Myomectomy, Fibroids and Fertility

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Dr. Gomel: I am Victor Gomel. I am a Professor at the University of British Columbia in Vancouver, Canada, and my guest today is Dr. Tamer Seckin, who is a well-known gynecologic surgeon in New York, New York. Dr. Seckin, I understand you get a lot of patients referred to you for myomectomy. What are the indications for which they are referred to you?

Dr. Seckin: Well, first of all, thank you, Victor, for the introduction. I also thank OBGYN.net for this opportunity. I mainly get three groups of patients: mainly patients who are referred for fertility reasons, patients who are symptomatic with fibroids, that is the second group, and maybe the third group, I must say, patients who are asymptomatic but incidentally diagnosed with fibroids on routine exam but they are looking for answers, if possible, maybe prophylactic myomectomy surgery.

Dr. Gomel: The first group were patients who wanted to become pregnant. What are the characteristics of these patients?

Dr. Seckin: These patients are typically looking for getting pregnant or have failed extensive and expensive course of IVF treatments. They are referred by infertilitists to me for surgical eradication of their fibroids. These fibroids are uniquely intrauterine or outside the uterine cavity, obstructing the tubes.

Dr. Gomel: So you have then patients who have either failed IVF, as you say.

Dr. Seckin: Yes.

Dr. Gomel: Or patients who wish to become pregnant, have no other parameters of infertility but have fibroids.

Dr. Seckin: Yes, this group of people is essentially thought to have lyomyomas causing their infertility. They are referred without any treatment to me prior to the trial of IVF.

Dr. Gomel: So I will return to this group of patients. What about the other group of patients who are those in whom fertility is not a problem? What are their characteristics?

Dr. Seckin: These are patients later in their reproductive years, close to menopause, who have typically fibroid-related issues with their uteruses. Their characteristics are rather larger fibroids or they are bleeding symptomatically and with pain or pressure symptoms. These patients are usually advised to have hysterectomy or told they are candidates for hysterectomy and they are coming to me as a hysterectomy alternative: myomectomy, solitary or multiple myomectomy, or they are basically coming for hysteroscopy, prevention of fibroids, a simple first episode that we treat if they do not want to have laparoscopy if the fibroids are in the uterine cavity. That is the second group of patients.

Dr. Gomel: Is your approach to these two groups of patients different?

Dr. Seckin: Mainly, my approach is not different. I use the minimally invasive technique of laparoscopic myomectomy, which is well-known to perform on these cases through small scars and they are usually sent home the same day. My approach is essentially the same. However, in the infertility group, extensive effort is made to eradicate and remove the intrauterine cavity and clean the uterine cavity with a hysteroscope. Not even leave anything bulging from above. Additional laparoscopic approach is also taken on this group.

Dr. Gomel: I will come to the technique, but if you have in the group of patients who come to you for symptoms, they may have intramural fibroids and also submucous fibroids. What do you treat first? Do you treat the submucous and see what would happen, maybe you do not need to treat the others? How do you handle that?

Dr. Seckin: Well, this is a very tough group of patients, but essentially submucosal resection is the first step in their treatment. I personally prefer looking to our past experience, prefer everything in one surgical episode after the removal of the hysteroscopic fibroids, submucosals, I go above and take the intramurals that are impinging on the cavity. Usually after myomectomy, there is a tendency for the intramural fibroids to impinge more on the cavity. They will come back as a cavitary fibroid in two months or so. I have seen these patients.

Dr. Gomel: Your technique for dealing with the intramural and subserous fibroids is the same irrespective of the indication for which you are doing it?

Dr. Seckin: Absolutely.

Dr. Gomel: Would you please describe your technique? This is your abdominal approach we are talking about.

Dr. Seckin: Yes. The challenging cases are obviously with the number and the size, it gets into a tougher surgery, but I have found over the years that if we solve the bleeding issue during myomectomy, the size and the number does not become an obstacle to my surgical procedure.

Dr. Gomel: Intraoperatively?

Dr. Seckin: Intraoperatively, I do one thing that is very special to these patients. I put a tourniquet, apply the tourniquet and cut the total uterine arteries’ blood supply and this allows me to have a total bloodless myomectomy and number-wise, nothing becomes a challenge because there is no bleeding. We can put as many and as tight suturing as we want at our total control.

Dr. Gomel: Tell me how you apply the tourniquet.

Dr. Seckin: It is very unique. I apply the tourniquet to a very tiny, half centimeter, 3 ml to 4 ml incision on the culdotomy, through a culdotomy I performed through the laparoscopy to the back of the uterine meninplative. I put the tourniquet abdominally through one of the trocars and I grabbed the tourniquet at one end from the vagina that is stable and the free end I pass through the broad ligaments like a ring around the neck of the uterus and I have two hands in the vagina and I tighten it down to the uterine manipulator. That basically cuts total uterine arterial pulsatile blood supply. You may have some small venous bleeding, but that is not going to be any obstacle in your way during surgery.

Dr. Gomel: And you do the whole procedure laparoscopically?

Dr. Seckin: I do the whole process laparoscopically. This also enables me to remove larger fibroids without any bleeding, so I have time and control of the case.

Dr. Gomel: What do you use to suture the site from which you remove the…?

Dr. Seckin: The uterine defect is typically closed one or two layers according to the thickness of the uterus muscle layer, but I use all Vicryl on a CT1 needle and I use interrupted, very snug and frequent suturing.

Dr. Gomel: Can you tell me how many patients you have operated on in each group?

Dr. Seckin: I do have around fifty patients for infertility purposes on whom I have operated and close to 500 for hysterectomy alternatives in the last 15 years.

Dr. Gomel: Outcomes?

Dr. Seckin: Outcomes are pretty satisfactory. In the myomectomy group, we do have 10% of the patients who got pregnant without any IVF in the interim period of six months of resting period, accidental pregnancies are there, and the IVF group, half of those patients have got pregnant and I have only one patient with a morbid outcome during their c-section and the follow-up c-section but most of these patients are delivered by c-section without any incident. Of the myomectomy group, only 10% to 15% have come back for hysterectomy requests and these were patients, incidentally, who had adenomyosis and other complicated pelvic pathology that made their cases difficult with pain or some other issues.

Dr. Gomel: Any serious complications?

Dr. Seckin: In the overall group that I have, because typically I deliver these masses through culdotomy, in the myomectomy group, I have one infection and one urethral obstruction which was relieved by removal of the culdotomy stitches on the corner, an overzealous bite on the corners which was due to the surgical technique. But these happened in the beginning of my career in the first six years. Absolutely the most important thing is, I think, is hemostasis under laparoscopic control after the tourniquet release, the bipolar forceps is used to clean the edges of small oozings and also meticulous approximation of the tissues equally on each side of the defect. I think these are basic, simple surgical principles that apply to the uterus also.

Dr. Gomel: Thank you very much, Dr. Seckin, for this opportunity.

Dr. Seckin: Thank you, Dr. Gomel.