Laparoscopic myomectomy vs. open myomectomy for treating uterine fibroids

Despite a longer procedural time, laparoscopic myomectomy achieves superior results compared to open myomectomy when treating uterine fibroids, according to a literature search and meta-analysis in the journal Laparoscopic, Endoscopic and Robotic Surgery.¹

The authors noted that both primary options for treatment are currently being debated as to their efficacy and safety.

A total of 10 randomized control trials published between 1996 and 2019 were selected by conducting a comprehensive literature search of PubMed, ScienceDirect, and the Cochrane Library, representing 449 patients who underwent laparoscopic myomectomy and 449 patients who underwent open myomectomy.

Compared to open myomectomy, laparoscopic myomectomy was linked to reduced blood loss (mean difference [MD] = -34.43; 95% confidence interval [CI]: -34.92 to -33.94 (P < 0.001), an attenuated decline in hemoglobin (MD = -1.04; 95% CI: -1.14 to -0.93 (P < 0.001), less postoperative pain at 24 hours (MD = -0.51; 95% CI:

-0.83 to -0.19 (P = 0.002), and fewer overall complications (odds ratio [OR] = 0.42; 95% CI: 0.24 to 0.71 (P = 0.001).

However, laparoscopic myomectomy had a longer operative time (MD = 12.96; 95% CI: 9.94 to 15.97 (P < 0.001).

But there were no significant differences in pregnancy rate (OR = 1.39; 95% CI: 0.72 to 2.68; P = 0.33) or recurrence rate of postoperative uterine fibroids (OR = 1.15; 95% CI: 0.60 to 2.18; P = 0.67) between the 2 groups.

The longer surgical time for laparoscopic myomectomy might be due to a steeper learning curve, according to the authors, who noted that the laparoscopic procedure requires high accuracy and concentration to enucleate, morcellate, and suture. A greater number and larger size myomas can also increase surgery time.

On the other hand, blood loss and hemoglobin reduction were less pronounced in laparoscopic myomectomy than in open myomectomy, due to the laparoscopic procedure’s ability to coagulate.

Bipolar diathermy was also preferred over monopolar because only the large vessels were targeted, thus inducing less destruction of healthy myometrium.

“The injection of antidiuretic hormone (vasopressin derivatives) or diluted adrenalin around the fibroid wall (extracapsular) causes blood vessels to constrict and minimizes the bleeding to facilitate dissection,” wrote the authors.

Likewise, temporary bilateral uterine artery clipping decreases the blood supply and bleeding during myoma excision versus open myomectomy.

Hence, the authors believe it is critical that surgeons prepare for transfusion with the laparotomic procedure.

Postoperative pain, which was measured via the visual analogue scale (VAS), was less with laparoscopy for wound healing. Surgical wound pain gauged by VAS is directly linked to the surgical duration and postoperative removal of CO2. Parity and the degree of abdominal wall laxity are also probably 2 important considerations that influence postop pain types.

Another drawback of open myomectomy is that organ damage to the peritoneal wall can precipitate an increase in inflammatory factors, which could result in a higher likelihood of febrile conditions.

Although the study found laparoscopic myomectomy preferable to open myomectomy, the results were dependent on patient selection by the gynecologist’s knowledge, as well as learning curve, equipment fidelity, instrument reliability, and hospital directives.

__

Reference

1. Yudha P, Putra P, Prameswari AS, et al. Laparoscopic myomectomy versus open myomectomy in uterine fibroid treatment: a meta-analysis. Laparoscopic, Endoscopic and Robotic Surgery. September 2021. Volume 4, Issue 3; 66-71. doi:org/10.1016j.lers.2021.08.002