Pre-treatment with GnRHa or ulipristal acetate prior to laparoscopic and laparotomic myomectomy: A systematic review and meta-analysis

Abstract

BackgroundMyomectomy has potential risks of complications. To reduce these risks, medical pre-treatment can be applied to reduce fibroid size and thereby potentially decrease intra-operative blood loss, the need for blood transfusion and emergency hysterectomy. The aim of this systematic review and meta-analysis is to study the effectiveness of medical pre-treatment with Gonadotropin-releasing hormone agonists (GnRHa) or ulipristal acetate prior to laparoscopic or laparotomic myomectomy on intra-operative and post-operative outcomes.MethodsWe performed an extensive search in Embase.com, Wiley/Cochrane Library and PubMed in accordance with the Prisma guidelines. All studies published as full papers in peer reviewed journals using GnRHa or ulipristal acetate as medical pre-treatment independent of route of administration or dosage before laparotomic or laparoscopic myomectomy were included. The primary outcome was duration of surgery. Secondary outcomes were duration of enucleation, blood loss, degree of difficulty of surgery, identification of cleavage planes, proportion of vertical incisions, conversion rate, frequency of blood transfusions, post-operative complications, duration of hospital stay, frequency of recurrence of fibroids, frequency of uterine adhesions, recovery time and quality of life. No language restrictions were applied. Meta-analysis were performed where possible.FindingsTwenty-three studies were included. In laparotomic myomectomy, pre-treatment with GnRHa decreases intra-operative blood loss with 97.39ml (95% CI -111.80 to -82.97) compared to no pre-treatment or placebo. Pre-treatment with GnRHa before laparoscopic myomectomies also shows a reduction in intra-operative blood loss by 23.03ml (95% CI -40.79 to -5.27) and in the frequency of blood transfusions (OR 0.17, 95% CI 0.05 to 0.55) compared to no pre-treatment.Only two retrospective cohort studies reported on pre-treatment with ulipristal acetate compared to no pre-treatment before laparoscopic myomectomy showing a statistically significant reduction in intra-operative blood loss, duration of surgery and frequency of blood transfusions after pre-treatment with ulipristal acetate.ConclusionAdministration of GnRHa prior to laparotomic myomectomy reduces blood loss and might decrease uterine adhesion formation. Pre-treatment with GnRHa before laparoscopic myomectomy reduces blood loss, the frequency of blood transfusions and might increase recurrence rate of fibroids, however it should be taken into account that some results are mainly based on cohort studies. Other pre-treatment agent ulipristal acetate has not been investigated sufficiently for relevant surgical outcomes.

Ulipristal Acetate before Hysteroscopic and Laparoscopic Surgery for Uterine Myomas: Help or Hindrance?

“…However, up to now, this potential benefit for UPA has not been yet demonstrated in published studies. A recent systematic review and meta-analysis reported that UPA has not been sufficiently evaluated yet for surgical outcomes [38]. Similarly, there are only limited data on the comparison between preoperative SPRMs and other hormonal therapies in patients undergoing hysteroscopic or laparoscopic myomectomy.…”

Preoperative Hormonal Treatment Before Laparoscopic Approach for Uterine Fibroids: Do We Need It?

“…Traditionally, GnRH-as have been routinely employed in this setting, as they have demonstrated to reduce abnormal uterine bleeding before surgery, increasing hemoglobin levels, as well as to reduce size of fibroids and uterus. However, a not negligible issue is related to the fact that under the administration of these hormonal drugs, patients can experience a not negligible rate of menopausalrelated adverse events, which may limit adherence to the schedule [4].…”

“…Overall, it should be under scored that until now few studies on surgical outcomes after UPA administration are available in the literature [7-9]; similarly, not sufficient data on the comparison between preoperative SPRMs and other hormonal therapies in patients undergoing laparoscopic myomectomy can be found [4]. Moreover, further trials should be planned for evaluating long-term outcomes such as frequency of myoma recurrence, recovery time and post-surgical quality of life after laparoscopic myomectomy with preoperative UPA use.…”

The past, present, and future of selective progesterone receptor modulators in the management of uterine fibroids

“…GnRHas are associated with a greater decrease in fibroid and uterine volume compared to SPRMs. 9,29 When compared to no pretreatment, use of a GnRHa is associated with decreased fluid absorption at hysteroscopic myomectomy, 30,31 and decreased blood loss and transfusions at laparotomic/laparoscopic myomectomy 29,32 (Level I, A). The primary advantage of UPA over GnRHas is the rapid control of uterine bleeding (5-7 days with 10-and 5-mg UPA doses, respectively, vs 21 days for leuprolide, P < .01).…”