Management of Uterine Leiomyoma: Abdominal Myomectomy Or Abdominal Hysterectomy?

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Management of Uterine Leiomyoma: Abdominal Myomectomy or Abdominal Hysterectomy?

Hanadi A. Baakdah1 ARAB BOARD

Abdulrahim A. Rouzi2 FRCSC

Fathia Hassanain2 PhD

Zouhir O. Amarin3 FRCOG

Hassan S. Abduljabbar2 FRCSC

Departments of Obstetrics and Gynaecology at the Maternity and Children’s Hospital1, Jeddah, King Abdulaziz University Hospital2, Jeddah, Saudi Arabia and Jordan University of Science and Technology3, Jordan.

Correspondance and reprint requests to

Abdulrahim A. Rouzi

KingAbdulazizUniversityHospital

PO Box 80215

Jeddah21589, Saudi Arabia

Fax 9662-5372502 Telephone 9662-6772027

E-mail address:

Abstract

Objective: To compare the morbidity of abdominal myomectomy to total abdominal hysterectomy (TAH) in the surgical management of uterine leiomyomas.

Materials and Methods: Operating theatre logbooks of the Maternity and Children’s Hospital, in Jeddah, Saudi Arabia,were reviewed to identify all women who underwent abdominal myomectomy or TAH between July 1, 1998 and July 1, 2000 for the preoperative diagnosis of leiomyoma. The hospital records were then retrospectively analyzed and relevant data were collected.

Results: There were statistically significant differences between the two groups for age, parity and the duration of the hospital stay, all being higher in the TAH group. There was no significant difference between the two groups for uterine size. There was no significant difference in the estimated blood loss between both groups, but the need for blood transfusion was significantly higher in the myomectomy group. There was one bowel injury in the TAH group and none in the myomectomy group. In the TAH group, one woman developed postoperative bleeding from vaginal vault and one had a gaping wound, while in the myomectomy group, one woman developed a burst abdomen. Three women in the TAH group developed wound infections and three developed urinary tract infections, while in the myomectomy group only one woman developed a wound infection at the site of the drain.

Conclusion: In the short term, abdominal myomectomy compares favorably with TAH in the surgical management of leiomyomas, with a greater need for blood transfusion. Medium and long term comparisons need further evaluation especially for those women who opted to preserve the uterus for reasons other than childbearing.

Keywords: Leiomyoma, myomectomy, hysterectomy

Introduction

Leiomyoma is a benign tumor composed mainly of smooth muscle cells and contains varying amounts of fibrous connective tissue. Various terms are used to refer to the tumor, such as fibromyoma, myofibroma, lieomyofibroma, fibrolieomyoma, myoma, fibroma, and fibroid. The term leiomyoma is a reasonably accurate one that emphasizes the origin of this tumor from smooth muscle cells and the predominance of the smooth muscle component.1 Approximately 25% of reproductive age women develop uterine leiomyomas.2 The highest prevalence occurs during the fifth decade of a woman’s life. Myomas vary greatly in size from microscopic to large and multinodular uterine tumors that may weigh more than 50 pounds and literally fill the woman’s abdomen.3 Surgical treatment of leiomyoma includes abdominal myomectomy or total abdominal hysterectomy (TAH). Abdominal myomectomy has been associated with concerns of excessive blood loss, postoperative complications and significant recurrence rate. Recently, a local comparative study from another institution involving 38 abdominal myomectomy and 73 TAH for symptomatic and big uterine fibroids was published.4 There was no difference in morbidity.The objective of this study was to compare the morbidity of women who underwent abdominal myomectomy with those who underwent TAH for the specific indication of uterine leiomyomas in another hospital setting.

Materials and Methods

All women with hospital procedure codes for TAH or myomectomy performed by a gynecologist at the Maternity and Children’s Hospital in Jeddah, Saudi Arabia from July 1, 1998 to July 1, 2000 were identified through operating room logbooks. Surgery for conditions other than leiomyomas were excluded. Women’s charts were reviewed and relevant data were extracted into data collection forms. The women were referred from primary health care centers and other hospitals. Consent for abdominal myomectomy and possible TAH was obtained from all women scheduled for myomectomy. All the operations performed by senior residents were supervised by the attending Consultant. Gonadotropin releasing hormone agonist was not used before surgery. No supracervical hysterectomy was performed in the study group. All the women received one gram of intravenous cefoxitin half an hour before surgery. Some of these women also received one or two postoperative doses. In premenopausal women undergoing hysterectomy, concomitant oophorectomy was performed only if intraoperative abnormalities were encountered or if the women were nearing menopause. Vasopressin injection or uterine tourniquets were not used during the study period. Operative time, obtained from the operating room records, was defined as the time of skin incision to the time of wound closure. Estimated blood loss was obtained from the surgeons’ operative notes. Duration of admission was counted from day of surgery until discharge day. Statistical analysis was done using SPSS-PC for Windows. A p value less than or equal to 0.05 was considered statistically significant.

Results

During the study period, 61 women had planned myomectomy and 59 women had planned TAH. In the myomectomy group 15 (24.6%) women were Saudi and 46 (75.4%) women were non-Saudi and in the TAH group 11 (18.6%) women were Saudi and 48 (81.4%) were non-Saudi. The age and parity of the women were statistically significantly lower in the myomectomy group than the TAH group (Table 1). There was no statistically significant difference between both groups in the preoperative clinical uterine size. The operative time in the hysterectomy group was longer than that in the myomectomy group, but this did not reach statistical significance. The need for blood transfusion and postoperative febrile morbidity were statistically higher in the myomectomy group. There was one bowel injury in the hysterectomy group and no intraoperative visceral injuries in the myomectomy group. One woman who underwent abdominal myomectomy returned to the operating room on the third postoperative day because of a burst abdomen. In the hysterectomy group, one woman underwent vaginal vault resuturing due to sudden active vaginal bleeding two weeks after the original operation and another woman required abdominal wound resuturing one month after surgery for wound gaping. Three women in the TAH group had infected wounds and three had urinary tract infection, while in the myomectomy group there was only one infected wound at the site of a drain. There were two (3.4%) women in the TAH group who were found to have leiomyosarcoma, while in the myomectomy group, one (1.6%) woman was found to have low grade uterine sarcoma and another one had transitional cell carcinoma of the ovary.

Discussion

A dictum perpetuated in many gynecologic training programs is that surgical intervention is necessary once the size of the uterus exceeds that of 10 to 12 weeks gestation in women presumed to have leiomyomas.2 Classic indications for myomectomy include a rapidly expanding pelvic mass, persistent abnormal bleeding, pain or pressure, or enlargement of an asymptomatic myoma to more than 8 cm in a woman who has completed childbearing. Often the presence or absence of myoma-related symptoms is of secondary importance in recommending surgical intervention when the uterus exceeds 10 to 12 gestational weeks in size. The choice between myomectomy and hysterectomy is usually determined by the woman’s age, parity, and most importantly, future reproductive plans.3 Hysterectomy is commonly recommended for women with enlarged uteri except for those younger than 40 years who want to preserve their reproductive potential; the latter women are candidates for myomectomy.

Hysterectomy is not without risks. Mortality in large scale reviews are 12 to 16 per 10,000.5,6 However, when deaths from pregnancy and cancer-related hysterectomies are excluded, the death rate drops to five or six per 10,000 operations. Overall, it is estimated that more than 300 deaths occur annually in the United States from hysterectomies for benign conditions.Morbidity from hysterectomy is significantly greater than is commonly appreciated. Several case series report morbidity of 25% to 50%.7,8The largest category, febrile morbidity, encompasses respiratory and urinary tract infections, wound and vaginal cuff infections and their sequelae, and fever without an identified source. Dicker et al. found febrile morbidity rates of 15% in vaginal hysterectomy and 32% in abdominal hysterectomy.7The results of randomized clinical trials show that routine use of prophylactic antibiotics will lower infection rates.9 Hemorrhage is difficult to study and is generally measured by its replacement; transfusion. Transfusion rates for hysterectomies performed at nine institutions between 1978 and 1981 ranged between 8% and 15%.7 However, a review of large numbers of women will be needed to quantify the change in transfusion rates caused by new patterns of practice. Other major morbidities include damage to adjacent organs and life-threatening sequelae as pulmonary embolism. Published rates for bladder injury, ureteral injury,bowel injury,and pulmonary embolism are between 0.1% to 0.8%.

Most gynecologists and women in the UnitedState choose TAH over myomectomy for the surgical management of leiomyomas.10 This may be due to concerns over leiomyoma recurrence and relative surgical morbidities. Untill today, there has not been an adequate comparison between hysterectomy and myomectomy for the management of uterine leiomyomas. LaMorte et al., in 1993, published a case series of myomectomies, comparing febrile morbidity and blood transfusion outcome with historical hysterectomy outcome data.11 The results suggested that myomectomy is an alternative to hysterectomy. Iverson et al., in 1996, retrospectively compared the morbidity of total abdominal hysterectomy in 89 women and abdominal myomectomy in 103 women and found that myomectomy compares favorably to hysterectomy in the surgical management of leiomyomas, with a possible decreased risk for visceral injury and infection.12 In another study, however, Iverson et al., in 1999, showed that elevated temperature is more common after abdominal myomectomy than after hysterectomy.13

In contrast to our previous work4, the current study showed that blood transfusion was higher in the myomectomy group than in the hysterectomy group. This is an interesting finding as the estimated intraoperative blood loss was not significantly different. This may be related to the fact that the age of the women in the myomectomy group is younger with more abnormal vaginal bleeding problems than women in the hysterectomy group. Febrile morbidity was also significantly higher in the myomectomy group than in the hysterectomy group. There was one bowel injury in the hysterectomy group. It makes intuitive sense that myomectomy would be less often associated with visceral injury. However, this type of morbidity is still relatively rare in both groups, making confirmation of statistical significance difficult without a larger scale of study.

In conclusion, the short term follow up shows that myomectomy seems to compare favorably with TAH in the surgical management of leiomyomas, with a greater need for blood transfusion. Medium and long term comparative studies will be necessary to further evaluate any discrepancies especially for those women who opt to preserve the uterus for reasons other than childbearing.

References

1-Thompson JD, Rock JA. Leiomyomata Uteri and Myomectomy. TeLinde’s Operative Gynecology 1997; 32:731-39.

2-Buttram VC, Reiter. Uterine leiomyomata: etiology, symptomatology and management. Fertile. Steril. 1981;36: 433-45.

3-Daniel RM, Morton AS, William D, Arther LH. Benign gynecologic lesions: leiomyomas. Comprehensive Gynecology 1997;17:485-8.

4-Rouzi AA, Al-Noury AI, Shobokshi AS, Jamal HS, Abduljabbar HS. Abdominal myomectomy versus abdominal hysterectomy for symptomatic and big uterine fibroids. Saudi Med J 2001;22:984-86.

5-Wingo PA, Huezo CM, Rubin GL, Ory HW, Peteson HB. The mortality risk associated with hysterectomy. Am J Obstet Gynecol 1985;152:803-8.

6-Loft A, Endersen TF, Bronnum-Hansen H, Roepstorff C, Madsen M. Early postoperative mortality following hysterectomy. A Danish population-based study, 1977-1981. Br J Obstet Gynecol 1991;98:147-54.

7-Dicker RC, Greenspan JR, Strauss LT. Complications of abdominal and vaginal hysterectomy among women of reproductive age in the United States. Am J Obstet Gynecol 1982;144:841-7.

8-Bachmann GA. Hysterectomy: a clinical review. J Reprod Med 1990;35:837-62.

9-Wttewaall-Evelaar EW. Meta-analysis of randomized controlled trials of antibiotic prophylaxis in abdominal hysterectomy. Pharm Weekbl [Sci] 1990;296-8.

10-NationalCenter for Health Statistics. Hysterectomies in the United States, 1965-1984. Vital and health statistics, Series 13, no. 92. Publication 88-1753. Bethesada, MD: public Health Service, 1987.

11-LaMorte Al, Lalwani S, Diamond MP. Morbidity associated with abdominal myomectomy. Obstet Gynecol 1993;82:897-4.

12-Iverson RE, Chelmow D, Strohbehn K, Waldman L, Evantash EG. Relative morbidity of abdominal hysterectomy and myomectomy for management of uterine leiomyomas. Obstet Gynecol 1996;88:415-5.

13-Iverson RE, Chelmow D, Strohbehn K, Waldman L, Evantash EG, Aronson MP. Myomectomy fever: testing the dogma. Fertil Steril 1999;72:104-8.

Table 1 Characteristics and outcome

VariableMyomectomyTAH P value

(n = 59)(n = 61)

Age (years)36.36 ± 6.7542.24 ± 7.27<0.001

Parity2.31 ± 2.303.47 ± 2.330.022

Uterine size 15.60 ± 3.9114.54 ± 3.370.120

(weeks)

Operative time105.57 ± 49.87119.32 ± 35.660.0.08

(min.)

Blood loss480.33 ± 339.40506.72 ± 240.810.624

(ml)

Blood transfusion21 (34.4%)16 (27.1%) 0.005

Days in hospital6.57 ± 1.687.91 ± 4.030.022

Febrile morbidty14 (22.9%)5 (10.9%)0.005

Data are presented as means ±SD or number and percentage