EDITORIAL

Cesarean myomectomy: Safe operation or surgical folly? In many countries cesarean myomectomy is now viewed as a safe and effective procedure in carefully selected clinical situations

Robert L. Barbieri, MD Chair Emeritus, Department of Obstetrics and Gynecology Interim Chief, Obstetrics Brigham and Women’s Hospital Kate Macy Ladd Distinguished Professor of Obstetrics, Gynecology and Reproductive Biology Harvard Medical School Boston, Massachusetts

terine leiomyomata (fibroids) women the opportunity to have a during a cesarean section that are the most common pel- cesarean birth and myomectomy was hanging by a thin stalk on U vic tumor of women. When in one operation, thereby avoiding the back of the . The berat- women are planning to conceive, a second major operation. Over the ing I received was severe and and their fibroid(s) are clinically sig- past 6 decades, most experts in the disproportionate to the crime. nificant, causing abnormal uterine United States and the United King- The rule was that myomectomy bleeding or bulk symptoms, it is often dom have strongly recommended performed at cesarean section optimal to remove the uterine tumor(s) against myomectomy at the time was not just frowned upon but before conception. Advances in mini- of cesarean delivery because of the expressly forbidden. It has always mally invasive surgery offer women risk of excessive blood loss and hys- been considered foolish to con- the option of laparoscopic or robot- terectomy. Recently, expert opinion sider removing fibroids at cesar- assisted myomectomy with a low rate has shifted, especially in continen- ean section, mostly because of of operative complications, including tal Europe and Asia, and cesarean the associated morbidity and the excessive blood loss and hysterec- myomectomy is now viewed as risk of haemorrhage requiring tomy, and a low rate of postoperative an acceptable surgical option in a .4 complications, including major pelvic limited number of clinical situa- Dr. Olah quoted guidance from adhesions and uterine rupture dur- tions, including removal of pedun- Shaw’s Textbook of Operative Gyn- ing subsequent pregnancy.1-3 How- culated fibroids, excision of large aecology,5 “It should be stressed that ever, many women become pregnant solitary subserosal fibroids, and to myomectomy in pregnancy should when they have clinically significant achieve optimal management of the be avoided at all costs, including at fibroids, and at least one-third of these hysterotomy incision. .” However, large women will have a cesarean birth. case series published over the past Important clinical issues are Decades of expert guidance: 10 years report that, in limited clinical the relative benefits and risks of per- Avoid cesarean myomectomy situations, cesarean myomectomy is forming a myomectomy at the time at all costs a viable surgical option, where ben- of the cesarean birth, so called cesar- Dr. K.S.J. Olah succinctly captured the efit may outweigh risk.6-14 The cur- ean myomectomy. Cesarean myo- standard teaching that cesarean myo- rent literature has many weaknesses, mectomy offers carefully selected mectomy should be avoided in this including failure to specifically iden- personal vignette: tify the indication for the cesarean Many years ago as a trainee I myomectomy and lack of controlled doi: 10.12788/obgm.0067 removed a subserosal fibroid prospective clinical trials. In almost

6 OBG Management | February 2021 | Vol. 33 No. 2 mdedge.com/obgyn all cases, cesarean myomectomy is save many patients a second major The FIGO type 2-5 fibroid performed after delivery of the fetus operation to perform a myomec- The type 2-5 fibroid is a transmural and placenta. tomy. The surgical risk of removing fibroid with significant mass abut- a pedunculated is low. ting both the endometrial cavity and The pedunculated, serosal surface. Excision of a type FIGO type 7 fibroid The solitary FIGO type 6 fibroid 2-5 fibroid is likely to result in a large The International Federation of Type 6 fibroids are subserosal transmyometrial defect that will be Gynecology and Obstetrics (FIGO) fibroids with less than 50% of more difficult to close and could be leiomyoma classification system their mass being subserosal. The associated with greater blood loss. identifies subserosal pedunculated type 6 fibroid is relatively easy to Although data are limited, I would fibroids as type 7 (FIGURE, page 8).15 enucleate from the uterus. Fol- recommend against cesarean myo- Pedunculated fibroids are attached lowing removal of a type 6 fibroid, mectomy for type 2-5 fibroids in to the uterus by a stalk that is closure of the serosal defect is rela- most clinical situations. ≤10% of the mean of the 3 diame- tively straightforward. In carefully ters of the fibroid. When a clinically selected cases, if the type 6 fibroid Myomectomy to achieve significant pedunculated fibroid, is causing bulk symptoms, cesar- optimal management of the causing bulk symptoms, is encoun- ean myomectomy may be indi- cesarean hysterotomy incision tered at cesarean birth, I recom- cated with a low risk of operative Many surgeons performing a

ILLUSTRATION: KIMBERLY MARTENS FOR OBG MANAGEMENT MARTENS KIMBERLY ILLUSTRATION: mend that it be removed. This will complications. cesarean birth for a woman with

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FIGURE FIGO classification of uterine fibroids15

5 0

4

3

2

6

1

2-5

7 ILLUSTRATION: KIMBERLY MARTENS FOR OBG MANAGEMENT MARTENS KIMBERLY ILLUSTRATION:

Abbreviation: FIGO, International Federation of Gynecology and Obstetrics.

clinically significant fibroids will without removing a fibroid that is facilitate the hysterotomy incision and plan the hysterotomy incision to abutting the hysterotomy incision. closure.16 Myomectomy prior to deliv- avoid the fibroids. However, follow- Surgeons have reported perform- ery of the newborn must be associated ing delivery and contraction of the ing myomectomy on lower uterine with additional risks to the fetus. uterus, proper closure of the hyster- segment fibroids before making the I would prefer to identify an opti- otomy incision may be very difficult hysterotomy incision in order to mal site to perform a hysterotomy,

8 OBG Management | February 2021 | Vol. 33 No. 2 mdedge.com/obgyn FIGURE FIGO classification of uterine fibroids15 complications of cesarean birth plus difference between the two groups in myomectomy compared with cesarean the incidence of postoperative fever. The birth alone in women with fibroids is lim- authors concluded that cesarean myo- Polyp Coagulopathy ited to case series. There are no reported mectomy is a safe procedure when per- Adenomyosis Ovulatory controlled clinical trials to guide prac- formed by experienced surgeons with dysfunction tice. The largest single case series appropriate hemostatic techniques. Leiomyoma Endometrial reported on 1,242 women with fibroids Malignancy & Iatrogenic who had a cesarean birth plus myomec- Techniques to reduce blood hyperplasia tomy compared with 3 control groups, loss at the time of cesarean Not otherwise classified including 200 women without fibroids myomectomy who had a cesarean birth, 145 women A detailed review of all the available Leiomyoma subclassification system with fibroids who had a cesarean birth techniques to reduce blood loss at and no myomectomy, and 51 women the time of cesarean myomectomy Submucous 0 Pedunculated intracavitary with fibroids who had a cesarean hys- is beyond the scope of this editorial. 1 <50% intramural terectomy. The investigators reported All gynecologists know that control of 2 ≥50% intramural no significant differences in preop- uterine blood flow through the uter- erative to postoperative hemoglobin ine artery, infundibulopelvic vessels 3 Contacts ; change, incidence of postoperative and internal iliac artery can help to 100% intramural fever, or length of hospital stay among reduce bleeding at the time of myo- Other 4 100% Intramural the 4 groups.8 The authors concluded mectomy. Tourniquets, vascular 5 Subserous and that myomectomy during cesarean clamps, and artery ligation all have ≥50% intramural birth was a safe and effective procedure. been reported to be useful at the time 6 Subserous and A systematic review and meta- of cesarean myomectomy. In addition, <50% intramural analysis reported on the results of 17 intravenous infusion of oxytocin and 7 Subserous studies which included 4,702 women tranexamic acid is often used at the pedunculated who had a cesarean myomectomy and time of cesarean myomectomy. Direct 8 Other (specify eg, cervical, parasitic) 1,843 women with cesarean birth with- injection of uterotonics, including car- 17 Hybrid Two numbers are listed out myomectomy. The authors of the betocin, oxytocin, and vasopressin, separated by a hyphen. meta-analysis noted that most reported into the uterus also has been reported. (contact By convention, the first case series had excluded women with a Cell saver blood salvage technology both the refers to the relationship endometrium with the endometrium high risk of bleeding, including women has been utilized in a limited number and serosal while the second refers with placenta previa, placenta accreta, of cases of cesarean myomectomy.8,18,19 layer) to the relationship to the coagulation disorders, and a history serosa. One example is: of multiple myomectomy operations. Medicine is not a static field 2-5 Submucous and subserous, each The investigators reported that, com- Discoveries and new data help guide with less than half pared with the control women, the advances in medical practice. After the diameter in women undergoing cesarean myo- 6 decades of strict adherence to the the endometrial and peritoneal mectomy had a statistically significant advice that myomectomy in preg- cavities, but clinically insignificant decrease nancy should be avoided at all costs, respectively in mean hemoglobin concentration including at caesarean delivery, (-0.27 g/dL), a significant increase new data indicate that in carefully Abbreviation: FIGO, International Federation of Gynecology and Obstetrics. in mean operative time (+15 min- selected cases cesarean myomec- utes) and a significant increase in the tomy is an acceptable operation. ● length of hospital stay (+0.36 days). deliver the newborn and placenta, There was an increase in the need for and then consider myomectomy. blood transfusion (risk ratio, 1.45; 95%

confidence interval, 1.05–1.99), but [email protected] Complications associated only 3% of women undergoing cesar- with cesarean myomectomy ean myomectomy received a blood Dr. Barbieri reports no financial rela- The evidence concerning the transfusion. There was no significant tionships relevant to this article.

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