Patients

Between January 2002 and December 2003, all patients (n = 437) eligible for benign uterine myomas treated with myomectomy through LT, UMLT, and LA-UMLT were recruited for this cohort study ( Figure ). The patients, who had given informed consent, were treated with 1 of the above-mentioned procedures based on their willingness and preference after explaining the details and advantages of the 3 surgical approaches, including postoperative pain control through methods such as the continuous pain-control anesthesia system. This study was approved by the institutional review board.

Flowchart showing assignment of study subjects

Wen. Comparing uterine fibroids treated by myomectomy through LT, UMLT, and LA-UMLT. Am J Obstet Gynceol 2010.

To obtain a homogeneous series of cases with comparable surgical difficulty, all patients had to fulfill the criteria of uncomplicated myomas provided by the National Health Insurance Bureau in Taiwan, including: (1) absence of previous abdominal or pelvic surgery; (2) a number of visible uterine masses (myomas) ≤5 intramural or subserous myomas (without peduncle); (3) a maximum diameter of not >8 cm; and (4) an absence of prominent or significant pelvic adhesion on clinical evaluation. In addition, the patients had to fulfill the following 3 basic requirements: absence of preoperative or postoperative adjuvant therapy; absence of other pelvic pathologies, except fibroids; and a final follow-up in 2007. The phrase “symptomatic” meant any disturbance induced by fibroids that troubled one’s life, which has been described previously.

Operative procedures

All operations were performed under general endotracheal anesthesia with the patient in the Trendelenburg position and the bladder catheterized. Diluted vasopressin (1:60) was injected into the myometrium around the myoma nodules and directly into the fibroid tissue of the patients in the 3 groups to decrease intraoperative bleeding.

LT

In the LT group, an 8- to 12-cm transverse incision (Pfannenstiel incision) was made 1-2 cm below the pubic hairline, 2-4 cm above the pubic symphysis. The subcutaneous fat was incised and the abdominal fascia was opened transversely 2-3 cm above the skin incision to a width of 10-16 cm. The abdominal muscle was opened longitudinally on the midline and the peritoneum was visualized and opened longitudinally to reach the pelvic cavity. Subsequently, a self-retaining retractor or Balfour retractors (Sklar Instrument, West Chester, PA) were inserted through the abdominal breach and the bowel was packed upward with warm, wet pads. After examination of the uterus and adnexa, all intact fibroids were removed smoothly. The uterine defects were closed in a double layer with interrupted sutures of Vicryl 1-0 (polyglactin 910, W9464; Ethicon, Somerville, NJ). After controlling the hemostasis and repeated washing of the pelvic cavity, the wound was closed layer by layer.

LA-UMLT

In the LA-UMLT group, a pneumoperitoneum was established as usual. A 10-mm port was inserted through the umbilicus to introduce the videolaparoscopic system. Three other accessory 5-mm trocars were inserted into the abdomen to the left lower quadrant, right lower quadrant, and suprapubic area for use by the operative instruments and the suction irrigator cannula. The myomas were grasped and pulled with a second needle. After infiltration with diluted vasopressin (1:60), the myometrium was incised and the myoma removed. After completing the procedure, the carbon-dioxide insufflator and videolaparoscopic system were turned off temporarily. Then, we extended the incision wound of the suprapubic trocar up to 3 cm. The myomas were extracted and removed piece by piece through the suprapubic wound, as in the UMLT procedure. In addition, the entire uterus was carefully palpated by the fingers through the suprapubic wound to exclude residual fibroids, which might be missed by the videolaparoscopic system. As in the UMLT procedure, the myometrial defects were repaired through a suprapubic wound. After closure of the suprapubic wound, videolaparoscopy was used again to clean the abdominal cavity. The use of a drainage system (closed wound vacuum reservoir) was dependent on the operator’s preference and the surgical situation.

Evaluation parameters

The parameters we considered for comparing the 3 groups were the characteristics of the uterine fibroids, the surgical parameters, morbidity, and outcome. Surgical parameters included the final incision length of the surgical wound (centimeters), operative time (minutes), estimated blood loss (milliliters), time of removal of drainage, percentage of blood transfusion, morbidity, and failure. Morbidity included percentage of febrile morbidity (body temperature >37.5°C), maximal temperature, duration of febrile morbidity, and percentage of paralytic ileus. Patient discomfort consisted of time of paralytic ileus, hospital stay (days), visual analog scale, postoperative use of analgesics, and accumulative dosage of meperidine hydrochloride. The outcome evaluation mainly focused on recurrence: either the occurrence of symptoms or any detection of uterine fibroids. The parameters, including recurrence rate, interval between operation and detection of recurrence, number, maximal size, location, and association of the previous uterine fibroids, were recorded. Recurrence was defined as any detected tumor with a minimal diameter >1 cm after operation. The term “association” meant the detection of any recurrent uterine fibroids at the original operative site (area of tumor excision) during the follow-up after operation. All patients received >4 semiannual follow-ups and then were followed up annually or when the symptoms or signs recurred. Routine pelvic examination and ultrasound were used for every patient.

Statistical analysis

Statistical software (SPSS, Version 15.0; SPSS Inc, Chicago, IL) was used to analyze all data. Data were presented as the mean ± SD. The parametric-independent samples t test was used to compare the differences between the 3 groups, and χ ² analysis was used for categorical variables. For all statistical evaluations, P < .05 was used to reject the null hypothesis.