Laparoscopic Myomectomy—Endpoint or Intermediate Step?

Saverio Arena, Errico Zupi
US Obstetrics & Gynecology, 2011;6(2):120-2
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Abstract

Uterine myomas are the most common benign female genital pathology, with an annual incidence of 12.8 %. Although widespread, there is still lack of unanimous agreement on when, why and how uterine myomas should be removed. Laparoscopic myomectomy is probably one of the most operator-dependent procedures, carrying a considerable risk of conversion. It should be noted that the number of laparoscopic myomectomies, although high, is not consistent with the incidence of the pathology. The learning curve is steep. There are a number of variables at play; the size, location, and number of myomas negatively affect not only the duration of the intervention but also the quality of the surgical outcome and its success. The correlation between myomectomy and pregnancy is important both in terms of complications and development. Myomectomy affects the miscarriage rate positively since it starts at 60 % before surgery and reaches 26–27 % after surgery. The majority of patients conceive between the 12th and 36th month after surgery. The cases of uterine rupture are often limited to case reports. Laparoscopic myomectomy is a safe and repeatable procedure that requires adequate training.
Keywords
Myomectomy, laparoscopy, myoma, fibroid
Disclosure The authors have no conflicts of interest to declare.
Received: July 22, 2011 Accepted August 26, 2011
Correspondence: Saverio Arena, MD, SC Ostetricia e Ginecologia, Azienda Ospedaliera S. Maria della Misericordia, Perugia, Italy. E: arenasft@tin.it

“Les bénéfices de la myomectomie coelioscopique sont d’éviter la laparotomie et l’hystérectomie tout en traitant la symptomatologie présente.”1 (“The advantage of laparoscopic myomectomy is to avoid laparotomy and hysterectomy while treating the symptoms.”)

– JB Dubuisson

Is there anything we could add to Dubuisson’s eloquent synthesis? Uterine myomas are the most common benign female genital pathology, with an annual incidence of 12.8 %.2 Although the incidence is relatively high and the new cases/year rate tends to increase, there still is lack of unanimous agreement on when and why uterine myomas should be removed. The American College of Obstetricians and Gynecologists (ACOG) divides the indications for myomectomy into four broad groups:

  • clinically apparent myomas that are a significant concern to the patient even if otherwise asymptomatic;
  • myomas causing excessive bleeding and/or anaemia;
  • myomas causing acute or chronic pain; and
  • myomas causing significant urinary problems not due to other abnormalities.2

A rapid growth due to a malignant transformation of the myoma is almost an outdated indication;2 besides, the incidence of uterine sarcoma in premenopausal women is less than 0.3 %.3 If there is little consensus on when and why to treat, how to treat appears to be an even more disputed matter.

The history of myomectomy is lost in the mists of time: we need to go back to 1844 to find the first description of the procedure. However, for the purposes of our argument it suffices to look at how the surgical approach to uterine myomas has completely changed over the past 20 years. In 1981 the surgical alternatives to watchful waiting were abdominal myomectomy and hysterectomy; today we have not only an increased number of treatment options but also completely different indications.4 Ideally, in the mind of every laparoscopic surgeon, endoscopic treatment, after the first hesitant steps, should have gradually replaced laparotomy. Attempts have been made to replace laparotomy not only with laparoscopy but also with alternative methods such as embolisation, ultrasound treatment and medical therapy alone. Despite all, often numbers do not support these theories and there are big research gaps on the topic.3

Today, we are at an intermediate stage, where perhaps the questions raised are of a more general nature than in the past. We ask not only how to remove a myoma but also simply whether it should be removed. Does the patient actually benefit from medical or surgical treatment? Is it appropriate in terms of health expenditure to take an ‘aggressive’ approach to the disease? To these and many other questions there is no unanimous answer.5 Last but not least, have the alternatives to surgery always been dictated by an attempt to improve the treatment or were they rather an attempt to try to keep up with the times using shortcuts?

References:
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