a hysteroscopic metroplasty to prevent the future need for cesarean section? With no major complications, no blood transfusions, and the normal postoperative length of stay, it is obvious that we cannot quarrel with the authors' meticulously thorough operative technique. Bonney would be proud. I have often thought how wonderfully perfect the surgery of the abdominal cavity would become, if we could send a team of trained Lilliputians down a ladder through the abdominal wound with instructions to get on with the job. What gentleness! What absolute hemostasis! What meticulous neatness of adjustment and suture! How little after-pain; not worse than a mild toothache. What safety! Gentleness is of great importance in myomectomy, for the hurried wrenching out of deeply-imbedded tumours shocks the patient and mauls the tissues. l
Drs. Smith and Uhlir for Lilliputians-of-the-Year! The average drop in the postoperative hematocrit was 6 points. With the hemodilution usually observed after operation when 100 ml of dextran 70 are left in the pelvis, this hematocrit fall is not unusual. When was the postoperative hematocrit sample drawn? Were the 12 infants who were born after myomectomy delivered vaginally or by cesarean section? If there were any cesarean sections, were they performed because the uterine cavity had been entered, or a significant portion of the myometrium violated, at the time of myomectomy? All the myomectomies were performed between 1981 and 1988. With the low rate of myoma recurrence, how many patients were followed
1481
up for how long (i.e., how many have been followed up 8 years, how many 7 years, etc?). Although all of the authors' cases involved uterine myomata, they were fortunate that on occasion they did not encounter an enlarged adenomyomatous uterus rather than an enlarged myomatous uterus. If the planned operation is a hysterectomy, differentiating between the two is unimportant. However, if the planned operation is a myomectomy, finding adenomyosis when the uterine wall is incised leaves only one conservative alternative: Back out, closing the abdominal incision as you go. Fortunately, today we have magnetic resonance imaging that can differentiate between adenomyosis and myomas before operation. With use of a high index of suspicion, especially with a globularly enlarged uterus, preoperative magnetic resonance imaging, with even just a few sagittal views, will prevent you from starting a "myomectomy" on an adenomyomatous uterus. Could the authors explain their nonmagnetic resonance imaging "skills" and could they also give their opinion on magnetic resonance imaging use? Given the lack of any significant cases of menorrhagia, one wonders whether the Seattle weather does not permit the development of submucous myomas or, in actuality, there were no submucous lesions? The difficult myoma cases involve a combination of submucous myoma(s), menorrhagia, and anemia. With the clinical availability of at least one gonadotropin-releasing hormone agonist, the bleeding can be stopped, thus allowing the anemia to be corrected with iron therapy, and the myoma(s) can be reduced to a size that can be handled hysteroscopically or through a Pfannenstiel skin incision, in contrast to the authors' midline vertical approach. Although no blood transfusions were necessary in this study, they are potentially necessary in all myomectomies. Autologous blood use is the preferred method of intraoperative and postoperative blood replacement. Even in the patient with menorrhagia, the use of a gonadotropin-releasing hormone agonist can create an amenorrheic state and allow restoration of a normal hemoglobin level and the ability to self-donate blood. In 1946, Victor Bonneyl wrote: "Very few cases of fibroids are now beyond the technical range of myomectomy. There is a pleasure, a pride, and a satisfaction in these conservative operations which cannot be appreciated save by those who have performed them, and I want to see them in the repertory of every surgeon called upon to operate on the womb."l Forty-three years later, Bonney would revel in Smith and Uhlir's last sentence: "It is our conclusion that virtually any patient in the reproductive age range, regardless of uterine size, is an appropriate candidate for consideration for myomectomy." REFERENCE 1. Bonney V. The technical minutiae of extended myomectomy and ovarian cystectomy. London: Hoeber, 1946.
1482
Smith and Uhlir
DR. SMITH (Closing). All questions posed by Drs. Israel and Blanchette are important and appropriate; however, time constraints preclude addressing most of them. I will comment briefly on a few of their questions. To clarify Dr. Israel's comments, we do not use vertical abdominal incisions. The incisions I alluded to are vertical uterine incisions. In regard to the use of magnetic resonance imaging for the definition of myoma as opposed to adenomyosis, I believe that use of ultrasonography and pelvic examination, together with presenting complaints, is sufficient to differentiate between the two disease entities and is more economical. In our series we have encountered adenofibromas but no frank cases of adenomyosis. With regard to Dr. Blanchette's three questions, I have no definite answers to these clinical dilemmas. In a patient with a submucous myoma, unless it marked distorts the cavity, an attempt at pregnancy is probably justified before myomectomy. Although the age of the
June 1990 Am J Obstet Gynecol
patient, size of the fibroid tumor, and the total clinical setting must be considered, I have seen patients with prominent lower-segment fibroids carry pregnancies to term. At what uterine size do we choose to intervene? There is no definite answer. I believe that uterine sizes larger than 12 to 14 weeks' gestational size begin to be more technically difficult, and allowing the uterus to grow beyond this point may produce a more difficult procedure. I would perform a myomectomy at that time, even if the patient was going to defer pregnancy attempts to some later date. The last question regards the infertile patient and fibroid tumors. If you think your evaluation is complete, no other cause has been uncovered, and more conservative therapeutic approaches have been unsuccessful, then, and only then, should myomectomy be considered.