Dr. Mehmet Ferdi Kinci is specialist at the Muğla Sıtkı Koçman University Education and Research Hospital, Obstetrics and Gynecology Department.
Objective : To assess the intra- and postoperative results of cesarean myomectomy.
Methods : A retrospective study was conducted to collect the results of cesarean myomectomy procedures performed in our tertiary center between June 2013 and December 2018. The subjects were 2219 pregnant women undergoing cesarean section at these units.
Results A total of 2219 scheduled patients undergoing CS were included in the present study. Sixty-five patients have undergone intramural myomectomy during CS; 82 patients have had subserosal myomectomy during CS. No statistically significant differences were found between the three groups in changes of preoperative Hb, postoperative Hb, mean Hb and length of hospital stay. Operation times were significantly longer in both intramural and subserosal myomectomy groups (45.23 ± 8.498 vs. 39.02 ± 6.824 vs. 32.14 ± 5.423 min, p 0.01). Only in the intramural myomectomy group, two patients were subjected to blood transfusion (3%). Assessment of intramural myomectomy patients was carried out by taking 5 cm as the cutoff value. No statistical differences were found between the two groups in terms of mean Hb change, operation time, length of hospital stay. In the group with intramural myomectomy larger than 5 cm, two (15.38%) patients needed a blood transfusion.
Conclusions : Cesarean myomectomy operation performed by experienced surgeons has no adverse effects other than lengthening the duration of operation and can be safely implemented.
Keywords Myoma uteri · Cesarean section · Myomectomy
Leiomyoma is the benign tumor of the genital system most commonly seen in women [1]. The incidence varies between 1.6 and 10.7% during pregnancy [2]. Myomas sizes are observed to be enlarged, particularly due to the hormonal changes in the first trimester (increased estrogen) [3]. In recent years, pregnancies are delayed until advanced ages as a result of frequent use of assisted reproductive techniques and adopting of urban life which has led to obstetricians identifying myomas more frequently during pregnancy.
The number of cesarean sections (CS) has recently increased rapidly, making cesarean the most common cause of laparotomy applications across the world. This ratio is around 50% in our country in 2013 [4]. Therefore, the risk of encountering myoma during CS has increased. There are drawbacks based on potential bleeding, hysterectomy or postoperative morbidity during the myomectomy phase of CS, for which different views have been suggested in the literature [5]. However, leading from the recent work on this subject, the possibility of complications connected to myomectomy in the same cesarean section is less than feared and the need for myomectomy in the second cesarean section is reduced [6].
In this study, we aimed to evaluate the outcome of myomectomy during CS and to compare it with a control group.
A total of 2219 scheduled patients undergoing CS were
included in the present study. Sixty-five patients have undergone
intramural myomectomy during CS; 82 patients have had subserosal
myomectomy during CS. No statistical differences were found between the
three groups in terms of maternal age, gravidity, parity and birth
weight (Table 1).
No statistically significant differences were
found between the three groups in changes of preoperative Hb,
postoperative Hb, mean Hb and length of hospital stay (Table 2).
Operation
times were significantly longer in both intramural and subserosal
myomectomy groups (45.23 ± 8.498 vs. 39.02 ± 6.824 vs. 32.14 ± 5.423
min, p 0.01; Table 2). Only in the intramural myomectomy group, two
patients were subjected to blood transfusion (3%). There was no
statistical significance (p 0.261) (Table 2).
Assessment of
intramural myomectomy patients was carried out by taking 5 cm as the
cutoff value. No statistical differences were found between the two
groups in terms of mean hemoglobin change, operation time, length of
hospital stay. In the group with intramural myomectomy larger than 5 cm,
two (15.38%) patients needed a blood transfusion (Table 3).
Since CSs have recently increased in number and pregnancy at advanced ages has become more common, myomectomy during CS has gained importance for obstetricians. Many obstetricians avoid myomectomy during cesarean section, except for cases of pedicled myomas [7]. Among the reasons are a great number of morbidities ranging from bleeding to hysterectomy. But the researches made in recent years have shown that, as opposed to popular belief, myomectomy during CS does not lead to complications [8–10].
Leiomyomas may be submucosal, intramural, subserosal, cervical, pedicled or located in broad ligament. However, resection of intramural myoma during CS is inadvisable and contraindicated by most of the leading textbooks of obstetrics, primarily because it may stimulate perfuse uncontrolled bleeding that could lead to hysterectomy [11, 12]. In this study, we applied myomectomy to subserosal and intramural myomas.
One of the most feared complications during cesarean myomectomy is a hemorrhage. Several methods may be used to reduce hemorrhage before a myomectomy is performed. Vasopressin injection, the use of uterotonics such as ergometrine, oxytocin, misoprostol, uterine tourniquets, bilateral uterine arterial ligation, the use of electrocautery– laser coagulation may be listed among such techniques [13]. In order to decrease the risk of bleeding, in all our cases, electrocautery and oxytocin infusion were applied. In a study by Özcan et al. [14], where similar methods were used, the average change in hemoglobin was found to be 1.48 ± 0.7 g/dL. In our study, on the other hand, it was 1.2 ± 0.862 g/dL for intramural myomectomy group and 1.15 ± 0.3 g/dL for the subserosal group. In the control group, it was 1.15 ± 0.042 g/dL (p 0.939). Hemorrhage was observed to be less than it was it in the study by Özcan et al. [14], but there is not a significant difference from our control group. Only two patients required transfusion (1.35%). The need for blood transfusion was identified as 20% only in the study by Ehigiegba et al. [15] where oxytocin infusion was applied. Compared to the literature, the average amount of hemorrhage and the need for transfusion were observed to be lower in our study.
Another controversial parameter in the literature is the size of excised myomas and the operation results. In the study by Özcan et al. [14], only the operation durations were found to be statistically significant between cesarean myomectomy patients grouped as 0–3 cm, 3–6 cm and over > 6 cm (p < 0.001). Kaymak et al. have, in their study, addressed only the volume of hemorrhage in patient groups having similar sizes and have not found any statistically significant difference [15]. In our study, we analyzed the intramural myomectomy patients based on the myoma dimension and considered myomas of 5 cm as the cutoff value. There were no significant differences in terms of average change in hemoglobin, operation duration and length of hospital stay. In the group of intramural myomectomy larger than 5 cm, two (15.38%) patients were given a blood transfusion (Table 3). The percent of patients undergoing blood transfusion is high because there are fewer patients in this group. This is a restriction of our study.
Another significant issue during cesarean myomectomy is the length of operation. In their study, Kaymak et al. [16] have discovered that the operation is 8.9 min longer in cesarean cases with myomectomy, and Kwawukume et al. [9] have calculated this prolongation to be 11.25 min. The duration of operation has been statistically significantly extended in both studies (p < 0.05). In our study, the duration was 13.09 min longer in the intramural myomectomy group and 6.88 min longer in the subserosal myomectomy group compared to the control group (p 0.01). Also, there was no statistically significant difference in the intramural myomectomy group where 5 cm was considered as the cutoff (p 0.46). The results of our study are supportive of the literature.
Today, with increased levels of health care expenses, costeffectiveness has become more important. The length of hospital stay and the need for re-operation are important aspects of cost-effectiveness. In their study, Özcan et al. [14] have identified that the length of hospital stay increases about 7.36 h in the group of patients who have had a cesarean myomectomy (p 0.006). Kaymak et al. [16] have calculated this increase to be 0.6 days on average (p < 0.05). In our study, there were no statistically significant differences among the three patient groups with regard to the length of hospital stay (0.449). Also, there was no statistically significant difference in the intramural myomectomy group where 5 cm was considered as the cutoff (p 0.958). We suppose that performing myomectomy during CS will help reduce the need for performing myomectomy or hysterectomy in the future. Based on the above-mentioned reasons, the results of our study support cesarean myomectomy with regard to cost-effectiveness.
Conflict of interest There is no conflict of interest between the authors and/or family members of the scientific and medical committee members or members of the potential conflicts of interest, counseling, expertise, working conditions, share holding and similar situations in any firm.
