Intrauterine adhesions after open myomectomy: an audit

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Abstract

Objective

To estimate the incidence of intrauterine adhesions after open myomectomy.

Study design

A prospective audit descriptive study was conducted involving thirty-six women who had undergone open myomectomy for symptomatic fibroids at a large undergraduate teaching hospital. A follow-up out-patient hysteroscopy was performed three months after surgery.

Results

At hysteroscopy, eighteen patients (50%) were found to have mild to moderate intrauterine adhesions. The number of fibroids removed was significantly higher in patient who developed adhesions (median value 22 versus 9.5, p < 0.05). Pre-operative GnRHa therapy, uterine size, opening of the uterine cavity during surgery, specimen weight, estimated blood loss, post-operative bleeding or pyrexia were similar whether or not adhesions were found.

Conclusion

Open myomectomy represents an important but currently underappreciated aetiological factor in the formation of intrauterine adhesions.

Introduction

Uterine myomas are the most common findings in woman with the highest prevalence registered by the age of 50 [1]. Open myomectomy is often considered the only realistic solution for symptomatic women with multiple and/or large fibroids who wish to retain their fertility. As more women opt for conservative surgery, the number of open myomectomies carried out is increasing. For instance, in UK, 1414 open myomectomy was performed in 2001–2002, while the most recent report published in 2012–2013 showed that the number is almost doubled to 2786 [2].

Although usually effective in terms of symptom relief, open myomectomy is not without risk, hemorrhage, infection and the need to convert to hysterectomy being the more common complications associated with surgery. Not often mentioned are post-operative intrauterine adhesions which, although not as dramatic, appear to be a definite risk as suggested by the study of Schenker and Margalioth in 1982. In a retrospective study involving 1856 women with intrauterine adhesions, they reported that myomectomy was an etiological factor in 1.3% of cases [3].

Hysteroscopy is considered the gold standard for the diagnosis of intrauterine adhesion. Compared with other methods such as ultrasound or hysterosalpingography, the accuracy of hysteroscopic images have significantly increased the detection of synaechiae worldwide allowing their treatment in most of the cases [4]. We carried out a prospective audit to document the incidence of post-operative intrauterine adhesions in patients undergoing open myomectomy at our institution.

Section snippets

Material and methods

Starting in June 2011, we arranged for all the patients who had undergone open myomectomy under the care of the senior author to have an outpatient (office) diagnostic hysteroscopy 3 months after their surgery. Indications for open myomectomy included symptomatic fibroids, a wish to preserve fertility/uterus and/or ineligibility for other treatment options such as uterine artery embolization and laparoscopic or hysteroscopic myomectomy. Patients were only treated with gonadotropins releasing

Results

Between June 2011 and February 2013 a total of 36 patients underwent hysteroscopy 3 months after open myomectomy. The average age of the study group was 39.8 (SD 5.7) years. Fourteen had been pre-treated with a GnRHa. The mean uterine size at the time of surgery was equivalent to a 19.9 weeks gestation (range: 12–36), and an average of 16.9 fibroids were removed per patient (range: 2–47), weighing 744 g (range: 68–3800). The uterine cavity was entered in 19 (52.8%) cases to remove submucous or

Comments

Our audit shows that 50% of women undergoing open myomectomy are found to have mild to moderate intrauterine adhesions three months after surgery when assessed by hysteroscopy. The risk of adhesions increased with increasing number of fibroids removed but was not influenced by opening the uterine cavity and nor were adhesions more severe in those cases where the uterine cavity had been opened. Injecting an anti-adhesive agent such as hyalobarrier into the uterine cavity did not seem to protect

Acknowledgements

We would like to thank Prof Giuseppe De Placido, Dr Antonio Mollo and Dr Carlo Alviggi for their support in the preparation of the manuscript.

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