Laparoscopic myomectomy for large intramural and submucous fibroids

Abstract

Hysteroscopic myomectomy is a therapeutic option for the treatment of submucous fibroids with uterine preservation [1]. However, transcervical resection of fibroids with deep intramural extension is performed only in selected patients [2]. A major concern is that complete hysteroscopic resection might result in uterine perforation or fluid overload.To avoid these problems, laparoscopic rather than hysteroscopic myomectomy was performed in 18 women who complained of persistent menorrhea probably due to submucous fibroids. Inclusion criteria were fibroids larger than 4 cm in diameter and an intramural extension greater than 50%. Informed consent forms were filled out by study participants.Patient characteristics and operative results are summarized in Table 1. No major complications such as ureter, bladder, or bowel injury occurred in any of the patients, and no patient required laparotomy or a blood transfusion during or after surgery. On histologic examination, the resected tissue was leiomyomatous in all patients. Three women incurred perforation of the uterine cavity during the procedure, but a hysteroscopic examination showed no intrauterine adhesion 4 weeks postoperatively. At the 6-month visit, excessive menstrual bleeding was controlled in 17 women (95.0%).With the 1-step hysteroscopic myomectomy [3,4], a second operation is sometimes required and uterine perforation can occur [3]. In the latter case, a surgical intervention via laparotomy or laparoscopy is required to correct the uterine defect. Therefore, it was suggested that the procedure not be performed when the intramural part of the fibroid is larger than 4 cm in diameter and the myometrial thickness at the implantation site is thinner than 5 mm [4].The intrauterine location of the submucous fibroid is also a major factor when deciding whether the operation can be performed hysteroscopically. When a large sessile fundal fibroid exists, it is sometimes inaccessible to the resectoscope owing to the design of the instrument. In this situation, transabdominal myomectomy, rather than hysteroscopy, is the definite manner to remove the fibroid.On the basis of the results obtained in the present study, in the presence of a submucous fibroid larger than 4 cm and with an intramural extension greater than 50%, laparoscopic rather than hysteroscopic myomectomy can be performed for the sake of safety and, if needed, for the concomitant removal of fibroids of a nonsubmucous type. However, this particular approach should be performed only by surgeons skilled in laparoscopic suturing. ⁎ Corresponding author. 5, Variable Value Age (years) 38.5 (33.8-44.3) a BMI (kg/m 2 ) 22.5 (20.3-23.6) Parity no. (%) Nulliparous 1 (5.6) Multiparous 17 (94.4) Wall where fibroid originated no. (%) Anterior 8 (44.4) Posterior 7 (38.9) Fundus 3 (16.7) Diameter of fibroid (cm) 5.0 (5.0-6.0) Fibroid weight (g) 60 (50-70) Fibroids removed no. 1 (1.0-2.3) Operating time (min) 62.5 (58.8-73.0) Blood loss (mL) 100 (50-150) Postoperative stay (days) 3 (2-3) BMI = body mass index. a Values ar...

The indication and curative effect of hysteroscopic and laparoscopic myomectomy for type II submucous myomas

“…However, for patients who are not suitable for hysteroscopic surgery, laparoscopic myomectomy should be considered for surgeons with experienced surgical skills. Previous studies reported that for patients with type II submucous myomas in whom the size of the myoma was equal or greater than 40 mm, the surgeon should select the optimal surgical approach with discretion according to the patients’ conditions and its own technical level [ 26 , 27 ]. The aforementioned findings in this study suggest the advantage of laparoscopic myomectomy in the type II submucous myomas equal or greater than 40 mm.…”

Laparoscopic removal of large submucous myomas

“…A study by Wang et al [11] concluded that, in the presence of a submucous fibroid larger than 4 cm and with an intramural extension greater than 50%, laparoscopic rather than hysteroscopic myomectomy can be performed for the sake of safety and, if needed, for the concomitant removal of fibroids of a nonsubmucous type. However, this particular approach should be performed only by surgeons skilled in laparoscopic suturing.…”

Reconstructive Endoscopic Myomectomy

“…Most of complications of HM are encountered with large sized myomas, or those with intramural extension (grade 1 or 2 according to the European Society of Hysteroscopy classification). They represent definite nightmare for hysteroscopists even with sufficient experience to the extent that some studies preferred laparoscopic approach in such cases (74). Hysteroscopically, several studies tried to facilitate one-step complete excision.…”