For women desiring pregnancy, removing benign uterine fibroids using laparoscopy is more beneficial than the conventional surgical approach. That's the opinion of a group of doctors in a new study.1
Laparoscopy is a form of minimally invasive surgery that involves the use of a rod-shaped telescope attached to a camera, which, along with other slender instruments, is inserted into small incisions in the abdomen. Then surgeons perform the operation under high magnification. Laparoscopy is also used to diagnose certain conditions. The benefit is that this approach is much less invasive than making large incisions into the skin and underlying muscle, and subsequently creating a large surgical opening.2
A Painful Cause of Infertility
One of the potential causes of infertility is the presence of fibroids in the uterus, and one treatment option for women who eventually want to have children is known as myomectomy, or surgical removal of the fibroid tissue. However, there is no hard-line approach to treating fibroids for women who desire motherhood, writes Bradley Hurst, MD, a reproductive endocrinologist at Carolinas Medical Center in Charlotte, North Carolina, and his colleagues. One common treatment approach is known as myomectomy, or surgical removal of the fibroid. But this isn't necessarily the absolute treatment for all women who wish to become pregnant, experts contend.
"Because the incidence of uterine leiomyomas [fibroids] increases with age, fertility declines with age, and many women with fibroids conceive spontaneously, it is difficult to assess the direct impact of leiomyomas on fertility," Hurst and his team wrote. "Therefore, myomectomy is indicated only after a complete evaluation of other potential factors for infertility."
Specifically, surgeons must consider the size, location, and number of fibroids before deciding whether or not to perform myomectomy in cases in which women hope to correct their infertility.
Laparoscopy: More Beneficial in the Long Run?
But is conventional myomectomy the best option in these cases? Hurst's group analyzed a series of previous studies in the medical literature, also known as a meta-analysis, to determine whether laparoscopic myomectomy provides more benefits for the patient than myomectomy performed in open surgery.
"Before embracing laparoscopic myomectomy, this approach must be proven to be safe, effective, and in some ways, superior to abdominal myomectomy and other treatment options," the researchers stated.
Citing a trio of randomized controlled clinical trials that compared laparoscopic versus abdominal myomectomy, Hurst and his fellow investigators concluded that using laparoscopy allows patients less time in the hospital, and provides them a faster recovery, lower cost, less pain, less blood loss, less fever and fewer surgical complications. Given that, pregnancy rates and the risk of fibroid recurrence resulting from laparoscopy seem to be similar to those of open surgery, the researchers noted.
Even less stringent studies reviewed showed that performing myomectomy laparoscopically was more valuable to the patient, Hurst's team wrote. The studies showed that surgical times using laparoscopy were longer, but that recovery times were shorter. The studies also showed that just 2 percent of patients who originally underwent laparoscopy were later forced to undergo abdominal surgery due to complications.
Value of Preoperative Medications
Hurst and his team also evaluated the value of using gonadotropin-releasing hormone (GnRH) agonists prior to laparoscopy for uterine fibroids. Theoretically, these medications, which block the production of reproductive hormones in the body, can potentially shrink the fibroids and make laparoscopic surgery easier to perform. It's been suggested that these hormones are the cause of fibroids, though it hasn't yet been proven.3
However, Hurst and his colleagues found little benefit to the use of preoperative GnRH agonists. Surgical times were longer in women given the drugs before surgery compared to those not given medication, and in at least one study, the size of the fibroids removed from women given GnRH agonists versus those who were not were actually similar, Hurst and his team learned.
Finally, the researchers noted that both the odds of pregnancy and the incidence of miscarriage were similar, overall, in women who underwent laparoscopic versus abdominal myomectomy in the studies they reviewed. "This appears to be true for patients who require laparoscopic repair of the endometrial cavity, have large myomas, and for those who require IVF," they wrote.
Similar Outcomes Found
The investigators only found one prospective, randomized trial that evaluated pregnancy rates after laparoscopy versus open surgery for uterine fibroids, but found them to be similar between the two groups.4 Fifty-four percent of the women who underwent laparoscopic myomectomy got pregnant later, compared to 56 percent of those who underwent abdominal myomectomy. About 20 percent of those who underwent laparoscopy had a subsequent miscarriage versus approximately 12 percent of those who had open surgery, though that difference was not considered significant.
Outcomes in other studies were similarly alike. Hurst and his team determined that young women with otherwise unexplained infertility in cases in which a fibroid distorts the uterine structure have the best prognoses for future fertility. But whether a C-section or vaginal delivery is more beneficial to women after this type of surgery is still unknown, they stated.
Risks Using Laparoscopy
There are concerns for women who become pregnant after laparoscopic myomectomy. One of the most serious risks is uterine rupture, which can occur due to insufficient suturing or healing of an incision. But determining the actual risk is difficult, they wrote, due to limited information in the medical literature about it. Despite that, "when laparoscopic myomectomy is performed by experienced surgeons, uterine rupture or [inadequate healing of the incision] is a very infrequent complication," Hurst's group pointed out. And based on the studies that they did uncover, the risk appears to be minute.
In conclusion, Hurst's team determined that performing myomectomy laparoscopically is likely the more beneficial approach to abdominal surgery as a fibroid treatment in women wanting to remain fertile afterwards. Still, there are new approaches on the horizon that might preclude the need for surgery, they wrote.
The Future
"Promising treatments in some circumstances may include minimally invasive surgical approaches, such as hysteroscopic myomectomy and myolysis, ultrasound, and other imaging-directed means of myoma ablation, including uterine artery embolization [UAE], and pharmaceutical agents," they wrote.
Similar to laparoscopy, hysteroscopic myomectomy involves the use of slender instruments and a camera inserted through the cervix and into the uterus; myolysis involves the use of electrical, thermal and ultrasound energy to ablate, or destroy, a fibroid; and UAE involves blocking bloodflow to the fibroid, eventually shrinking it.5
1. Hurst BS, Matthews ML, Marshburn PB. Laparoscopic myomectomy for symptomatic uterine myomas. Fertil Steril 2005 Jan;83(1):1-23.
2. The Society of Laparoendoscopic Surgeons. About Laparoscopy & Endoscopy. Available at: http://www.sls.org/i4a/pages/index.cfm?pageid=3294. Accessed February 24, 2005.
3. Cook JD, Walker CL. Treatment strategries for uterine leiomyoma: the role of hormonal modulation. Semin Reprod Med 2004 May;22(2):105-11.
4. Seracchioli R, Rossi S, Govoni F et al. Fertility and obstetric outcome after laparoscopic myomectomy of large myomata: a randomized comparison with abdominal myomectomy. Hum Reprod 2000;15:2663-8.
5. American Academy of Family Physicians. Uterine Fibroid Embolization: A New Way to Treat Fibroids. Available at: http://familydoctor.org/601.xml. Accessed February 24, 2005.
John Martin is a long-time health journalist and an editor for Priority Healthcare. His credits include coverage of health news for the website of Fox Television's The Health Network, and articles for the New York Post and other consumer and trade publications.
