Uterine fibroids affect 25% of women worldwide. Symptomatic women can be treated by either medical or surgical treatment. Development of endoscopic surgery has widely changed the management of myoma. Currently, although laparoscopic or laparoscopic robot-assisted myomectomies or hysterectomies are common, there has been no consensual guideline concerning the surgical techniques, operative route, and usefulness of preoperative treatment. Hysteroscopy management is a major advancement avoiding invasive surgery. This study deals with a literature review concerning surgical management of fibroids.
Introduction
Uterine fibroids affect 25% of women worldwide. Fibroids are the most common benign uterine tumors in women of reproductive age . Surgical or medical treatment can be proposed for symptomatic (constipation, pollakiuria, pelvic discomfort or pressure, metrorrhagia) and/or infertile women. Depending on the patient and fibroid characteristics, after medical treatment failure, surgical treatment such as myomectomy and hysterectomy can be proposed. Surgical treatment for fibroids involved hysterectomy for women who have completed childbearing and myomectomy for those who want to preserve their uterus or desire future pregnancy. Apparition of laparoscopic and hysteroscopic surgery allowed development of gynecologic surgery. The first complete laparoscopic hysterectomy for fibroids treatment was performed by the American gynecologist Harry Reich, removing the uterus through a colpotomy and closing laparoscopically . The first laparoscopic myomectomy was reported by Semm in 1979 . Neuwirth et al. described the first submucus fibroids hysteroscopic excision . Currently, minimally invasive techniques have become common for most surgical gynecologic treatments. The aim of this study was to describe each endoscopic technique.
Laparoscopic myomectomy
Indication
Surgical treatment can be proposed for symptomatic (constipation, pollakiuria, pelvic discomfort or pressure, metrorrhagia) and/or infertile women. Laparoscopic myomectomy is useful for interstitial and subserosal fibroma. On the basis of the country guidelines, indications of laparoscopic myomectomy depend on fibroid characteristics (number, size, etc.) and the surgeon’s experience. As an example, French College of Obstetrics and Gynaecology concluded that myomectomy was feasible and reproducible by laparoscopy when the number of fibroids was low (<3) and their diameter was <8 cm . In case of surgery for symptoms, age of the patient has also to be taken into account because of the risk of recurrence. Few studies focused on the risk of recurrence after myomectomy . In a retrospective study of 224 patients with a mean follow-up of 108 months, Radosa et al. observed 75 (33.4%) recurrences. They founded that, women aged 30–40 years, with more than one fibroid at the time of the surgery, have high symptomatic recurrence (31.25% and 38.71%, respectively; both p < 0.01) . Three studies analyzed the rationale of performing myomectomy in symptomatic women >40 and 45 years of age . Kim et al. , including 92 patients >45 years of age, with a mean follow-up of 30.5 months, found a 17.1% cumulative recurrence rate using transvaginal ultrasonography. Among them, only one patient (1.1%) underwent hysterectomy because of symptomatic recurrence. Authors concluded that myomectomy would be an option for women of age >45 with a low rate of surgical reintervention . Patients have to be informed about the risk of recurrence, irrespective of their age. Doridot et al. found that the cumulative risk of fibroid recurrence after laparoscopic myomectomy was 12.7% at 2 years and 16.7% at 5 years. However the reoperative rate was 4% .
Preoperative treatment
Intervention to reduce fibroid size and increase preoperative hemoglobin
Different preoperative treatments existed. Until ulipristal acetate (UPA) apparition, the most common preoperative treatment was gonadotropin-releasing hormone (GnRH) analog therapy. In a Cochrane meta-analysis, Lethaby et al. observed that administration of GnRH analog therapy before surgery significantly improved pre- and postoperative hemoglobin and reduced fibroid volume. However, adverse events such as menopausal symptoms were more likely during GnRH analog therapy. According to meta-analysis results, authors recommended the use of GnRH analogs for 3–4 months before fibroid surgery. Donnez et al. in a comparative randomized control trial (RCT) evaluated the effect of UPA on fibroids . They showed that an intake of 5 or 10 mg of UPA for 13 weeks was more efficient than placebo in terms of reducing bleeding symptoms and fibroid size. However, they did not show if this therapy changed the initially predicted operative route. Further studies showed that long-term intermittent UPA therapy (18 months meaning four courses of 3 months) could be prescribed to maximize the effect of UPA on fibroid size. The effect of UPA on surgical data had not been yet evaluated.
Preoperative embolization
Goldman et al. conducted a retrospective pilot study, which compared uterine artery embolization (UAE) just before laparoscopic myomectomy versus laparoscopic myomectomy. They showed that uterine was four times heavier in the UAE group. They concluded that UAE performed immediately before laparoscopic myomectomy facilitated minimally invasive surgery for larger uteri and larger uterine myomas, with no change in operative time or blood loss. The small sample size (12 vs. 14 patients) did not permit to conclude concerning blood loss.
Preventive uterine artery occlusion
A recent meta-analysis, including 11 studies (nine nonrandomized and two RCTs), concluded that uterine artery occlusion (permanent or temporary) associated with laparoscopic myomectomy appears to be an effective procedure improving symptoms and reducing the risk of recurrence . The small sample size of those studies did not permit to conclude on the reduction of risk of intraoperative and postoperative bleeding. Moreover, because of lack of prospective data, this technique is not recommended for women who desire future pregnancy .
Different laparoscopic surgical routes
Traditional laparoscopic myomectomy
In 2014, a Cochrane review evaluated laparoscopic surgery versus open myomectomy for uterine fibroids . Open surgery included open laparotomy, mini-laparotomy, and laparoscopy-assisted mini-laparotomy. Primary outcome criteria were postoperative pain (visual analog scale at 6, 24, and 48 h) and in-hospital adverse events. Secondary outcomes were length of hospital stay, operating time, improvement in menstrual symptoms, change in quality of life, recurrence of fibroids, and repeat myomectomy and hysterectomy afterward. Among the 23 theoretical studies assessed for eligibility, only nine were included in the meta-analysis (808 patients). Even if there was no significant difference of pain at 24 h between both surgical techniques (MD −0.29, 95% CI −0.7 to 0.12), laparoscopic approach seemed to be less painful than open surgery at 6 (MD −2.4, 95% CI −2.88 to −1.92) and 48 h (MD −1.90, 95% CI −2.80 to −1.00). There was no difference in perioperative in-hospital adverse event (laparoconversion, injury to pelvic organs or unscheduled return to operation theater). Postoperative fever was less reported in the laparoscopic group (OR 0.44, 95% CI 0.26–0.77). Hemoglobin drop was different among studies and was not pooled due to heterogeneity. Four of six studies found a significant reduction of blood loss in the laparoscopic group. Even if the operating time was longer in the laparoscopic surgery (MD 13.8, 95% CI 9.61–16.56), length of hospital stay was shorter in most of the included studies .
Single-port laparoscopic myomectomy
Lee et al. studied learning curve of traditional single-port laparoscopic myomectomy in a retrospective study including 161 consecutive cases. They reported that proficiency in single-port laparoscopic myomectomy was achieved after 45 consecutive cases depending on the operating duration. Learning curve was not associated with more complication, postoperative hemoglobin drop loss, fever, and length of hospital. Because of technical difficulties of single-port laparoscopic myomectomy, particularly in laparoscopic suturing and knotting, teams have developed alternative techniques called “single-port laparoscopy-assisted transumbilical ultraminilaparotomic myomectomy” . This technique, which combined the advantage of mini-invasive laparoscopic dissection and the rapidity of suturing and knotting during ultraminilaparoscopy, allowed shorter operative time without less postoperative pain. Few studies, which focused on single-port laparoscopic myomectomy, concluded that this technique is eligible for intraligamentary, subserosal myoma and intramural myomas located in the anterior wall of the uterus. The median size of fibroid varied from 6 to 10 cm .
Robot-assisted laparoscopic myomectomy
Few studies compared robot-assisted laparoscopic myomectomy (RALM) with traditional laparoscopic myomectomy. Most of them concluded that RALM appears to provide the same short-term surgical outcomes as traditional laparoscopic myomectomy . Hsiao et al. found that RALM was associated with longer operation time than laparoscopic myomectomy, but resulted in less postoperative abdominal drainage . Barakat et al. showed that RALM was associated with decreased blood loss and length of hospital stay compared with traditional laparoscopy, but longer operative time. No study reported the long-term outcomes of RALM. No study compared fertility outcomes between RALM and laparoscopic myomectomy.
Surgical techniques
Uterus incision
Litta et al. , in an RCT, compared the effectiveness and safety of harmonic scalpel versus electrosurgery to reduce blood loss during laparoscopic myomectomy. They showed that the use of the harmonic scalpel was associated with lower total operative time (88.8 ± 35.5 min vs. 71.8 ± 26.7 min, p = 0.001), lower intraoperative blood loss (1.2 ± 0.9 δ Hb vs. 0.9 ± 0.8 δ Hb, p = 0.03), and lower immediate (24 h) postoperative pain (visual analog scale 5.6 ± 0.8 vs. 4.4 ± 1.1, p = 0.001), with no improvement in surgical difficulty. Moreover, treatment with electrosurgery devices was concomitant to a vasoconstrictive solution (epinephrine) use, which permits reduction of blood loss. One retrospective study compared the safety and effectiveness of the pulsed bipolar system and conventional electrosurgery . Although they did not show any difference in the decrease of hemoglobin between the two groups, they found a significantly lower amount of blood loss in pulsed bipolar system group than the electrosurgery group (190.4 ± 178.5 mL vs. 243.8 ± 150.4 mL, p = 0.025).
Suture
There was no RCT whose primary outcomes analyzed the effectiveness of uterine closure (scare dehiscence, uterine rupture), according to the number of layer closure. Without any evident proof, we can hypothesize that multilayer suture might be more efficient than single-layer suture. The number of layers has to be adjusted according to the depth of the uterine scar. Pellicano et al. in a prospective randomized study with a small sample size of patients (18 vs. 18) showed that subserous sutures were associated with a higher occurrence of pregnancy than simple deep figure-of-eight suture. According to a recent meta-analysis, which included three studies (148 vs. 73 patients, in the barbed suture group and conventional suture group, respectively), the use of barbed suture was associated with a significant reduction of operative time (SMD (standardized mean difference): 0.58; 95% CI, 20.88–20.28). However, blood loss was not different between both groups and barbed suture seemed to be efficient in case of single-port laparoscopic myomectomy. One prospective control study including 60 consecutive cases of single-port laparoscopic myomectomy observed that the use of barbed suture was strongly associated with a reduced suturing time ( p = 0.014), as well as the total operative time ( p = 0.027), less operative blood loss ( p = 0.040), and less technical difficulty ( p = 0.001) .
Usefulness of abdomino-pelvic drains after laparoscopic myomectomy
Hurrell et al. analyzed the usefulness of abdomino-pelvic drains after laparoscopic myomectomy in a retrospective study, which included 217 consecutives cases. Primary outcome was to study the effect of drains on the length of hospital stay. Secondary outcome was to identify factors affecting the use of abdominal drains. During laparoscopic myomectomy, vasopressin, intrarectal misoprostol, and anti-adhesion barriers were administered. Abdominal drains were not associated with a longer duration of hospitalization (2.1 ± 1 days vs. 2.1 ± 1 days, MD −0.015 (95% CI −0.28–0.25), p = 0.91). They observed that leaving an in situ drain was correlated with a high number of fibroids (4.6 ± 3.8 vs. 2.8 ± 2.1, p < 0.0001), increased weight of fibroids (277 ± 211 vs. 133 ± 153 g, p < 0.0001), more complex and longer surgery (133 ± 40 vs. 90 ± 35 min, p < 0.0001), higher estimated blood loss (406 ± 265 vs. 199 ± 98 ml, p < 0.0001), and higher postoperative drop in hemoglobin (1.63 ± 1.31 vs 1.18 ± 0.90 g/dl). Even if postoperative complication rates were similar in both groups, pain was not evaluated.
Interventions to reduce hemorrhage during myomectomy for fibroids
Fibroids surgery is associated with risk of blood loss, need for blood transfusion, and postoperative complications, such as fever or unscheduled return to operation theater. Many interventions have been proposed to reduce bleeding and blood transfusion. Kongnyuy et al. have evaluated the effectiveness of these techniques in a meta-analysis, which included 18 studies of laparoscopic or laparotomy surgery (633 patients in the intervention group vs. 617 in the control group) . There was moderate quality of evidence that misoprostol and intrauterine muscle injection of vasopressin were effective for blood loss reduction. Infiltration of vasopressin into uterine muscle was associated with moderate quality of evidence in reduction of operating time and blood transfusion. All results are summarized in Table 1 .
