eMedicine Specialties > Obstetrics and Gynecology > Gynecologic Surgery
Gynecologic Myomectomy: Follow-up
Updated: Aug 6, 2008
Outcome and Prognosis
Despite a long history of using myomectomy and extensive literature on this procedure, data are actually poor because of 2 important issues related to outcome. In particular, both the recurrence rate and the impact on fertility have been poorly studied.
Abdominal myomectomy
In 1998, Vercellini et al extensively reviewed abdominal myomectomy as a fertility-enhancing procedure.102 They noted that although numerous papers report on fertility outcomes after myomectomy, they all share the same serious flaws. In particular, not a single study included controls or used randomization. Only a few of the studies used life-table analysis. All used differing definitions of infertility and included heterogeneous uses of other infertility treatments. Nonetheless, the studies were fairly consistent, with approximately two thirds of patients with myomas and otherwise unexplained infertility conceiving after myomectomy.
Similar results were noted in both prospective and retrospective studies. However, results were inconsistent when subgroups were analyzed. Myomectomy continues to be offered routinely to patients with uterine fibroids and infertility, but until controlled studies with expectantly managed controls are performed, the benefit of this procedure for patients remains unclear.
The risk of myoma recurrence is similarly poorly studied. Patients undergoing myomectomy should be counseled that they are at risk for fibroid recurrence and the potential for additional surgery in the future. Unfortunately, proper studies to determine recurrence risk are not available. Most studies are limited because they include heterogeneous study groups composed of a mixture of symptomatic patients who are treated for fibroids and asymptomatic patients who are treated for infertility. Follow-up in all of these studies is poor, with many patients lost to follow-up and most with short follow-up periods. Because fibroids may recur slowly over a long period, studies with short follow-up times do not yield the necessary information.
In addition, the studies use different definitions of recurrence, some limited only to symptomatic recurrence and some including patients with asymptomatic fibroids detected after ultrasonographic or pelvic examination. Most do not use life-table analysis.
Many women are likely to experience recurrence of myomas after myomectomy. In 1995, Fedele et al reported on the use of ultrasonography to help diagnose recurrences and noted a cumulative recurrence rate of 51% over 5 years.103 However, asymptomatic recurrence is not generally a relevant outcome. Limiting to studies that look at patients who require reintervention after myomectomy and appreciating that most of these studies have short (<5-y) follow-up, recurrence rates of 8-27% are noted (see Table 1). Most of the higher rates are noted in older studies, when hysterectomy was performed for much more liberal indications and was performed much more frequently. Looking at these studies, the medium-term risk for the need for repeat surgery after myomectomy is 5-10%. In the only study of risk factors for subsequent surgery, Stewart et al reported that the repeat surgery rate was 35%, with most of these being endoscopicprocedures.104
Several studies established particular risk factors for reoperation. In 1969, Malone noted that removal of multiple myomas was a strong risk factor for reoperation.105 Future repeat surgery was required in 26% of patients with multiple myomas, compared with 11% of patients with single myomas. Also, pregnancy after myomectomy appears to be protective. In 1991, Candiani et al noted that over 10 years following myomectomy, 15% of patients achieving pregnancy and 30% of patients not achieving pregnancy required repeat surgery.106
In 2002, Stewart et al noted a decreased risk of repeat surgery if the uterus was greater than 12 weeks' size at the time of the initial surgery (hazard ratio, 0.1; 95% confidence interval, 0.01-0.4) and an increased risk with weight gain of more than 30 pounds since age 18 years.104 In 2005, a retrospective analysis of 132 patients after myomectomy via laparotomy revealed a 62% 5-year recurrence rate and a 17% rate of reoperation for myomas. Lower recurrence rates were seen in patients with uterine size <10 weeks, patients with a single myoma, and those who had a subsequent childbirth.107
Table 1. Summary of Studies Reporting Need for Future Surgery for Myomas After Myomectomy
Open table in new window
Table
| Study | Year | Follow-up, mo | Reoperation Rate |
| Finn and Muller 108 | 1950 | 24-120+ | 13% |
| Brown et al 109 | 1956 | >72 | 17% |
| Malone 105 | 1969 | >60 | 27% |
| Berkeley et al 110 | 1983 | 17 | 8% |
| Garcia and Tureck 111 | 1984 | >10 | 6% |
| Rosenfeld 112 | 1986 | >12 | 4% |
| Smith and Uhlir 113 | 1990 | NR | 5% |
| Verkauf 114 | 1992 | 42 | 6% |
| Gehlbach et al 115 | 1993 | >12 | 12% |
| Acien and Querada 116 | 1996 | 4-144 | 8% |
| Stewart et al 104 | 2002 | 84 ± 35 | 35% |
| Hanafi 107 | 2005 | 2-136 | 17% |
| Study | Year | Follow-up, mo | Reoperation Rate |
| Finn and Muller 108 | 1950 | 24-120+ | 13% |
| Brown et al 109 | 1956 | >72 | 17% |
| Malone 105 | 1969 | >60 | 27% |
| Berkeley et al 110 | 1983 | 17 | 8% |
| Garcia and Tureck 111 | 1984 | >10 | 6% |
| Rosenfeld 112 | 1986 | >12 | 4% |
| Smith and Uhlir 113 | 1990 | NR | 5% |
| Verkauf 114 | 1992 | 42 | 6% |
| Gehlbach et al 115 | 1993 | >12 | 12% |
| Acien and Querada 116 | 1996 | 4-144 | 8% |
| Stewart et al 104 | 2002 | 84 ± 35 | 35% |
| Hanafi 107 | 2005 | 2-136 | 17% |
Another long-term complication that must be considered is the risk of uterine rupture during pregnancy. Fortunately, this is quite rare and is most likely to occur in labor. Although data are limited to support it, the usual recommendation is to offer cesarean delivery to patients who had myomectomies in which large defects in the active segment of the uterus were created by removal of the fibroids. Some recommend cesarean delivery any time the endometrial cavity is entered during the procedure, but what seems more likely is that the total extent of the defect, not entry into the endometrium, is the factor that presents the risk to the patient. Recommendations must be individualized for each patient. These recommendations are best made by the physician performing the myomectomy and should be clearly documented in the chart and conveyed to the patient so that the recommendations are clear in the event of future pregnancy.
Laparoscopic myomectomy
Regarding fertility, successful reproductive outcomes are possible after both laparoscopic and abdominal myomectomy. A retrospective study by Seracchioli et al in 2006 reported a 54% pregnancy rate and a 67% delivery rate postlaparoscopic myomectomy.117 Cumulative pregnancy rates and live birth rates in a randomized controlled trial comparing laparoscopic myomectomy and abdominal myomectomy noted no difference between these 2 groups. However, the per cycle live birth rate and pregnancy rate were higher in patients who underwent laparoscopic fibroid removal.30 In a 2006 Cochrane review that included only 1 randomized controlled trial, pregnancy rates were similar in infertile patients who underwent myomectomy via laparotomy compared to laparoscopic myomectomy.118
A few studies have reported on the risk of recurrence after laparoscopic myomectomy. One study observed 114 women for a mean of 37 months and defined recurrence as the return of any myoma. The cumulative recurrence risk was 10.6% at 1 year, 31.7% at 3 years, and 51.4% at 5 years. Eight patients underwent repeat laparoscopic myomectomies. One patient underwent 2 laparoscopic myomectomies. One patient had a myomectomy and then a total abdominal hysterectomy, and 6 had total abdominal hysterectomies. Of the patients, 14% required repeat surgery.66
Another group observed 192 women after laparoscopic myomectomy and found, based on symptoms and ultrasonographic findings, a cumulative recurrence risk of 16.7% at 5 years. Approximately 4% of the patients required further surgery.119 Interestingly, another study noted that the preoperative use of GnRH agonist increased the risk of myoma recurrence after laparoscopic myomectomy.68
In 1992, Goldfarb presented data on patients who underwent myolysis with the Nd:YAG laser. He studied 75 patients and reported 50% shrinkage of the myomas at 6 months. This series, similar to most others on minimally invasive techniques, reported no medium- or long-term data on pregnancy or need for future procedures.64 In 1998, Chapman reported on a similar procedure performed on 293 patients. Of these, 6 patients required hysterectomy and 30 had future pregnancies.120 In 1995, Goldfarb reported on myolysis with bipolar cautery and reported 83% shrinkage over 6 months.63 One series reported 2 of 3 patients with uterine rupture after they became pregnant within 3 months of the procedure.121
Compared with abdominal myomectomy, patients having undergone laparoscopic myomectomy have less pain, shorter hospitalization59,122 , and fewer postoperative adhesions, but longer operative time.122 Overall, no difference is apparent in postoperative complications or fibroid recurrence between the 2 groups.65
Hysteroscopic myoma resection
Many studies have assessed fertility rates after hysteroscopic myomectomy and have noted pregnancy rates similar to those after abdominal myomectomy, approximately 60% (see Table 2). Again, no studies include expectantly managed control groups.
Table 2. Pregnancy Rates in Patients Undergoing Hysteroscopic MyomectomyOpen table in new window
| Author | Year | Study Size | Pregnancy Rate |
| Donnez et al 73 | 1990 | 24 | 67% |
| Goldenberg et al 123 | 1995 | 15 | 47% |
| Vercellini et al 124 | 1999 | 40 | 37% |
| Fernandez et al 125 | 2001 | 59 | 27% |
| Bernard et al 126 | 2000 | 31 | 35% |
| Shokeir 127 | 2005 | 29 | 72% |
Reoperation after hysteroscopic myomectomy has also been studied. As usual, these studies are limited by short follow-up periods. In 1995, Ubaldi et al reviewed older studies, which had reoperation rates of 5-25% after as long as 3 years of follow-up.82 In 1999, Vercellini et al studied 108 women who had hysteroscopic resection of submucous, pedunculated, sessile, or intramural leiomyomas. After a mean follow-up of 41 months, 27 patients had myoma recurrence based on ultrasonographic findings, with a 3-year cumulative recurrence rate of 34%. Twenty women had recurrent menorrhagia, with a 3-year rate of 30%.124
In 1999, Emanuel et al reported on 285 women who had submucous myomas treated with hysteroscopic myoma resection without endometrial ablation. Several patients required multiple procedures. Patients were monitored for a median of 46 months. Forty-one patients (14.5%) required repeat surgery. Patients who required repeat surgery were more likely to have larger uteri and higher numbers of submucous myomas. Hysterectomy was required in 20 of the 41 patients who required repeat surgery. Most (90.3%) patients with normal-sized uteri and 2 or fewer myomas did not require future surgery at 5 years.128
In a second series from Britain, also reported in 1999, Hart et al studied 122 women for a mean of 2.3 years. Of these women, 21% required repeat surgery by 4 years and 0% thereafter. Their regression analysis suggested that outcome was better in older women in whom the uterus was smaller than or equal to 6 weeks' gestational size or the fibroid was smaller than or equal to 3 cm and mainly intracavitary.129 In 1994, Donnez et al studied the recurrence of menorrhagia based on the site of the myoma. They noted that women who had multiple submucosal myomas were much more likely to have recurrent symptomatic menorrhagia than women who had only 1-2 myomas. Having the largest diameter inside the uterine cavity and the largest portion of the uterine wall were less accurate predictors.130
Although many reports exist regarding fertility after hysteroscopic myomectomy, currently no good randomized controlled trials have evaluated this outcome. 118
Vaginal removal of a prolapsed myoma
Management of a prolapsed vaginal myoma can also be problematic. A single study noted that removal of prolapsed myomas represented 2.5% of all procedures for myomas. Approximately 93.5% of these procedures were successful with transvaginal removal, and 6.5% of patients needed a total abdominal hysterectomy. Of the failures, only 1 had very serious complications. After the initial vaginal myomectomy, 34 patients were monitored for a median of 5.5 years. In these patients, 79% had no further symptoms from their fibroids. Of those remaining, 21% developed other symptoms, of whom 6% required a hysterectomy, 6% had a single repeat prolapsed myoma, and 3% (1 patient) had multiple repeat procedures.131
Future and Controversies
Many questions remain regarding the natural course of untreated fibroids, the efficacy of medical management, and the unanswered questions regarding surgery as discussed. The 2007 Agency for Health Care Research and Quality evidence-based review provides a superb review of these topics.23
Current controversies include the role of minimally invasive procedures. In particular, laparoscopic myomectomy has many theoretical advantages, including lower cost and avoidance of prolonged hospitalizations. However, whether the repair of the defect is as effective as that performed with abdominal myomectomy remains unclear, and the procedure may be associated with an increased risk of uterine rupture during pregnancy.
Medical therapy is also being explored. At present, data for medical management, particularly new treatments such as tibolone or older treatments such as controlling symptoms with birth control pills, are very scant. The role of GnRH analogs also requires further clarification. The advantages in terms of making the fibroids smaller must be balanced against the high cost and the subsequent inability to locate fibroids that were previously reduced by treatment.
A number of newer treatments are being explored. Uterine artery embolization (UAE), in particular, may be an especially promising minimally invasive approach to fibroids.132,133 In this procedure, angiographic catheters are introduced in the groin and passed to the uterine artery under fluoroscopic guidance. Microspheres are then injected, which lodge in the blood supply to the myomas and cause them to infarct. Significant pain from the acute infarction of the myomas usually requires hospital admission for pain control.
A number of complications have been reported, including prolapsing myomas, infection, and hematoma at the catheter placement site in the groin, and bleeding and infection requiring hysterectomy. However, short-term results for relief of heavy bleeding and pelvic pain and pressure have been good. In a meta-analysis comparing uterine artery embolization to surgical interventions for fibroids, embolization offers a shorter hospital stay and quicker return to normal activities but failed to show any significant benefit in effectiveness or safety.134 In the FIBROID registry, more than 1200 patients undergoing UAE were observed for 3 years after the procedure. More than 85% would recommend the procedure and about 15% of patients failed and underwent further surgery or repeat embolization.135Although UAE is reserved for women who do not desire fertility, reports exist of pregnancies postembolization. One study suggested that women are able to achieve successful pregnancies after uterine fibroid embolization without significant adverse outcomes.136 A review of studies observing pregnancy after embolization concluded that these patients may have higher rates of spontaneous miscarriage, preterm delivery, malpresentation, and abnormal placentation.137 The ACOG Committee Opinion on UAE states that the procedure should be considered investigational or relatively contraindicated in women wishing to retain fertility.28 Overall, data are extremely limited and larger prospective studies are needed.
In 2004, the US Food and Drug Administration approved a new technology, ExAblate 2000. Use of high-intensity focused ultrasonographic waves under MRI guidance to induce coagulation necrosis in fibroids has been shown to be effective for treating solid tumors like fibroids. In one study of 109 patients, 71% had significant improvement in symptoms at 6 months and 51% at 12 months.138 More studies are needed for longer term analysis and evaluation of cost-effectiveness.
Robotic surgery has become increasingly popular in gynecologic procedures involving cancer staging, hysterectomies, and myomectomies. Advantages to the da Vinci including 3-dimensional imaging and enhanced dexterity may help surpass the obstacles encountered while enucleating the fibroid, and repairing the uterine defect in laparoscopic myomectomy. More prospective trials are needed in this area of interest.139
As more is learned about the genetics of leiomyomas, targeting the specific genetic defect to help prevent or treat myomas may eventually be possible.
The authors and editors of eMedicine gratefully acknowledge the contributions of previous author, Susan Lee, MD, to the development and writing of this article.
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Further Reading
Keywords
abdominal myomectomy, hysteroscopic myomectomy, laparoscopic myomectomy, uterine leiomyomas, uterine artery embolization, MR guided focused ultrasound, infertility, pregnancy, conception, myomas, leiomyomata, fibroids, hysterectomy, childbearing, uterine preservation, benign uterine growths, abnormal uterine bleeding, estrogen stimulation, smooth muscle tumors, intermenstrual bleeding, menorrhagia, menstrual irregularity
