Myomectomy Case File

Myomectomy Case File

Eugene C. Toy, MD, Konrad P. Harms, MD, Keith O. Reeves, MD, Cristo Papasakelariou, MD, FACOG

Case 19

A 33-year-old African American G1P0010 woman complains about increasing pelvic pressure and urinary frequency for the past 6 months. She reports that her menses have increased from lasting 5 days to now 12 days in duration with heavier flow and quarter-size clots. She denies any dizziness, shortness of breath, or constipation. She has no chronic medical conditions. She has no children, and she and her husband would like to have a child.

On examination, she is noted to be afebrile with normal vital signs. Her abdominal examination reveals an irregular mass in the midline approximately 16 weeks in size and nontender. Pelvic examination reveals a mobile, irregular mass in midline approximately 16 weeks in size and nontender. She has no adnexal tenderness, and no masses are palpated. A CBC reveals that she is anemic with hemoglobin of 6.8 g/dL. Her urine culture was negative.

➤ What is the most likely diagnosis?

➤ What is your diagnostic workup for this patient?

➤ What is the best therapy for this patient?

➤ What complications can result from the treatment?

ANSWERS TO CASE 19:

Myomectomy

Summary: This is a 33-year-old woman, nulliparous, with menorrhagia, and a pelvic mass suggestive of leiomyomata.

➤ Most likely diagnosis: Uterine leiomyoma

➤ Diagnostic workup: CBC, endometrial biopsy, prolactin, thyroid-stimulating hormone (TSH), follicle-stimulating hormone (FSH), pregnancy test, pelvic ultrasound

➤ Best treatment: Myomectomy

➤ Complications: Hysterectomy, recurrence, adhesions, longer hospitalization, continued infertility

ANALYSIS

Objectives

1. List indications for myomectomy.
2. Describe several routes for myomectomy.
3. List possible complications resulting from myomectomy.

Considerations

This is a 33-year-old nulliparous woman whose symptoms and physical findings are consistent with uterine fibroids. She complains of menorrhagia (with resultant anemia) and urinary frequency. Her symptoms include both menorrhagia (with resultant anemia) and urinary frequency. Because of her asymptomatic anemia, the patient is a candidate for medical therapy and iron supplementation. Medical therapy options include the use of medroxyprogesterone acetate depot (Depo-Provera), oral contraceptive pills, and GnRH-a. Of the options listed, GnRH-agonist would be the most effective treatment for her uterine fibroids. However, because of limited duration of GnRH usage (6 months) and likely recurrence after treatment, medical management would not be the best management option at this time. Given her age, desired fertility, and symptoms, the patient is a candidate for a myomectomy. Alternative treatments for fibroids including uterine artery embolization and ultrasonography-focused ablation are not options for this patient given her desired fertility.

APPROACH TO

Myomectomy

CLINICAL APPROACH

Leiomyomas (also fibroids or myomas) are benign monoclonal tumors originating from a single smooth muscle cell that has undergone a chromosomal mutation. They are a bundle of smooth muscle cells and fibrous tissue surrounded by a fibrous capsule. The leiomyomas are symptomatic in 25% to 50% of women, but upon pathological review of hysterectomy specimen, the prevalence may be as high as 80%. Risk factors for the development of leiomyoma include increasing age, early menarche, low parity, tamoxifen use, obesity, and some studies show high-fat diet. Myomas tend to grow and become more symptomatic in nulliparous women. African American women have the highest incidence of fibroids. Hispanic, Asian, and Caucasian women have similar rates for the development of leiomyoma. There is a familial tendency to develop fibroids. Smoking has been associated with a decrease in incidence of leiomyoma. Leiomyomas can grow in any part of the body that has smooth muscle; the uterus is the most common organ in the pelvis to develop fibroids. Leiomyoms can be found in the fallopian tubes, round ligament, and about 5% of the time on the cervix.

Uterine leiomyoma can be diagnosed with 95% certainty with physical examination alone. On palpation, a uterus feels enlarged, firm, and irregular. Myomas can grow laterally and may inhibit the palpation of the adnexa. Ultrasound is recommended when the patient is obese and/or when adnexal pathology cannot be ruled out with physical examination alone.

Most leiomyoms are asymptomatic and do not require treatment. The number, size, and location of the myoma can produce different symptoms. Symptoms include pelvic pressure, dysmenorrhea, menorrhagia, urinary frequency, and constipation. Fibroids can cause hydroureter or hydronephrosis and have been linked to infertility. Therapeutic options include medical management with progestins (norethindrone, medrogestone, medroxyprogesterone acetate), antiprogestins (mifepristone), and gonadotropin-releasing hormone analogues. Surgical procedures include myomectomy and hysterectomy. Other methods for treatment of fibroids include uterine artery embolization, high-frequency ultrasonography, laser treatment, cryotherapy, and thermoablation. Approximately 30% of hysterectomies list symptomatic uterine fibroids as the primary indication. The choice of the treatment method should be based on various medical and social characteristics of the patient. These factors include age, parity, desire for childbearing, severity of symptoms, size and number of leiomyoms, location of the myoma, other medical conditions, suspicion of malignancy, proximity of menopause, and desire to preserve uterus.1

In the presence of leiomyoms, myomectomy may be the management option if the patient desires to retain her uterus, if there is a single pedunculated myoma, or if the presence of myoma is thought to be the cause of infertility or repeated pregnancy losses. Women with symptomatic uterine fibroids who no longer desire to bear children may be best treated with a hysterectomy, the definitive treatment for uterine leiomyoma. For women who desire future childbearing or who want to preserve their uterus, myomectomy may be the best management.

Myomectomy only removes the portion of the myoma that is visible and accessible. Occasionally, small myoma may be retained intentionally. If myomectomy is the chosen therapy, the myoma can be removed via an abdominal incision, laparoscopy, or hysteroscopy. Before proceeding with the removal of the myoma, appropriate evaluation must be done for the presence of a pelvic mass and abnormal uterine bleeding. Anemia may be treated with GnRH-a and iron supplementation prior to the myomectomy. GnRH-a can also decrease the size of the leiomyoma, but the enucleation of the myoma is more difficult due to a less distinct plane between the myoma and the normal uterus. Myomectomy is associated with more adhesions and longer hospital stays than a hysterectomy. Hysterectomy is associated with more urinary tract injuries. Contraindications to a myomectomy include pregnancy, advanced adnexal disease, malignancy, and the situation where removal of the myoma would result in the significant reduction of the endometrial surface causing the uterus not to be functional.2-9

Abdominal Myomectomy

An abdominal myomectomy is the route of choice when there are numerous myomas in multiple locations (subserosal, intramural, submucosal). Multiple myomectomy is usually more difficult and time consuming than a hysterectomy. Intraoperative blood loss for myomectomy correlates with the uterine size prior to surgery, total weight of the myomas removed, and operating time. Resolution of menorrhagia and pelvic pressure is overall 81%. Several studies show that the morbidity of the two procedures is similar. The risk of unexpected hysterectomy when performing a myomectomy is less than 1%. The hysterectomy can result from leiomyomatosis or from complications of the myomectomy. Recurrence of myomas is of concern after myomectomy. Studies using transvaginal ultrasound show recurrence of approximately 51% at 5 years. Other studies show that clinically significant myoma recurrence is 10% at 5 years, with one-third of those patients eventually undergoing a hysterectomy. The rate of recurrence of myomas depends on the number of myomas removed. The recurrence risk is 11% for a single myoma and 26% for multiple myomas. When myomectomy is performed in patients desiring fertility, pelvic adhesions, and dissection in the area of the interstitial portion of the fallopian may result in postoperative infertility.10-12

A careful pelvic examination while the patient is under anesthesia will allow for a better idea of which type of skin incision to make. After the appropriate skin incision is made and peritoneum entered, the uterus and adjacent adnexal structures are to be evaluated. When multiple fibroids are noted, the uterine incision should be the one that allows the exposure to multiple fibroids minimizing the number of uterine incisions. To decrease intraoperative blood loss, uterine tourniquets or injectable intrauterine vasoconstrictive agents can be used. Multiple studies have demonstrated the effectiveness of vasoconstrictive agents in decreasing the need for blood transfusion.13 and decreasing intraoperative blood loss.14 When comparing mechanical occlusion and injection of vasoconstrictive agents, Ginsberg et al.15 found no significant differences in blood loss or transfusion requirements between the groups. A linear or elliptic incision is then made on the uterus and carried down to underlying myoma. The myoma can then be grasped and the cleavage plane between the myoma and surrounding myometrium can be easily identified (Figure 19–1). After the myoma is removed, the dead space can be

Figure 19–1. Removal of fibroid from myometrium. A. Making an incision over the

fibroid. (A-D: Reproduced, with permission, from Schorge JO, Schaffer JI, Halvorson LM,

et al. Williams Gynecology. New York: McGraw-Hill, 2008: 901-904.)

Figure 19–1. Removal of fibroid from myometrium. B. Using blunt and sharp dissection to free the fibroid from the uterus. C. Clamping the vascular pedicle to the fibroid to prepare for ligature.

Figure 19–1. Removal of fibroid from myometrium. D. The uterue defect is repaired in layers.

obliterated with interrupted sutures. The serosal edge can be reapproximated with a “baseball” stitch (Figure 19–2). The risk of adhesive disease can be minimized with meticulous surgical technique and possibly with the use of absorbable or nonabsorbable barriers.16

Laparoscopic Myomectomy

A laparoscopic myomectomy can be considered if the myomas are subserosal or pedunculated and easily accessible. Benefits for a laparoscopic approach include decreased postoperative morbidity and faster recovery.17 The myoma can be excised and removed from the peritoneal cavity via a colpotomy incision or after morcellation via the laparoscopic cannula. A laparotomy is recommended for myomas that are larger than 8 cm, multiple leiomyoms, or with deep intramural myomas. There is a 2% to 8% rate of converting to an open procedure. There is also a recurrence rate of 33% at 27 months, which is higher than that of an open myomectomy. Cases of uterine rupture in pregnancies following laparoscopic myomectomy have been reported. This may be

Figure 19–2. Uterine closure after myomectomy. A large uterine defect is in three separate layers using interrupted sutures for the first two layers, and a “baseball stitch” for the last layer.

due to inadequate reconstruction of the myometrium at the time of the myomectomy.18-20

The use of robotics to perform myomectomies has had mixed results. Most studies have demonstrated a quicker recovery, shorter length of stay, and less intraoperative blood loss. However, the costs and operative times were significantly higher in the robotic group and conversion rate to laparotomy was 8.6%.21,22 It appears the same limitations of traditional laparoscopy hold true for robotic myomectomy—difficult enucleation of myoma without tactile feedback.23

Hysteroscopic Myomectomy

Hysteroscopy is used to remove submucosal leiomyoms. Indications for hysteroscopic myomectomy include abnormal bleeding, history of pregnancy loss, infertility, and pain. Contraindications include endometrial cancer, pelvic infection, inability to distend the uterine cavity, inability to go around the lesion, and the extension of the myoma deep into the myometrium. Fertility rates after hysteroscopic myomectomy are good; 59% of patients conceived after resection of the submucosal fibroids. Approximately 20% of patients who underwent hysteroscopic myomectomy will need additional treatment after 5 to 10 years. Symptomatic myoma after the initial surgery can result from the growth of new myoma or recurrence from incompletely excised myoma.

To minimize the risk of uterine perforation, the submucosal fibroid should be evaluated closely for myometrial involvement. When the fibroid invades the myometrium, there is a greater risk of uterine perforation and a simultaneous laparoscopy/hysteroscopy can be performed. After the appropriate operative hysteroscopic distending medium (sorbitol, Hyskon [dextran, high molecular weight]) is infused, the endometrial cavity can be evaluated for the extent of myoma involvement. Using the resectoscope and a cutting current of 60 to 80 W, the myoma can be sequentially resected. Care must be taken to only apply current when resectoscope loop is being withdrawn from the fundus (never toward fundus due to increased perforation risk). Careful attention must be paid to distending media in/out and deficits.

Many authors recommend a hysterosalpingogram 4 months after a myomectomy to evaluate the uterine cavity and the fallopian tubes and a delay of 4 to 6 months after surgery before attempting to conceive. Previously, a cesarean delivery was recommended only if the endometrium was entered during the myomectomy. However, if extensive dissection of the myometrium is carried out in the process of a myomectomy, even if the endometrium in not disturbed, a cesarean delivery is usually advised following a pregnancy. Cesarean delivery is not recommended after the removal of a pedunculated fibroid or after small hysteroscopic resection.24

Comprehension Questions

19.1 A 43-year-old white G3P3 woman has symptoms of pelvic pressure and abnormal uterine bleeding. A pelvic examination reveals a 16-week-size irregular uterus. An ultrasound shows a 10-cm pedunculated leiomyoma from the fundus of the uterus. No adnexal masses were noted. Which of the following should be the next step?

A. Endometrial biopsy

B. Hysterectomy

C. Abdominal myomectomy

D. Laparoscopic myomectomy

19.2 Which of the following cases has a higher chance of recurrence of leiomyoma?

A. A 32-year-old woman who underwent hysteroscopic myomectomy for a single pedunculated fibroid

B. A 44-year-old woman who underwent a laparoscopic resection of a 5-cm subserosal fibroid

C. A 32-year-old woman who underwent an abdominal myomectomy for an 8-cm myometrial fibroid

D. A 44-year-old woman who underwent an abdominal myomectomy for five uterine fibroids

19.3 Which of the following points is most important to be emphasized in counseling a patient undergoing myomectomy for infertility?

A. Complications of myomectomy can lead to a hysterectomy.

B. Adhesions caused by the myomectomy surgery usually can be prevented.

C. Patients with infertility are usually cured after a myomectomy.

D. The location of fibroid and its resection do not affect fertility.

ANSWERS

19.1 A. Before any therapeutic measures are taken, it is critical to complete a full diagnostic evaluation. It is possible that the abnormal uterine bleeding is caused by leiomyoma; however, endometrial pathology must be ruled out in this patient who is older than 35 years with abnormal uterine bleeding. This patient’s symptoms as well as physical examination are consistent with uterine leiomyoms. If she did not wish to retain her uterus, hysterectomy would be the definitive treatment of choice. If she desired future children, myomectomy would be the best option. Since this is a pedunculated fibroid, laparoscopic removal can be considered.

19.2 D. The recurrence rate of leiomyoma depends on the number of myomas removed at the initial myomectomy. There is 11% recurrence after one myoma is removed. There is 26% recurrence rate after multiple myomas are removed.

19.3 A. Submucosal leiomyoms are most often associated with infertility and recurrent pregnancy losses. Myomectomy can improve fertility rates if all other causes of infertility have been ruled out. Risk of myomectomy includes formation of adhesions and blockage of the fallopian tube. A conservative surgery for uterine preservation can lead to a definitive hysterectomy.

Clinical Pearls

See Table 1-2 for definition of level of evidence and strength of recommendation

➤ Improvement in menorrhagia, pelvic pressure, and infertility has been noted after myomectomy (Level A).

➤ Hysterectomy is the only definitive cure for leiomyoms.Myomectomy has the risk of recurrence (Level B).

➤ The risks of myomectomy include possible hysterectomy, recurrence, adhesions, longer hospitalization, and continued infertility (Level B).

➤ After significant disturbance of the myometrium during a myomectomy, a cesarean delivery should be offered in the event of a pregnancy even if the endometrium was not disturbed (Level C).

➤ Myomectomy should be performed if the patient desires to retain her uterus or childbearing function (Level C).

➤ Laparoscopic and hysteroscopic myomectomy should be carried out only by experienced surgeons (Level C).

REFERENCES

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3. American College of Obstetricians and Gynecologists. Surgical Alternatives to Hysterectomy in the Management of Leiomyomas. ACOG Practice Bulletin No. 16, May 2000. Washington DC. 

4. Cramer SF, Patel A. The frequency of uterine leiomyomas. Am J Clin Pathol. 1990;94:435-438. 

5. Ecker JL, Foster JT, Friedman AJ. Abdominal hysterectomy or abdominal myomectomy for symptomatic leiomyoma: a comparison of preoperative demography and postoperative morbidity. J Gynecol Surg. 1995;1:11-18. 

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12. Nezhat FR, Roemisch M, Nezhat Ch, Seidman DS, Nezhat CR. Recurrence rate after laparoscopic myomectomy. J Am Assoc Gynecol Laparosc. 1998;5:237-240. 

13. Dillon T. Control of blood loss during gynecologic surgery. Obstet Gynecol. 1962;19:428. 

14. Frederick J, Fletcher A, Simeon D, et al. Intramyometrial vasopressin as a hemostatic agent. BJOG. 1994;101:435. 

15. Ginsberg E, Benson C, Garfield J, et al. The effect of operative technique and uterine size on blood loss during myomectomy: a prospective randomized study. Fertil Steril. 1993;60:956. 

16. Rock J, Jones H. Leiomyomata uteri and myomectomy. In: Te Linde’s Operative Gynecology. 10th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2008:707- 721. 

17. Mais V, Ajossa S, Guerrriero 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. 2005;174:654-658. 

18. Rock J, Jones H. Diagnostic and operative laparoscopy. In: Te Linde’s Operative Gynecology. 10th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2008:330- 331. 

19. Chu J, Hu Y, Xia-Chan C, et al. Laparoscopy versus open myomectomy—a metaanalysis of randomized controlled trials. Eur J Obstet Gynecol Reprod Biol. 2009;145:14-21. 

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22. Advincula AP, Song A, Burke W, Reynolds RK. Preliminary experience with robot assisted laparoscopic myomectomy. J Am Assoc Gynecol Laparosc. 2004;11:511-518. 

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24. Ubaldi F, Tournaye H, Camus M, Van der Pas H, Gepts E, Devroey P. Fertility after hysteroscopic myomectomy. Hum Reprod Update. 1995;1:81-90.

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