Jansen, L.I. (2017) Perioperative outcomes of myomectomy for extreme myomas : A comparison of surgical approaches. thesis, Medicine.
Full text available on request.Abstract
Introduction – Myomas affect 225 million women worldwide, and can significantly impair quality of life and productivity. A myomectomy is a surgical option for women with symptomatic myomas who want to preserve their uterus. However, choosing the optimal surgical approach for particularly heavy or numerous myomas remains a matter of debate. The aim of the study is to compare the perioperative outcomes of abdominal myomectomy (AM), laparoscopic myomectomy (LM) and robotic myomectomy (RM) in women with extreme myomas, defined by high specimen weight and/or myoma number. The secondary aim is to define thresholds of myoma weight and count at which certain modes of myomectomy are associated with an increased risk of perioperative complications. Materials and methods – This retrospective cohort study consists of women who underwent an AM, LM or RM at Brigham and Women’s Hospital, a large academic medical center in Boston, between 2009 and 2016 for extreme myomas; a subgroup compromised of the upper quartile for specimen weight and/or myoma count within a database of myomectomy cases as a whole. Medical records were reviewed to collect data on patient and procedure characteristics. Perioperative outcomes included estimated blood loss, operative time, length of stay and complications. Linear and logistic regression models were used to determine the association between these outcomes and AM, LM or RM. Cumulative Incidence Function (CIF) curves were plotted to evaluate the association between increasing myoma weight or number and the probability of any perioperative complication among each mode of surgery. To determine a threshold (in myoma weight and number) within the cohort of extreme myomas at which differential complication rates were maximal, logistic regression was performed. Results – A total of 659 women underwent AM (47.2%), LM (28.1%) or RM (24.7%) for extreme myomas. The uppermost quartile for extreme myomas was a total specimen weight equal to or greater than 434.6 grams, or 7 or more myomas. Myoma burden was different for the three routes with the greatest myoma burden removed in the AM group (mean weight 696.2 ± 784.5 grams for AM vs. 586.6 ± 426.1 grams for LM vs. 399.6 ± 250.1 grams for RM, p < .001; mean myoma count 16.8 ± 15.0 for AM vs. 7.2 ± 7.0 for LM vs. 6.7 ± 4.7 for RM, p < .001). The three routes also had different operative times and length of stay, with RM having the longest operative time (mean 239.7 minutes, p < .001) and AM the longest length of stay (mean 2.2 ± 0.9 days, p <.001). Other perioperative outcomes including estimated blood loss and complications were similar across the surgical approaches. The probability of any perioperative complication differed across modes with respect to both increasing specimen weight (p < .008) and number of myomas (p < .001). In addition, a threshold of 13 myomas was suggested at which an almost twofold-higher risk of perioperative complications (OR = 1.77; p = .009). Conclusion – Myomectomy for extreme myomas is feasible using an abdominal, laparoscopic, or robotic approach. Increased myoma burden is associated with an increased risk of perioperative complications, with a preference for AM or LM over RM for increased myoma weight, and a preference of AM over LM or RM for increased myoma count. In addition, a threshold of 13 myomas is associated with an almost twofold-higher risk of complications.
| Item Type: | Thesis (Thesis) |
|---|---|
| Supervisor name: | Klinkert, Dr. E.R. Gynecologist (faculty supervisor) |
| Supervisor name: | Cohen, Dr. S.L. gynecologist (second supervisor) and Department of obstetrics/gynecology, Division of Minimally I |
| Faculty: | Medical Sciences |
| Date Deposited: | 25 Jun 2020 10:43 |
| Last Modified: | 25 Jun 2020 10:43 |
| URI: | https://umcg.studenttheses.ub.rug.nl/id/eprint/486 |
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