Unplanned hysterectomy following myomectomy at a tertiary institution: A case series and review of the literature

Abstract

Introduction: Myomectomy is the gold standard uterine-sparing treatment for fibroids. However, the procedure is often complicated by blood loss. In rare cases, haemorrhage may be so severe that a conversion to hysterectomy is warranted. The aim of our study was to investigate the rates of and the clinical reasoning behind unplanned hysterectomies following attempted myomectomies at our institution. Methods: All patients who underwent an open or laparoscopic myomectomy at the Royal Women's Hospital were identified using a gynaecology unit database, maintained from January 2004 to December 2013. Records for patients whose surgeries were unexpectedly converted to a hysterectomy were examined. A review of the literature was also performed, investigating the rates of unplanned hysterectomies following myomectomies. Results: Of the 1501 myomectomies performed, six resulted in an unplanned hysterectomy; an incidence rate of 0.4%. Fibroids were either intramural or pedunculated with the median number of tumours per patient being 2.5 (interquartile range: 1-6). The largest tumour for each patient varied significantly from 4.0 × 3.2 cm to 29.0 × 25.0 cm. In all cases, despite being strongly advised to have a planned hysterectomy, patients insisted on having a myomectomy. Two patients underwent conversion to hysterectomy intraoperatively while the remainder required a return to theatre. Difficulty achieving intraoperative haemostasis (n = 2), and the development of postoperative bleeding and coagulopathy (n = 4) were reasons cited for proceeding to hysterectomy. Conclusion: The rate of conversion from myomectomy to hysterectomy at our institution was low at 0.4%. In all cases, the reason for conversion was difficulty with haemostasis, despite infrequent use of haemostatic agents, and coagulopathy.

The use of sealing hemostat patch (HEMOPATCH®) in laparotomic myomectomy: a prospective case–control study

“…Because myomectomy can result in considerable blood loss, intraoperative bleeding control requires a sudden and appropriate use of various modes of primary hemostasis, such as tampons, electrocoagulation, clips, and double-layer manual sutures [20][21][22]. Even with these techniques, diffuse parenchymatous bleeding has been di cult to manage, and it remains one of the major reasons for hysterectomy conversion [12]. Recently, a Cochrane Library review analysed non-mechanical techniques to reduce blood loss during abdominal myomectomy [22].…”

“…Intraoperative bleeding control requires precise and appropriate use of various modalities of primary hemostasis, such as tampons, electrocoagulation, clips, and double-layer manual sutures [11]. Also with these techniques, diffuse parenchymatous bleeding remains one of the main intra and postoperative complications requiring unplanned hysterectomies, with an overall incidence rate of 0.4% [12]. Recently, many hemostatic agents and sealants have been used to prevent excessive blood loss during surgical repair [13][14][15][16][17][18].…”

Treatment of symptomatic fibroid disease using uterine fibroid embolisation: An Australian perspective

“…Myomectomy (open or laparoscopic) is the most evidence‐based treatment for women who wish to preserve or increase fertility and is performed under general anaesthetic with a short hospital stay. Some women may not be a candidate for this treatment due to a large number of fibroids and there is a small risk of bleeding requiring transfusion or hysterectomy …”

“…Some women may not be a candidate for this treatment due to a large number of fibroids and there is a small risk of bleeding requiring transfusion or hysterectomy. 6,8 Hysterectomy is the most definitive treatment for women with refractory disease, particularly when child-bearing is no longer a consideration. 3,9 It is estimated that 20% of hysterectomies in Australia are performed for fibroid disease.…”

The cost to perform uterine fibroid embolisation in the Australian public hospital system

“…Myomectomy is the uterine‐sparing surgical option for these women. However, it can be complicated by intra‐procedural haemorrhage which may require transfusion or even emergency hysterectomy and fibroids may recur …”