European Journal of Cardiovascular Medicine

Uterine leiomyomata (myomas or fibroids) are the most common benign pelvic tumor in women, with lifetime prevalence between 12-80%.¹ Myomas may present with symptoms of bleeding, pressure, pain, or subfertility, however when asymptomatic do not require treatment. For symptomatic women, severity may be influenced by myoma size and location.^2-4 Uterine preserving approaches include myomectomy, via laparotomy, laparoscopy or with robotic-assisted procedures; uterine artery embolization, magnetic resonance guided focused ultrasound (MRgFUS) and myolysis. More radical options include hysterectomy by any approach Bonney described myomectomy in 1931 with the myoma removed by laparotomy. ³ The first laparoscopic myomectomy (LM) was reported by Semm in 1979. Although there have been changes in technology and technique, the aim to remove pathology, minimize morbidity, and preserve fertility remains.⁵ At laparoscopy, multiple myomas may be removed during one procedure, and with the introduction of morcellation, myoma size is no longer the limiting factor it was once was. Whereas abdominal myomectomyresults in limited morbidity, similar to that with hysterectomy, laparoscopic myomectomy has resulted in remarkable advantages for the patient in medical, social, and economic terms, with less postoperative pain and shorter recovery time.⁶ Semm and Mettler published their first findings on laparoscopic myomectomy in 1980. Today, larger intramural myomas are also enucleated by this technique.⁷ The World health organization (WHO) criteria for laproscopic myomectomy- uterine size less than or equal to 14 weeks after 12 weeks of gonadotropin-releasing hormone (GnRH) agonist therapy; no individual myoma larger than 7 cm; no leiomyoma near the uterine artery, or near the tubal cornua if fertility was desired; and at least 50% of the leiomyoma subserosal, to be accessible and to allow adequate repair of the myometrium through the laparoscope. However, laparoscopic myomectomy (LM) seems to be affected by some limits related to the number and size of UM.8 Independently from the surgeons’ experience, the most frequent complications remain the severe intra-postoperative bleeding (20 % of cases) and the conversion to hysterectomy (2 % of cases).⁹ Although several studies and techniques (such as compression of uterine artery, vasoconstrictor agents use, premyomectomy uterine artery embolization or artery ligation) have been proposed to minimize blood loss during LM, massive perioperative bleeding remains the main challenge for the surgeon.¹⁰

AIM OF THE PRESENT STUDY

Purpose of the present research was to evaluate the clinical considerations as well as the outcome of laproscopic myomectomy in various uterine myomas.

An observational study on women undergone to LM between January Nov 2013 and June 2014 were included in the present research. All patients agreed to the aim of the study and the use of their data after signing written consent. Women with single myoma more than 4 cm in diameter (type 3, 4, 5 and 6 of Munro’s classification) were considered eligible for the study. Patients, before surgery, underwent transvaginal ultrasound investigation in order to assess myomas features (number, size, localization and type). Preoperative work up also included Pap-smear and anesthesiology assessment. All LM were performed under general anesthesia with a 10-mm telescope. Harmonic Scalpel was used to enucleate the myomas and to perform uterine hemostasis. Data about age, parity, indication to surgery, myomas features (considering as localization site anterior wall, posterior wall or fundus), intraoperative estimated blood loss, operative time (from the insertions of trocars to skin closure), length of hospital stay and time needed to resumption of personal activities were collected. Intraoperative/ postoperative complications (blood transfusion, conversion to laparotomy, pelvic organ injuries) were also recorded. Descriptive analysis was performed for the entire sample using SPSS 25.0. To assess the relationship between myoma’s features and surgical outcomes, only patients with single myoma were considered. Myomas type 3, 4 and 5 were considered as intramural, while type 6 was considered subserosal. Patients were divided into six groups: intramural myoma less than 8 cm in diameter (group 1), intramural between 8 and 12 cm (group 2), intramural more than 12 cm (group 3), subserosal myoma less than 8 cm (group 4), subserosal between 8 and 12 cm (group 5), subserosal more than 12 cm (group 6). Categorical data were expressed as number (%), and for the continuous ones, median and interquartile range were used to describe non-normal data. Mean ± standard deviation were used to describe normal distribution. p values <0.05 were considered statistically significant.

The surgical prescriptions for LM were Abnormal uterine bleeding (AUB) (61.3 %), chronic pelvic pain (28.1 %), pelvic heaviness (8.5 %) and urinary symptoms (2.1 %). (Graph 1)

Graph 1: Signs and symptoms associated with myomas in the present study

Concerning myoma localization, 184 (41.4 %) were in anterior uterine wall, 150 (33.8 %) in posterior uterine one and 110 (24.8 %) fundal. The mean size of the removed myomas was 7.6 ± 2.7 cm, the intraoperative mean blood loss was 184.1 ± 233.5 ml, the mean operative time was 77.2 ± 33 min and the mean length of hospital stay was 2.54 ± 1.1 days. Patients returned 17.9 ± 9.5 days after surgery to their personal activities. (Table 1)

Table 1: Data about size of myomas and intraoperative/postoperative surgical outcomes

Considering intraoperative complications, 6 (1.35 %) cases required conversion to laparotomy because of massive intraoperative bleeding. Logistic regression showed that size and type of myomas were good predictors of blood loss. Myomas with size between 8 and 12 cm were associated with an increased amount of blood loss with a statistical significant difference between the two myoma types (median 275 vs. 200 ml, respectively; p < 0.05). The removal of myomas more than 12 cm (both intramural and subserosal) caused an higher blood loss. Considering surgical time, we observed that the removal of intramural myomas more than 8 cm and the subserosal ones more than 12 cm required a significant longer surgical time compared to the smaller ones.

Surgical myomas removal is the most common conservative approach in the management of symptomatic patients, and it remains the gold standard in reproductive age. Hysteroscopic myomectomy has been proved to be safer and long-term effective in type 0, 1 and 2 myomas. Although new techniques have been proposed as alternative to the surgical myoma removal (particularly type 3, 4, 5, 6, 7 myomas), the LM is considered the gold standard.^11-15 Compared to laparotomic approach, LM offers more advantages such as smaller incision, shorter hospitalization/ convalescence time, reduced postoperative pain, faster return to normal activities and reduced risk of postoperative adhesions. However, some concerns as intraoperative blood loss, longer operating time, difficulty in enucleating big myomas and endoscopic suture, risk of iatrogenic parasitic leiomyomas and complications related to trocar insertion remain about LM safety.¹⁶ Several authors compared open myomectomy to the laparoscopic approach in order to choose the most appropriate choice. Mais et al. did not find statistically significant differences in terms of blood loss or operating time.¹⁷ In a randomized controlled trial including myomas more than 5 cm or uterine size above the umbilicus, Seracchioli et al. reported that laparotomy resulted in a more pronounced hemoglobin drop, while laparoscopy required conversion to laparotomy only in a 4.3 % of cases because of difficulties in hemostasis and/or suturing time.¹⁸ In a large-scale study including 368 women undergone to LM, Landi et al. reported a 3.4 % intraoperative complication rate, mostly due to hemorrhage requiring blood transfusion or re-intervention. Evidences underlined that size, number and type of myomas can influence the choice of surgical approach: In woman with two or three myomas sized between 4 and 7 cm, laparoscopy can be considered safe and efficient.¹⁹ During the removal of larger myomas (>8 cm), technical difficulties may occur because of their difficult cleavage, longer operative time and unavoidable risk of perioperative bleeding.^20-21

LM can be considered safe and effective surgical approach remaining the gold standard one also in cases of large and intramural myomas. Large-scale studies are necessary to validate the role of proposed predictors to increase LM safety and to bring further down perioperative complications rate.

1. Baird DD, Dunson DB, Hill MC, et al. High cumulative incidence of uterine leiomyoma in black and white women: ultrasound evidence. American Journal of Surgery 2003;188:100-7. 2. Buttram VC, Reiter RC. Uterine leiomyomata: etiology, symptomatology, and management. Fertility & Sterility 1981;36:433-45.
2. Cramer SF, Patel A. The frequency of uterine leiomyomas. American Journal of Clinical Pathology 1990;94:435-8.
3. Downes E, Sikirica V, Gilabert-Estelles J, et al. The burden of uterine fibroids in five European countries. European Journal of Surgery 2010;152:96-102.
4. Stovall D. Clinical symptomatology of uterine leiomyomas. Clinical General Surgery 2001;44:364-71.
5. Wallach E, Vlahos NF. Uterine myomas: an overview of development, clinical features, and management. Surgery 2004;104:393-406.
6. Wegienka G, Baird DD, Hertz-Picciotto I, et al. Self-reported heavy bleeding associated with uterine leiomyomata. Obstetrics and Gynecology 2003;101:431-7.
7. Nevadunsky NS, Bachmann GA, Nosher J, et al. Women's decision-making determinants in choosing uterine artery embolization for symptomatic fibroids. Journal of Reproductive Medicine 2001;46:870-4.
8. Lippman SA, Warner M, Samuels S, et al. Uterine fibroids and gynecologic pain symptoms in a population-based study. Fertility & Sterility 2003;80:1488-94.
9. Pritts EA, Parker WH, Olive DL. Fibroids and infertility: an updated systematic review of the evidence. Fertility & Sterility 2009;91:1215-23.
10. Casini ML, Rossi F, Agostini R, et al. Effects of the position of fibroids on fertility. Gynecological Endocrinology 2006;22:106-9.
11. Gobern JM, Rosemeyer CJ, Barter JF, et al. Comparison of robotic, laparoscopic, and abdominal myomectomy in a community hospital. Journal of the Society of Laparoendoscopic Surgeons 2013;17:116-20.
12. Mansour FW, Kives S, Urbach DR, et al. Robotically assisted laparoscopic myomectomy: a Canadian experience. Journal of Obstetrics & Gynaecology Canada: JOGC 2012;43:353-8.
13. Mattei A, Cioni R, Bargelli G, et al. Techniques of laparoscopic myomectomy. Reproductive Biomedicine Online 2011;23:34-9.
14. Nash K, Feinglass J, Zei C, et al. Robotic-assisted laparoscopic myomectomy versus abdominal myomectomy: a comparative analysis of surgical outcomes and costs. Archives of Gynecology and Obstetrics 2012;285:435- 40.
15. Ruuskanen A, Hippelainen M, Sipola P, et al. Uterine artery embolization versus hysterectomy for leiomyomas: primary and 2-year follow-up results of a randomized prospective clinical trial. European Radiology 2010;20:2524-32.
16. van der Kooij SM, Hehenkamp WJ, Volkers NA, et al. Uterine artery embolization vs hysterectomy in the treatment of symptomatic uterine fibroids: 5-year outcome from the randomized EMMY trial. American Journal of General Surgery 2010;203:105 e 1-13.
17. van der Kooij SM, Ankum WM, Hehenkamp WJ. Review of nonsurgical/minimally invasive treatments for uterine fibroids. Current Opinion in Surgery 2012;24:368-75.
18. Schneider A, Merker A, Martin C, et al. Laparoscopically assisted vaginal hysterectomy as an alternative to abdominal hysterectomy in patients with fibroids. Archives of Surgery & Obstetrics 1997;259:79-85.
19. Istre O, Langebrekke A, Qvigstad E. Changing hysterectomy technique from open abdominal to laparoscopic: new trend in Oslo, Norway. Journal of Minimally Invasive Surgery 2007;14:74-7. 21. Di Spiezio Sardo A, Mazzon I, Bramante S, et al. Hysteroscopic myomectomy: a comprehensive review of surgical techniques. Human Reproduction Update 2008;14:101- 19.