Myomas: Treatment in Young Women

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Dr. Hugo Verhoeven: “Hello, my name is Hugo Verhoeven from Dusseldorf in Germany. I’m a member of the Editorial Advisory Board of the OBGYN.net Infertility, and it is a great pleasure for me to have the chance to talk this afternoon with Professor Rudy De Wilde from Germany. I’ve known Professor De Wilde for quite a long time and we’ve been cooperating also for several years. We are reporting here from the AAGL meeting in Las Vegas and one of the interesting topics is the problem of myomas in infertile patients, younger patients, and the perimenopausal patients. So my question to you is - what is your opinion on the state of the art on how to treat myomas in the younger patients?”

Professor Rudy De Wilde: “Since most of the younger patients want to preserve their womb, if they want their uterus to be left in place, the best method today is the hysteroscopic or laparoscopic myomectomy. That means dissection of the myoma out of the womb transvaginally or by means of laparoscopy.”

Dr. Hugo Verhoeven: “So those techniques are certainly for those indications. When do you prefer the hysteroscopic approach and when do you prefer the laparoscopic approach? It is my understanding that you sometimes like to combine those techniques. Tell me something about the indications.”

Professor Rudy De Wilde: “The womb consists of a wall and a cavity, when the myoma is in the uterine cavity, the best way to take the myoma out is to go transvaginally through the vagina, getting into the womb, and resect the myoma out of the cavity. When the myoma is more than half into the wall of the womb, the better way to get at it is the laparoscopic way. “

Dr. Hugo Verhoeven: “You have, of course, a big hole in the wall of the uterus. Is that correct?”

Professor Rudy De Wilde: “When you resect the myoma by laparoscopy there’s a hole in the wall, especially in those cases where the myoma goes deep into the wall, and you have to suture the wall afterwards.”

Dr. Hugo Verhoeven: “Is that easy, the laparoscopic way?”

Professor Rudy De Wilde: “It’s a bit difficult because you don’t have enough room as you normally would when you open broad the abdomen. It’s a bit difficult but with enough experience it is possible.”

Dr. Hugo Verhoeven: “But you still think there is no longer a place for laparotomy in the treatment of myomas - is that correct?”

Professor Rudy De Wilde: “Let’s say over 90% of the myoma can be operated upon endoscopically. There are still a small percentage of people who have to have their womb operated by laparotomy; that means a broad opening of the abdomen especially in those cases where the myoma starts at the internal wall of the uterus and goes through the wall reaching the uterine cavity. In those cases when you operate upon the uterus and you have to transect all of the uterus, then sometimes it is necessary to have a good suturing to open the abdomen.”

Dr. Hugo Verhoeven: “Can you give me some percentages on how many of your patients are still treated by laparotomy? We’re talking now about the younger patient who would do everything to conserve her uterus.”

Professor Rudy De Wilde: “We can in nearly all cases preserve the uterus. I can’t remember during the last five or six years where we had to take the uterus out in a young patient, so in any case, the womb can be preserved. A laparotomy takes place in 5%-6% of the patients but in any case they keep their uterus.”

Dr. Hugo Verhoeven: “For the people listening to us it would be, I think, interesting to know how big can a myoma be before you say - this is not possible anymore by laparoscopy? Maybe you say it in centimeters or the size of a football - what size can you remove by laparoscopy?”

Professor Rudy De Wilde: “There are different sorts of myoma. The myoma of six or seven centimeters going deep into the womb and reaching the uterine cavity is more difficult to operate upon as compared to a myoma of ten or twelve centimeters and sitting on the uterus. This myoma can be better prepared for removal out of the uterus, so how big it is, is not always the factor that decides upon the way to operate on a myoma. Certainly, it’s possible to have a very big myoma, we had one patient with a myoma of 2.7 kg so we opened the abdomen, took the myoma out by means of laparotomy, and left the uterus in place. So it is possible to take a myoma out as big as a man’s head and still leave the uterus in place, and leave the possibility for the patient to become pregnant again.”

Dr. Hugo Verhoeven: “Let’s talk now about the older patients. We know in Europe, that in several countries like in France and in Italy, women will do everything, even if they are older, to conserve their uterus. So they say, “I just want to have the myoma resected because of heavy bleeding, pain, or abdominal distention.” What is your strategy in, let’s say, perimenopausal patients with myomas, if they have symptoms - what do you do?”

Professor Rudy De Wilde: “When they want to have their uterus preserved, this is the thing we always try to do in any case, we try to leave the womb in place. This is nearly always possible.”

Dr. Hugo Verhoeven: “That is a very important statement - this is nearly always possible. So through the vagina, if it’s not working you have to reduce first the myoma, but with laparoscopic assistance, and then you take out the uterus through the vagina. Is that correct?”

Professor Rudy De Wilde: “When there is no possibility to leave the uterus in place, then you have to resect the uterus - you have to take the uterus out. Sometimes the patients come and want their womb resected, they want to have a hysterectomy so when we operate upon those patients, we try to take the uterus out by means of a vaginal operation. That means we take it out through the vagina, as those uteri are very often very big, they’re as big as two, three, or four fists. It is not always possible to take it out through the vagina without preparing this uterus so we start by means of laparoscopy, dissecting the uterus from the ligaments connected to the pelvic wall and to the ovaries and tubes. We leave the tubes and the ovaries in place, transect their connections until the uterus is completely freed and can be moved in the pelvis without any connections. Then we go to the vagina and start resecting the uterus through the vagina.”

Dr. Hugo Verhoeven: “I know this is an interesting question for the people listening to us - if you take the myoma out of the wall laparoscopically, how do you get that myoma out of the abdominal cavity? What do you do?”

Professor Rudy De Wilde: “There’s a sort of mixing device that can be brought into the abdomen by means of a one centimeter incision, it is brought into the abdomen and consists of a circular knife. You grasp the myoma, and there is a circular knife turning around and making cigars out of the myoma. These cigars you can pull out in pieces of seven, eight, or even ten centimeters long and one centimeter broad, and take them out until you have resected the hole of the myoma.”

Dr. Hugo Verhoeven: “That’s out of the myoma – you reduce the volume.”

Professor Rudy De Wilde: “That’s it.”

Dr. Hugo Verhoeven: “Thank you very much for this informative discussion.”

Professor Rudy De Wilde: “Thank you very much.”