© Springer International Publishing AG 2018Nash S. Moawad (ed.)Uterine Fibroidsdoi.org/10.1007/978-3-319-58780-6_13
13. Solitary Myoma: Laparo-Endoscopic Single Site (LESS) Surgery
Department of Gynecology and Obstetrics, Johns Hopkins University Hospital, 600 N. Wolfe Street, Phipps 249, Baltimore, MD 21287, USA
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Twenty-seven year-old presents with menorrhagia and is found to have a 3.5 cm intramural fibroid. She desires fertility in the future. She elects medical management with oral contraceptive pills at this time. She returns 14 months later with significant pelvic pain, deep dyspareunia, and anemia with hemoglobin of 7.2 g/dL, and ultrasound reveals the fibroid has increased in size to 9 cm.
There are several questions that this case scenario brings up.
Is There a Concern for Malignancy?
This patient had a rapid growth of her fibroid with her fibroid growing from 3.5 to 9 cm in the course of 14 months. Rapid growth is considered to be when a uterus has increased by 6 weeks’ gestational size within 1 year . Historically, rapid growth of fibroids gave the suspicion for a leiomyosarcoma. In the premenopausal patient, there is wide variation in growth and that growth does not correlate with risk of leiomyosarcoma as it does in the postmenopausal patient [1–5]. Normal fibroids can demonstrate growth of up to 138% in 6 months . If this patient was postmenopausal, a growing (slow or rapid) uterine mass should definitely be evaluated for a malignancy .
How do We Assess Her Risk for a Leiomyosarcoma?
Screening markers are used to help identify leiomyosarcomas . This is important to minimize the need for surgery and especially a laparotomy due to the low incidence of leiomyosarcoma and the high incidence of fibroids. Nagai T et al. created a preoperative diagnostic scoring system to improve the identification of these patients . They identified four predictive factors: preoperative age, serum lactate dehydrogenase (LDH) levels, endometrial cytology findings, and magnetic resonance imaging (MRI).
The first factor to consider is her age. This patient is 27 years old. Among myomectomy patients, age correlates with risk of a uterine cancer . The risk of a hidden cancer in a patient <40 years old is 1 in 2337, in a 40-49 year old is 1 in 702, in a 50-59 year old is 1 in 154 and >/=60 year old is 1 in 31.
Serum levels of total LDH and its isoenzymes were evaluated in predicting leiomyosarcoma. Total has the highest sensitivity but diagnostic accuracy was only 88.6% . LDH isoenzyme 3 has a sensitivity and specificity of >90% for predicting leiomyosarcoma , though both the total LDH and isoenzyme 3 can be elevated with leiomyoma, which is why it is not a good screen in isolation.
Preoperative endometrial sampling can suggest an invasive tumor 86% of the time and predict the correct histologic diagnosis in 64% .
Should We Proceed with Surgery Now or Resolve the Anemia First?
She is anemic at this point and how do we address it. There are two schools of thought here. One is to proceed with surgery now, but the patient is at increased risk for needing a blood transfusion at the time of surgery since her starting hemoglobin is 7.2 g/dL. Transfusions prior to pregnancy can increase the incidence of antibodies and can result in acquisition of viral disease, both of which can complicate any subsequent pregnancy. As a result, it is recommended for this patient population to request leuko-reduced packed red blood cells if transfusion is necessary.
The other option is to resolve the anemia first to allow for a larger potential blood loss reserve before a blood transfusion is necessary. To help resolve the anemia, iron supplementation is utilized to provide the building blocks for red cell production and hormonal suppression to decrease the blood loss related to her menses. Iron supplementation can be provided orally and through intravenous (IV) infusions. Oral iron supplementation can be associated with constipation and there is limitation in absorption. IV iron infusions work faster than the oral approach and can be helpful when a patient has side effects from the oral approach.
Hormonal suppression with combined oral contraception or progestins is usually first-line treatment. Depot Lupron can be used if the patient fails first-line treatment. Depot Lupron usually will have 2–3 weeks of increased bleeding initially after the first injection before the bleeding improves. Per Cochran, it has not been shown to decrease blood loss at the time of myomectomy but may decrease operating time . It does potentially increase the risk of resection of normal myometrium at the time of the myomectomy because it can blur the tissue planes between the fibroid and myometrium.
Is There an Optimal Approach to the Removal?
This is a solitary fibroid. Ideally, a minimally invasive approach is the best for myomectomy cases when feasible . Myomectomies are notorious surgeries for adhesion formation. Adhesions can be a source for infertility . A minimally invasive approach helps to decrease the risk of adhesion formation . In addition, the use of fibrin gel and fibrin sheets helps minimize the risk of adhesion formation [16, 17]. Other aspects that influence the risk of adhesion formation include number of fibroids removed, number of incisions on the uterus, and size of the largest fibroid . Febrile morbidity occurs half as often with a laparoscopic myomectomy versus via laparotomy .
A minimally invasive approach has no difference in pregnancy rates, abortion rates, or preterm delivery when compared to laparotomy [19–21]. But in a logistic regression model, it was shown that chance to conceive is significantly higher with young patients, larger removed fibroids, intramural localization, and laparoscopic surgery . In women that had symptomatic fibroids, women who had their fibroids removed laparoscopically had a shorter time to pregnancy .
Higher blood losses and a more pronounced hemoglobin drop with laparotomy [13, 21, 23, 24]. And as stated before, transfusions prior to pregnancy can increase the incidence of antibodies and can result in acquisition of viral disease, both of which can complicate subsequent pregnancy.