Department of Obstetrics and Gynaecology, Catholic University of The Sacred Heart, Largo A. Gemelli 8, 00168, Rome, Italy
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Abstract |
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Key words: GnRH analogue/myomectomy/operative laparoscopy/pregnancy
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Introduction |
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Abdominal myomectomy is associated with an acceptable morbidity rate, comparable to that of hysterectomy (LaMorte et al., 1993). The introduction of minimally invasive surgical techniques and video laparoscopy for the treatment of numerous benign gynaecological pathologies, such as ovarian cysts, tubal pregnancies and endometriosis, has resulted in remarkable advantages both for the patient (reduced intra-operative and post-operative morbidity) as well as in social and economic terms, since minimally invasive surgery necessitates a shorter hospitalization and allows an earlier resumption of normal activities (Saidi et al., 1994
; Damiani et al., 1998
).
The first laparoscopic myomectomy was performed by Semm and Mettler (1980). Recently, the technique has also been employed for the excision of large intramural fibroids (Daniell and Gurley, 1991; Dubuisson et al., 1991
; Nezhat et al., 1991
; Hasson et al., 1992
; Mettler et al., 1995
). Gonadotrophin-releasing hormone (GnRH) analogue treatment has been shown to result in a decrease in the dimensions of uterine myomas (Filicori et al., 1983
). A maximum effect is observed following three or four cycles of such treatment (Golan et al., 1989
; Friedman, 1993
). However, the usefulness of such therapy prior to laparoscopic myomectomy is still the subject of debate. In the present study, the outcome of laparoscopic myomectomy in patients submitted to preoperative GnRH analogue treatment is compared with that observed in patients not submitted to such therapy prior to surgery.
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Materials and methods |
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In all infertile patients, myomectomy was performed when the myoma exceeded 3 cm in diameter or when serial sonography revealed the presence of a rapidly growing myoma and when all other possible causes of infertility were excluded at ovulation studies, hysterosalpingography, post-coital test and semen analysis. The location of the myoma was not considered as an exclusion criterion. All patients with submucous myomas were submitted to hysteroscopic myomectomy and were excluded from the present series. Patients with myomas >10 cm in diameter (Dubuisson et al., 1991) as well as those with more than three myomas >4cm in diameter were excluded from the present series and submitted to laparotomic myomectomy.
Patients included in the present series were randomized according to a computer-generated sequence: 30 patients were submitted to three cycles of preoperative GnRH analogue treatment (Decapeptyl, 3.75 mg; IPSEN Biotech, Paris, France) administered intramuscularly and 30 were not submitted to any preoperative medical therapy. All patients treated using preoperative GnRH analogues were also submitted to monthly sonography in order to evaluate any variations in myoma dimensions. Informed consent, including the possibility of necessarily resorting to laparotomy, was obtained in all cases according to the local Ethics Committee criteria.
Patient age, parity, number and size of the myomas excised, operative time, blood losses, intra- and post-operative complications, length of hospitalization as well as pregnancy outcome were analysed using the Student's t-test and Fisher exact test. A P-value 0.05 was considered statistically significant.
Surgical procedure
Videolaparoscopy was performed with the patient under general anaesthesia and with endotracheal intubation. A pneumoperitoneum at a pressure of 15 mm Hg was established using a carbon dioxide insufflator (Electronic Laparoflator; Storz, Germany) and was maintained constantly throughout surgery. The laparoscopic trocar was inserted through an umbilical incision. Two ancillary trocars (5 and 1012 mm) were inserted lateral to the right and left epigastric vessels for the operating instruments. When necessary, a medial supra-pubic trocar was also inserted.
Pedunculated myomas were excised using bipolar forceps and scissors. In cases of intramural myomas more than 3 cm in diameter, 20 ml of a vasoconstrictor solution containing 50 µg of terlipressine acetate (Glipressina®; Ferring, Milano, Italy) were injected into the uterine serosa overlying the myoma using a long spinal needle inserted, under laparoscopic vision, directly through the abdominal wall. A monopolar needle was used to incise the uterine serosa. The myoma was then excised by means of a combination of blunt dissection and activated energy using bipolar forceps. The uterine lesion was repaired by applying a single or double layer of interrupted or running 20 Polyglactin sutures. Removal of the myomas from the abdominal cavity was achieved using a manual S.E.M.M. macro-morcellator (Wisap, Sauerlach-Munchen, Germany) introduced into the pelvis through a trocar sleeve.
Blood losses were estimated by calculating the difference between the volumes of aspirated and irrigated fluids. The operating time was considered to be the time elapsed between endotracheal intubation and complete suturing of the abdominal incisions.
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Results |
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The average length of hospitalization was 2.39±1.24 days (range: 16 days) and was similar for both groups. Only two patients developed post-operative fever. They were both treated using cephalosporins (2 g/day) for 5 days and were discharged on the 5th and 6th post-operative days respectively.
Twenty-four infertile patients had a mean follow-up of 13 months (range: 632 months). Eight spontaneous pregnancies occurred among 16 patients with a history of primary infertility (50%) whereas five spontaneous pregnancies occurred among eight patients with a history of secondary infertility (62.5%). In particular, amongst the latter group, three pregnancies occurred in patients with a history of recurrent abortion and two in patients with a history of secondary infertility. There was no significant difference between the pregnancy outcome of the two groups of patients. Thus, the global pregnancy rate was 13/24 (54.1%). Ten pregnancies (76.9%) occurred within 1 year of surgery. The pregnancy outcome included vaginal delivery in six cases (46.1%), Caesarean section in five cases (38.4%) and spontaneous abortion in two cases (15.3%). Thus, the delivery rate was 45.8%. In no case did ectopic pregnancy occur. Caesarean section revealed the presence of uterine adhesions in one patient.
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Discussion |
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In the present study, laparoscopic myomectomy was performed on patients with a maximum of eight myomas each not exceeding 10 cm in diameter. In accordance with other studies published in the literature (Daniell, 1995; Mettler et al., 1995
), preoperative GnRH analogue therapy was administered to 30 women included in the present study. Such therapy resulted in a mean 33% reduction in the dimensions of the myomas. This observation is similar to that made by other authors (Fridman et al., 1989
; Kiltz et al., 1994
). The rationale for preoperative GnRH medical therapy includes the presumed facilitation of laparoscopic myomectomy as well as a reduction of blood losses (Fridman et al., 1989
; Golan et al., 1993
). In the present study, the mean global estimated blood loss was 223 ml. In no case was blood transfusion necessary. Blood losses for the group of patients treated preoperatively using GnRH analogues did not significantly differ from those observed for the group of patients not submitted to any preoperative medical therapy. This observation is similar to that reported by other authors for abdominal myomectomy (Fedele et al., 1990
; Kiltz et al., 1994
). We would like to stress that, in case of large myomas (>3 cm), we have utilized a vasoconstrictor and that adequate haemostasis using bipolar coagulation was performed prior to suturing of the uterine lesion.
In our cases the mean operative time was 126 min, which is comparable to that reported by other authors for laparoscopic myomectomy (Table II) and similar to (Smith and Uhlir, 1990
; Diamond, 1996) or slightly longer than that reported in the literature for abdominal myomectomy (Fridman et al., 1989
; Fedele et al., 1990
; Ginsburg et al., 1993
; Mais et al., 1996
). Suturing of the uterine incisions and removal of large myomas from the pelvic cavity take up most of the time of laparoscopic myomectomy. The authors of the present study have employed the manual Semm macro-morcellator. However, the Steiner electric morcellator (Steiner et al., 1993
) allows a significant reduction in the operative time without having to resort to culdotomy or mini-laparotomy.
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Several studies have reported on the successful pregnancy outcome following abdominal myomectomy. Pregnancy rates ranging from 40 to 65% have been reported following this procedure (Buttram and Reiter, 1981; Starks, 1988
; Verkauf, 1992
). The pregnancy rates reported in the literature following laparoscopic myomectomy range from 17 to 100% (Table III
). In the present series, 13 spontaneous pregnancies occurred among 24 infertile patients submitted to laparoscopic myomectomy. A delivery rate of 45.8% was observed. A spontaneous pregnancy is most likely to occur within 1 year of abdominal (Verkauf, 1992
; Gehlbach et al., 1993
; Tulandi et al., 1993
; Sudik et al., 1996
) or laparoscopic myomectomy (Dubuisson et al., 1996
). Ten of the 13 spontaneous pregnancies observed in the present study (76.9%) occurred within 1 year of surgery, with no significant difference between the two groups of patients. In a retrospective study including 67 patients, Sudik et al. (1996) did not report any difference in the post-operative pregnancy rates between a group of patients submitted to preoperative GnRH analogue treatment and another group of patients in whom such therapy was not administered.
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Routine second-look laparoscopy for post-operative adhesion evaluation was not performed in this series. Among five patients submitted to Caesarean section, only one presented with uterine adhesions. Bulletti et al. (1996), in a case-controlled study, showed that laparoscopic myomectomy resulted in less post-operative adhesion formation than abdominal myomectomy. Absorbable or non-absorbable barriers (Mais et al., 1995; Myomectomy Adhesion Multicenter Study Group, 1995
; Diamond, 1996) seem to be effective in significantly reducing post-operative adhesion formation even though the risk is not completely eliminated. Moreover, such barriers are not effective unless adequate haemostasis is achieved.
In conclusion, laparoscopic myomectomy can be successfully and safely performed in all patients who wish to avoid laparotomy and retain their fertile status. However, the surgeon must have a vast experience in laparoscopic surgery and must be particularly familiar with laparoscopic suturing. The pregnancy outcome observed in the present study is encouraging. However, further studies evaluating the risk of post-operative adhesion formation and of uterine rupture during pregnancy or labour are required in order to reach definite conclusions regarding the efficacy of this technique. Preoperative GnRH analogue treatment is effective in reducing the size of myomatous nodules, but does not seem to offer any significant advantages for laparoscopic myomectomy. More studies including larger series of patients are necessary in order to evaluate this aspect further.
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Notes |
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References |
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Submitted on April 22, 1998; accepted on October 1, 1998.