Current Controversy: Laparoscopic Myomectomy

Uterine fibroids are the most common pelvic tumor in women present in up to 20-40% of reproductive age women. This incidence rises with age. They are usually benign monoclonal tumors arising from the smooth muscle cells of the myometrium.

Presenting symptoms depend on the size, number and position (type) of the fibroids. These might include heavy menstrual bleeding, pelvic pain, pressure symptoms on the bladder e.g. urinary frequency and bowel symptoms. From a reproductive perspective associations with infertility and miscarriage has been found. Finally, fibroids may complicate the antenatal course and delivery.

The management of uterine fibroids depends not only on the type and number of fibroids but also on the severity of symptoms, patient age and her reproductive goals. 

Medical treatments for fibroids are not effective and only serve to help us reach certain surgical goals like reduction in blood loss or to make certain surgical access possible.

From a minimally invasive gynaecological surgery perspective, the two main surgical options are myomectomy and hysterectomy.

myomectomy
 

Myomectomy (removal of fibroids) is indicated when women have not completed her family or otherwise wishes to retain the uterus. This is an effective option for treatment of menorrhagia and pelvic pressure and pain, but there is about a 40% risk of recurrence following myomectomy.

At WA Gynaescope we offer hysteroscopic resection in cases where submucosal fibroids are present and thought to be impacting her reproductive potential. For subserosal or intramural fibroids we do a laparoscopic myomectomy although certain cases still need to be done via the open/ laparotomy technique.

One of the very useful inventions was the development of so-called Power Morcellation devices that would reduce the tissue to the size of a thin strip of tissue that we could pull through an existing operative port. This was being used with great success as the risk of using this device was quite low.

In the past, it was thought that the prevalence of leiomyosarcoma in these fibroids/uterus was quite low at about 0.02-0.3%. In April 2014 however, an FDA Safety Communication ushered in an era of controversy related to the potential for power morcellation devices to spread malignant cells in patients with previously undetected malignancy.

This has been filling the pages of many academic articles and has fuelled widespread academic discussion. It has taken a while for clinicians to develop techniques to adapt to this information while still offering the benefits of a minimally invasive approach.

At WA Gynaescope we have adopted and refined the so-called Ïn-Bag-Morcellation Technique. With this new technique that we have adapted, the risks if any dissemination of malignant cells is well restricted. As most cases of leiomyosarcoma are unexpected, we encourage other units to consider techniques like the so-called In-Bag-Morcellation to extract tissue specimens

Dr Sunny Baruah & Dr Gian Urbani