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Best Practice & Research Clinical Obstetrics and Gynaecology xxx (2015) 1e7

Contents lists available at ScienceDirect

Best Practice & Research Clinical

Obstetrics and Gynaecology
journal homepage: www.elsevier.com/locate/bpobgyn

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Uterine myomata: Organ-preserving surgery*

Francois Closon, MD,
Togas Tulandi, MD, MHCM, Professor and Academic Vice
Chairman of Obstetrics and Gynecology, and Milton Leong
Chair in Reproductive Medicine *
Department of Obstetrics and Gynecology, McGill University, Montreal, Canada

Keywords:
myoma
laparoscopic myomectomy
operative hysteroscopy
robotic myomectomy
radiofrequency ablation

Most women with uterine myoma are asymptomatic and do not

require any treatment. However, myoma can also lead to menorrhagia, pressure symptoms, abdominal pain, and infertility. Management of symptomatic women with myoma depends on several
factors, including age, desire for fertility, and myoma characteristics. Uterine myoma that distorts the uterine cavity, either submucous myoma or intramural myoma, with a submucous
component reduces fertility, and is associated with increased
uterine bleeding. The treatment of choice is hysteroscopic myomectomy or abdominal myomectomy, preferably by laparoscopy.
Robotic assistance in laparoscopic myomectomy leads to outcomes
similar to conventional laparoscopic myomectomy. However, it is
expensive. Newer techniques include either laparoscopic or
transcervical radiofrequency thermal ablation.
2015 Elsevier Ltd. All rights reserved.

Introduction
About 25% of women above 35 years of age have uterine myoma and most of them are asymptomatic. Symptoms are experienced by only a quarter of women with myoma. The main symptoms are
menorrhagia, pressure symptoms, and abdominal pain. Infertility or repeated pregnancy loss could be
experienced by women with submucous myoma or intramural myoma that distorts the uterine cavity.

Theme of the journal: Avoiding Complications in Gynaecological minimal access surgery.

* Corresponding author. McGill University, 687 Pine Ave West, F6.01, Montreal, QC H3A 1A1, Canada. Tel.: 1 514 843 1650;
Fax: 1 514 843 1448.
http://dx.doi.org/10.1016/j.bpobgyn.2015.09.005
1521-6934/ 2015 Elsevier Ltd. All rights reserved.

Please cite this article in press as: Closon F, Tulandi T, Uterine myomata: Organ-preserving surgery, Best
Practice & Research Clinical Obstetrics and Gynaecology (2015), http://dx.doi.org/10.1016/
j.bpobgyn.2015.09.005

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The relationship between myoma and the endometrium is the key point in the management of
symptomatic women with myoma [1]. For example, myomectomy for submucous myoma or laparoscopic myomectomy for intramural myoma with submucous component will increase the subsequent
live birth rate [2]. The recent classication of the Federation International of Gynecology and Obstetrics
clearly identied the type of broids as they are dened in terms of their relationship with the
endometrium and the uterine serosa [3].
Management of women with uterine myoma depends on several factors, including age, desire for
fertility, symptoms, and size and location of the myoma. Several treatment methods are available for
uterine myoma such as expectant management, medical treatment, uterine artery embolization,
excision or ablation of the myoma, and hysterectomy. Nonsurgical treatment of uterine myoma and
hysterectomy are beyond the scope of this study.
Preoperative
Careful history taking, physical examination, and pelvic imaging are important. In most cases, a
thorough transvaginal ultrasound with or without abdominal scan is usually sufcient. In general,
symptoms caused by broids are subjective. It is noteworthy that other conditions such as endometriosis or adenomyosis could coexist with myoma [4,5].
Management of the myoma without considering such coexistence might lead to treatment failure.
Before the commencement of surgical approach, management of other alternative uterine myoma,
including the risks and implications of each treatment, should be discussed.
Prior to hysteroscopic myomectomy, long-acting gonadotropin-releasing hormone agonist (GnRHa)
was regularly administered 4 weeks before the start of the procedure. It reduces the thickness of the
Q 6 endometrium, making it visible. It is also associated with decreased uid absorption [6]. GnRHa was
used thrice monthly for 4 months before surgery for submucous myoma of 3 cm, which completely
removes myoma in a single setting. In order to allow laparoscopic approach, the same regime is used
for a larger uterus of >18 gestational weeks. Thrice-monthly administration of one dose of GnRHa
results in a 30% shrinkage of the myoma volume [7].
Ulipristal acetate, a selective progesterone receptor modulator, can also be used. New studies to
determine whether administration of ulipristal acetate for 3 months consistently reduces the size of
the myoma are still needed. The use of GnRHa or ulipristal acetate can result in myoma degeneration,
which makes the myoma soft. Manipulation and enucleation are more difcult for soft myoma than
solid myoma.
Submucous myoma
Type 0, 1, and 2 myomas (submucous myoma) are associated with infertility, miscarriages, and
menorrhagia. Hysteroscopic myomectomy is the best surgical treatment for type 0 and 1 myomas.
Although in most cases, type 2 myoma can be removed by hysteroscopy, large type 2 myoma of >3 cm
that occupies the entire myometrium is better removed by laparoscopy, thereby completely removing
the myoma. In women with repeated pregnancy loss, myomectomy decreases the miscarriage rate and
increases the live birth rate from 23% to 52% [8].
Hysteroscopic resection of type 2 myoma could be challenging and associated with a longer
operating time. The type of myoma and the duration of surgery seem to be the most important factors
inuencing uid decit [9]. In order to improve resection of myoma, a hysteroscopic morcellator has
been developed, which automatically and rapidly removes tissue fragments during the resection and
improves visualization during the entire the procedure [10].
Intramural myoma
The need and results of myomectomy in infertile women with intramural myoma and no distortion
of the uterine cavity remain controversial. In general, removal of this type of myoma does not improve
the outcome of pregnancy [2].
Please cite this article in press as: Closon F, Tulandi T, Uterine myomata: Organ-preserving surgery, Best
Practice & Research Clinical Obstetrics and Gynaecology (2015), http://dx.doi.org/10.1016/
j.bpobgyn.2015.09.005

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Laparoscopic myomectomy is associated with less blood loss, less pain, shorter hospital stay, and
faster recovery than laparotomic myomectomy [11,12]. However, it is technically demanding, and requires expertise in laparoscopic suturing. Saccardi et al. reported increased bleeding and operating
time for the removal of intramural myoma >8 cm or subserosal myoma >12 cm [13]. Several methods
have been proposed to reduce bleeding, including the thrice-monthly administration of one dose of
GnRHa for 4 months before myomectomy. Intravaginal administration of one dose of misoprostol 400
mcg an hour before surgery is also benecial [14].
It is a common practice to inltrate dilute solution of vasopressin (20 units per 100 mL normal
saline) into the myometrium before making the myomectomy incision. Because of the possible side
effects such as cardiac arrhythmia and change in blood pressure, the anesthesiology team should be
informed before injecting vasopressin [15,16]. Barbed suture facilitates laparoscopic suturing more
effectively than conventional sutures [17,18].
Postmyomectomy adhesions
Most myomectomies are associated with intra-abdominal adhesions, which can cause infertility,
bowel obstruction, and abdominal pain [19]. In order to reduce adhesion formation, surgery should be
performed using microsurgical principles including gentle tissue handling, meticulous hemostasis
without excessive coagulation, and copious irrigation to prevent serosal drying [20]. Laparoscopy is
associated with lesser adhesion than laparotomy. However, adhesion-reducing substances should also
be used. Many pharmacological agents, such as anti-inammatory drugs, both steroidal and nonsteroidal, GnRHa, and heparin, have been proposed to prevent the formation of adhesion, but the results
have been unfavorable [21].
Peritoneal instillates capable of producing hydrootation including isotonic solutions, such as
normal saline or Ringer's lactate, have been tested; however, as the peritoneum has a high capacity of
uid absorption, the solution will not be retained long enough to prevent adhesion formation [22].
Compared with isotonic solution, 32% dextran (Hyskon, Pharmacia Inc., Uppsala, Sweden) stays longer
in the abdominal cavity. However, randomized studies showed that it was ineffective. The only agent
approved by the US Food and Drug Administration (FDA) to be used by laparoscopy is 4% icodextrin
solution (Adept, Baxter Healthcare, Deereld, IL, USA), another peritoneal instillate that is associated
with lesser adhesion formation than Ringer's lactate [23].
The widely used adhesion-preventing substances are adhesion barriers such as oxidized regenerated cellulose (Interceed: Gynecare, Somerville, NJ, USA) and combined hyaluronic acid (HA) and
carboxymethylcellulose (Sepralm: Genzyme Corporation, Cambridge, MA, USA).
HA is one of the components of several gels and adhesions barriers. It is a linear polysaccharide that
naturally protects tissue, and has been shown to reduce the formation of adhesions [24]. It is marketed
in combination with carboxymethylcellulose (Sepraspray or Sepralm, Genzyme Corporation, Cambridge, MA, USA) and as auto-cross-linked HA (Hyalobarrier gel: Nordic Pharma, Reading, UK). In a
meta-analysis including 335 patients who underwent hysteroscopic procedure or laparoscopic myomectomy, the authors showed that auto-cross-linked HA signicantly reduced intraperitoneal or intrauterine adhesions [25]. Pregnancy rate of women who underwent laparoscopic myomectomy was
also higher in the treated than the control group (77% vs. 38%) [26]. However, the use of Sepralm by
laparoscopy is cumbersome as the fabric easily sticks together.
Oxidized regenerated cellulose (Interceed, Gynecare, Somerville, NJ, USA) is the most popular
adhesion barrier in gynecology. It consists of a knitted fabric, which can be easily applied on the tissue
by laparoscopy. It becomes a gelatinous coat that prevents migration of broblasts, and is totally
resorbed within few weeks. Before using Interceed, hemostasis should be secured as bleeding is
reduced [27,28].
Laparoscopically assisted myomectomy
The procedure is similar to laparoscopic myomectomy except that a transverse suprapubic skin
incision is made to allow delivery of the myoma and to repair the myomectomy incision. The length of
the incision is up to 4 cm. Laparoscopically assisted myomectomy (LAM) offers advantages of both
Please cite this article in press as: Closon F, Tulandi T, Uterine myomata: Organ-preserving surgery, Best
Practice & Research Clinical Obstetrics and Gynaecology (2015), http://dx.doi.org/10.1016/
j.bpobgyn.2015.09.005

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laparoscopy and laparotomy. In a retrospective study of 116 patients who underwent laparoscopic
myomectomy or LAM, the authors reported no signicant difference in surgical complications, length
of hospital stay, or recovery time. Estimated blood loss was higher in the LAM group (303 vs. 200 ml),
but the mean operating time was lower (66 vs. 94 min) [29]. Several factors could contribute to these
differences, including the surgeon's expertise and familiarity of laparoscopic suturing and the size and
location of the myoma.
Extraction of myoma from the abdominal cavity
In LAM, myoma can be easily removed by abdominal incision. In laparoscopic myomectomy, the
myoma is usually removed in pieces, using a morcellator. Following a case of a physician who underwent laparoscopic morcellation of uterine sarcoma, the safety of the procedure has been questioned
and has led to an amplied chain reaction. This included a communication from the FDA on April 17,
2014, discouraging the use of laparoscopic morcellation for removal of uterus or uterine broids
because it poses a risk of spreading unsuspected cancerous tissue, notably uterine sarcomas, beyond
the uterus. As a consequence, Johnson and Johnson, one of the companies that produce an electric
morcellator (Morcellex), subsequently withdrew their product from the market [30].
In a systematic review, Pritts et al. reported poor evidence for the association of morcellation with
worse outcome than en bloc uterine removal [31]. Although the incidence of leiomyosarcoma is very
rare (0.64 per 100,000 women), it poses severe threats [32].
In any event, gynecologists are trying to nd a method that prevents the scattering of tissue fragments inside the abdominal cavity. LAM is one such method, but it needs an abdominal incision.
Another method is removal of the specimen through a colpotomy incision. The elasticity of the vagina
allows removal of even a large specimen. However, the specimen can also be morcellated through a
colpotomy opening [33,34].
A relatively new technique is laparoscopic in-bag morcellation. The endoscopic bag is expanded by
passing CO2 gas, and an ancillary laparoscopic trocar is placed directly through the bag allowing
placement of the laparoscope. This technique appears to be safe, but the devices are used in an off-label
setting and requires several adjustments [35]. Studies to develop safe morcellators are currently
ongoing [36].
Radiofrequency thermal ablation
A few authors prefer ablation of the myomas (myolysis) over myoma removal. Primarily, energy was
obtained from Nd:YAG laser, followed by other kinds of sources such as monopolar and bipolar energy
or cryotherapy [37]. However, laparoscopic myolysis is associated with adhesion formation, and
uterine rupture has been reported as well. Recently, radiofrequency thermal ablation has been performed to remove myoma [38]. The procedure is carried out by placing a probe inside the myoma
under laparoscopy and laparoscopic ultrasound imaging. Seven titanium prongs are then used, and the
cell is activated by heating it to 100 C. The extent of the damage depends on the distribution of the
prongs. It takes approximately 5 min to ablate a 3-cm myoma. A volume reduction of up to 85% at 12
months has been reported [38,39]. However, laparoscopic intra-abdominal ultrasound is not easy to
perform, and the procedure needs a laparoscopic and an ultrasound monitor. Further, there is no tissue
diagnosis.
A similar device is used for transcervical uterine broid ablation, the VizAblate System (Gynesonics, Redwood City, CA, USA). It combines real-time sonography and radiofrequency for ablation and
consists of an intrauterine ultrasound probe inserted into the uterine cavity. An electrode is inserted
into the myoma under ultrasound guidance [40], and a >50% reduction in the myoma volume has been
reported [41].
Robotic-assisted laparoscopic myomectomy
Robotic surgery has several advantages such as a three-dimensional vision system, intuitive and
multidirectional movements with a wristed instrumentation, and a higher comfort of work as the
Please cite this article in press as: Closon F, Tulandi T, Uterine myomata: Organ-preserving surgery, Best
Practice & Research Clinical Obstetrics and Gynaecology (2015), http://dx.doi.org/10.1016/
j.bpobgyn.2015.09.005

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surgeon seats at the surgical console [42]. It facilitates laparoscopic suturing, yet there is no tactile
feedback [43]. However, it is expensive, associated with an increased operating time, and requires at
least four incisions [44]. In addition, it is associated with increased blood loss, complications, length of
hospital stay, and operating time compared with conventional laparoscopic myomectomy. Thus, it
appears that robotic-assisted laparoscopy myomectomy offers no additional short-term benet
compared to its conventional laparoscopic counterpart [45]. In any event, it is valuable for obese
women [46].
Barbed suture for myomectomy
Barbed suture, a relatively new type of suture, consists of a standard monolament suture with tiny
barbs cut into the length of the suture in a helical array set facing in opposite directions. Because of the
presence of barbs on the suture, it approximates the tissue without the need of a surgical knot facilitating laparoscopic suturing. Another advantage of barbed suture is that it maintains tension of the
suture line during suturing. The presence of barbs allows good approximation of the tissue at the
beginning of suturing, leading to early hemostasis. In a meta-analysis, Tulandi and Einarsson found that
the use of barbed suture for uterine closure is associated with reduced operating and suturing times
and decreased blood loss [18].
Postoperative adhesion formation with barbed suture is similar to that of conventional suture [47].
However, the barbs tend to stick to the tissue, and small bowel obstruction related to barbed suture has
Q 7 been reported [48,49]. Cutting the tail of the barbed suture ush to the tissue could be helpful. In
practice, we regularly cover the suture line with an adhesion barrier.

Practice points
 Myoma that distorts the uterine cavity is associated with infertility and repeated pregnancy
loss
 Myomectomy should be limited for women of childbearing age
 Pelvic imaging is essential for mapping myoma and chooses the best surgery approach
 As adhesion formation is closely related to myomectomy, microsurgical principles and
adhesion-reducing substances should be used
 Barbed suture for uterine closure is less technically demanding and facilitates laparoscopic
suturing

Research agenda





Radiofrequency thermal ablation for women with desire for childbearing or future fertility
Preoperative effects of ulipristal acetate on myomectomy
Safe myoma morcellation technique
Randomize trial on robotic surgery for myomectomy

Conict of interest
Dr. Tulandi is an advisor for Acatvis Inc, and AbbVie Canada; Dr. Closon has no conict of interest.
Q8

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Please cite this article in press as: Closon F, Tulandi T, Uterine myomata: Organ-preserving surgery, Best
Practice & Research Clinical Obstetrics and Gynaecology (2015), http://dx.doi.org/10.1016/
j.bpobgyn.2015.09.005

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Please cite this article in press as: Closon F, Tulandi T, Uterine myomata: Organ-preserving surgery, Best
Practice & Research Clinical Obstetrics and Gynaecology (2015), http://dx.doi.org/10.1016/
j.bpobgyn.2015.09.005