R9003
Myomectomy During Cesarean Section – Time To Reconsider?
Zion Ben-Rafael, Tamar Perri, Haim Krissi, Dov Dicker and Arie Dekel
Department of Obstetrics and Gynecology, Rabin Medical Center, Petah Tiqva, and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
Background
Myomectomy during cesarean section is strongly discouraged in all the leading textbooks despite the lack of any direct evidence supporting the approach. Leiomyomata are the most common gynecologic tumors, with a reported incidence of 20-25%. Fibroids are the most common indication for hysterectomy, accounting for over 200,000 hysterectomies per year in the United States. Fibroids affect mainly women in their childbearing years and may be asymptomatic or cause a variety of symptoms, including menometrorrhagia, dysmenorrhea, pelvic pain, reproductive failure, and compression of adjacent pelvic viscera. The estimated prevalence of fibroids in pregnancy is 1-4% (1,2).
Management depends on the goal of therapy. Hysterectomy is most often used for definitive treatment, and myomectomy when preservation of childbearing ability is desired. Intracavitary and submucous leiomyomata can be removed by hysteroscopic resection, whereas intramural and subserosal fibroids are usually removed by laparotomy. Although laparoscopic myomectomy is also technically feasible today, it apparently has an increased risk of uterine rupture during pregnancy. Gonadotropin-releasing hormone-agonist induces hypogonadism and can reduce the volume of leiomyomata, but its severe side effects and association with prompt recurrences makes them useful only for short-term goals such as reversing anemia or shrinking an intracavitary tumor prior to hysteroscopic resection. New approaches such as myolysis and uterine artery embolization are currently being evaluated and may offer more options providing their safety in women desiring fertility is established (3).
According to Te Linde (4) “ Myomectomy delivery in conjunction with cesarean section is contraindicated. If there is a pedunculated subserous fibroid attached to the uterus with a small pedicle, suturing and excision of the pedicle may be done easily. However, the removal of intramural myomata from the pregnant uterus is inadvisable due to recognized difficulty in controlling blood loss”. Bleeding may be profuse and lead to hysterectomy. According to other textbooks, myomas resected during pregnancy may show bizarre nuclear changes often resembling sarcoma. Furthermore, they often undergo remarkable involution after delivery when myomectemy is much safer (5,6). Our computer medline search yielded only one study supporting this finding, where in large intramural leiomyomas found at cesarean section became pedunculated postpartum, making them more amenable to myomectomy (7). Otherwise, we were able to identify very few articles concerning myomectomy during cesarean sections, with the majority reporting favorable results. In 1989, Burton and colleagues (8) reported on 13 successful cesarean myomectomies with the sole complication of intraoperative hemorrhage. They concluded that surgical management of leiomyomata during pregnancy (and cesarean section) is safe in carefully selected patients. Four years later, Hsieh et al (9) reviewed 47 incidental cesarean myomectomies. The procedure added only 11 minutes to the operation time, 112 ml to the operative blood loss and a half-day to hospitalization time. There were no wound infections or serious morbidity. Exacoustos et al (1) reported on nine myomectomies performed during cesarean delivery. Of which three were complicated by severe hemorrhage necessitating hysterectomy. They emphasized the importance of ultrasound findings of myoma size, position, location, relationship to the placenta, and echogenic structure in identifying women at risk of myoma-related complications. Michalas and colleagues (10) described a patient in whom 8 fibroids obstructing the lower part of the uterus were removed during cesarean section in the 39th week of pregnancy. There were no maternal or fetal complications.
In 1999, Dimitrov and co-workers (11) in Bulgaria conducted a prospective study to evaluate whether myomectomy could be performed on a routine basis during cesarean section. In a comparison of 21 women in whom myomectomy was done during cesarean section and 162 consecutive women after cesarean section without myomectomy, they found that myomectomy during cesarean section increased hemorrhage by 10%. Placental disorders (abruptio placentae and placenta previa) were the main cause of the overall increase in blood loss. There were no postoperative complications. The authors concluded that irrespective of the number and magnitude of the myomas, myomectomy during cesarean section is a feasible option. The same year, Omar and colleagues (12) described 2 large uterine myomas located in the anterior aspect of the lower segment of the uterus complicating pregnancy at term. Myomectomy in both instances allowed delivery of the fetus through the lower segment, making vaginal delivery in subsequent pregnancies possible. In the most recent study of this issue, Ehigiegba et al (13) assessed the intra- and postoperative complications of cesarean myomectomy in 25 pregnant women. Five required blood transfusions and none required a hysterectomy. They concluded that with adequate experience and the use of high dose oxytocin infusion (intra- and post-operatively), myomectomy at cesarean section is not as hazardous as many now believe.
For the last 7 years we have been performing planned myomectomy during cesarean section in cases in which the fibroid is known to be large enough to require surgery in the future or is the cause of malpresentation. Meticulous attention is directed to hemostasis, with enucleation using sharp dissection with Metzenbaum scissors and adequate approximation of the myometrium and all dead spaces to prevent hematoma formation. An experienced surgeon performed the first operations, but the procedure is now more common and is performed by different surgeons including residents.
In the light of the inconclusive data in the literature, we conducted the present retrospective analysis.
Objective
To assess the intra- and postoperative complications of cesarean myomectomy.
Methods
After completion of the CS, an interlocked suture was temporarily placed on the uterine incision without closing it. This allowed working from within or from the outer part of the uterus without having any significant bleeding from the incision. Myomectomy was performed using sharp dissection. Oxytocin drip was given during and after the enucleating the fibroid..
The files and operative records of 32 consecutive patients who underwent cesarean myomectomy between 1997 and 2001 were reviewed for demographics, indication for cesarean section, emergency or elective procedure, and characteristics of the fibroids. Outcome measures were type of anesthesia, type of incision, intraoperative blood loss, need for blood transfusion, intra- or postoperative complications, and duration of hospital stay.
Results
Thirty-nine myomas were removed from the 32 patients in 15 elective and 17 emergency procedures. Indications for cesarean section were obstetric (breech presentation, more than one previous cesarean section, etc) in 26 women. Of the reminder 3 had tumor previa, 1 degenerative myoma, and 2 previous myomectomy with uterine cavity penetration. Ninety percent of the myomas were subserous or intramural and 10% were submucous. Average size (largest dimension) was 6 cm (1.5-20), with 26 myomas > 3 cm and 11 > 6 cm. Four sections (12.5%) were classical and the reminder low segmental. Three operations were done with regional anesthesia (9.3%) and the reminder with local anesthesia (spinal block). The difference in hemoglobin and hematocrit levels before and 12 hours after the operation was statistically significant compared with a group of women who underwent cesarean section without myomectomy (p<0.05); however only 4 patients required blood transfusion. Re-operation was done in one patient with 2 large myomas and excessive bleeding and in another because of a hematoma below the scar. None of the patients required hysterectomy. Six patients had postpartum fever (18.7%). Average duration of hospitalization was 5.7 days, with 5 patients requiring more than 6 days. There was no correlation between complications or duration of hospital stay and patient age, gravidity, parity or indication for cesarean section.
Conclusions
Myomectomy during cesarean section is feasible. Meticulous attention to hemostasis with enucleation using sharp dissection with Metzenbaum scissors and adequate approximation of the myometrium and all dead spaces to prevent hematoma formation can increase the safety of the procedure. Despite the lack of prospective randomized studies we believe that myomectomy during cesarean section is an easy and safe procedure when done appropriately. The old dictum discouraging cesarean myomectomy should be reassessed.
References
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