Myomectomy with Preservation of Fertility

James E. Carter, MD, PhD, FACOG, OBGYN.net Editorial Advisor interviews Charles Miller, MD

Dr. Carter: I'm here with Dr. Charles Miller. He is from Chicago and he has a very large practice dealing with infertility and myomas. He has done many laparoscopic myomectomies without complications. Dr. Miller, would you please describe for us how you approach a myomectomy in a patient who wants to preserve fertility?

Dr. Miller: Well, Jim, I think that are certain concepts that have to be understood. Number one, you have to take the time to adequately map out where the fibroids are. Whether you do that via transvaginal ultrasound with hysterosonogram or through MRI, depending on what your sophistication and what your hospital's and your practice's capabilities are. You must be able to map out fibroids. You need to know size, number and exactly where they are inside the uterus, because remember you don't have the tactile sensation when you're dealing with a laparoscopic case. Secondly, it's important that you, at the time of surgery, properly evaluate the patient's uterine cavity. Make sure that you're not missing any submucosal myomata that should be removed by the hysteroscope. So we start all of our cases with hysteroscopy, at least to diagnose a submucosal myoma. Thirdly, we want to make sure that we have an adequate probe placed inside the uterus. We have to make sure that we have a cannula that allows us the ability to anteflex, posteroflex, move the uterus laterally. There are a number of uterine manipulators such as the Peloci, there's a Valchev and the Jarcho. We, currently are using the Jarcho cannula. That is a very, very important process. Next, when we go in with our laparoscope, one has to be sure that you place your secondary probes lateral and above the sides of the uterus, because if you have to work upward or you have to work backward, it is very difficult to get at that fibroid. Now, that's the preliminary, once you're there you have other concepts that have to be looked at. You have to use energy to adequately get down to the level of the uterus. We use vasopressin; we use a vasoconstrictor to allow us excellence in hemostasis. But then it's about using energy. We do not use bipolar energy, we do not do monopolar energy, and we do not do electrical coagulation. We are very conservative. You need to make sure that you utilize energy that allows you to get down to the level of the myoma, without using energy that is going to necrose tissue. We utilize ultrasonic energy and have been doing so since the early 1990's. The advantage of ultrasonic energy, it allows us to cut and coagulate with minimal damage to lateral tissue and that is a definite advantage that has been seen in studies that have been done by Dr. Joe Amoral, as well as our own work. Utilizing harmonic energy allows us to get down to the level of the fibroid and then to dissect and excise that fibroid. 

So step one is to take the fibroid out. Of all of the steps, that is indeed the easiest, but is very consequential, because if you use too much energy you're going to coagulate and destroy tissue. The second step is to make sure you have adequate hemostasis. I am absolutely sure that you must repair the uterus in multiple layers if you are dealing with an intramural myoma. If not, you're at risk of creating hematoma within the myometrium or having a defect within the myometrium that can ultimately lead to rupture at time of pregnancy. Remember virtually all of the cases of uterine rupture after laparoscopic myomectomy occur because the uterus is not repaired in multiple layers and because too much energy was used within the myometrium.

Dr. Carter: And by energy you mean unipolar cautery?

Dr. Miller: I mean unipolar and bipolar cautery. I don't think that one generally needs to gain hemostasis on the myometrium more than utilizing harmonic energy. Your ability to gain hemostasis within the myometrium should be done with suturing, not with energy.

Dr. Carter: And it's my understanding that you have never had a case of uterine rupture with pregnancy.

Dr. Miller: We have dealt with laparoscopic myomectomy for patient's interested in fertility since 1989, we've never had a case of uterine rupture. We've reported our pregnancy rates, which are at 75% with delivery rates at 70%.

Dr. Carter: And I know it's hard to say how many total patients, but approximately how many?

Dr. Miller: I average approximately 150 laparoscopic myomectomies a year.

Dr. Carter: So we're talking in excess of 500 myomectomies.

Dr. Miller: Absolutely, well for sure. Well between, I believe, 1997 and the present time, we have done approximately 400 myomectomies.

Dr. Carter: Of those 400 you have no ruptures?

Dr. Miller: No ruptures.

Dr. Carter: So we have to look at the European experience where they are reporting ruptures of 1 in a 100 after laparoscopic myomectomy and look at technique. Perhaps it's energy source, unipolar cautery or bipolar cautery as the primary source, and perhaps closure techniques?

Dr. Miller: Right, absolutely multiple layer closure is imperative. And then the third step is being able to remove the fibroid. Now, we know that morcellators, at the present time, are rather large instruments and therefore people bring up the risk of hernia formation in lateral ports. The way that we've been able to take down that risk and make it essentially nil is by placing our 5 mm laparoscope through the lateral 5 mm ports, only using 5 mm ports. We then go in and place our morcellator through the 12 mm umbilical incision and do our morcellation through that port. That way you do not have to close the fascia of your lateral ports. Then we look back at 274 continuous myomectomies, from January 1st of 1995 through March of 1997, we had a total of two hernias. Each of those cases were 10 mm port closures. Since the time I abandoned using 10 mm ports, except for all but the largest myomectomies, I've had no hernia formation. So, the third aspect is take your morcellator through the umbilical port, if possible and that will also be a key to patient safety.

Dr. Carter: Dr. Miller, thank you for joining us here in Australia at the ISGE meeting and giving us your tips on how to do safe and effective myomectomies, even for those patients, especially for those patients who wish to preserve fertility.

Dr. Miller: I can only say one thing, is a laparoscopic approach to myomectomy is an approach for the patient interested in future fertility. Remember, the risk of adhesion formation in a laparoscopic myomectomy is, in every case report, in every study, has been lower than at time of laparotomy. Thank you Dr. Carter.

Dr. Carter: One last question, how do patients reach you if they want to have a myomectomy performed by you?

Dr. Miller: Probably the best way to reach me is they can email me at my email site, which is bhecks1011@aol.com. My fax is 847-966-2757.

Dr. Carter: And of course, patients can call, if they're in the Chicago area directly, for an appointment or any place in the United States. What is the phone number?

Dr. Miller: At 847-593-1040.

Dr. Carter: Thank you Dr. Miller.