Perioperative Outcomes of Myomectomy for Extreme Myoma Burden: Comparison of Surgical Approaches

Abstract

To describe the perioperative outcomes of various modes of myomectomy (abdominal [AM], laparoscopic [LM], or robotic [RM]) in cases of extreme myoma burden. Design: Retrospective cohort study (Canadian Task Force classification II-2). Setting: A tertiary academic center in Boston, Massachusetts. Patients: All women who underwent an AM, LM, or RM for extreme myoma burden, defined as representing the upper quartile for specimen weight (≥434.6 g) or myoma count (≥7 myomas), between 2009 and 2016. Interventions: Baseline demographics and perioperative outcomes were collected from review of medical records, including estimated blood loss, operative time, length of stay, and complications. Univariate linear and logistic regression analyses were conducted. Measurements and Main Results: During the study period 659 women underwent myomectomy for extreme myoma burden; 47.2% of cases were AM, 28.1% LM, and 24.7% RM. Overall myoma burden differed across the 3 routes and was greatest in the AM group (mean weight: 696.2 § 784.5 g for AM vs 586.6 § 426.1 g for LM and 586.6 § 426.1 g for RM; mean number: 16.8 § 15.0 for AM vs 7.2 § 7.0 for LM and 6.7 § 4.7 for RM; p <.001 for both). The 3 routes differed in operative time and length of stay, with RM having the longest operative time (mean, 239.7 minutes; p <.001) and AM the longest length of stay (mean, 2.2 § .9 days; p <.001). Other perioperative outcomes were similar across the surgical approaches. Increasing myoma burden was associated with an increased risk of perioperative complications for all surgical approaches, with a threshold of 13 myomas associated with an almost 2-fold higher risk of perioperative complications (odds ratio, 1.77; 95% confidence interval, 1.17−2.70; p = .009). Cumulative incidence of perioperative complications with increasing specimen weight was greater in the RM cases as compared with AM (p = .002) or LM (p = .020), whereas the cumulative incidence of perioperative complications with increasing myoma count was lowest with AM compared with LM (p <.001) or RM (p <.001). Conclusion: Myomectomy for extreme myomas is feasible using an abdominal, laparoscopic, or robotic approach. Increased myoma burden is associated with an increased risk of perioperative complications. A threshold of 13 myomas was associated with an almost 2-fold higher risk of perioperative complications for all modes. Perioperative complication outcomes were more favorable in AM or LM over RM with increased myoma weight and AM over LM or RM with increased myoma number.

Impact of uterine weight on robotic hysterectomy: Analysis of 500 cases in a single institute

“…In the report evaluating three surgical approaches for myomectomy (abdominal; AM, laparoscopic; and LM, robotic; RM), the author concluded that surgical outcomes were more favorable in AM or LM over RM with increasing uterine weights, although myomectomy for extreme myomas is feasible for AM, LM, and RM. 10 The limitation of our report is the retrospective nature of the study, first. We only reviewed data from medical records and noticed the amount of the cases lacking clinical data.…”

“…Considering the result of our analysis and the previous report, huge uterus over 750 g was considered not the candidate for the robotic hysterectomy for benign diseases. In the report evaluating three surgical approaches for myomectomy (abdominal; AM, laparoscopic; and LM, robotic; RM), the author concluded that surgical outcomes were more favorable in AM or LM over RM with increasing uterine weights, although myomectomy for extreme myomas is feasible for AM, LM, and RM …”

Non-extirpative Treatments for Uterine Myomas: Measuring Success

“…Non-extirpative Treatments for Uterine Myomas myoma burden and women with anemia, because these women are at a higher risk of perioperative complications, including transfusion after myomectomy, especially in those undergoing a minimally invasive approach [5,56]. In women who are not deemed appropriate candidates for minimally invasive myomectomy (laparoscopic, robotic, hysteroscopic) to address their symptoms, nonextirpative treatments may be preferred to abdominal myomectomy in order to avoid potential risks associated with open surgery [6].…”

“…The advancement of these uterine-preserving procedures has decreased the rates of hysterectomy [4]. However, myomectomy remains an invasive procedure that is associated with perioperative complications, including significant bleeding [5,6]. In order to assess the relative success of these 2 categories of uterine-preserving procedures, we performed a systematic review analyzing outcomes of nonextirpative treatments compared with surgical removal by myomectomy.…”

The Number of Myomas Is the Most Important Risk Factor for Blood Loss and Total Operation Time in Robotic Myomectomy: Analysis of 242 Cases

“…A minimally invasive approach is preferable to an open approach, particularly with respect to better perioperative outcome considering that patients who underwent open myomectomy took two weeks longer to return to work than those who underwent laparoscopic myomectomy (LM) [3]. In addition to that, minimally invasive myomectomies decrease the postoperative adhesion formation, which are important to optimize the reproductive outcomes of patients [5,6]. LM can be conducted with a low rate of major complications including uterine rupture during pregnancy [7,8] and in terms of estimated blood loss (EBL) during myomectomy, surgical approaches such as laparotomy, conventional laparoscopy, or robot-assisted laparoscopy can have an effect, in terms of not only the length of skin incision but also the available methods for hemostasis including manual compression (available only in laparotomy) and the ease of rapid myometrial suturing.…”