3. Consider preoperative MRI
Preoperative imaging greatly supplements the clinical examination and facilitates identification of the number, location, and characteristics of the fibroids. Pelvic ultrasonography (US) is appropriate for most patients. We prefer preoperative MRI of the pelvis in the following scenarios:
- uterus larger than 12 weeks (280 g) on clinical examination
- identification of multiple fibroids via US
- history suggestive of adenomyosis.
MRI facilitates preoperative planning by accurately delineating the size and location of the fibroids, and by distinguishing between an adenomyoma and fibroid in most cases.9 For an example of its utility, see "How MRI can guide treatment: 3 cases."
4. Preoperative medical therapy may be indicated
When given preoperatively, gonadotropin-releasing hormone (GnRH) agonists have been shown to reduce blood loss and shorten operative time. The exception: cases involving hypoechoic fibroids, because the cleavage plane may be more difficult to identify, prolonging operative time.10
We generally prefer to use a GnRH agonist in two clinical scenarios: 1) anemia and 2) a uterus that extends above the umbilicus. In the second scenario, the GnRH agonist helps reduce the uterus to a more manageable size.
Aromatase inhibitors show great promise as preoperative agents because there is no initial flare. In addition, because fibroids have a higher concentration of aromatase activity than the surrounding myometrium, a low dosage of an aromatase inhibitor is effective and does not cause significant menopausal symptoms.
A recent comparative study found that fibroid shrinkage was greater after 3 months of letrozole (2.5 mg/day) than after use of a GnRH agonist.11 Total myoma volume decreased by 45.6% in the letrozole group, compared with 33.2% in the group that received a GnRH agonist (P =.02).11
Aromatase inhibitors have also been successfully used during the initial period of GnRH agonist therapy to prevent the symptoms of flare.12 However, because clinical experience is limited, the long-term efficacy and safety of aromatase inhibitors in premenopausal women is unknown.
How MRI can guide treatment: 3 cases
Findings A 40-year-old nulliparous woman seeks treatment for menometrorrhagia and dysmenorrhea but wants to conserve her uterus. MRI reveals a 4.5-cm submucosal fibroid (arrow) that extends all the way to the uterine serosa, with no evidence of adenomyosis. Her thyroid-stimulating hormone (TSH) level is normal, as is an endometrial biopsy.
CASE 1
Outcome We decide to proceed with laparoscopic myomectomy because a hysteroscopic approach would carry a risk of uterine rupture.
Findings A 36-year-old nulliparous woman complains of significant "bulk" symptoms (heaviness, urinary frequency, and abdominal bloating). She has a visible mass that extends four finger-breadths above the umbilicus. Pelvic MRI reveals multiple intramural fibroids in a uterus estimated to weigh roughly 2,850 g. The patient is given a 3-month course of a GnRH agonist.
CASE 2
Outcome After treatment with the GnRH agonist, the patient undergoes hand-assisted, laparoscopic, multiple myomectomy. She is discharged home the following day and resumes normal activities within two weeks.
Findings A 32-year-old nulliparous patient seeks treatment for menomenorrhagia and symptoms of bulk and expresses a desire for uterine conservation. Pelvic MRI reveals two distinct intramural fibroids, 6 cm and 9 cm in size.
CASE 3
Outcome The patient undergoes laparoscopic myomectomy without preoperative treatment with a GnRH agonist and is discharged home the same day without postoperative complication. (Although the uterus had two large fibroids, we did not use a GnRH agonist because the uterus was well below the belly button.)
5. Use careful surgical technique
Pay attention to set-up, initial entry
Although we lack definitive data on the practical utility of preoperative, intravenous (IV) antibiotics, we administer cefazolin prophylactically, switching to IV clindamycin if there is a documented allergy to penicillin.
In addition, a uterine manipulator is helpful when the patient has a small or medium-sized uterus. A variety of manipulators are available, but we generally use the VCare manipulator (ConMed Corp) because it is easy to insert and provides excellent uterine mobility.
Initial entry is at the umbilicus, unless the uterus extends above the umbilicus, in which case we enter in the left upper quadrant. We generally place the camera through the umbilical port and use two parallel operative ports on the left side of the patient, where the primary surgeon stands. A detailed description of our laparoscopic entry technique was published recently.13
Place the first trocar two finger-breadths medial and superior to the iliac spine and the second trocar 8 cm cephalad to the first port ( FIGURE 2 ). In a large uterus, trocars may have to be placed higher on the abdomen. A third operative port may be added on the right side, if it is needed.
