Myomectomy

Uterine leiomyomas, or fibroids, are the most common type of solid tumors in adult women, clinically apparent in at least 25% of those of reproductive age [24-26]. Abnormal menstrual bleeding, pelvic pain, and infertility are the most commonly experienced symptoms in these women. Uterine fibroids are the leading cause of hysterectomies performed in the United States, accounting for over 200,000 of these procedures each year. Other invasive surgical interventions for the treatment of uterine fibroids include myomectomy and uterine artery embolization. Leiomyomas are estrogen-responsive tumors that can be treated... 

The three-month (II) and one-year (10) results of both surgical myomectomy and alcohol septal ablation were comparable, however, surgical myomectomy was superior to ablation in terms of improved exercise test parameters (Table I) (14). Studies indicate maintenance of clinical and hemodynamic... 

Diamond M. Rednction of adhesions after nterine myomectomy by Seprafilm membrane (HAL-F) a blinded, prospective, randomized, mnlticenter clinical study. FertU Steril 1996 66 904-910. 

Traditionallysymptomaticfibroidshavebeen treated either surgically or medically. Surgical treatments include hysterectomy, myomectomy (either hy open procedure, laparoscopically or hysteroscopically), myolysis or endometrial ablation. 

Currently, UAE is not recommended as the first line of therapy in patients with infertility presumed to be caused by fibroids. Patients in whom fibroids are not symptomatic but who are infertile, should be evaluated for other causes of infertility and, if fibroids are the cause, the potential for myomectomy. In patients who are symptomatic from the fibroids (menorrhagia, bulk symptoms) and whom myomectomy is not... 

Table 10.2.3. Prevalence of obstetric complications seen in the general population, those following UAE and those following laparoscopic myomectomy...

Fedele L, Parazzini F et al (1995) Recurrence of fibroids after myomectomy a transvaginal ultrasonographic study. Hum Reprod 10 1795-1796... 

Goldberg J, Pereira L et al (2004) Pregnancy outcomes after treatment for fibromyomata uterine artery embolization versus laparoscopic myomectomy. Am J Obstet Gynecol 191 18-21... 

LaMorte Al, Lalwani S et al (1993) Morbidity associated with abdominal myomectomy. Obstet Gynecol 82 897-900... 

Razavi MK, Hwang G et al (2003) Abdominal myomectomy versus uterine fibroid embolization in the treatment of symptomatic uterine leiomyomas. AJR Am J Roentgenol 180 1571-1575... 

Subramanian S, Clark MA et al (2001) Outcome and resource use associated with myomectomy. Obstet Gynecol 98 583-587... 

Vercellini P, Trespidi L et al (2003) Gonadotropin-releasing hormone agonist treatment before abdominal myomectomy a controlled trial. Fertil Steril 79 1390-1395... 

In addition to volume reduction, the detection of new fibroids should be a priority since it is very common with other uterus-sparing therapies [20]. The remaining question is the duration between UFE and clinical recurrence due to new fibroids and whether this interval is different from that seen after myomectomy. 

Another measure of outcome is the effectiveness of UFE in avoiding other treatments for fibroids, as measured by subsequent medical therapies or additional surgery. For example, hysterectomy or additional hysteroscopic resection or myomectomy for clinical failure or recurrence after UFE is an important measure of safety and a key outcome measure of UFE [2]. Spies et al. [9] reported nine (4.5%) hysterectomies out of 200 patients within 12 months of therapy. Seven of the patients underwent hysterectomy for clinical failure after UFE. The other two patients underwent incidental hysterectomy for treatment of a tubo-ovarian abscess and an adnexal mass. In a series of 400 women. Walker and Pelage [7] reported 23... 

Fig. 10.4.6a,b. A 36-year-old woman with bulk-related symptoms, a Pre-embolization sagittal T2 weighted MRI shows a large pedunculated subserosal fibroid (F). b At 6 months post-embolization MRI shows a degenerative fibroid (F) with no volume reduction. The patient ultimately required myomectomy... 

Table 10.4.4. Results of a study comparing embolization to abdominal myomectomy ([111])...

Embolization (n=102) Hysterectomy Statistics (n=50) Embolization (n=67) Myomectomy (n=44) Statistic... 

It appears that after pluridisciplinary evaluation with gynecologists and interventional radiologists involved, UFE can be offered to women who plan future pregnancy if the only surgical options are repeated myomectomy or hysterectomy. 

In conclusion, uterine artery embolization is both a safe and effective procedure to offer patients with symptomatic uterine fibroids. UFE has been described as a valuable alternative to hysterectomy and recurrent multiple myomectomy. Clinical success rates for control of heavy menstrual bleeding, pelvic pain and bulk-related symptoms have been reported to be 80%-95% of patients treated with a low rate of recurrence. The risk of major complications, including pulmonary embolism, uterine... 

McLucas B, Adler L (2001) Uterine fibroid embolization compared with myomectomy. Int J Gynaecol Obstet 74 297-299... 

Baker CM, Winkel CA, Subramanian S, Spies JB (2002) Estimated costs for uterine artery embolization and abdominal myomectomy for uterine leiomyomata a comparative study at a single institution (2002) J Vase Interv Radiol 12 1207-210... 

Al-Fozan H, Dufort J, Kaplow M, Valenti D, Tulandi T (2002) Cost analysis of myomectomy, hysterectomy and uterine artery embolization. Am J Obstet Gynecol 187 1401-1404... 

Sabatini L, Atiomo W, Magos A (2003) Successbil myomectomy following infected ischaemic necrosis of uterine fibroids after uterine artery embobsation. Br J Obstet Gynaecol 110 704-710... 

Broder MS, Goodwin SC, Chen G et al. (2002) Comparison of long-term outcomes of myomectomy and uterine artery embolization. Obstet Gynecol 100 864-868... 

Recently, two minimally invasive therapies have been introduced to treat uterine fibroids. High frequency focused ultrasound and transvaginal paracervical clamping of the uterine arteries have been reported in the management of symptomatic uterine fibroids [10]. From our own experience with the use of uterine fibroid embolization, we know that unless complete devascularization of all identified fibroids is obtained after these therapies, the results in terms of recurrence will not be better than after myomectomy and maybe higher than after embolization. 

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