Myomectomy during cesarean section

Uterine fibroids are the most common gynecological disorder. According to some authors, it prevails in 20–70% of women of reproductive age [1–4]. The prevalence of uterine fibroids in pregnant women is 0.5–6% [3, 5–7], and is steadily increasing and correlates with advanced maternal age, the increasing use of assisted reproductive technologies, the prevalence of hormonal therapy and contraception, as well as endocrine disorders. During pregnancy, growth of uterine fibroids occurs in the first trimester [8]. Currently, there is no consensus on performing myomectomy during cesarean section. It is a known that Victor Bonney, a British gynecological surgeon performed the first myomectomy during caesarean section in 1913. He performed myomectomy (removed six large fibroids) in 30-year-old patient, and she had 3 vaginal births afterwards [9].  Over 100 years have passed since that publication, but the situation was not significantly clarified. Currently, there are no clear indications or description of techniques to perform myomectomy during cesarean section. Online information search for “myomectomy during cesarean section” is presented by descriptions of clinical cases in most publications in the Russian and English languages [10–17]. There are controversial opinions on advisability of myomectomy during cesarean section due to prolonged operative duration, larger wound surface area and increased blood loss, as well as possible complications, such as intraoperative hemorrhage, intramuscular hematoma formation in the area of  surgical incision, postoperative purulent-septic complications, venous thromboembolism, abdominal adhesive disease and long-term complications associated with uterine scar and its effect on subsequent fertility [18–22]. Moreover, the area of expertise of the vast majority of today’s doctors is focused on obstetrics, and they have no necessary skills in gynecological surgery that allow them, if necessary, to extend surgical intervention to  hysterotomy.

The latest clinical guidelines “Uterine fibroids” (2020) of the Ministry of Health of Russia indicate that during cesarean delivery it is advisable to perform myomectomy only in the presence of fibroids preventing extraction of the fetus [4]. However, most practicing obstetricians are well aware that postpartum uterine contractions lead to malnutrition and ischemia of large uterine fibroids, subinvolution and abnormal lochia after giving birth that worsens the course of the postpartum period. Broader indications for myomectomy during cesarean section are presented in the national guidelines “Obstetrics” (2018). It is stated there that myomectomy during cesarean section should be performed in the presence of subserous fibroids in thin layer in any accessible location, subserous fibroids at the wide base (excluding the lower segment), in the presence of no more than 5 large intramural fibroids > 10 cm (no more than one fibroid with centripetal growth (more than 10 cm (no more than one fibroid), with good access to fibroids in different locations, excluding intramural fibroids < 5 cm [1]. In addition, in the presence of multiple uterine fibroids with low location (cervical or isthmic fibroids), malignancy of the fibroid that is histologically confirmed during surgery, when the circumstances require ssimultaneous removal of the uterine appendages (ovarian tumors, tubo-ovarian masses), hysterectomy is indicated.

The technique for performing myomectomy to remove intramural (interstitial) uterine fibroids was described by V.I. Krasnopolsky [23]. The technique comprises performing a linear or oval uterine incision with a scalpel, until the capsule of fibroid is visualized, which is also dissected. Fibrous connective tissue is fixed with bullet forceps in the longitudinal direction and pulled into the wound. Fibroid is removed and the uterine fibroid bed is sutured with double-row or three-row of sutures. The disadvantage of this method is increased bleeding due to gestational changes in myometrium; hemostasis is time consuming due to injury of serous membrane of the uterus, and there is a risk adhesion development at the site of the injury to visceral peritoneum. The problems for providing effective hemostasis increase the duration of surgery, the amount of needed suture material, and the risk of early and late postoperative complications. Surgical techniques of endometrial myomectomy, which is performed during cesarean section through incision in the uterus, are described in literature [24].

Unfortunately, the latest mandatory clinical guidelines do not provide legal protection for doctors against extension of surgery during cesarean section. Under these circumstances, the surgeon is responsible for making a decision about the choice of surgical methods for myomectomy and surgical outcome.

The purpose of our study was to assess the feasibility of performing myomectomy during cesarean section using different techniques, the effect of extension of surgery on the duration of surgery, intraoperative blood loss, and the course of the postoperative period.

Materials and methods

The study was conducted at the Department of Pregnancy Pathology, the University Clinic of Saint Petersburg State Pediatric Medical University. The surgical protocols of 377 patients, who delivered babies through cesarean section, and the delivery histories of 69 women with uterine fibroids were investigated. The patients were divided into 2 groups: group 1 consisted of 24 women who underwent myomectomy during cesarean section and group 2 consisted of 45 patients, who did not undergo myomectomy. The medical histories, surgical protocols, laboratory data (clinical laboratory tests results, biochemical, bacteriological, histological findings) and instrumental data (ultrasound examination) were analyzed.

Statistical analysis

Statistical analysis of the data was performed using Statistica software program. The Lilliefors-corrected Kolmogorov–Smirnov test was used for normality of distribution of the parameters. Descriptive statistics for normal distribution of the data is presented as mean (M) and standard deviation (SD). The quantitative data that do not follow a normal distribution are presented as median and interquartile range – Me (Q1; Q3). Comparison of data sets for quantitative characteristics with a normal distribution was made using the independent samples T-test. Skewed distribution of data were analyzed using the Mann–Whitney U-test. The threshold value, that determined statistical significance, was considered as p=0.05. Descriptive statistics for qualitative data is presented as absolute frequency and relative frequency.

Results

Delivery records of 377 patients of the Department of Pregnancy Pathology, the University Clinic of Saint Petersburg State Pediatric Medical University, who underwent elective cesarean delivery in 2022, were investigated. Uterine fibroids were diagnosed in 69/377 (18.3%) patients. Myomectomy during cesarean section was performed in 24/377 (6.4%) patients. The decision about necessity to perform myomectomy taking into account personalized risks, was made collectively together with the deputy Chief Physician and the Head of the Department, on the day before surgery or intraoperatively. Depending on the volume of surgery, the patients were divided into 2 groups. Group 1 included 24 women who underwent myomectomy during cesarean section and group 2 consisted of 45 patients with uterine fibroids, who underwent elective cesarean delivery without extension of surgery to myomectomy. The mean age of patients in group 1 was 36/08 (4/4/) years versus 38.58 (5.1) years in group 2, p=0.048.

Detailed evaluation of the group of women who underwent myomectomy during cesarean section showed that in 12/24 (50%) women, uterine fibroids were the major indication for cesarean delivery due to the fact, that uterine fibroids were located in the isthmus of uterus along the anterior and posterior walls and would obstruct the passage of the fetus through the maternal birth canal, or due to very large fibroids that would lead to abnormalities of labor. A total of 39 uterine fibroids 2–15 cm in size were removed in 24 patients. The analysis of localization of removed fibroids showed that most of them were located on the anterior uterine wall –  23/39 (59.0%), 5/39 (12.8%) and 5/39 (12.8%) fibroids were removed from the anterior uterine wall in the region of isthmus and the fundus of the uterus, 3/39 (7.7%) and 3/39 (7.7%) were located on the posterior site of uterine isthmus and on the posterior wall of the uterus. According to the FIGO classification system for fibroids, most of removed fibroids 18/39 (46.1%) were intramural (type 4), 14/39 (35.9%) were subserosal/intramural (type 5), and 5/39 (12.8%) were subserosal (type 6–7). Submucosal and intramural fibroids (type 2–3) and intraligamentary fibroids (type 8) were removed less often – 1/39 (2.6%) and 1/39 (2.6%), respectively.

We could use various fibroid removal options. The final decision was made intraoperatively after the fibroid was assessed by visualization or palpation. For fetal extraction, myomectomy was performed to remove 2/39 (5.1%) fibroids before hysterotomy. These were the cases when large fibroids were located in the anterior uterine wall of the lower uterine segment in the area of incision of the uterus to remove the fetus. However, despite the abnormal signs of cesarean section, fetal extraction in these situations was performed at 4 and 5 minutes from the start of surgery and did not affect the Apgar birth scores for newborns. More than half of uterine fibroids 22/39 (56.4%) were removed using traditional surgical technique after opening uterine serous membrane [23]. However, in these cases, we made sagittal incision above the fibroid that was 2 times smaller than the size of palpated fibroid. Adequate uterine contractility and smaller incision size makes it possible to reduce the number of complications associated with hemostasis of the wound. Myomectomy of 2/39 (5.1%) fibroids, which is called endometrial myomectomy, was performed at the site of uterine cavity.  In our opinion, this technique is most successful for submucosal/intramural and intramural fibroids. Postpartum uterine plasticity allows expulsion of the fibroid during palpation in the direction desirable for the surgeon. Surgery performed without damaging uterine serous membrane has the advantage of reducing intraoperative blood loss. In 13/39 (33.3%) cases, transmural myomectomy was performed, when intramural fibroid was located on the anterior wall of the uterus at a distance of no more than 4 cm from the edge of uterine incision in caesarean section. The performance of myomectomy in this case was as follows: the classical cesarean section was performed. The transverse uterine incision was done in the lower segment. Then the size, location and the growth pattern of uterine fibroid was determined by visual examination and palpation. When intramural fibroid (type 3–5 according to the FIGO classification) measuring 5 cm was located in the anterior wall of the uterus at a distance of no more than 4 cm from the edge of the hysterotomy incision, transverse uterine muscle splitting incision was performed at the site of hysterotomy incision in cesarean section.

The lower pole of fibroid was reached through formation of the tunnel, the capsule of fibroid was opened, the fibroid was grasped with bullet forceps, the fibroid was enucleated using a combination of sharp and blunt dissection. The length of the incision and the depth of the tunnel depend on the size of fibroid.  Then, uterine fibroid bed and the tunnel made for its removal were sutured using U-shaped suture technique through uterine wall thickness, and the knots were tied involving the uterine serous membrane. The number of U-shaped sutures depends on the size of the removed fibroid. We believe that transmural myomectomy during cesarean section leads to reduction of uterine injuries, preserving the structural integrity of uterine serous membrane, reduction of intraoperative bleeding intensity, shortening the operative time, lesser amount of suture material, and lower number of postoperative complications [25].

Cesarean section and myomectomy was performed in 11/24 (45.8%) women, who underwent additional surgical procedures. In particular, 7/24 (29.2%) patients underwent uterine devascularization by ligation of the branches of the uterine arteries: 1/24 (4/2%) patient underwent ovariocystectomy and 1/24 (4/2%) patient underwent adhesiolysis. Endometrial myomectomy was performed on one of the patients, and    intrauterine Zhukovsky balloon catheter was used to prevent bleeding in the early postoperative period. One patient in the group of cesarean section with myomectomy underwent hysterectomy. This was patient Z, aged 38 years, who gave birth the second time and had multiple large uterine fibroids, that were located in the isthmus of the uterus. Intraoperative examination found that the size of dominant  intramural fibroid No.1 was 15 cm. It was located in the isthmus of uterus along the posterior wall, and deformation of the uterine cavity was due to its size. Below fibroid No.1, subserosal fibroid No. 2 with restricted mobility, 8 cm in diameter, was visually determined in the uterine isthmus. Given a high risk of massive intraoperative hemorrhage in myomectomy, due to the topography and size of fibroids, the intraoperative concilium made a decision to perform total hysterectomy without removal of the appendages.

The comparative analysis of surgeries performed in the groups and surgical outcomes included duration of surgical intervention, the time of fetal extraction, blood loss, the length of postoperative period in patients in group 1 (who underwent myomectomy during cesarean section, n=24) and in patients in group 2 (who had uterine fibroids, but did not underwent myomectomy during cesarean section, n=45) (Table). It was found that duration of surgical intervention was significantly longer in patients in group 1, and was 60.0 (20.49) minutes versus 46,2 (13.15) minutes in group 2, p=0.001. In group 2, 6 pregnant women gave birth to twins, and 45 patients gave birth to 51 infants. There was no statistically significant difference between the groups in the time of fetal extraction from the start of surgery – 3 (3; 5) minutes in group 1 and 4 (3; 5) minutes in group 2, p=0.31. There was no statistically significant difference between the groups in intraoperative blood loss –  700 (550; 850) ml in group 1 and 650 (500; 700) ml in group 2, p=0.64. Uterine fibroids had no significant effect on the weight and condition in newborns. The babies in both groups were born without hypoxia weighing 3144.17 (452.5) g in group 1 and 3037.45 (584.6) g in group 2, p=0,43. In the postoperative period, antimicrobial therapy with ceftriaxone daily dose of 2.0 g for 5 days was indicated. Low molecular weight heparin was indicated for the prevention of venous thromboembolism. The duration of intake depended on the calculated risk of venous thromboembolism. Extension of surgery did not lead to occurrence of postoperative complications. The puerperant women in both groups were timely discharged from hospital on day 4–6 in the postpartum period.

Conclusion

The rational approach to planning and performance of myomectomy during abdominal delivery does not lead to increased blood loss and other intra- and postoperative complications. Myomectomy during cesarean section should be performed by a multidisciplinary team at level 3 facility. The surgical team should include surgeons (who have experience in hysterotomy technique, ligation of blood vessels, different suturing techniques), anesthesiologist, transfusiologist, and neonatologist. Preoperative preparation requires thorough physical examination, including ultrasound and magnetic resonance imaging for an accurate topographic description of the tumor. It is necessary to communicate with the patient regarding peculiarities of surgery, risks and possible intraoperative complications, and obtain informed consent to perform cesarean section with expansion of surgical intervention to hysterectomy. The risk of intraoperative blood loss is reduced by preoperative blood components procurement for possible blood transfusion, the use of blood-saving techniques (intraoperative reinfusion of blood), and surgical hemostatic technologies. The technique for optimizing myomectomy depends on the location of fibroid, its growth pattern, and surgeon’s preferences. Traditionally, myomectomy can be performed by transmural access through surgical wound, opening serous membrane over the fibroid and further enucleation of the fibroid via trans-endometrial approach. The results obtained in the study confirm the feasibility of performing myomectomy during cesarean section and safety approach, that helps to improve immediate and long-term treatment results and has significant medical and cost effectiveness.