GYNAECOLOGY
Laparoscopic Versus Abdominal Myomectomy: Practice Patterns and Health Care Use in British Columbia

https://doi.org/10.1016/S1701-2163(15)30484-9Get rights and content

Abstract

Objective

To examine the relative frequency and surgical outcomes of laparoscopic myomectomy compared with abdominal myomectomy in British Columbia.

Methods

A linked database containing hospital admission, operating room, and emergency room data from 2007 to 2011 from eight Vancouver Coastal Health and Providence Health Region hospitals in British Columbia was used to conduct a retrospective cohort study of women who had myomectomy for uterine fibroids. All consecutive women who had abdominal or laparoscopic myomectomy at five hospitals were included in the study. Patients who had submucosal fibroids or hysteroscopic procedures were excluded. Abdominal and laparoscopic myomectomies were contrasted in terms of patient characteristics and surgical outcomes. Statistical significance was assessed using t tests, Wilcoxon, chi-square, and Fisher exact test; a two-sided P value < 0.05 was considered significant.

Results

Of eight hospitals offering gynaecologic surgery, myomectomies were performed at five hospitals located in metropolitan areas. Of 436 women undergoing myomectomy, 88 cases (20.2%) were laparoscopic, 342 (78.4%) were abdominal, and 6 (1.38%) were laparoscopic with conversion to laparotomy. Women who had laparoscopic rather than abdominal myomectomies were slightly older (mean 38.7 vs. 37.4 years, respectively, P < 0.05). No significant difference was observed in median operative time (106 vs. 95 min), but length of stay was decreased for laparoscopic myomectomies (median 1 vs. 2 days, P < 0.01). No significant differences were observed between laparoscopic and abdominal routes in the rates of admission to intensive care, prolonged hospitalization (> 3 days), or rehospitalization.

Conclusion

Myomectomies are performed in urban, metropolitan areas in British Columbia, and a significant fraction of myomectomies are performed by laparoscopy. Compared with abdominal myomectomies, laparoscopic myomectomies in pre-selected patients are associated with decreased length of stay and comparable perioperative surgical outcomes.

Résumé

Objectif

Examiner la fréquence relative et les issues chirurgicales de la myomectomie laparoscopique, par comparaison avec la myomectomie abdominale, en Colombie-Britannique.

Méthodes

Une base de données liées contenant des données obtenues au moment de l’hospitalisation, dans la salle d’opération et dans la salle d’urgence entre 2007 et 2011 au sein de huit hôpitaux de la Vancouver Coastal Health and Providence Health Region, en Colombie-Britannique, a été utilisée pour mener une étude de cohorte rétrospective auprès de femmes ayant subi une myomectomie en raison de la présence de fibromes utérins. Toutes les femmes consécutives qui ont subi une myomectomie abdominale ou laparoscopique au sein de cinq hôpitaux ont été admises à l’étude. Les patientes qui présentaient des fibromes sous-muqueux ou qui ont subi des interventions hystéroscopiques ont été exclues. Les myomectomies abdominales et laparoscopiques ont été comparées en fonction des caractéristiques des patientes et des issues chirurgicales. La signification statistique a été évaluée au moyen des tests t, de Wilcoxon, de chi carré et exact de Fisher; une valeur P bilatérale < 0,05 a été considérée comme étant significative.

Résultats

Parmi les huit hôpitaux offrant des services de chirurgie gynécologique, les cinq hôpitaux qui ont mené des myomectomies étaient situés en région métropolitaine. Chez les 436 femmes ayant subi une myomectomie, 88 interventions (20,2 %) ont été menées par laparoscopie, 342 (78,4 %) l’ont été par voie abdominale et 6 (1,38 %) ont été menées par laparoscopie ensuite convertie en laparotomie. Les femmes qui ont subi une myomectomie laparoscopique, par comparaison avec celles qui ont plutôt subi une myomectomie abdominale, étaient légèrement plus âgées (moyenne : 38,7 vs 37,4 ans, respectivement, P < 0,05). Bien qu’aucune différence significative n’ait été constatée en matière de temps opératoire médian (106 vs 95 min), la durée de l’hospitalisation était moindre dans le cas des myomectomies laparoscopiques (médiane : 1 vs 2 jours, P < 0,01). Aucune différence significative n’a été constatée entre les voies laparoscopique et abdominale pour ce qui est des taux d’admission aux soins intensifs, d’hospitalisation prolongée (> 3 jours) ou de réhospitalisation.

Conclusion

En Colombie-Britannique, les myomectomies sont menées en région urbaine et métropolitaine; une proportion considérable de ces myomectomies sont menées par laparoscopie. Par comparaison avec les myomectomies abdominales, les myomectomies laparoscopiques menées chez des patientes présélectionnées sont associées à une durée d’hospitalisation moindre et à des issues chirurgicales périopératoires comparables.

Section snippets

INTRODUCTION

Fibroids (leiomyomata) are benign tumours that are common in women of reproductive age, affecting nearly 80% of premenopausal women.1 Symptoms of fibroids include heavy menstrual bleeding and increased abdominal pressure, causing significantly decreased quality of life.2 Surgical treatments for uterine fibroids tend to be invasive and expensive, but they are associated with increased quality of life.3 While hysterectomy remains the definitive treatment for fibroids, myomectomy is the preferred

METHODS

We conducted a study of all women undergoing laparoscopic or abdominal myomectomy for a benign indication between April 1, 2007, and September 15, 2012, in any hospital within the regions of British Columbia serviced by the Vancouver Coastal Health and Providence Health Care authorities. Together, these health authorities serve more than one million people (more than one quarter of the provincial population) and cover urban and rural geographic areas that include the city of Vancouver,

RESULTS

Of 436 women undergoing myomectomy, 88 cases (20.2%) were laparoscopic, 342 (78.4%) were abdominal, and 6 (1.38%) were laparoscopic with conversion to laparotomy.

Within the eight hospitals in the Vancouver Coastal Health and Providence Health Care regions that offered gynaecologic surgery, myomectomies were performed at five hospitals, all of which were located in the metropolitan area of Vancouver. Among the five hospitals, the proportion of myomectomies performed by laparoscopy ranged from 0%

DISCUSSION

Our study showed that between 2007 and 2012, approximately 20% of myomectomies for benign fibroids in the Vancouver Coastal Health and Providence Health Care regions of British Columbia were performed by laparoscopy. Most myomectomies occurred in hospitals within urban and metropolitan areas in British Columbia; such centralization of surgery for myomectomy may be appropriate, because the morbidity associated with myomectomy, compared with other gynaecologic procedures, increases the need for

CONCLUSION

Myomectomies are mostly performed in urban metropolitan hospitals in British Columbia. Approximately 20% of myomectomies are performed by laparoscopy, and these procedures are performed at a few centres of surgical expertise. Compared with abdominal myomectomy, laparoscopic myomectomy in pre-selected patients is not associated with increases in need for operating time or for emergency or hospital resources. Instead, laparoscopic myomectomy is associated with a decreased length of hospital stay.

ACKNOWLEDGEMENTS

We are grateful to the Vancouver Coastal Health Authority Decision Support and Providence Health Care Decision Support for providing the data used in this study. Innie Chen is supported by a Frederick Banting and Charles Best Canada Graduate Scholarship Award from the Canadian Institutes of Health Research, and K.S. Joseph is supported by a Chair in maternal, fetal, and infant health services research from the Canadian Institutes of Health Research.

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Competing Interests: None declared.

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