Conventional Laparoscopy Myomectomy
Katrin S. Arnolds
Stephen E. Zimberg
Michael L. Sprague
General Principles
Definition
Uterine leiomyomas are the most common gynecologic tumor, with an incidence approximating 20% to 25% in women aged 18 to 65 years.1 Uterine myomas are discreet, sharply circumscribed masses, and histologically appear as whorled bundles of smooth muscle. Most commonly, leiomyomas grow within the uterine corpus, but may also occur within the uterine ligaments, uterine cervix, or on other abdominal structures. Individual myomas are believed to be monoclonal and result from somatic mutations yielding dysregulation of genes involved in growth regulation. Growth of uterine leiomyomas lead to uterine enlargement, which may yield symptoms such as abnormal uterine bleeding, dysmenorrhea, dyspareunia, subfertility, pelvic pressure, urinary frequency, or defecatory dysfunction. Uterine myomectomy is the preferred surgical therapy for management of symptomatic uterine myomas in women who desire future pregnancy or uterine preservation. Laparoscopic myomectomy is a feasible, minimally invasive procedure and has been demonstrated to yield less pain, shorter hospital stays, improved cosmesis, less blood loss, and faster recovery compared to laparotomic procedures, and similar surgical outcomes with less overall cost compared to robot-assisted procedures.
Differential Diagnosis
Adenomyosis
Congenital uterine anomaly
Endometrial polyp
Hematometra
Pregnancy
Uterine leiomyosarcoma
Uterine carcinosarcoma
Endometrial carcinoma
Metastatic disease
Tubo-ovarian neoplasm
Nonoperative Management
The goal of nonoperative management for uterine leiomyomas is to decrease symptomatology and improve the quality of life. To maximize patient satisfaction and compliance, therapies must be convenient for the patient and with minimal deleterious side effects. From a surgical perspective, medical therapies for uterine leiomyomas are frequently employed to raise preoperative hemoglobin levels or to reduce uterine volume to optimize a patient prior to surgical intervention.
Observation, which entails no immediate intervention, is reasonable for patients who experience minimal symptoms or who elect not to receive treatment. Watchful waiting is a practical option to select women who are approaching menopause as uterine leiomyomas often regress as circulating levels of estradiol and progesterone naturally.
Steroid hormones are commonly employed to manage bothersome symptoms attributable to uterine myomas. A common first-line therapy for management of abnormal uterine bleeding and dysmenorrhea is combination oral contraceptive pills (OCPs). Although the efficacy of combination OCPs for the treatment of symptomatic fibroids is uncertain and scientific evidence is scarce,2 oral contraceptives may sufficiently reduce the bothersome symptoms attributable to leiomyoma uteri in certain women. The levonorgestrel intrauterine system (LNG-IUS) is another option for management of abnormal uterine bleeding and has been shown to decrease menstrual blood loss, reduce uterine volume, and lead to improvement in hemoglobin levels.3 Of note, the presence of submucous myomas that significantly distort the uterine cavity is a relative contraindication for LNG-IUS.
Administration of GnRH agonists results in downregulation of hypothalamic GnRH receptors, ultimately inducing a reversible hypogonadal state by 2 weeks. The GnRH agonist, leuprolide acetate, is approved by the Food and Drug Administration (FDA) to increase hemoglobin levels and decrease myoma size prior to myomectomy. Women who receive leuprolide acetate therapy typically develop amenorrhea within 3 months. The expected mean reduction in uterine volume is 36% by 3 months and 45% by 6 months following initiation therapy. Patients treated with GnRH agonists may experience menopausal symptoms such as hot flushes, vaginal dryness, mood changes, and a reversible decrease in bone density. Hormonal add-back therapy may be initiated to minimize side effects from GnRH agonists. Of note, preoperative treatment with leuprolide acetate may not improve blood loss during myomectomy.
GnRH antagonists compete with endogenous GnRH for pituitary binding sites and have the advantage of a comparatively rapid onset of clinical effects without certain side effects observed with GnRH agonists. Evidence suggests that a 31.3% reduction in uterine leiomyoma size can be achieved by 14 days of treatment.4 GnRH antagonists currently available in the United States require daily injections, which may be an obstacle for many patients.
Mifepristone is a weak progesterone receptor agonist that has been demonstrated to reduce heavy menstrual bleeding and improve myoma-specific quality of life. Treatment with mifepristone yields a reduction of uterine volume by 26% to 74% in women with leiomyomas.5 At present, mifepristone is not FDA-approved in the United States for the treatment of uterine leiomyomas.
Ulipristal acetate (UPA) is an orally administered selective progesterone receptor modulator that inhibits proliferation of leiomyoma cells, but not in normal myometrial cells.6 UPA has been shown to significantly reduce fibroid volume, decrease abdominal pressure, and decrease myoma-related pain. UPA has stimulatory effects on the endometrium and its progesterone antagonist action could result in an increased
risk for endometrial hyperplasia and endometrial carcinoma. However, studies have demonstrated that the incidence of endometrial hyperplasia and malignancy after treatment with UPA appears to be low. Pregnancies after UPA administration have been reported without maternal complications related to leiomyomas.
Magnetic resonance–guided focused ultrasound surgery (MRgFUS) is an outpatient treatment option for uterine leiomyomas in premenopausal women. MRgFUS is a noninvasive, thermoablative technique in which waves of ultrasound energy converge on a small volume of tissue, which leads to the thermal destruction, coagulative necrosis, and reduction of leiomyoma of volume.7 Pregnancies have been described after MRgFUS with no specific pattern of complications.
Uterine fibroid embolization (UFE) reduces uterine arterial blood flow and results irreversible infarction of leiomyomas. The leiomyomas eventually decrease in size and bothersome myoma-related symptoms improve. Most commonly, the approach to percutaneous embolization is via the right or left femoral artery under local anesthesia. UFE may reduce menstrual loss by 85% and the mean dominant fibroid volume by 30% to 46%.8 The safety of pregnancy after UFE has not been established to date; however, pregnancies after UFE have been reported.9
Imaging and other Diagnostics
Multiple imaging modalities are available for the evaluation of suspected uterine myomas, each with relative strengths and weaknesses. In addition to documenting the number and size of any myomas present, a primary objective of pelvic imaging prior to laparoscopic myomectomy is to rule out other pathologies such as adenomyosis and gynecologic malignancy.
Pelvic ultrasound provides high-quality imaging of the uterus and adnexa and is oftentimes the primary imaging modality for the evaluation of patients with suspected uterine myomas (Fig. 7.2.1). Pelvic ultrasound is widely available, with advantages that include relatively low cost, high diagnostic accuracy, and lack of ionizing radiation. Ultrasound of the pelvis is performed using both transabdominal and transvaginal techniques to ensure the best-quality anatomic survey is obtained. It is important to note that, although effective at evaluating total endometrial thickness, transvaginal ultrasound has low sensitivity for detecting intracavitary masses and determining the type of submucous myomas. Saline-infused sonography (SIS) differs from nonenhanced transvaginal ultrasound in that saline is employed to distend the uterine cavity, which serves as a contrast medium and allows for detailed examination of the endometrium.
Figure 7.2.1. Pelvic ultrasound for evaluation fundal, subserosal myoma.
Magnetic resonance imaging (MRI) of the uterus is the preferred imaging method for evaluating uterine myomas prior to laparoscopic myomectomy (Fig. 7.2.2). MRI allows for efficient, comprehensive evaluation of the uterus and clearly demonstrates the size and location of myomas present. Compared to SIS, MRI is superior at accurately estimating the degree of submucosal myoma ingrowth into the endometrial cavity, which is crucial for preoperative planning, as a surgeon may choose to excise certain submucous myomas in hysteroscopic fashion. MRI allows for assessment of the junctional zone, which is important for identifying adenomyosis. Compared to computed tomography and pelvic ultrasound, MRI is superior at differentiating benign uterine leiomyomas from uterine leiomyosarcomas.
Preoperative Planning
Appropriate preoperative patient counseling is important to define a patient’s goals from surgery and to establish reasonable expectations following laparoscopic myomectomy. In general, the intent of uterine myomectomy is to improve, not necessarily eliminate, bothersome symptoms attributed to uterine myomas. The risks of laparoscopic myomectomy should be emphasized, including perioperative blood loss possibly necessitating transfusion, postoperative adhesion formation which may yield pain or subfertility, and the rare
need for hysterectomy if unexpected pathology or uncontrollable bleeding is encountered. Additionally, the patient should be informed of the possibilities of future myoma recurrence and of intrapartum uterine rupture. The patient should understand that any procedure that begins laparoscopically may require laparotomy to complete.
Figure 7.2.2. Pelvic MRI for evaluation of fundal, subserosal myoma.
Favorable surgical outcomes require that medical comorbidities are optimized prior to laparoscopic myomectomy. Commonly, patients with abnormal uterine bleeding have iron deficiency anemia, which should be corrected prior to surgery to minimize risk of perioperative transfusion and maximize wound healing potential. Options for iron repletion include oral iron therapy and intravenous iron infusions. Oftentimes, concomitant medical therapy is required to reduce abnormal uterine bleeding in order to achieve a net increase in hemoglobin. Pre-existing cardiopulmonary disease may lead to difficulty with ventilation or tolerance of Trendelenburg position and should be addressed prior to laparoscopic surgery. Poorly controlled diabetes mellitus may lead to poor wound healing and increased risk of perioperative infection.
Surgical Management
Laparoscopic myomectomy should be avoided in patients with suspected gynecologic malignancy and contraindications to pneumoperitoneum or Trendelenburg positioning. Other limitations to laparoscopic myomectomy include the size and number of myomas to be excised and a surgeon’s ability to efficiently perform laparoscopic suturing. In many instances, it is more difficult to remove numerous small myomas as opposed to fewer, larger myomas.
Positioning (Figs. 7.2.1 and 7.2.3)
The patient is placed in dorsal lithotomy position with their legs in stirrups and their arms tucked in neutral positions at their sides. As Trendelenburg positioning will eventually be necessary for the completion of the surgery, it is prudent to take the opportunity to place the patient in Trendelenburg position prior to surgical preparation to ensure that patient does not shift on the operative table. Beanbag or foam egg crate mattress covers are effective measures to ensure the patient’s position does not change during Trendelenburg positioning. Following surgical preparation of the abdomen and vagina, the patient is draped, a Foley catheter is introduced into the bladder, and a uterine manipulator is placed. We prefer to use a uterine manipulator through which fluid can be introduced into the uterine cavity and allow performance of chromopertubation.
Placement of laparoscopic cannulas is dependent on the size and position of the myomas. In general, we place laparoscopic cannulas at the umbilicus, within the left and right epigastrum at the level of the umbilicus, and in the left lower quadrant to facilitate laparoscopic suturing in an ipsilateral approach from the patient’s left side (Fig. 7.2.3). As total uterine length increases, port placement may need to shift cephalad, but the overall geometry of the port placement need not change. The diameter of each port depends on surgeon preference, myoma size, and quality of the laparoscopic instruments.
Figure 7.2.3. Typical port configuration for laparoscopic myomectomy.
Procedures and Techniques (Video 7.2)
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