Arch Gynecol Obstet (2012) 285:15771580 DOI 10.

1007/s00404-011-2197-y

G E N E RA L G Y N E CO L O G Y

Successful pregnancy following myomectomy of a giant uterine myoma: role of a combined surgical approach
Antonio Macci Clelia Madeddu Antonio CaYero Anna Maria Paoletti

Received: 22 September 2011 / Accepted: 19 December 2011 / Published online: 30 December 2011 Springer-Verlag 2011

Abstract Purpose There are very few reports in the literature about the conservative surgical approach of large uterine myoma. The individualization of the surgery approach, the technical expertise and skill of the surgeon, the use of modern technologies/facilities could oVer the optimal individualized treatment. Methods We performed a conservative combined surgical approach consisting of open laparoscopy myomectomy followed by laparotomy for the treatment of a very large uterine myoma of the anterior uterine wall in a 27-year-old non-pregnant woman with a history of progressive abdominal distension and symptoms related to abdomen pressure and constipation. Results The myoma weighted 12.010 kg. The postoperative course was good and 20 months after surgery, the patients had a successful pregnancy with a spontaneous delivery at the 39th week of a healthy baby weighting 3.260 kg. Conclusions In the case reported here, the careful presurgical evaluation, the technical expertise and skill of the surgeon, the choice of a combined approach with laparoscopy and open surgery and the use of modern surgical
A. Macci (&) A. CaYero Department of Obstetrics and Gynaecology, Sirai Hospital, 09013 Carbonia, Italy e-mail: a.maccio@tin.it C. Madeddu Department of Medical Oncology, University of Cagliari, Cagliari, Italy e-mail: clelia_md@yahoo.it A. M. Paoletti Department of Obstetrics and Gynaecology, University of Cagliari, Cagliari, Italy

instruments have enabled us to achieve a signiWcant result: the preservation of the anatomical integrity of the uterus and adnexa which allowed a successful natural pregnancy with spontaneous delivery. Keywords Uterine myoma Pregnancy Conservative surgery Open laparoscopy

Introduction Uterine leiomyomas or myomas are the most common benign neoplasms in the female genital tract, showing a high prevalence in the late reproductive age. Ovarian hormones stimulate myomas growth. Therefore, their size regresses after the menopause. In addition, autocrine, paracrine factors and genetic abnormalities play a key role in the development and growth of uterine myomas. Their size can be very diVerent. There are small myomas, generally incapable of causing symptoms, whose diagnosis is made, by chance, during common clinical or ultrasound examinations. More frequently they reach a size capable of distorting the uterine wall or the uterine cavity. In these cases, they can lead to abnormal uterine bleeding, pregnancy loss and sterility. According to their size and number, myomas may result in increased abdominal distension followed by several symptoms such as pelvic pressure, constipation, pelvic pain, increased urinary frequency and acute urinary retention [1]. Myomas are generally classiWed by their location [2]. Intramural myomas are contained entirely or mostly within the myometrium. Subserosal myomas project outside the myometrium into the pelvic cavity, while submucosal myomas are located under the endometrium. Pedunculated myomas are attached to the uterine wall by stalks and they can be directed into either the peritoneal or

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the uterine cavity. The development of uterine myomas can cross the myometrium with the involvement of the lower uterine segment, the cervix and the broad ligament [3]. The latter are very diYcult to remove with many surgical risks involved. Some myomas can grow outside the pelvis into the abdominal cavity. In some cases, their size is so large as to deform the abdominal wall, making it look like an abdomen with a pregnant uterus. Some myomas growing in an extremely large uterus are well tolerated, probably due to both the slow growth of myomas and the accommodation of the woman. This silent myoma can delay its surgical removal, which can become very diYcult in relation to the size of myoma. Several management options can be considered: watchful waiting, medical therapy, surgery or, more recently, uterine artery embolization and focused ultrasound surgery [4]. Surgery is currently the main approach for myomas for symptomatic myomas. Although myomectomy has priority among surgical approaches in patients who wish to retain their fertility, in several cases hysterectomy is necessary because of the diYculties related to the size, localization, and number of myomas [5]. Moreover in the presence of the fertility desire, the myomectomy should be performed with a correct reconstruction of the uterus, in order to preserve its anatomical integrity and function for the reproductive process [6]. As early as 1845, the American Journal of Medical Sciences reported a successful abdominal myomectomy by Washington and John Atlee [7]. Based on their work, numerous reports have been published establishing the eVectiveness and safety of this technique in properly selected cases. Laparoscopic myomectomy is an appropriate alternative to abdominal myomectomy and hysterectomy [8]. The main advantages of a laparoscopic approach are the removal of myomas through small abdominal incisions and the repair of the uterus, as well as a less hospitalization time and faster recovery. However, there is a controversy as to whether the closure techniques available for laparoscopic suturing are equal to those achieved at laparotomy: this is most relevant to women contemplating a future pregnancy [9]. In addition to the number, size and location of myomas, previous scars can also reduce or prevent the surgical approach by laparoscopy [10].

Case report A 27-year-old non-pregnant woman with a previous at term pregnancy was admitted to the Department of Obstetrics and Gynecology at the Sirai Hospital of Carbonia (Italy), with a history of a progressive abdominal distension, mainly in the previous 12 months, and with symptoms caused by abdomen pressure and constipation. Her previous pregnancy occurred 3 years ago and was complicated by

post-partum blood loss due to uterine atonia probably dependent on the presence of a large uterine myoma (size 11 8 cm2) of the anterior uterine wall. The gynecologic assessment showed that her menstrual cycles were in the normal range both for frequency (every 2830 days) and intensity (56 days of duration and not more than three sanitary towels per day). No intermenstrual bleeding, pain and dysuria were reported. At admission, general objective examination showed good health conditions. The vital signs and laboratory Wndings were normal. The hemoglobin values were 13.6 g/dl. The abdominal physical examination showed a very large Wxed mass, starting from the pelvis up to the third space above the transverse umbilical line. The liver and the spleen were not palpable. Bowel sounds were absent. At the gynecologic examination, the external genitalia were normal and the vaginal mucosa was healthy, whereas uterus, as well as adnexa, was not valuable. The pelvic ultrasound scanning conWrmed a bulky mass occupying the whole abdomen. Neither the uterus nor the ovaries were distinguishable. Under Xuid distension at hysteroscopy, the uterine cavity appeared normal, without submucosal Wbroids or endometrial polyps, and the tubal ostia appeared also normal. An endometrial biopsy was performed to have a histological examination, which showed a regular endometrium with proliferative pattern. Then a diagnosis of a very large uterine myoma of the anterior uterine wall was hypothesized, even if a malignant nature of the mass cannot be excluded. Therefore, considering the symptomatology due to the pressure of such a large myoma on the other abdominal organs and the patient worsening discomfort, the myoma extirpation was necessary. The patient was given clear and exhaustive counselling and was fully informed of her clinical condition so that she could choose a surgical approach on the basis of the complexity of the pathology and the diYculty to preserve the uterus and the adnexa. The patient opted for a conservative surgical approach consisting of a diagnostic and operative laparoscopy, followed by a laparotomy if necessary to remove the myoma. The patient was asked to sign an informed consent form. An open laparoscopy [11] was performed to obtain a better view of the abdominal cavity and to obtain an objective evaluation of the true chances of complete debulking of such a large mass, potentially malignant, nature that has been immediately excluded by the intraoperative extemporaneous histological examination. Liver, gallbladder, stomach and diaphragm appeared normal and a very large myoma occupying the entire abdominal cavity was found. The presence of the myoma prevented seeing the ovaries and the fallopian tubes. After the visualization of the reXection of the parietal peritoneum on the myoma, we proceeded to open it at its extreme lateral margins. Thereafter, under the guidance of the laparoscopic optic we carried out,

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by retroperitoneal view, the dissection of the myoma from the abdominal wall to the pubis using the harmonic scalpel and the BiClamp LAP forceps (ERBE G.m.b.H., Germany). The surgical approach was then converted from laparoscopy into laparotomy with a longitudinal incision to externalize the very large myoma, showing to origin from the anterior wall of the uterus with a prevalent subserosal growth. Indeed, the body of the uterus and both the adnexa could be clearly visualized behind the myoma, showing a normal morphology and size. We proceeded with the lysis of some adhesions, the isolation of both the ureters and uterine vascular vessels. In addition to the traditional instruments of laparoscopic surgery, this surgery was facilitated by the use of surgical loupes, single-use electrosurgical pencils and bipolar scissors (BiSect 180, biClamp 110 MIC, ERBE G.m.b.H., Germany). The myoma was then removed from the front wall of the uterus with its preservation. In fact, it was originated without a peduncle from the inferior third of the anterior wall from the histhmic and precervical region, thus not altering severely the remaining anatomy of the uterus. In detail, a catheter was inserted into the uterus and a blue dye was injected to stain the uterine cavity to help evaluate its integrity. The blue dye was also raced into the fallopian tubes to determine whether the fallopian tubes were blocked. The endometrial cavity was not breached and the fallopian tubes were open. Repeated washings conWrmed adequate hemostasis. During and after myoma removal, hemostasis was carefully carried out and the perimetrium and myometrium closed with one layer of interrupted sutures in a front-to-back closure using number 2/0 Vicryl sutures. No macroscopic blood was observed in the urine and the peristalsis of both the ureters was conWrmed. The estimated blood loss was 400 ml. The weight of the myoma was 12.010 kg, its histological evaluation conWrmed a leiomyoma. Postoperative observations were stable and the patient was discharged 4 days after surgery with excellent general and local conditions. Twenty months after surgery, the patient was in excellent health and became naturally pregnant. During pregnancy, the monitoring of possible uterine rupture was performed by frequent ultrasound evaluation of regularity and thickness of uterine wall. The course of the pregnancy was in the normal range and a spontaneous delivery of a healthy baby weighing 3.260 kg (Apgar score 10 at the Wrst minute and 10 at the Wfth minute) occurred at the 39th week of pregnancy. No complications occurred after delivery and the patient was discharged 48 h after delivery.

Discussion A number of surgical therapies are available for the management of uterine myomas including hysterectomy,

abdominal myomectomy, laparoscopic myomectomy and hysteroscopic myomectomy. Myomas are still commonly treated with total abdominal hysterectomy; this procedure, however, is often performed for absolutely inappropriate indications. The American College of Obstetricians and Gynecologists had previously established the exact criteria for the management of leiomyomas identifying the large size of the myoma as an absolute indication for hysterectomy [9]. However, this technical bulletin has now been superseded by ones that are more recent. Although speciWc indications for hysterectomy are not given, the description of innovative surgical techniques and the demonstration of the eVectiveness of new therapeutic approaches have contributed to a behavioral change in clinicians [12]. Indeed, clinicians are now able to keep their therapeutic choice in order to meet patient preferences in terms of preserving fertility or retaining the uterus. Importantly, no randomized studies have been performed to show pregnancy success rates after myomectomy in comparison to other surgical techniques. Interestingly, a number of women who have completed childbearing age still request myomectomy for the management of symptomatic myoma. On the other hand, relevant contraindications include the high risk that a functional uterus may not be reconstructed after the excision of the myoma. Indeed, as myomectomy is carried out to preserve the uterus for future pregnancy, maintaining the integrity of the uterine wall during repair is of the utmost importance. For a myomectomy to be considered successful, the uterus should be reconstructed with patent tubes. Leiomyomas located in the region of the uterine vessels or broad ligament are sometimes diYcult to remove without performing a hysterectomy. Excision of very large myomas that constitute the entire anterior or posterior wall of the uterus may leave defects so large that closure is not allowed [13]. In any event, both old and new criteria should be directed at relieving symptoms or improving quality of life by addressing the patient concerns and meeting the patients wishes. Patients and physicians should work together to ensure that proper diagnostic evaluation is made and that the most appropriate treatments are considered before hysterectomy is recommended. The case reported here is peculiar for the very large size of the myoma and the conservative approach by the choice of a combined surgical approach, using the most advanced instruments, which allowed a successful natural pregnancy with a spontaneous vaginal delivery. The rate of natural pregnancy with vaginal delivery after myomectomy for large myomas in published series was around 15%, but the dimension of the mass removed was inferior to our case [14]. Moreover, systematic literature reviews shows that large subserosal Wbroids do not aVect fertility outcomes, and removal does not confer beneWt [15]. Nevertheless, it is

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Arch Gynecol Obstet (2012) 285:15771580 4. Miller CE (2009) Unmet therapeutic needs for uterine myomas. J Minim Invasive Gynecol 16:1121 5. Haney AF (2000) Clinical decision making regarding leiomyomata: what we need in the next millenium. Environ Health Perspect 108:835839 6. Smith DC, Uhlir JK (1990) Myomectomy as a reproductive procedure. Am J Obstet Gynecol 162:14761479 7. Atlee WL (1845) Case of successful extirpation of a Wbrous tumour of the peritoneal surface of the uterus by the large peritoneal section. Am J Med Sci 18:309335 8. Walid MS, Heaton RL (2010) Laparoscopic myomectomy: an intent-to-treat study. Arch Gynecol Obstet 281:645649 9. American College-of Obstetricians and Gynecologists (2004) Clinical Management Guidelines for the Obstetrician-Gynecologist. Surgical alternative to hysterectomy in the management of leyomiomas. In: American College of Obstetricians and Gynecologists (ed) Compendium of selected publications. ACOG, Washington, DC, pp 665673 10. Camanni M, Bonino L, Delpiano EM, Ferrero B, Migliaretti G, Deltetto F (2010) Hysteroscopic management of large symptomatic submucous uterine myomas. J Minim Invasive Gynecol 17:5965 11. Ahmad G, DuVy JM, Phillips K, Watson A (2008) Laparoscopic entry techniques. Cochrane Database Syst Rev 16(2):CD006583 12. Hurst BS, Matthews ML, Marshburn PB (2005) Laparoscopic myomectomy for symptomatic uterine myomas. Fertil Steril 83:123 13. Dubuisson JB, Fauconnier A, Fourchotte V, Babaki-Fard K, Coste J, Chapron C (2001) Laparoscopic myomectomy: predicting the risk of conversion to an open procedure. Hum Reprod 16:1726 1731 14. Malzoni M, Rotond M, Perone C et al (2003) Fertility after laparoscopic myomectomy of large uterine myomas: operative technique and preliminary results. Eur J Gynaecol Oncol 24:7982 15. Pritts EA, Parker WH, Olive DL (2009) Fibroids and infertility: an updated systematic review of the evidence. Fertil Steril 91:1215 1223 16. Kalogiannidis I, Prapas N, Xiromeritis P, Prapas Y (2010) Laparoscopically assisted myomectomy versus abdominal myomectomy in short-term outcomes: a prospective study. Arch Gynecol Obstet 281:865870

necessary to remove these giant myomas as that reported in the present case. Noteworthy, we think that the laparoscopic support in the presence of large abdominal masses of uncertain nature allows to evaluate in advance the whole abdominal cavity, thus allowing: the view of relationship between the mass and the abdominal organs, a fast extemporaneous histological examination for the assessment of the potential malignant nature with a more accurate modulation of the Wnal surgical procedure chosen. Moreover, it is undoubtedly that some surgical times of the laparoscopic approach may make it easier to perform abdominal surgical interventions otherwise more complex and invasive [16]. In conclusion, in our case, the careful pre-surgical evaluation, the thorough consultation between patient and physician, the choice of a tailor-made combined approach of laparoscopy and open surgery, the technical expertise and skill of the surgeon, and the use of modern technologies have enabled us to achieve such signiWcant results and oVer an optimal treatment which meets the patients wishes.
ConXict of interest of interest. The authors declare that they have no conXict

References
1. Derbent A, Turhan NO (2009) Acute urinary retention caused by a large impacted leiomyoma. Arch Gynecol Obstet 280:1045 1047 2. Istre O (2008) Management of symptomatic Wbroids: conservative surgical treatment modalities other than abdominal or laparoscopic myomectomy. Best Pract Res Clin Obstet Gynaecol 22:735747 3. Meniru GI, Wasdahl D, Onuora CO, Hecht BR, Hopkins MP (2001) Vaginal leiomyoma co-existing with broad ligament and multiple uterine leiomyomas. Arch Gynecol Obstet 265:105107

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