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Strategy of cervical myomectomy under laparoscopy
TECHNIQUES AND INSTRUMENTATION Strategy of cervical myomectomy under laparoscopy Wen-Chun Chang, M.D.,a Szu-yu Chen, M.D.,b Su-Cheng Huang, M.D.,a Daw-Yuan Chang, M.D., Ph.D.,a Li-Yun Chou, M.D.,a and Bor-Ching Sheu, M.D., Ph.D.a a
Department of Obstetrics and Gynecology, National Taiwan University Hospital, College of Medicine, National Taiwan University, and b Cathay General Hospital, Taipei, Taiwan
Objective: To evaluate a strategy of laparoscopic excision of a cervical myoma (CM). Design: Prospective study. Setting: University-affiliated hospital. Patient(s): Twenty-eight patients with CM underwent laparoscopic myomectomy. These cases were classified into five types according to the location: [1] anterior cervical myoma (ACM); [2] posterior cervical myoma (PCM); [3] central cervical myoma (CCM); [4] lateral cervical myoma [LCM]; and [5] deep-rooted cervical myoma (DCM). Intervention(s): After preoperative assessment, patients underwent laparoscopic myomectomy. Ligation of the uterine artery and diluted vasopressin injection were performed to decrease bleeding during laparoscopy. Main Outcome Measure(s): Myoma numbers, myoma weight, operative time, estimated blood loss, hospital stay, complication rate. Result(s): Most of the lesions were ACM (43%) and PCM (32%). The mean operative time was 121 minutes, mean blood loss was 99 mL, and mean myoma weight was 287 g. The mean hospital stay was 2.2 days. There were no complications. Histopathologic examination showed that all lesions were leiomyoma. Hypermenorrhea, dysmenorrhea, and symptoms of compression improved after the operation. Two infertile patients conceived spontaneously at 1 and 7 months postoperatively, and successfully delivered infants by cesarean section at term. Conclusion(s): Surgical treatment of CM is empirically difficult. It is important that the approach be changed according to the location and size of the myoma. (Fertil Steril 2010;94:2710–5. 2010 by American Society for Reproductive Medicine.) Key Words: Myoma, cervical myoma, laparoscopic myomectomy
Uterine myoma is a common gynecologic disorder occurring in 20%–50% of women of late reproductive age (1) and preservation of fertility is the primary concern. Recently, laparoscopic myomectomy has been advocated because of its small operative wound, short hospital stay, quick recovery, and outcome comparable to traditional laparotomy (2). Ninety-five percent of myomas occur in the uterine corpus. Cervical myomas (CM) account for less than 5% of uterine myomas (1, 3). Cervical myoma increases surgical difficulties such as poor operative field, difficult suture repairs, and blood loss. Increased surgical morbidity might be associated with CM when using conventional surgical approaches, especially laparoscopy. When performing myomectomy for CM, care must be taken to avoid injuries to neighboring structures in the pelvic cavity. These structures include the bladder in front of the cervix, the rectum behind the cervix, and the uterine arteries and ureters on both sides. Myomectomy for CMs is empirically difficult and Received January 27, 2010; revised and accepted February 23, 2010; published online April 7, 2010. W.-C.C. has nothing to disclose. S.-y.C. has nothing to disclose. S.-C.H. has nothing to disclose. D.-Y.C. has nothing to disclose. L.-Y.C. has nothing to disclose. B.-C.S. has nothing to disclose. Wen-Chun Chang and Szu-yu Chen contributed equally to this work. Reprint requests: Bor-Ching Sheu, M.D., Ph.D., Department of Obstetrics and Gynecology, National Taiwan University Hospital, No. 7, Chung-Shan South Road, Taipei, Taiwan, 100 (FAX: 886-2-2751-2361; E-mail: [email protected] or [email protected]).
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frequently problematic (4, 5). The approach should be varied according to the size and location of the myoma. Previously we have described useful surgical procedures for laparoscopic myomectomy (6). With the advances in laparoscopic techniques, almost all uterine myomas in the uterine corpus can be treated by laparoscopic myomectomy. However, the treatment of CM by laparoscopic operations remains crucial. In this study, we explore techniques for safely and easily performing laparoscopic myomectomy with different types of CM.
MATERIALS AND METHODS From July 2003 to November 2009, 367 patients underwent laparoscopic myomectomy at National Taiwan University Hospital. Among them, 28 patients had both image and surgically proven CM. In this study we classified these cases of CM into the following five types according to location: [1] anterior cervical myoma (ACM); [2] posterior cervical myoma (PCM); [3] central cervical myoma (CCM); [4] lateral cervical myoma (LCM); and [5] deeprooted cervical myoma [DCM].
General Surgical Techniques for Laparoscopic Myomectomy The surgical procedure for laparoscopic myomectomy has been described previously (6). Briefly, we performed laparoscopic surgery
Fertility and Sterility Vol. 94, No. 7, December 2010 Copyright ª2010 American Society for Reproductive Medicine, Published by Elsevier Inc.
0015-0282/$36.00 doi:10.1016/j.fertnstert.2010.02.049
under general anesthesia by endotracheal intubation in the lithotomy position. A uterine manipulator was inserted through the cervix into the uterus before surgery. The uterine manipulator could not be inserted in two patients with a CM bulging out of the external os of the uterus into the vagina. Pneumoperitoneum was obtained by the closed method, and a 10-mm trocar was inserted at a point 2–3 cm above the umbilicus for the laparoscope (7). A 12-mm trocar was inserted in the left lower abdominal region and a 5-mm trocar was inserted in the right lower abdominal region. Bilateral uterine arteries were identified and ligated at its origin from the internal iliac artery through retrograde umbilical ligament tracking (8). An average of 20–30 mL of vasopressin (20 U/mL diluted in 50 mL of saline) was laparoscopically injected into the myoma and the layer between the myoma and the serosa. After the CM was completely enucleated, morcellation was performed. If complete enucleation is difficult with large myomas and limited pelvic space for traction, the myoma was morcellated with an electric morcellator while still attached to the uterus (5, 6, 9, 10). The wound was closed with 1-0 Vicryl (Polyglactin 910; Johnson & Johnson, Somerville, NJ) suture. The first layer included the cervical endothelium and a small amount of myometrium. Interrupted sutures with 1-0 Vicryl using Keckstein’s method were used in the second layer of serosa (11). After the operation, a 7-mm closed wound vacuum drain was inserted in the cul-de-sac in all patients. We had Institutional Review Board (IRB) approval of laparoscopic myomectomy. In addition, endoscopic surgical and anesthetic informed consent from each patient was acquired.
Statistics Data were expressed as mean SD (range) unless stated otherwise. All statistical analyses were performed with SPSS version 12.0 for Windows (SPSS, Inc., Chicago, IL). Patient and clinical data are given in Table 1.
TABLE 1 Baseline characteristics and operative parameters of 28 patients undergoing laparoscopic myomectomy. Characteristic Type of myoma, n (%) ACM PCM CCM LCM DCM Symptoms, n (%) Dysmenorrhea Hypermenorrhea Urinary frequency Tenesmus Pregnany problem Age, y BMI (kg/m2) Gestation, n Parity, n Nulliparous, n (%) Previous pelvic sugery, n (%) Myoma number, n Myoma weight, g Operative time, min EBL, mL Hospital stay, d
Data
12 (43) 9 (32) 1 (4) 4 (14) 2 (7) 14 (50) 7 (25) 10 (36) 8 (29) 6 (22) 38.0 7.0 (24–52) 20.86 2.03 (16.20-24.56) 0.89 1.03 (0–3) 0.57 0.88 (0–3) 16 (57) 8 (28.6) 1.8 1.4 (1–7) 287.0 310.0 (30–1,200) 121.0 56.0 (45–280) 99.0 114.0 (50–500) 2.2 0.7 (1–5)
Note: Data expressed as mean SD (range), unless otherwise stated. ACM ¼ anterior cervical myoma; PCM ¼ posterior cervical myoma; CCM ¼ central cervical myoma; LCM ¼ lateral cervical myoma; DCM ¼ deep-rooted cervical myoma; BMI ¼ body mass index; EBL ¼ estimated blood loss. Chang. Laparoscopic myomectomy in cervical myoma. Fertil Steril 2010.
Surgical Techniques for the Five Types of CM ACM: Figure 1A, B shows an anterior subserosal lesion. After an incision was made to the capsule (Fig. 1B), the capsule was pushed away to expose the myoma with the aid of a myoma screw (Fig. 1C). The bladder was adequately separated from the myoma and morcellation was performed (Fig. 1D). The myometrial defect and vesicouterine peritoneum were reapproximated by two-layered closure (Fig. 1E). PCM: Figure 1F, G shows a posterior subserosal lesion. After an incision to the capsule (Fig. 1G), the capsule was pushed away to expose the myoma with the aid of a myoma screw. The ureters, uterine arteries, and rectum were adequately separated from the myoma. Then, morcellation could be performed. CCM: Figure 1H, I shows a central intramural lesion, which looks like a snowman. After an incision to the anterior or posterior capsule (Fig. 1I), neighboring organs, such as the ureters, uterine arteries, bladder, and rectum, were pushed away, and morcellation could be performed. LCM: Figure 2A, B shows a lesion on the lateral cervix extending into the broad ligament. An incision was made into the prominent capsule of the myoma (Fig. 2C), and the capsule was pushed away to expose the myoma with the aid of a myoma screw (Fig. 2D). The ureters, uterine arteries, and rectum were adequately separated from the myoma. Bipolar coagulation of the pedicular vessels was needed (Fig. 2E), and morcellation was performed. DCM: Figure 3A, B shows a lesion within the cervix with the main part protruding into the vagina. It was difficult to identify Fertility and Sterility
the uterine cervix on vaginal examination because of compression and distortion by the large CM. A transverse incision of 4–5 cm was made reaching the myoma nucleus within the cervix (Fig. 3C). The incision was extended until the entire myoma in the cervix was visible. A 10-mm myoma screw was inserted into the myoma and enucleation was attempted, but failed because the myoma was too large (Fig. 3D, G). An assistant manually pushed the CM upward in the direction of the abdominal cavity (Fig. 3E, F), facilitating removal of the myoma. Then, morcellation was performed (Fig. 3H).
RESULTS All procedures in these 28 cases were performed laparoscopically. Most of the lesions were ACM (43%) and PCM (32%) (Table 1). The most common symptom was dysmenorrhea (50%) and tenesmus and urinary symptoms (30%). One quarter of the patients had hypermenorrhea. Pregnancy problems including pregnancy loss (11%) and infertility (11%), occuring in 22% of patients. The mean age of the patients was 38 years. More than half were nulliparous. The mean operative time was 121 minutes and mean blood loss during surgery was 99 mL. The mean number of removed myoma was 1.8 and mean weight of the excised specimen was 287 g (<250 g: 18 cases, 250–499 g: 5 cases, 500–749 g: 2 cases, and R750 g: 3 cases). The mean hospital stay was 2.2 days.
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FIGURE 1 Laparoscopic myomectomy in an anterior cervical myoma, posterior cervical myoma, and central cervical myoma. (A) Preoperative ultrasonographic image of the anterior cervical myoma. (arrow ¼ uterine body; M ¼ myoma.) (B) The myoma is under the bladder. The dotted line indicates the incision. (C) The myoma is exposed with the aid of a myoma screw. (D) Morcellation is performed. (E) The cervical endothelium, the muscle layer, and serosa are sutured with interrupted sutures. (F) Preoperative ultrasonographic picture of the posterior cervical myoma. (arrow ¼ uterine body; M ¼ myoma.) (G) The posterior cervical myoma is above the rectum. The dotted line indicates the incision. (H) Preoperative ultrasonographic picture of the central cervical myoma. (arrow ¼ uterine body; M ¼ myoma.) (I) The central cervical myoma is under the uterine body and resembles a snowman. The dotted line indicates the incision.
Chang. Laparoscopic myomectomy in cervical myoma. Fertil Steril 2010.
Histopathologic examination showed all lesions were leiomyoma. Hypermenorrhea, dysmenorrhea, and symptoms of compression improved after the operation. Two infertile patients conceived spontaneously at 1 and 7 months postoperatively, and successfully delivered infants by cesarean section at term.
DISCUSSION The most frequently cited symptoms of uterine myoma are abnormal uterine bleeding, pelvic pain and pressure (12, 13). In contrast to uterine corpus myoma, the most common clinical symptom of CM was dysmenorrhea, which was present in 50% of patients in our study. These patients also experienced bleeding (25%), pressure symptoms (29%–36%), and infertility (11%). Cervical myomas are likely to cause pressure symptoms by compressing the bladder, urethra, and rectum. The symptoms improved after
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the operation in our patients. The number and location of myomas correlates with symptoms and effect on fertility. Approximately 5%–10% of infertile women have at least one myoma, and myomas are the sole etiologic factor in 1%–2.4% of infertile women (14). In our study, two of the three (67%) infertile patients became pregnant and had successful deliveries after laparoscopic myomectomy, similar to previous reports (15, 16). Cervical myomas are mainly classified into subserosal lesions (extracervical type) and those that occur within the cervix (intracervical type). In this study, CM was classified into five types according to the surgical technique and location on the cervix. For most lesions, a transverse incision was made at the near junction between the myoma and the uterine corpus to prevent injury to vital organs, such as the bladder in ACM (Fig. 1B), rectum in PCM (Fig. 1G), and ureter in the DCM (Fig. 3B, C). In addition, the upper wound
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FIGURE 2 Laparoscopic myomectomy in a lateral cervical myoma. (A) Preoperative ultrasonographic image. (arrow ¼ uterine body; M ¼ myoma.) (B) The myoma arises from the lateral cervix and is growing into the broad ligament. The dotted line indicates the incision. (C) A transverse incision is made at the prominent part of myoma. (D) The myoma is exposed with the aid of a myoma screw, and morcellation is performed. (E) Bipolar coagulation of the pedicular vessels is performed. (F) The wound is sutured with two-layer interrupted sutures.
Chang. Laparoscopic myomectomy in cervical myoma. Fertil Steril 2010.
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FIGURE 3 Laparoscopic myomectomy in a deep-rooted cervical myoma. (A) Preoperative ultrasonographic image shows the myoma projecting into the vagina. (arrow ¼ uterine body; M ¼ myoma.) (B) The main part of myoma is deep-rooted in the vagina. The dotted line indicates the incision and the arrowheads indicate the bilateral ureters. (C) A transverse incision is made just below the uterine body. (D,G) Attempts to expose the myoma with the aid of a myoma screw have failed. (E, F) The cervical myoma is pushed upward manually in the direction of abdominal cavity. (H) Morcellation is performed. (I) The wound is sutured with two-layer interrupted sutures.
Chang. Laparoscopic myomectomy in cervical myoma. Fertil Steril 2010.
facilitated suturing. The LCM is usually a pedunculated or subserosal myoma extending into the broad ligament. With this type of lesion, the prominent peritoneum surrounding the myoma was incised (Fig. 2B, C), and the myoma was gently enucleated to avoid injuring neighboring structures such as the ureter or uterine vessels. As the base of the myoma was reached, coagulation of the blood supply was obtained with bipolar forceps (Fig. 2E). Intraoperative hemorrhage is a significant concern in myomectomy (17, 18), and various methods have been developed to minimize bleeding, such as preoperative administration of GnRH agonists (GnRH-a) (19), ligation of the uterine artery (8, 20), temporary balloon occlusion of bilateral internal iliac arteries (5), and vasopressin injection (21) into the myoma. In our study, two patients were given GnRH-a preoperatively; all had ligation of the uterine artery and vasopressin injection. These innovations resulted in minimal blood loss during surgery. In cases of CM, vascular
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supply to myoma is not always simple (20). Aberrant blood supply that causes unexpected bleeding may be frequently noted as in LCM. Furthermore in large CMs (especially large lateral myomas), ligation might be difficult, as pelvic sidewall dissection cannot sufficiently be made. Therefore, in the large LCM, bipolar coagulation of the pedicular vessels was needed (Fig. 2E). After decompression of the LCM by partial enucleation and morcellation, the pelvic sidewall dissection could be made and the uterine artery was ligated. After the CM was completely enucleated, morcellation was performed (Figs. 1D and 3H). In large CM with myoma weight more than 500 g, complete enucleation is difficult because of limited pelvic space for traction; the myoma was morcellated by an electric morcellator while still attached to the uterus (5, 6, 9, 10). In the present study, the case with myoma weight of 1,200 g was in a 33-year-old woman. She was never pregnant, did not use
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contraception for more than 3 years, and two large LCM, 15 cm at the right and 10 cm at the left, were incidentally found. During laparoscopic myomectomy, bilateral uterine arteries were ligated after decompression of the mass. The operative time was 280 minutes and blood loss was 500 mL. She was pregnant 1 month after the surgery and had term delivery by cesarean section. If the CM projected in the vagina (DCM), a transverse incision of 4–5 cm reaching the myoma within the cervix was made using a bipolar electrode and scissors. The incision was lengthened until the entire myoma in the cervix was visible (Fig. 3C). In this study, one CM was too large and heavy to be enucleated with a 10-mm myoma screw (Fig. 3G), and it was pushed manually into the pelvis (Fig. 3E, F), followed by morcellation (Fig. 3H). Vaginal myomectomy for DCM may be dangerous (4). The mechanics of delivering an enlarged myoma without unacceptable trauma to the myometrium are such that performing the procedure through a posterior colpotomy is impractical (22). Transvaginal methods, such as blindly twisting out the myoma (19, 23) and hysteroscopic myomectomy (24), are effective if the myoma is small. If the myoma is large, the possibility of hemorrhage increases because the twisting may lead to loss of a great part of the cervical wall where the myoma is attached. (4). In addition, because the cervix lacks flexibility,
hysteroscopic myomectomy is difficult. Pelosi and Pelosi (22) reported 21 cases in which they combined traditional laparoscopic myomectomy with posterior colpotomy and concluded that this combination allows for digital repair and inspection of the uterus while maintaining the benefits of minimally invasive surgery. However, if vaginal exposure was restricted, a midline episiotomy was made. With this type of surgery, the longer operative time, risk of infection, bowel or ureteral injury, and the need to maintain two surgical sites must be considered (22, 25, 26). Modifications in the standard technique of laparoscopic myomectomy enable efficient performance of the procedure in all patients. Regardless of the anatomical position of the myomas, we believe that these procedures are safe, easy to perform, and minimally invasive for treating different types of CM in expert hands in a well-equipped surgical setting. Although uterine myoma is a common gynecologic disorder (1), most myomas occur in the uterine corpus and CM account for less than 5% of uterine myomas (1, 3). Therefore only 28 patients had CM of our 367 cases underwent laparoscopic myomectomy in 6 years. Admittedly, this study was limited by its small sample size, and further large studies are warranted to establish guidelines for choosing the laparoscopic approach versus other approaches.
REFERENCES 1. Stovall T. Myomectomy. In: Mann WJ ST, ed. Gynecologic surgery. New York, NY: Churchill Livingstone, 1996:445–61. 2. Mais V, Ajossa S, Guerriero S, Mascia M, Solla E, Melis GB. Laparoscopic versus abdominal myomectomy: a prospective, randomized trial to evaluate benefits in early outcome. Am J Obstet Gynecol 1996;174:654–8. 3. Stenchever M, Droegemueller W, Herbst A, Mishell D. Comprehensive gynecology. 4th ed. St. Louis, MO: Mosby Inc., 2001. 4. Takeuchi H, Kitade M, Kikuchi I, Shimanuki H, Kumakiri J, Kobayashi Y, et al. A new enucleation method for cervical myoma via laparoscopy. J Minim Invasive Gynecol 2006;13:334–6. 5. Takeda A, Koyama K, Imoto S, Mori M, Sakai K, Nakamura H. Temporary endovascular balloon occlusion of the bilateral internal iliac arteries for control of hemorrhage during laparoscopic-assisted myomectomy in a nulligravida with a large cervical myoma. Fertil Steril 2009;91:935–9. 6. Torng PL, Hwang JS, Huang SC, Chang WC, Chen SY, Chang DY, et al. Effect of simultaneous morcellation in situ on operative time during laparoscopic myomectomy. Hum Reprod 2008;23:2220–6. 7. Lee YS. Benefits of high epigastric port placement for removing the very large uterus. J Am Assoc Gynecol Laparosc 2001;8:425–8. 8. Chang WC, Torng PL, Huang SC, Sheu BC, Hsu WC, Chen RJ, et al. Laparoscopic-assisted vaginal hysterectomy with uterine artery ligation through retrograde umbilical ligament tracking. J Minim Invasive Gynecol 2005;12:336–42.
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9. Sinha R, Hegde A, Warty N, Mahajan C. Laparoscopic myomectomy: enucleation of the myoma by morcellation while it is attached to the uterus. J Minim Invasive Gynecol 2005;12:284–9. 10. Sinha RY, Hegde A, Warty N, Jain R. Laparoscopic devascularization of uterine myomata followed by enucleation of the myomas by direct morcellation. J Am Assoc Gynecol Laparosc 2004;11:99–102. 11. Keckstein J. Cirugia Laparoscopica en Ginecologia. In: Keckstein J, Hucke J, eds. Cirugia conservadora y miomas. Bogota, Caracas, Madrid, Mexico, Sao Paulo: Editorial Medica Panamericana S.A. Buenos Aires, 2003:214–31. 12. Victory R, Romano W, Bennett J, Diamond M. Uterine leiomyomas: epidemiology, diagnosis and management. In: Clinical gynecology. Philadelphia: Elsevier, 2006. 13. Cheng MH, Chao HT, Wang PH. Unusual clinical presentation of uterine myomas. Taiwan J Obstet Gynecol 2007;46:323–4. 14. Donnez J, Jadoul P. What are the implications of myomas on fertility? A need for a debate? Hum Reprod 2002;17:1424–30. 15. Campo S, Campo V, Gambadauro P. Reproductive outcome before and after laparoscopic or abdominal myomectomy for subserous or intramural myomas. Eur J Obstet Gynecol Reprod Biol 2003;110:215–9. 16. Seracchioli R, Manuzzi L, Vianello F, Gualerzi B, Savelli L, Paradisi R, et al. Obstetric and delivery outcome of pregnancies achieved after laparoscopic myomectomy. Fertil Steril 2006;86:159–65. 17. Kongnyuy EJ, Wiysonge CS. Interventions to reduce haemorrhage during myomectomy for
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fibroids. Cochrane Database Syst Rev 2007; 24:CD005355. Neilson JP. Interventions to reduce haemorrhage during myomectomy for fibroids. Obstet Gynecol 2007;109:1197–8. Sims JA, Brzyski R, Hansen K, Coddington CC 3rd. Use of a gonadotropin releasing hormone agonist before vaginal surgery for cervical leiomyomas. A report of two cases. J Reprod Med 1994;39:660–2. Sinha R, Sundaram M, Lakhotia S, Hegde A. Cervical myomectomy with uterine artery ligation at its origin. J Minim Invasive Gynecol 2009;16:604–8. Takeuchi H, Shimanuki H, Kobori H, Kitade M, Kikuchi I, Kinoshita K. Effect of vasopressin on blood flow and RI of the uterine artery during laparoscopic myomectomy. J Minim Invasive Gynecol 2005;12:10–1. Pelosi MA 3rd, Pelosi MA. Laparoscopic-assisted transvaginal myomectomy. J Am Assoc Gynecol Laparosc 1997;4:241–6. Goldfarb HA, Fanarjian NJ. Laparoscopic-assisted vaginal myomectomy: a case report and literature review. JSLS 2001;5:81–5. Goldfarb RS, Davidson BN. Hysteroscopic resection of cervical nerve sheath tumor. JSLS 1999;3:145–7. Agostini A, Gerbeau S, Al Nakid M, Ronda I, Cravello L, Blanc B. Complications of vaginal myomectomy by posterior colpotomy. Eur J Obstet Gynecol Reprod Biol 2008;138:100–4. Wang CJ, Yuen LT, Lee CL, Kay N, Soong YK. A prospective comparison of morcellator and culdotomy for extracting of uterine myomas laparoscopically in nullipara. J Minim Invasive Gynecol 2006;13:463–6.
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Department of Obstetrics and Gynecology, National Taiwan University Hospital, College of Medicine, National Taiwan University, and b Cathay General Hospital, Taipei, Taiwan
Objective: To evaluate a strategy of laparoscopic excision of a cervical myoma (CM). Design: Prospective study. Setting: University-affiliated hospital. Patient(s): Twenty-eight patients with CM underwent laparoscopic myomectomy. These cases were classified into five types according to the location: [1] anterior cervical myoma (ACM); [2] posterior cervical myoma (PCM); [3] central cervical myoma (CCM); [4] lateral cervical myoma [LCM]; and [5] deep-rooted cervical myoma (DCM). Intervention(s): After preoperative assessment, patients underwent laparoscopic myomectomy. Ligation of the uterine artery and diluted vasopressin injection were performed to decrease bleeding during laparoscopy. Main Outcome Measure(s): Myoma numbers, myoma weight, operative time, estimated blood loss, hospital stay, complication rate. Result(s): Most of the lesions were ACM (43%) and PCM (32%). The mean operative time was 121 minutes, mean blood loss was 99 mL, and mean myoma weight was 287 g. The mean hospital stay was 2.2 days. There were no complications. Histopathologic examination showed that all lesions were leiomyoma. Hypermenorrhea, dysmenorrhea, and symptoms of compression improved after the operation. Two infertile patients conceived spontaneously at 1 and 7 months postoperatively, and successfully delivered infants by cesarean section at term. Conclusion(s): Surgical treatment of CM is empirically difficult. It is important that the approach be changed according to the location and size of the myoma. (Fertil Steril 2010;94:2710–5. 2010 by American Society for Reproductive Medicine.) Key Words: Myoma, cervical myoma, laparoscopic myomectomy
Uterine myoma is a common gynecologic disorder occurring in 20%–50% of women of late reproductive age (1) and preservation of fertility is the primary concern. Recently, laparoscopic myomectomy has been advocated because of its small operative wound, short hospital stay, quick recovery, and outcome comparable to traditional laparotomy (2). Ninety-five percent of myomas occur in the uterine corpus. Cervical myomas (CM) account for less than 5% of uterine myomas (1, 3). Cervical myoma increases surgical difficulties such as poor operative field, difficult suture repairs, and blood loss. Increased surgical morbidity might be associated with CM when using conventional surgical approaches, especially laparoscopy. When performing myomectomy for CM, care must be taken to avoid injuries to neighboring structures in the pelvic cavity. These structures include the bladder in front of the cervix, the rectum behind the cervix, and the uterine arteries and ureters on both sides. Myomectomy for CMs is empirically difficult and Received January 27, 2010; revised and accepted February 23, 2010; published online April 7, 2010. W.-C.C. has nothing to disclose. S.-y.C. has nothing to disclose. S.-C.H. has nothing to disclose. D.-Y.C. has nothing to disclose. L.-Y.C. has nothing to disclose. B.-C.S. has nothing to disclose. Wen-Chun Chang and Szu-yu Chen contributed equally to this work. Reprint requests: Bor-Ching Sheu, M.D., Ph.D., Department of Obstetrics and Gynecology, National Taiwan University Hospital, No. 7, Chung-Shan South Road, Taipei, Taiwan, 100 (FAX: 886-2-2751-2361; E-mail: [email protected] or [email protected]).
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frequently problematic (4, 5). The approach should be varied according to the size and location of the myoma. Previously we have described useful surgical procedures for laparoscopic myomectomy (6). With the advances in laparoscopic techniques, almost all uterine myomas in the uterine corpus can be treated by laparoscopic myomectomy. However, the treatment of CM by laparoscopic operations remains crucial. In this study, we explore techniques for safely and easily performing laparoscopic myomectomy with different types of CM.
MATERIALS AND METHODS From July 2003 to November 2009, 367 patients underwent laparoscopic myomectomy at National Taiwan University Hospital. Among them, 28 patients had both image and surgically proven CM. In this study we classified these cases of CM into the following five types according to location: [1] anterior cervical myoma (ACM); [2] posterior cervical myoma (PCM); [3] central cervical myoma (CCM); [4] lateral cervical myoma (LCM); and [5] deeprooted cervical myoma [DCM].
General Surgical Techniques for Laparoscopic Myomectomy The surgical procedure for laparoscopic myomectomy has been described previously (6). Briefly, we performed laparoscopic surgery
Fertility and Sterility Vol. 94, No. 7, December 2010 Copyright ª2010 American Society for Reproductive Medicine, Published by Elsevier Inc.
0015-0282/$36.00 doi:10.1016/j.fertnstert.2010.02.049
under general anesthesia by endotracheal intubation in the lithotomy position. A uterine manipulator was inserted through the cervix into the uterus before surgery. The uterine manipulator could not be inserted in two patients with a CM bulging out of the external os of the uterus into the vagina. Pneumoperitoneum was obtained by the closed method, and a 10-mm trocar was inserted at a point 2–3 cm above the umbilicus for the laparoscope (7). A 12-mm trocar was inserted in the left lower abdominal region and a 5-mm trocar was inserted in the right lower abdominal region. Bilateral uterine arteries were identified and ligated at its origin from the internal iliac artery through retrograde umbilical ligament tracking (8). An average of 20–30 mL of vasopressin (20 U/mL diluted in 50 mL of saline) was laparoscopically injected into the myoma and the layer between the myoma and the serosa. After the CM was completely enucleated, morcellation was performed. If complete enucleation is difficult with large myomas and limited pelvic space for traction, the myoma was morcellated with an electric morcellator while still attached to the uterus (5, 6, 9, 10). The wound was closed with 1-0 Vicryl (Polyglactin 910; Johnson & Johnson, Somerville, NJ) suture. The first layer included the cervical endothelium and a small amount of myometrium. Interrupted sutures with 1-0 Vicryl using Keckstein’s method were used in the second layer of serosa (11). After the operation, a 7-mm closed wound vacuum drain was inserted in the cul-de-sac in all patients. We had Institutional Review Board (IRB) approval of laparoscopic myomectomy. In addition, endoscopic surgical and anesthetic informed consent from each patient was acquired.
Statistics Data were expressed as mean SD (range) unless stated otherwise. All statistical analyses were performed with SPSS version 12.0 for Windows (SPSS, Inc., Chicago, IL). Patient and clinical data are given in Table 1.
TABLE 1 Baseline characteristics and operative parameters of 28 patients undergoing laparoscopic myomectomy. Characteristic Type of myoma, n (%) ACM PCM CCM LCM DCM Symptoms, n (%) Dysmenorrhea Hypermenorrhea Urinary frequency Tenesmus Pregnany problem Age, y BMI (kg/m2) Gestation, n Parity, n Nulliparous, n (%) Previous pelvic sugery, n (%) Myoma number, n Myoma weight, g Operative time, min EBL, mL Hospital stay, d
Data
12 (43) 9 (32) 1 (4) 4 (14) 2 (7) 14 (50) 7 (25) 10 (36) 8 (29) 6 (22) 38.0 7.0 (24–52) 20.86 2.03 (16.20-24.56) 0.89 1.03 (0–3) 0.57 0.88 (0–3) 16 (57) 8 (28.6) 1.8 1.4 (1–7) 287.0 310.0 (30–1,200) 121.0 56.0 (45–280) 99.0 114.0 (50–500) 2.2 0.7 (1–5)
Note: Data expressed as mean SD (range), unless otherwise stated. ACM ¼ anterior cervical myoma; PCM ¼ posterior cervical myoma; CCM ¼ central cervical myoma; LCM ¼ lateral cervical myoma; DCM ¼ deep-rooted cervical myoma; BMI ¼ body mass index; EBL ¼ estimated blood loss. Chang. Laparoscopic myomectomy in cervical myoma. Fertil Steril 2010.
Surgical Techniques for the Five Types of CM ACM: Figure 1A, B shows an anterior subserosal lesion. After an incision was made to the capsule (Fig. 1B), the capsule was pushed away to expose the myoma with the aid of a myoma screw (Fig. 1C). The bladder was adequately separated from the myoma and morcellation was performed (Fig. 1D). The myometrial defect and vesicouterine peritoneum were reapproximated by two-layered closure (Fig. 1E). PCM: Figure 1F, G shows a posterior subserosal lesion. After an incision to the capsule (Fig. 1G), the capsule was pushed away to expose the myoma with the aid of a myoma screw. The ureters, uterine arteries, and rectum were adequately separated from the myoma. Then, morcellation could be performed. CCM: Figure 1H, I shows a central intramural lesion, which looks like a snowman. After an incision to the anterior or posterior capsule (Fig. 1I), neighboring organs, such as the ureters, uterine arteries, bladder, and rectum, were pushed away, and morcellation could be performed. LCM: Figure 2A, B shows a lesion on the lateral cervix extending into the broad ligament. An incision was made into the prominent capsule of the myoma (Fig. 2C), and the capsule was pushed away to expose the myoma with the aid of a myoma screw (Fig. 2D). The ureters, uterine arteries, and rectum were adequately separated from the myoma. Bipolar coagulation of the pedicular vessels was needed (Fig. 2E), and morcellation was performed. DCM: Figure 3A, B shows a lesion within the cervix with the main part protruding into the vagina. It was difficult to identify Fertility and Sterility
the uterine cervix on vaginal examination because of compression and distortion by the large CM. A transverse incision of 4–5 cm was made reaching the myoma nucleus within the cervix (Fig. 3C). The incision was extended until the entire myoma in the cervix was visible. A 10-mm myoma screw was inserted into the myoma and enucleation was attempted, but failed because the myoma was too large (Fig. 3D, G). An assistant manually pushed the CM upward in the direction of the abdominal cavity (Fig. 3E, F), facilitating removal of the myoma. Then, morcellation was performed (Fig. 3H).
RESULTS All procedures in these 28 cases were performed laparoscopically. Most of the lesions were ACM (43%) and PCM (32%) (Table 1). The most common symptom was dysmenorrhea (50%) and tenesmus and urinary symptoms (30%). One quarter of the patients had hypermenorrhea. Pregnancy problems including pregnancy loss (11%) and infertility (11%), occuring in 22% of patients. The mean age of the patients was 38 years. More than half were nulliparous. The mean operative time was 121 minutes and mean blood loss during surgery was 99 mL. The mean number of removed myoma was 1.8 and mean weight of the excised specimen was 287 g (<250 g: 18 cases, 250–499 g: 5 cases, 500–749 g: 2 cases, and R750 g: 3 cases). The mean hospital stay was 2.2 days.
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FIGURE 1 Laparoscopic myomectomy in an anterior cervical myoma, posterior cervical myoma, and central cervical myoma. (A) Preoperative ultrasonographic image of the anterior cervical myoma. (arrow ¼ uterine body; M ¼ myoma.) (B) The myoma is under the bladder. The dotted line indicates the incision. (C) The myoma is exposed with the aid of a myoma screw. (D) Morcellation is performed. (E) The cervical endothelium, the muscle layer, and serosa are sutured with interrupted sutures. (F) Preoperative ultrasonographic picture of the posterior cervical myoma. (arrow ¼ uterine body; M ¼ myoma.) (G) The posterior cervical myoma is above the rectum. The dotted line indicates the incision. (H) Preoperative ultrasonographic picture of the central cervical myoma. (arrow ¼ uterine body; M ¼ myoma.) (I) The central cervical myoma is under the uterine body and resembles a snowman. The dotted line indicates the incision.
Chang. Laparoscopic myomectomy in cervical myoma. Fertil Steril 2010.
Histopathologic examination showed all lesions were leiomyoma. Hypermenorrhea, dysmenorrhea, and symptoms of compression improved after the operation. Two infertile patients conceived spontaneously at 1 and 7 months postoperatively, and successfully delivered infants by cesarean section at term.
DISCUSSION The most frequently cited symptoms of uterine myoma are abnormal uterine bleeding, pelvic pain and pressure (12, 13). In contrast to uterine corpus myoma, the most common clinical symptom of CM was dysmenorrhea, which was present in 50% of patients in our study. These patients also experienced bleeding (25%), pressure symptoms (29%–36%), and infertility (11%). Cervical myomas are likely to cause pressure symptoms by compressing the bladder, urethra, and rectum. The symptoms improved after
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the operation in our patients. The number and location of myomas correlates with symptoms and effect on fertility. Approximately 5%–10% of infertile women have at least one myoma, and myomas are the sole etiologic factor in 1%–2.4% of infertile women (14). In our study, two of the three (67%) infertile patients became pregnant and had successful deliveries after laparoscopic myomectomy, similar to previous reports (15, 16). Cervical myomas are mainly classified into subserosal lesions (extracervical type) and those that occur within the cervix (intracervical type). In this study, CM was classified into five types according to the surgical technique and location on the cervix. For most lesions, a transverse incision was made at the near junction between the myoma and the uterine corpus to prevent injury to vital organs, such as the bladder in ACM (Fig. 1B), rectum in PCM (Fig. 1G), and ureter in the DCM (Fig. 3B, C). In addition, the upper wound
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FIGURE 2 Laparoscopic myomectomy in a lateral cervical myoma. (A) Preoperative ultrasonographic image. (arrow ¼ uterine body; M ¼ myoma.) (B) The myoma arises from the lateral cervix and is growing into the broad ligament. The dotted line indicates the incision. (C) A transverse incision is made at the prominent part of myoma. (D) The myoma is exposed with the aid of a myoma screw, and morcellation is performed. (E) Bipolar coagulation of the pedicular vessels is performed. (F) The wound is sutured with two-layer interrupted sutures.
Chang. Laparoscopic myomectomy in cervical myoma. Fertil Steril 2010.
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FIGURE 3 Laparoscopic myomectomy in a deep-rooted cervical myoma. (A) Preoperative ultrasonographic image shows the myoma projecting into the vagina. (arrow ¼ uterine body; M ¼ myoma.) (B) The main part of myoma is deep-rooted in the vagina. The dotted line indicates the incision and the arrowheads indicate the bilateral ureters. (C) A transverse incision is made just below the uterine body. (D,G) Attempts to expose the myoma with the aid of a myoma screw have failed. (E, F) The cervical myoma is pushed upward manually in the direction of abdominal cavity. (H) Morcellation is performed. (I) The wound is sutured with two-layer interrupted sutures.
Chang. Laparoscopic myomectomy in cervical myoma. Fertil Steril 2010.
facilitated suturing. The LCM is usually a pedunculated or subserosal myoma extending into the broad ligament. With this type of lesion, the prominent peritoneum surrounding the myoma was incised (Fig. 2B, C), and the myoma was gently enucleated to avoid injuring neighboring structures such as the ureter or uterine vessels. As the base of the myoma was reached, coagulation of the blood supply was obtained with bipolar forceps (Fig. 2E). Intraoperative hemorrhage is a significant concern in myomectomy (17, 18), and various methods have been developed to minimize bleeding, such as preoperative administration of GnRH agonists (GnRH-a) (19), ligation of the uterine artery (8, 20), temporary balloon occlusion of bilateral internal iliac arteries (5), and vasopressin injection (21) into the myoma. In our study, two patients were given GnRH-a preoperatively; all had ligation of the uterine artery and vasopressin injection. These innovations resulted in minimal blood loss during surgery. In cases of CM, vascular
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supply to myoma is not always simple (20). Aberrant blood supply that causes unexpected bleeding may be frequently noted as in LCM. Furthermore in large CMs (especially large lateral myomas), ligation might be difficult, as pelvic sidewall dissection cannot sufficiently be made. Therefore, in the large LCM, bipolar coagulation of the pedicular vessels was needed (Fig. 2E). After decompression of the LCM by partial enucleation and morcellation, the pelvic sidewall dissection could be made and the uterine artery was ligated. After the CM was completely enucleated, morcellation was performed (Figs. 1D and 3H). In large CM with myoma weight more than 500 g, complete enucleation is difficult because of limited pelvic space for traction; the myoma was morcellated by an electric morcellator while still attached to the uterus (5, 6, 9, 10). In the present study, the case with myoma weight of 1,200 g was in a 33-year-old woman. She was never pregnant, did not use
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contraception for more than 3 years, and two large LCM, 15 cm at the right and 10 cm at the left, were incidentally found. During laparoscopic myomectomy, bilateral uterine arteries were ligated after decompression of the mass. The operative time was 280 minutes and blood loss was 500 mL. She was pregnant 1 month after the surgery and had term delivery by cesarean section. If the CM projected in the vagina (DCM), a transverse incision of 4–5 cm reaching the myoma within the cervix was made using a bipolar electrode and scissors. The incision was lengthened until the entire myoma in the cervix was visible (Fig. 3C). In this study, one CM was too large and heavy to be enucleated with a 10-mm myoma screw (Fig. 3G), and it was pushed manually into the pelvis (Fig. 3E, F), followed by morcellation (Fig. 3H). Vaginal myomectomy for DCM may be dangerous (4). The mechanics of delivering an enlarged myoma without unacceptable trauma to the myometrium are such that performing the procedure through a posterior colpotomy is impractical (22). Transvaginal methods, such as blindly twisting out the myoma (19, 23) and hysteroscopic myomectomy (24), are effective if the myoma is small. If the myoma is large, the possibility of hemorrhage increases because the twisting may lead to loss of a great part of the cervical wall where the myoma is attached. (4). In addition, because the cervix lacks flexibility,
hysteroscopic myomectomy is difficult. Pelosi and Pelosi (22) reported 21 cases in which they combined traditional laparoscopic myomectomy with posterior colpotomy and concluded that this combination allows for digital repair and inspection of the uterus while maintaining the benefits of minimally invasive surgery. However, if vaginal exposure was restricted, a midline episiotomy was made. With this type of surgery, the longer operative time, risk of infection, bowel or ureteral injury, and the need to maintain two surgical sites must be considered (22, 25, 26). Modifications in the standard technique of laparoscopic myomectomy enable efficient performance of the procedure in all patients. Regardless of the anatomical position of the myomas, we believe that these procedures are safe, easy to perform, and minimally invasive for treating different types of CM in expert hands in a well-equipped surgical setting. Although uterine myoma is a common gynecologic disorder (1), most myomas occur in the uterine corpus and CM account for less than 5% of uterine myomas (1, 3). Therefore only 28 patients had CM of our 367 cases underwent laparoscopic myomectomy in 6 years. Admittedly, this study was limited by its small sample size, and further large studies are warranted to establish guidelines for choosing the laparoscopic approach versus other approaches.
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