Myomectomy surgical choice considerations

Fibroids affect about 40% of women of reproductive age, and up to 70% of women by the age of 50.1 While the effects of fibroids on pregnancy can be controversial regarding intramural fibroids, submucosal fibroids are generally thought to decrease fertility, and subserosal fibroids have little to no impact, study authors reported. They noted that for reproductive-aged women, myomectomy is the treatment of choice and sought to determine the best method overall and for the preservation of fertility.

Héctor Salvador Godoy Morales, MD, head of the fertility clinic at Ángeles del Pedregal Hospital and lead professor of the Human Reproductive Medicine Course, Robotic Gynecological Surgeon, in Mexico City, Mexico and colleagues conducted the study.

From 2010 to 2018, researchers obtained records from the Fertility Clinic of the Angeles del Pedregal Hospital in Mexico City and used clinical archive records to perform the observational, analytical, retrospective, and cross-sectional research. Sixty-nine study participants were divided into 3 groups: open surgery (n=21), laparoscopy (n=24), and robotic surgery (n=24). Researchers said the mean age of women was 36.43 years. Average body mass index was reported as 24.47, and average hemoglobin prior to surgery was 10.53 g/dL.

Twenty-one percent of study participants had undergone prior myomectomy. Researchers evaluated surgery approaches for number and weight of fibroids, surgical bleeding, time, and reproductive results.

Study results showed that surgical approaches should be determined by the individual patient’s number, size, and location of myomas. Researchers said that minimally invasive surgery (MIS) has been the preferred method when possible due to less bleeding and postoperative pain. Researchers also noted that this type of surgery, which includes laparoscopic and robotic, also has a shorter hospital stays, allows patients to resume daily activities faster, and has less scarring.

Researchers reported no difference in bleeding between the 3 surgical procedures. However, “in some cases, transfusion was needed, which was apparently related to the larger number and size of fibroids,” they wrote.1

Consistent with other studies, Morales and colleagues found that robotic surgery took the longest—189 minutes—due to device engagement time, and noted that this method was the most expensive and requires a higher level of specialized training. Laparotomy and laparoscopy had much shorter average durations.

The strongest indicator for pregnancy success was the number and size of myomas—fewer and smaller are connected to higher success rates. Researchers said that, following myomectomy, pregnancy outcomes were better for robotic and laparoscopic surgery.

“In the analysis of the influence of the number of fibroids to achieve pregnancy, the result was in favor of the minimally invasive routes, after surgery, both in the group of < 6 fibroids (P = 0.017), and that of > 6 fibroids (P = 0.001), without differences in the time from surgery to pregnancy (P = 0.979),” researchers said.1 They also noted that fibroid surgery is important, and patients should avoid pregnancy until treatment.

It took an average of 3.87 years for women to become pregnant following surgery and according to researchers, “intervention is better than conventional and expectant management, since the patients were diagnosed with infertility and some of the achieved pregnancy after the surgical procedure, although it would be ideal not to seek pregnancy in the short term, to improve the results, since our patients achieved spontaneous pregnancy after 3 years.”1

For study limitations, Morales and colleagues said the small number of cases and the retrospective nature of the study were factors. Overall, they emphasized the success of the study’s findings, and that MIS should be offered to patients whenever possible as it has the best outcomes for recovery and fertility.

Reference

Morales HSG, López RR, López GGP, et al. Surgical approach to uterine myomatosis in patients with infertility: open, laparoscopic, and robotic surgery; results according to the quantity of fibroids. JBRA Assist Reprod. 2022;26(1):44-49. Published 2022 Jan 17. doi:10.5935/1518-0557.20210049.