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A 38 year old woman presented with menorrhagia. She had had two previous vaginal deliveries. Abdomino-pelvic examination revealed a bulky uterus. Pelvic ultrasound revealed a 6X8X8 cm fibroid uterus. She was upto date with cervical smear. Medical and surgical options were discussed. She had already tried Mefenamic and Tranexamic acid. She was keen for surgical treatment. Myomectomy, Laparoscopic assisted Vaginal Hysterectomy and Laparoscopic Subtotal Hysterectomy (LSH) were discussed. She opted for Laparoscopic subtotal hysterectomy with conservation of ovaries.LSH was performed under a pneumoperitoneum of 15mmHg, an adequate uterine manipulator, two lateral ancillary 5-mm, 10 mm ports respectively and a 12-mm suprapubic port. Lateral ports were inserted under vision avoiding the inferior epigastric artery. LigaSureâ„¢ Technology was used to divide round ligaments and both uteroadnexal pedicle. The uterovesical fold was incised and dissected and the uterine vessels clearly exposed before bipolar current was used to coagulate and then divide the vessels. The uterus was then transacted using monopolar current attached to laparoscopic hook (120Wcoagulation) (laparoscopic loop was not available) and the uterus was removed by means of a uterine morcellator (Morcellex/Gynaecare) through the suprabubic port (12MM). Tissue removed was sent for histology. Haemostasis was achieved. Endocervical canal was diathermised using monopolar current (60 W, coagulation). Vicryl on J shaped needle was used to close the rectus sheath at 10 and 12 mm ports. Vicryl rapide was used to close skin.10ml of 0.25%Marcaine was infiltrated at the port site.
Case Summary MO6B
A 43 year old nulliparous woman presented with pelvic pain, menorrhagia and irregular vaginal bleeding. Pain was particularly worse at the time of periods.
Abdominal examination was unremarkable. Pelvic examination revealed normal size uterus. Hysteroscopy revealed a normal uterine cavity and cervical canal. Endometrial biopsy was performed. Endometrial biopsy revealed atypical endometrial hyperplasia. She was counselled for various treatment options available and opted for surgical treatment. She was listed for Laparoscopic assisted vaginal hysterectomy and bilateral salpingoophorectomy. A laparoscopy was carried out using open entry technique. Two secondary ports 5mm each were inserted avoiding inferior epigastric artery. Careful attention was paid to identify the ureters. Laparoscopic assisted vaginal hysterectomy and bilateral salpingoophorectomy was performed under a pneumoperitoneum of 15mmHg. An adequate uterine manipulator was used. Bipolar current attached to bipolar forceps at 40W was used to coagulate and divide round ligaments and both infundibulopelvic ligaments after identifying the ureters. The uterovesical fold was incised and dissected and the uterine vessels clearly exposed before bipolar current was used to coagulate and then divide the vessels.
Rest of the procedure was performed vaginally. After the vault was closed, laparoscopic examination of peritoneal cavity was done to ensure adequate haemostasis. Rectus sheath at 10mm port was closed with vicryl on J shaped needle. Vicryl rapide was used to close skin.
Uterus cervix and both tubes and ovaries were sent for histology. Histology revealed atypical endometrial hyperplasia.
Case Summary MO6C
(Hysteroscopic resection of a type 1 or type 2 submucous fibromyoma )
Thirty-nine year old women presented with irregular and heavy vaginal bleeding. She had had one previous vaginal delivery. Outpatient hysteroscopy revealed evidence of a 5cm x5 cm (type 1) submucous fibroid. Endometrial biopsy performed at the same time revealed evidence of proliferative endometrium with no evidence of hyperplasia or malignancy.
Options of medical and surgical treatment were discussed however the woman was keen for fertility conserving surgery. Hystersocopic resection of the fibroid was then planned four weeks after administration of one dose of Gonadotrophin releasing hormone analogue (Protap 3.75mg subcutaneous).
Hysteroscopic resection of the fibroid was carried out by inserting a hysteroresectoscope (Karl Storz Gmbh &Co, KG, Tutlingem Germany) after dilating the cervix upto 9mm Hegar dilator. Uterus was distended with 1.5% Glycine up to a maximum pressure of 100mm of Hg. Inflow and outflow was carefully measured and the deficit was registered. The fibroid was resected by repeated and progressive insertion of angled monopolar loop (monopolar current 100W cut 60 W coagulation-) with technique of slicing. . The specimen was sent for histological examination. Roller ball ablation was then used to achieve haemostasis (60W coagulation current attached to resectoscope). Fluid balance was satisfactory with 2.5litres as inflow and 2 litres as outflow. At three months a follow up appointment was arranged. Symptoms improved dramatically. Repeat outpatient hysteroscopy revealed a normal cavity. Histology confirmed leiomyoma.
Critical reflection of management of Uterine disease-GYNMOO6
First patient presented with menorrhagia. Examination revealed a large fibroid uterus. She opted for Laparoscopic subtotal hysterectomy.
Management options also included uterine artery embolization (UAE) and myomectomy.
UAE has been reported to be an effective and safe alternative in the treatment of fibroid-related symptoms in women not desiring fertility. Three RCTs in a meta-analysis compared UAE with abdominal hysterectomy (2RCT) and myomectomy (1RCT) (Gupta, 2006). Included trials were relatively small with follow up of between six weeks (Hehenkamp, 2005) and six months (Pinto 2003, Mara 2005).
Menstrual loss was at least 85% in the UAE group from both trials. Both methods were highly effective in treating symptoms. 21/ 24 women (87.5%) had significant relief of symptoms six months after embolization as compared to 28/ 30 (93.3%) women after myomectomy. There was a higher proportion of completely asymptomatic women after myomectomy (70%) than after UAE (46%), but the difference was not significant (p<0.1). Mean shrinkage of dominant fibroid at six months after embolization was assessed in all 30 women: 29.7% ± 14.1 (range 5% to 57%). Mean shrinkage at 12 months after UAE was assessed in only 13 women (due to excluding women with secondary myomectomy and with shorter follow-up): 38.9% ± 18.1 (range 7% to 63%).
Eleven women (37%) in UAE group underwent secondary myomectomy (five laparoscopic, five open, and one transcervical resection) for a persisting significant fibroid. In the myomectomy group only two women (6%) underwent re-operation for fibroid recurrence.Three women in the myomectomy trial had elevated FSH levels post UAE indicating possible ovarian dysfunction.
The proponents of subtotal hysterectomy believe that it requires less dissection of surrounding tissue thus reduced risk of damage to the bladder and ureter (Kilkku, 1981; Parys ,1990); reduced risk of a postoperative pelvic haematoma (Nathorst-Boos, 1992), reduced risk of prolapse and damage to neuro-anatomical structures and better sexual function (Helstrom, 1994). However a recent meta-analysis (Lethaby, 2006) of three randomised controlled trials (733 women) compared outcomes after subtotal hysterectomy and total hysterectomy (laparoscopic, vaginal, abdominal approach) for benign gynaecological conditions where this perception was not confirmed.
There was no evidence of a difference in the rates of incontinence (WMD 95%CI: urge incontinence 2.18 (0.38, 12.33), stress incontinence 3.07 [0.77, 12.16] constipation or measures of sexual function. Sexual function, as measured by satisfaction with sexual life (Learman, 2003), prevalence of dyspareunia (Gimbel, 2003; Thakar, 2002) and rate of sexual problems (Learman, 2003) did not differ according to type of hysterectomy at 1 or 2 years after surgery.
Length of surgery (WMD=11.41mins, 95% CI 6.6 to 16.3) and amount of blood lost during surgery were significantly reduced during subtotal hysterectomy when compared with total hysterectomy (WMD=85.1mls, 95% CI 27.4 to 142.9), but there was no evidence of a difference in the odds of transfusion and prolapse at 12 months follow up. Febrile morbidity was less likely (OR=0.43, 0.25 to 0.75) and ongoing cyclical vaginal bleeding one year after surgery was more likely (OR=11.3, 4.1 to 31.2) after subtotal when compared with total hysterectomy. There was no evidence of a difference in the rates of other complications, recovery from surgery or readmission rates. The data were underpowered to detect a difference in rates of urinary tract injury; however more urinary tract injuries occurred in women undergoing total hysterectomy (1.9%) than in women undergoing subtotal hysterectomy (0.5%) (p=0.24).
All three studies revealed adequate randomization, allocation concealment and power calculation but blinding was present in only one trial (Thakkar, 2002).
Four retrospective observational studies (Kilkku, 1981; Kilkku, 1985; Neumann, 2004; Roovers, 2001) and one systematic review (Brown, 2000) have also assessed the effects of type of hysterectomy on various measures of urinary function after surgery. Results were inconsistent in the observational studies and the systematic review confirmed no evidence of a difference in urge or stress incontinence or urinary frequency according to type of hysterectomy
Opponents of subtotal hysterectomy argue for removal of cervix to avoid risk of cervical malignancy. Kilkku and Gronroos (1982) followed 2712 women who underwent subtotal hysterectomy and reported an incidence of cervical stump carcinoma of 0.11%. However these rates are not significantly different from the 0.17% incidence of vaginal cuff cancer after TAH (Fox, 1999).
Second patient presented with heavy and irregular vaginal bleeding. Abdomino pelvic examination was unremarkable. Hysteroscopy revealed a normal cavity. Histological examination of the endometrial biopsy revealed atypical endometrial hyperplasia. Management options at the time of diagnosis were dependent on patient choice, availability of laparoscopic surgery and no desire conservative surgery.
Tirso Pérez-Medina et. al. (1999) assessed the long-term effect of gonadotropin-releasing hormone analogues in combination with high-dose progestogens in the treatment of atypical endometrial hyperplasia. At a 5-year follow-up of 22 patients persistence in 1 (5.1%), recurrence in 1 (5.1%), and progression in 1 (5.1%) were noted.Patient opted for hysterectomy in view of no desire for fertility and risk of persistent or progressive disease.
Laparoscopic route of hysterectomy was chosen after obtaining an informed consent. Even though vaginal hysterectomy is widely considered to be the operation of choice for abnormal uterine bleeding, the VALUE study has shown that in the UK, 67% of the hysterectomies performed for this indication were abdominal hysterectomies (Maresh, 2002).
A recent meta- analysis (Chapron et al, 2002) of 27 trials (n=3611) addressed the issue whether the risk of complications with laparoscopic surgery were greater than that by laparotomy for patients who needed surgery (including hysterectomy) for benign gynaecological pathology. The overall risk of complications was significantly lower for patients operated by laparoscopic route (RR 0.59; 95% CI 0.50-0.70), with no statistically significant difference in major complications (RR 1.0; 95% CI 0.60-1.65).
The results of met-analysis depend on the quality of included trials. All the trials included (except WHO 1982) were not designed or powered to detect any difference in major complication rate. The authors acknowledge publication bias for trials looking at surgical technique.
The other option available was AH (abdominal hysterectomy). However in a meta-analysis 11 trials (1047 women) Nieboer et al ( 2009) reported several advantages of LH (laparoscopic hysterectomy) compared to AH : quicker return to normal activities (MD 13.6 days, 95% CI 11.8 to 15.4 days; 520 women, 6 trials), less post-operative pain, fewer wound or abdominal wall infections(OR 0.31, 95% CI 0.12 to 0.77; 530 women, 6 trials), fewer febrile episodes or unspecified infections(OR 0.67, 95% CI 0.51 to 0.88; 2138 women, 15 trials), less blood loss (MD 45.3 ml, 95% CI 17.9 to 72.7 ml; 693 women, 7 trials), earlier discharge from hospital (MD 2.0 days, 95% CI 1.9 to 2.2 days; 1007 women, 10 trials), and improved quality of life at six weeks and four months after surgery, the disadvantages being more urinary tract injuries (OR 2.41, 95% CI 1.21 to 4.82; 2090 women, 12 trials) and longer operating time (MD 11.8 minutes, 95% CI 8.6 to 14.9 minutes; TLH was associated with significantly greater use of tramadol and less blood loss, longer operating time (111 minutes) Vs LAVH (85 minutes) (P < 0.001).
Garry et. al. (2004) (for LH versus AH), demonstrated better quality of life (measured by the SF12 scoring system) for LH at six weeks; body image was significantly improved at six weeks and four months, but not 12 months; and sexual frequency was significantly higher at six weeks.
However urinary tract damage, in particular ureteric injury, remains the major concern related to the laparoscopic approach (Garry, 2004; Garry, 1995; Harkki-Siren ,1997).
Harkki-Siren et al (1997) reported data from the Finnish Hospital Discharge Register on 62,379 hysterectomies carried out in a 5 year study period. They reported an incidence of 13.9/ 1000 of injury to the ureter after LH as compared to 0.4 per 1000 after TAH. The risk of vesicovaginal fistula was 1/1000 for TAH as compared to 2.2/ 1000 for LH. Evaluate study (Garry et al, 2004) confirmed the increased risk of urinary tract injuries associated with LH.
Met-analysis (Nieboer, 2009) of RCTs was underpowered to detect a clinically significant increase in the incidence of bladder and ureter damage from a laparoscopic approach When bladder and ureter injuries were pooled as 'urinary tract injury', a significant increase in urinary tract injury was detected for LH versus AH (OR 2.4, 95% CI 1.2 to 4.8) and TLH versus VH (OR 3.7, 95% CI 1.1 to 12.2).
Any meta-analysis is as good as the included trials. In 15 studies included in the met-analysis it was not clear whether the outcome measures had been pre-defined since the primary outcome was not reported and no sample size had been performed. One concern was the statistical heterogeneity of the trials included in this review. The heterogeneity in such outcomes as operating time, directly relates to the fact that some surgeons are better trained in and thus perform faster either type of hysterectomy. Concerning the heterogeneity in recovery time, hospital policies on post-operative stay and advice regarding when to resume work can differ, hence the observed differences. It is particularly difficult to address the issues surrounding effectiveness and complications in surgical procedures where the skill base of surgeons is variable.
The third patient presented with heavy menstrual bleeding and outpatient hysteroscopy revealed a type 1 submucous fibroid. The choice of a treatment depended on efficacy, acceptability, and desire for conservative surgery. Patient opted for hysteroscopic resection of fibroid.
There is clear evidence from randomised trials that the use of GnRH analogues is associated with a significant reduction in uterine volume and fibroid size (Lethaby 2009).Pre-treatment may also enable greater use of vaginal hysterectomy (Stovall 1991) as compared to abdominal hysterectomy or more conservative surgical options such as laparoscopic or hysteroscopic removal. However, concern has been expressed about difficult cervical dilatation and that the fibroid capsule becoming less evident and difficulty in shelling out tumours, thus making excision more difficult (Stovall 1989).
Lethaby (2009), in a met-analysis (26 RCT) investigated the role of pre-treatment with gonadotropin releasing hormone (GnRH) analogues prior to a surgical procedure, either hysterectomy or myomectomy, for uterine fibroids.
Results from pre-operative outcomes were combined for both types of surgery but results from intra- and post-operative outcomes were reported separately.
Pre- and post-operative haemoglobin (Hb) and haematocrit (HCT) were significantly improved, (WMD=1.0g/dL, 95% CI 0.7-1.2 and WMD=3.1%, 95% CI 1.8-4.5 respectively) by GnRH analogue therapy prior to surgery, and uterine volume, uterine gestational size and fibroid volume were all reduced (WMD=-159ml, 95% CI -169 - -149, WMD=-2.2 gestational weeks, 95% CI -2.3 - -1.9 and WMD=-12mls, 95% CI=-18.3 - -6.6 respectively). Pelvic symptoms were also reduced but some adverse events were more likely during GnRH analogue therapy (OR=2.1, 95% CI 1.3-3.4). There was no difference in intra-operative blood loss or duration of surgery between treatment groups. However women in the GnRH analogue group were more likely to have recurrence of their fibroids 6 months after myomectomy than in the no treatment group (combined trials, OR=4.0, 95% CI, 1.1-14.7). The increased costs associated with GnRH analogue therapy were not assessed.
Cammani et al (2010) evaluated the feasibility of hysteroscopic resection of submucous uterine myomas in a prospective study. Thirty-three women with submucous myomas 5 cm or larger in diameter with menorrhagia, dysmenorrhea, or infertility underwent hysteroscopic myomectomy. Satisfaction with the surgery and an improvement in symptoms were the primary outcomes. Possibility of 1-step resection; complication rate, and disease recurrence were also considered. Menorrhagia was the most frequent indication (91%)
Mean operating time was 50 minutes (interquartile range, 35-65). One-step excision was achieved in 81.8% (95%CI 65.6-91.4) of patients. Of 5 women with incomplete resection, 3 needed a second surgery, and 2 were symptom-free. Procedure was successful in 94 %( 95%CI 80.4-98.3) of women. In patients with myomas larger than 6 cm, recovery time was significantly longer (OR 14, 95%CI 1.3-156) than in those with smaller myomas. Intravasation, uterine perforation, and postoperative anaemia, in 1 patient each were recorded. Authors reported increased risk (OR22:95%CI 2-232) to 2 step procedure with myomas larger than 5 cm diameter. Median (range) follow-up was 10 (6-22) months. 27 patients (81.2%) reported they were very satisfied; 5 patients (15.2%) were satisfied; and 1 patient (3%) was dissatisfied. Shorter hospital stays (hour IQR 4(3.25-11.1) and earlier return to normal activities days IQR 7(5-13) were reported.
There are several limitations in this study. It is a small prospective study. Women with subfertility and menorrhagia were grouped as one. The length of follow up is small and a similar study with a longer follow up may not be able to demonstrate such a high success rate. This may well be due to incomplete excision of large myomas as well as due to development of other dysfunctional causes of menorrhagia.
Note the wide confidence interval and IQR range.
Polena et al (2007) reported a success rate of 94.4% in a retrospective study of 235 women who underwent hysteroscopic resection of submucous fibroid with long term follow up of 40 months (18-66). However women with fibroids 5cm or more were excluded. 37% of women underwent associated ablation of endometrium which may contribute to the long term positive result.
Due to lack of firm evidence base, women's clinical condition and surgeon's skill and experience should be individually evaluated.