Ginekologia Polska 2020, vol. 91, no. 3, 149–157 Copyright © 2020 Via Medica REVIEW PAPER / GYNECOLOGY ISSN 0017–0011 DOI: 10.5603/GP.2020.0032 Minimally invasive surgery for uterine fibroids Yuehan Wang1 , Shitai Zhang1 , Chenyang Li2 , Bo Li1 , Ling Ouyang1 1Department of Obstetrics and Gynecology, Shengjing Hospital of China Medical University, Shenyang, China 2Shenyang Maternity and Child Health Hospital, Shenyang, China ABSTRACT The incidence of uterine fibroids, which comprise one of the most common female pelvic tumors, is almost 70–75% for women of reproductive age. With the development of surgical techniques and skills, more individuals prefer minimally invasive methods to treat uterine fibroids. There is no doubt that minimally invasive surgery has broad use for uterine fibroids. Since laparoscopic myomectomy was first performed in 1979, more methods have been used for uterine fibroids, such as laparoscopic hysterectomy, laparoscopic radiofrequency volumetric thermal ablation, and uterine artery emboliza- tion, and each has many variations. In this review, we compared these methods of minimally invasive surgery for uterine fibroids, analyzed their benefits and drawbacks, and discussed their future development. Key words: minimally invasive surgery; uterine fibroid; laparoscopic hysterectomy; laparoscopic myomectomy Ginekologia Polska 2020; 91, 3: 149–157 INTRODUCTION fibroids. They found that those two kinds of surgery did Uterine fibroids comprise one of the most common not have different recurrence risks, but that laparoscopic female pelvic tumors. When including the small, clinically myomectomy may be associated with less postoperative undetectable fibroids and microscopic fibroids, the incidence pain, lower postoperative fever, and shorter hospital stays is approximately 70–75% for those of reproductive age. The compared with all other types of open myomectomy [3]. cause of uterine fibroids is not clear, and most fibroids pre- Minimally invasive surgery truly has its own advantages sent with no symptoms. Only 20–50% fibroids have obvious when dealing with uterine fibroids. symptoms, submucous type particularly, for example, abnor- In this review, we compared the techniques, methods, mal uterine bleeding, urinary frequency or retention, obvious and complications of many types of minimally invasive abdominal or pelvic pressure, and infertility. Most fibroids do surgery to analyze their indications, advantages, and dis- not need treatment. However, indications for therapy include advantages (Tab. 1). We also evaluated their development anemia resulting from metrorrhagia, pelvic pain or pressure status and have provided some evidence of the future de- affecting daily life, uterine compression, rapid tumor growth, velopment of minimally invasive surgery for uterine fibroids. tumor growth after menopause, and infertility [1]. The first laparoscopic myomectomy was performed by Laparoscopic hysterectomy Semm in 1979 [2], and it may be the first minimally invasive In 1989, Harry Reich performed the first laparoscopic surgery recorded. Since then, there have been numerous hysterectomy [4]. Laparoscopic hysterectomy has devel- advancements in minimally invasive surgery for uterine oped into many types, with three of most common being fibroids. With the increasing of number of surgical methods total laparoscopic hysterectomy (TLH), laparoscopic-assisted and development of surgical techniques, uterine fibroid vaginal hysterectomy (LAVH), and laparoscopic supracervi- surgery is becoming easier, more feasible, and less inva- cal hysterectomy (LASH). sive and results in fewer complications. Minimally inva- sive surgery has been considered an advanced approach Total laparoscopic hysterectomy (TLH) for dealing with uterine fibroids. In 2014, Chittawar et al The TLH procedure has some features of laparoscopic performed a meta-analysis to compare minimally invasive surgery and abdominal hysterectomy. The use of the trocar surgical techniques and open myomectomy for uterine is comparable to that of conventional laparoscopic myomec- Corresponding author: Ling Ouyang Department of Obstetrics and Gynecology, Shengjing Hospital of China Medical University, Sanhao St No. 36, Shenyang, 110004, China phone: 18940251964, fax: 024-96615-40131, e-mail: [email protected] 149 Ginekologia Polska 2020, vol. 91, no. 3 150 Table 1. The comparison of different minimally invasive surgery Laparoscopic radiofreqency Uterine artery MR-guided Laparoscopic Laparoscopic hysterectomy Laparoscopic myomectomy volumetric embolization focused myolysis thermal ablation (UAE) ultrasound (RFVTA) Totally Laparoscopic Laparoscopic • one of the most common operations in infertile patients • more fibroids • the diameter of • fit for patients • required costly laparoscopic assisted vaginal supracervical • have less effect on overian function, serum pain index and oxidative can be detect fibroids usually with multiple equipment hysterectomy hysterectomy Hysterectomy damage index, and higher succesful pregnancy rate than open • fit for more ranged from fibroids, very • forbidden (TLH) (LAVH) (LSH) abdominal myomectomy but also higher recurrence rate kinds of 3 to 8 cm large fibroids, for patents • the maximal size might be 8–10 cm and the numer of uterine fibroids, such as • patients may restricted ongoing fibroids not exceed 4–5 large fibroids, have severe operatibility, pregnancy • has the risk of uterine rupturę during pregnancy or labor multiple pain, uterine or a history of • may have fibroids abscess and multiple opera- complications • faster recov- • most similar • operation Laparoscopic- Laparoscopic- Total Isobaric and deep pelvic adhesion tions such as ery, less in- with TLH procedur pis assisted assisted vaginal laparoscopic laparoscopic intramural after operation • contraindica- skin burns, traoperative • don’t recom- more simpli- abdominal myomectomy myomectomy myomectomy fibroids • the risk tions include vi- postoperation blood loss, mend to pa- field myomectomy • less blood of uterine able pregnancy, pain, nausea enhanced tients whose • fit for • avoid the • similar with • difficult to • the opera- loss and no rupture when active infection, and allergic cosmetic uterine nuliparous laparoscopic laparoscop- operate tion is under laparoscopic pregnancy and suspected reactions appearance weight over patients, suturing, ic-assisted • limited direct visu- uterine • fibroids uterine, cervi- • more clinical than tradi- 800 g • may have provide abdominal indications: alization suturing can decrease cal, or adnexal research is tional hyster- less serum multilayer myomec- fundal or • avoid the • significant but may not malignancy needed ectomy, AMH levels exactly su- tomy subserosal side effects reduction in disappear • postembliza- • may limited decrease, turing • determined myomas and poten- uterine size, tion syndrome by uterine more over- • reduce the by the vagi- tial risks of reduction of may prevent size but ian function complexity nal capacity CO2 elimination the widespread related to reserve, of technol- • mostly used • conven- of myoma application surgeon’s low rates of ogy and to deal with tional long symptoms, and • may has lower experience re-operation economize posterior laparotomy improvement pregnancy • may have and bet- much opera- fibroids instrumants in quality of life rate higher some influ- ter sexual tive time • forbidden in can be used • the reproduc- miscarriage ence on ove- function • mostly used nulliparous to facilitate tiveoutcomes rate and higher rian function parameters to deal with women the proce- of RFVTA also reintervention than LSH, than THL, posterior dure affirmative than myomec- • more fit for • more fit for fibroids • reduction of • may have tomy patients patients who the opera- equivalence who has pel- has cesar- tive costrs in safety and vic surgery ean delivery nad the patent report before or hysteres- operating efficacy with copy before time LM • more easier The comparision of different minimally invasive surgery minimally invasive of different comparision The to learn www. journals.viamedica.pl/ginekologia_polska Yuehan Wang et al., Minimally invasive uterine fibroid surgery tomy. Pneumoperitoneum with 10–14 mmHg needs to be Research has been performed to determine the differ- created and three trocars are usually needed. The advantages ences between TLH, LAVH, and LSH. LSH may involve lower of TLH compared with traditional abdominal hysterectomy serum AMH levels, more ovarian function reserve, low rates include faster recovery, less intraoperative blood loss, less of re-operation and spotting, and better quality of life and postoperative pain, and enhanced cosmetic appearance. sexual function than TLH [ 9–11]. Previous gynecologic con- Surgeons have discussed the largest fibroid weight that is ditions were also associated with the type of laparoscopic still treatable with TLH. In 2017, Antonio et al reported TLH for hysterectomy (LH) performed. Patients with a previous ce- a uterus containing 5352 g of fibroids [5]. Therefore, uterine sarean delivery and previous hysteroscopy are more likely size may no longer be a factor that influences whether to use to undergo LSH than LAVH. However, TLH is more suitable laparoscopic hysterectomy. However, according to a multi- than LSH for patients who have undergone previous pelvic variable analysis, there are some factors that present a high surgery. Estimated blood loss, operative time, and length risk for conversion to open surgery, such as the surgeon’s ex- of hospital stay