VAGINAL MYOMECTOMY IN TREATMENT OF UTERINE

FIBROIDS.

K.V. Mekoshvili, E.B. Troik, S.V. Vardanyan,

B.L. Tsivyan.

Department of Obstetrics and Gynecology, City Hospital 40,

Saint Petersburg, Russia.

23rd ESGE Congress Brussels BE

25.09.2014

The History

Vaginal myomectomy was the first described by James Murphy in 1893.

D. O. Ott is the famous Russian gynecologist, reported 50 fibroids cases that were successfully performed by vaginal route from 1898 to 1912.

( D.O.Ott, Operative gynecology, 1912)

Design: Retrospective and prospective study.

Object: To establish the feasibility, safety and clinical effectiveness of vaginal myomectomy in comparison with laparoscopic and traditional approaches.

Patients: 61 women with symptomatic myomas who refused hysterectomy and/or desired to become pregnant.

Preoperative investigations

Anamnesis

Clinical - laboratory examination

US

MRI

Сharacteristics of the fibroids

Form of the fibroids:

Subserous - 19 (31%).

Intramural and subserous - 42 (68%).

Location:

Posterior wall - 31 (51%).

Fundal - 14 (23%).

Combined -16 (26 %).

Number of fibroids:

1- 18 (29,5%)

2- 13(21,3%)

>2- 30 (49%)

Weight of excised fibroids, g.(M+/-SD) 124,5±35,78

Diameter of dominant fibroid, cm.(M+/-SD) 8,6 ±1,3.

Indications for surgical treatment

Menorrhagia in 27 (44%) of cases.Pelvic pain in 8 (13%) of cases.Rapid growth in 11 (18%) of cases.Recurrent pregnancy loss in 6 (9,8%) of cases. Primary infertility in 17 (27,8%) of cases.Secondary infertility in 5 (8%) of cases.

The first study group comprised 18 patients underwent vaginal myomectomy.

.

The control groups

Second study group comprised 24 patients underwent laparoscopic myomectomy.

Third study group comprised 19 patients underwent laparotomic myomectomy.

Surgical Technique

Steps:

1. Infiltration of posterior vaginal wall by vasoconstrictor solution.

2. Posterior colpotomy.

3. Removal body uterus with

myoma into the vagina

a. b.

4. Removing of the myoma(s)

5. Suturing the uterine wall

6. Moving the uterus back inside and draining the abdominal cavity

7. Suturing the vaginal wall.

Main results

Characteristics

Operative way

Blood loss

Operating time

Vaginal (n=18).

113,61±67,12  63,61±32,84

Laparoscopic (n=24)

135±97,08    114,58±48,09

Laparotomic (n=19)

246±113,18   97±33,60

Length of hospital stay 3,6±1,4. 4,2 ±1,1. 5,35 ±1,2.

VAS pain score

Vaginal group-

3,5±0,9.

Laparoscopic group-

3,3 ±1,3.

Laparotomic group-

4,7 ±1,3.

Complications

Intraoperative complications - 1 case

(5,5%) in vaginal group (injury of small

intestine.)

Postoperative complications - 0 case.

Conversion to laparotomy - 0 case.

Comparison current and previous studies in vaginal myomectomy.

Source. No of patients.

Blood loss, ml Operative time, min

Hospital stay, days

Bowel injury

No. of conversionsto laparotomy

Current, n=18

113,61±67,12 63,61±32,84 3,6±1,4. 1 0

Rolli R2012n= 46

data not available

70 (30-120) 1 (1-6) 0 2

Yu X2011n=43

78.3 ± 64.4 66.4 ± 22.6 4.9 ± 3.3 0 0

Plotti 2008n=18

210 (350) 48±22 3,5±2,4 0 1

Carminati 2006n=54

80 (20–350) 80 (30–170) 2 (1-3) 0 0

Subsequent Fertility

Operative way No. ofpregnancies

Method of delivery

Vaginal 4 (22.2%)spontaneously

1-Vaginal

3- Cesarean section

Laparoscopic 7 (29,16 %) 4-spontaneously 3- ART

6- Cesarean section

1- Elective abortion

Laparotomic 2 (10,2%) spontaneously

2- Cesarean section

Fertility after vaginal myomectomy (current and previous studies)

Source No. ofpregnancies

Method of delivery

Currentn= 18

4 (22,2%) 1- Vaginal

3- Cesarean section

Plotti n= 18

3 (16,6%) 1- Elective abortion

2 - Vaginal

Daviesn=35

3 (8,57%) 1 - Vaginal

2- Cesarean section

Rovion=10

3 (30%) 2 - Vaginal

1- Cesarean section

Carminatin=54

6 (11,1%) data not available.

Advantages of vaginal myomectomy

Vaginal myomectomy as laparoscopy may offer same advantages:

low intraoperative blood loss

less trauma

short recovery time in comparison with laparotomy.

Advantages of vaginal myomectomy

In addition

Short operating time is the benefit of this surgical aproach.

The quality of uterine suturing is better (in comparison with laparoscopy).

Morcelation is no necessary.

Main conditions for successful operation = features for selection of patients

Mobility of the uterus (parous women).

Localization of myomas – fundus and posterior

uterine wall

Size of myomas < 8 cm.

Number of myomas ≤ 5.

No pathologic pelvic adhesions, no associated

adnexal disease

Conclusions

Vaginal myomectomy in selected cases is a feasible, safe and effective surgical procedure. This approach may be an alternative to laparoscopic and traditional routes in surgery to treat uterine fibroids.

Thank you for your attention