Hemorrhage: A strong indicator for myomectomy-related complication

Abstract

Uterine fibroid (leiomyoma or myoma) is the most common benign uterine tumor, accounting for 20–60% of cases in women of reproductive age.1 Three variant-subcategories include: (1) ordinary leiomyoma—benign, including nondegenerated and degenerated [cystic, hemorrhagic (carneous), fatty (lipoleiomyoma), hyaline, and myxoids]; (2) leiomyoma variants—unclassified (mitotically active, cellular, atypical, and smooth muscle tumors of uncertain malignant potential); and (3) leiomyosarcoma—malignant.2 The use of a uterine-preservation strategy, including medical or surgical treatment rather than hysterectomy, to treat uterine myoma has become popular, because it not only provides adequate symptom control, but also preserves fertility.3–5 Advanced surgical instruments, including new and innovative laparoscopic techniques with and without robotics-assisted systems, have allowed a greater number of gynecologic surgeons to use laparoscopic surgery in place of conventional exploratory laparotomy in the management of various kinds of diseases, including some gynecological malignancies.6–8 Furthermore, these so-called minimally invasive surgeries claim to have many patient-focused benefits, such as a decreasing risk of postoperative adhesion, promoting rapid recovery, and cosmetic advantages.9 However, the malignant form (leiomyosarcoma) is difficult to differentially diagnose clearly between benign and malignant tumors, resulting in an almost impossible presurgical diagnosis and contributing to the elevated possibility of widespread malignant tumors during and after operation, especially for those surgeries using morcellation. An increasing number of surgeons are hesitant, and some are outright opposed, to this approach in the management of uterine fibroids. Therefore, conventional laparotomy has regained a measure of popularity.10–12 Moreover, as surgical techniques have continued to advance, it is now possible to shorten the incision wound (ultramini-laparotomy), enabling patients to receive benefits similar to those of traditional laparoscopic surgery.11,12 Therefore, abdominal myomectomy is still considered the best choice for women with fibroids and who need to maintain their reproductive function.10,11 The study by Çinar et al13 in this issue of the Journal of the Chinese Medical Association entitled, “Association of clinical outcomes and complications with obesity in patients who underwent abdominal myomectomy,” investigated the outcomes of obese women who underwent abdominal myomectomy. The authors separated their patients into two groups: those with a body mass index (BMI) > 30 kg/m2 (n = 90; obese women), and those with a BMI ≤ 30 kg/m2 (n = 183; controls). The authors found that obese women had a significantly higher risk of both early and late complications relative to the controls (15.6% vs. 7.7%, p = 0.046; and 26.7% vs. 1.1%, p < 0.001, respectively), contributing to a longer hospital stay (3.3 ± 1.8 days vs. 2.8 ± 1.0 days, p = 0.001). Furthermore, the logistic regression model used to identify the association between BMI and the occurrence of both early and late complications showed a positive correlation, with an odds ratio (OR) of 1.446 [95% confidence interval (CI) 1.218–1.717). However, it was interesting to note that nonserosal type contributed to an even higher degree of positive correlation (OR 5.875, 95% CI 1.557–22.160), suggesting that the disease itself may play a critical role in the development of both early and late complications. After further analysis, we found that hemorrhage during operation was the most common early-type complication in both obese and nonobese women undergoing abdominal myomectomy, which occurred in 7% of all women, regardless of BMI. It is well known that tumor size, location, and operative time contribute to increased blood loss (hemorrhage) during operation. Our findings might explain why the authors showed that nonserosal-type uterine fibroids were the most significant predictive fac