Laparoscopic myomectomy

M R C O G PA R T 2 · S O S P O C K E T C A R D · K N O W L E D G E A R E A 3 – C O R E S U R G I C A L S K I L L S

Laparoscopic Myomectomy: Alternatives, Techniques and Controversies Bryant-Smith A, Holland T. Laparoscopic myomectomy: a review of alternatives, techniques and controversies. TOG 2018;20:261–268. doi:10.1111/tog.12520

~1600/yr 70–80% 1 in 500–100 MYOMECTOMIES PERFORMED IN UK LIFETIME FIBROID INCIDENCE AGE-RELATED LEIOMYOSARCOMA RISK (<30 TO (EUROPEAN/AFRICAN ORIGIN) 75–79YR)

DO N' T-M IS S FA C TS

  1. No preoperative test definitively excludes leiomyosarcoma – must be stated explicitly during consent for LM/morcellation

  2. Age-related leiomyosarcoma risk (Brohl): 1 in 405 at 40–44yr vs 1 in 216 at 50–54yr; use power morcellation with extreme caution if LM offered >45yr

  3. FDA occult leiomyosarcoma prevalence estimate 1 in 350 (2014) was criticised – recalculated 1 in 1550 (Parker) to 1 in 8300 (Pritts)

  4. Overall LM complications ~11% (major 2%); conversion to open 1%; emergency hysterectomy 0.0–0.3%

  5. Parasitic myomata/DPL after morcellation: incidence 0.1–1%; uncontained morcellation obscures leiomyosarcoma diagnosis in 20% of cases

  6. Vasopressin doses as low as 0.2 units/ml may cause severe cardiopulmonary complications – liaise with anaesthetist

  7. Misoprostol 400 micrograms vaginally preoperatively + intraoperative vasopressin = moderate-quality evidence for reduced blood loss (Cochrane 2014)

  8. In-bag morcellation is still experimental – no proven prognostic benefit for unsuspected malignancy

EVIDENCE/CONSENT ESSENTIALS

Gold standard: LM for ≤3 symptomatic fibroids, fertility desired

Consent musts: parasitic myomata/DPL, occult malignancy upstaging, no test excludes leiomyosarcoma

ABBREVIATION KEY

LM — laparoscopic myomectomy RCOG — Royal College of Obstetricians and Gynaecologists

HMB — heavy menstrual bleeding GnRH-a — gonadotrophin-releasing hormone agonist

MRI — magnetic resonance imaging DPL — disseminated peritoneal leiomyomatosis

UAE — uterine artery embolisation FDA — US Food and Drug Administration

MRgFUS — magnetic resonance-guided focused ultrasound AAGL — American Association of Gynecologic Laparoscopists

RCT — randomised controlled trial BSGE — British Society for Gynaecological Endoscopy

NICE — National Institute for Health and Care Excellence

Source: The Obstetrician & Gynaecologist (TOG), RCOG journal — 2018;20:261–268. doi:10.1111/tog.12520

Clinically reviewed by NHS obstetricians and gynaecologists

MRCOG AI is an independent educational tool. It is not affiliated with, endorsed by, or connected to the Royal College of Obstetricians and Gynaecologists (RCOG).

Included with a Pass Package

Start free