Fertility and Pregnancy Outcome after Myoma Enucleation by Minilaparotomy under Microsurgical Conditions in Pronounced Uterus Myomatosus

 

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Abstract

Introduction: Besides the typical complaints and symptoms, myomas can cause sterility, infertility and complications during pregnancy. Laparoscopic interventions reach their limits with regard to organ preservation and the simultaneous desire to have children in the removal of multiple and larger intramural myoma nodes. The aim of this study is to examine fertility status and pregnancy outcome after myoma removal by minilaparotomy (skin incision maximal 8 cm) in women with pronounced uterus myomatosus. Materials and Methods: This retrospective study makes use of the data from 160 patients with an average age of 34.6 years. Factors analysed include number, size and localisation of the myomas, complaints due to the myoma, pre- and postoperative gravidity, mode of delivery, and complications of birth. Results: Indications for organ-sparing myoma enucleation were the desire to have children (72.5 %), bleeding disorders (60 %) and pressure discomfort (36.5 %). On average 4.95 (SD ± 0.41), maximally 46 myomas were removed. The largest myoma had a diameter of 6.64 cm (SD ± 2.74). 82.5 % of the patients had transmural myomas, in 17.5 % the uterine cavity was inadvertently opened. On average the operating time was 163 minutes (SD ± 45.47), the blood loss 1.59 g/dL (SD ± 0.955). 60.3 % of the patients with the desire to have children became pregnant postoperatively. 75.3 % of the pregnancies were on average carried through to the 38th week (28.4 % vaginal deliveries, 71.6 % Caesarean sections). In the postoperative period there was one case of uterine rupture in the vicinity of a previous scar. Discussion: By means of the microsurgical “mini-laparotomy” even extensive myomatous uterine changes can, in the majority of cases, be operated in an organ-sparing manner with retention of the ability to conceive and to carry a pregnancy through to maturity of the infant. The risk for a postoperative uterine rupture in a subsequent pregnancy and during delivery is minimal.

Zusammenfassung

Einleitung: Myome können neben typischen Beschwerden und Symptomen Sterilität, Infertilität und Schwangerschaftskomplikationen verursachen. Laparoskopische Eingriffe stoßen bei der Entfernung multipler und großer intramuraler Myomknoten bez. der Organerhaltung bei vorhandenem Kinderwunsch an ihre Grenzen. Ziel der Arbeit ist, das Fertilitätsvermögen und Schwangerschaftsoutcome nach Myomentfernung per Minilaparotomie (Hautinzision max. 8 cm) bei Frauen mit ausgeprägtem Uterus myomatosus zu untersuchen. Material und Methodik: Die retrospektive Arbeit beinhaltet Daten von 160 Patientinnen mit einem mittleren Alter von 34,6 Jahren. Analysiert wurden Zahl, Größe und Lage der Myome, myombedingte Beschwerden, prä- und postoperative Graviditäten, Entbindungsmodus und Geburtskomplikationen. Ergebnisse: Indikationen zur konservierenden Myomenukleation waren Kinderwunsch (72,5 %), Blutungsstörungen (60 %) und Druckbeschwerden (36,5 %). Im Mittel wurden 4,95 (SD ± 0,41), max. 46 Myome entfernt. Der größte Myomdurchmesser betrug 6,64 cm (SD ± 2,74). In 82,5 % lagen transmurale Myome vor, in 17,5 % wurde das Cavum uteri intraoperativ ungewollt eröffnet. Die Operationsdauer betrug durchschnittlich 163 min (SD ± 45,47), der Blutverlust 1,59 g/dl (SD ± 0,955). 60,3 % der Kinderwunschpatientinnen wurden postoperativ schwanger. 75,3 % der Schwangerschaften wurden im Mittel bis zur 38. SSW ausgetragen (28,4 % vaginale Geburt, 71,6 % Sectiones). Postoperativ trat einmal eine Uterusruptur im Bereich einer alten Sectionarbe auf. Diskussion: Mittels mikrochirurgischer „Mini-Laparotomie“ lassen sich selbst erhebliche myomatöse Uterusveränderungen organerhaltend operieren und die Konzeptionsfähigkeit sowie das Vermögen, eine Schwangerschaft bis zur Reife des Kindes auszutragen, in hohem Maße wiederherstellen. Das Risiko für postoperative Uterusrupturen in graviditate und während der Geburt ist minimal.

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