Peri-operative morbidity associated with abdominal myomectomy for very large fibroid uteri.

OBJECTIVE

To evaluate the safety of abdominal myomectomy for very large fibroid uteri, and to assess the effect of relevant confounding variables on the occurrence of major peri-operative complications.

STUDY DESIGN

A cohort study of 200 abdominal myomectomies for fibroid uteri of 16 gestational weeks or greater. Logistic regression analysis was used to examine the influence of important clinical variables on the risk of complications. A systematic literature search was conducted for evidence related to peri-operative morbidity associated with abdominal myomectomy for very large fibroid uteri.

RESULTS

The mean (±standard deviation) uterine size was 21±5 weeks. The overall rate of major complications was 30%. Peri-operative bleeding necessitating blood transfusion occurred in 49 (24.5%) cases. During surgery, two patients had bowel injury, two had bladder injury, seven women returned to theatre and two (1%) had hysterectomy. Four patients were re-admitted within 14 days of surgery. Multivariable logistic regression analysis showed that the risk of major complications was significantly higher in cases with a uterine size of 20 gestational weeks or more [odds ratio (OR) 3.4, 95% confidence interval (CI) 1.1-10.2; p=0.03], where 10 or more fibroids were removed (OR 3.5, 95% CI 1.1-10.8; p=0.05) and where midline skin incision was required (OR 6.1, 95% CI 1.7-22.3; p=0.006). On comparison of primary vs repeat abdominal myomectomy, there was significantly higher blood loss (mean 1023±1112 ml vs 579±787 ml; p=0.02) and risk of major complications in the repeat myomectomy group (40% vs 5%; p<0.001). The systematic review identified only one study that reported a comparable risk of major complications related to abdominal myomectomy for very large fibroid uteri.

CONCLUSION

The risk of organ injury, hysterectomy, re-operation or hospital re-admission after abdominal myomectomy for very large fibroid uteri is low, but the procedure is associated with a significant risk of bleeding necessitating blood transfusion. This risk is increased after repeat myomectomy, and in patients with a uterine size of 20 gestational weeks or larger, requiring removal of 10 or more fibroids, and requiring a midline skin incision.