| TYPE Original Research PUBLISHED 26 December 2022 DOI 10.3389/fsurg.2022.997078 Comparison of surgical and obstetric outcomes in women EDITED BY Tai-Ho Hung, Taipei Chang Gung Memorial Hospital, Taiwan with uterine leiomyomas after REVIEWED BY Kelly Wright, laparoscopic vs. abdominal Cedars Sinai Medical Center, United States Antonio Simone Laganà, myomectomy: A single-center University of Palermo, Italy *CORRESPONDENCE cohort study Emanuela Spagnolo ema.spagnolo@libero.it † Polán Ordás1† , Emanuela Spagnolo1†* , These authors have contributed equally to this work and share first authorship Lucía Gómez-Lavín Fernández2, María Dolores Diestro SPECIALTY SECTION Tejeda1 , Pilar Lafuente1 , Patricia Salas1, Ana Lopez This article was submitted to Obstetrics and Carrasco1 , María Carbonell1 and Alicia Hernández1,3 Gynecological Surgery, a section of the journal 1 Frontiers in Surgery Department of Obstetrics and Gynecology, La Paz University Hospital, Madrid, Spain, 2Department of Obstetrics and Gynecology, Consorci Sanitari Parc Taulí, Hospital de Sabadell, Barcelona, Spain, RECEIVED 18 July 2022 3 Department of Obstetrics and Gynecology, Faculty of Medicine, Universidad Autónoma de Madrid, ACCEPTED 08 December 2022 Madrid, Spain PUBLISHED 26 December 2022 CITATION Our aim was to study the advantages, complications and obstetrical outcomes Ordás P, Spagnolo E, Fernández LG-L, Diestro Tejeda MD, Lafuente P, Salas P, Lopez of laparoscopic myomectomy (LM) compared with abdominal myomectomy Carrasco A, Carbonell M and Hernández A (AM). We conducted a retrospective cohort study at La Paz University (2022) Comparison of surgical and obstetric Hospital that included LMs and AMs performed between 2012 and 2018, outcomes in women with uterine leiomyomas analyzing 254 myomectomies (142 AMs [55.7%] and 112 LMs [43.9%]). The after laparoscopic vs. abdominal myomectomy: mean number of fibroids was 1.8 ± 1.5 and 3 ± 2.9 for the LM and AM A single-center cohort study. Front. Surg. 9:997078. groups, respectively ( p < 0.006). The mean size of the largest myoma was doi: 10.3389/fsurg.2022.997078 7.6 cm ± 2.7 cm and 10.2 cm ± 5.4 cm for the LM and AM groups, COPYRIGHT respectively ( p < 0.001). LMs were associated with longer surgical times © 2022 Ordás, Spagnolo, Fernández, Diestro ( p < 0.001) and shorter hospitalizations ( p = 0.001). There were no significant Tejeda, Lafuente, Salas, Lopez Carrasco, differences in the intraoperative and postoperative complication rates Carbonell and Hernández. This is an open- access article distributed under the terms of the ( p = 0.075 and p = 0.285 for LM and AM, respectively). The subsequent Creative Commons Attribution License (CC BY). pregnancy rate was higher for the LM group (30.8% vs. 16.8%, p = 0.009), The use, distribution or reproduction in other with a vaginal delivery rate of 69% and no cases of uterine rupture. forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this KEYWORDS journal is cited, in accordance with accepted academic practice. No use, distribution or uterine leiomyoma, laparoscopy, myomectomy, obstetric outcome, uterine rupture reproduction is permitted which does not comply with these terms. Introduction Uterine fibroids, or leiomyomas, are benign uterine neoplasms that arise from smooth-muscle tissue and are present in 20%–40% of women of reproductive age (1–3) and 70%–80% of women older than 50 years (4, 5). In most cases, however, uterine fibroids go unnoticed, with only 40% of cases presenting symptoms. The most frequent symptoms are severe vaginal bleeding (and consequent anemia), pelvic pain, dysmenorrhea, worsening quality of life and reproductive dysfunction (6–9). The Frontiers in Surgery 01 frontiersin.org Ordás et al. 10.3389/fsurg.2022.997078 symptoms will depend basically on the composition, size, was conducted in all cases, classifying the fibroids according location and number of myomas (4–6, 9). to the International Federation of Gynecology and Obstetrics The classical treatment for uterine fibroids has been open classification (17). We analyzed the details of the surgery, abdominal hysterectomy. Cultural and social developments, as hospital stay and histology and described and compared the well as delayed conception age, have led to the development intraoperative and postoperative complications according to and improvement of myomectomy, which was first described the Clavien-Dindo classification (18), as well as the recurrence in the 1970s. For those patients who wish to retain their rates. Lastly, we investigated the pregnancy rates, conception reproductive ability, myomectomy is an alternative to method, delivery type and delivery outcomes. hysterectomy (3). The advent of minimally invasive techniques has significantly improved the short-term outcomes of major gynecologic surgery, including myomectomy, by enhancing Surgical technique recovery and decreasing pain and postoperative complications (10, 11). However, the current criteria for selecting patients Myomectomy was performed in both groups using the and deciding on the surgical approach are still a matter of intracapsular technique with pseudocapsule preservation, as debate (10, 12). previously described (19). The surgeries were performed by The presence of leiomyomas can affect obstetrical outcomes, an expert (more than 10 years of experience) minimally causing decreased fertility, increased pregnancy loss and invasive gynecologic surgeon (Table 1) or training surgeon. complications during pregnancy (13–15). The delivery mode To reduce intraoperative bleeding during the laparoscopic for these patients is controversial, given that many myomectomy, the patients were administered an obstetricians recommend elective caesarean delivery for most intramyometrial injection of dilute vasopressin (20 IU/100 ml patients with a previous history of myomectomy (mainly if normal saline), or a temporary uterine artery occlusion was the uterine cavity was entered at the time of surgery), despite performed using vascular clips (10-mm Hem-o-lok clip or a lack of strong supporting evidence (15). medium titanium clip). LM was performed using a 10-mm Therefore, this study’s main objective was to compare the trocar for the camera (placed at or above the umbilicus, surgical and obstetrical outcomes of laparoscopic depending on the size of the uterus). Two ancillary 5-mm myomectomy (LM) vs. open abdominal myomectomy (AM), trocars were inserted in each iliac fossa, and one ancillary thereby establishing selection criteria for the most appropriate 10–12 mm trocar was inserted in the suprapubic area. For surgical approach. the LM group, a RUMI® II System uterine manipulator (Cooper Surgical, Inc, Trumbull, United States) was employed. The surgeon therefore performed the following Materials and methods steps: transversal or oblique hysterotomy using a crochet needle electrode, enucleation of the myoma (by traction and After institutional review board approval (PI-3661), this counter-traction movements using a strong grasper and an retrospective cohort study included all patients who irrigator cannula inserted in the space under the myoma underwent LM or open AM at the Department of Gynecology pseudocapsule and fibroid) and suture of the uterine defect. of La Paz University Hospital between May 2012 and A bipolar clamp was used for selected hemostasis. The December 2018. The study included patients aged 18–50 myoma was finally extracted from the abdominal cavity years, with an ultrasound diagnosis of at least 1 myoma with using manual morcellation through the umbilical incision in a mean diameter ≥3 cm and presenting heavy menstrual endobag. The uterine walls were sutured in 1 or 2 layers, bleeding or infertility, pelvic pain or suspicious ultrasound according to the depth of the hysterotomy, with a findings (16) as the main indications for myomectomy. The continuous suture. For the uterine suture, the surgeon exclusion criteria were a postmenopausal state, history of employed a size 0 barbed suture (VLock, Covidien) or an primary ovarian insufficiency or tubal factor infertility and the absorbable monofilament thread 1/0 (Biosyn, Covidien). presence of uterine mass suspicious for malignancy. Patients The AM procedure was performed by a mini-Pfannenstiel were grouped according to the surgical approach: LM group incision. The surgeon attempted to remove all visible myomas and AM group. by using a minimum number of incisions. The uterine defect We collected preoperative data that included age, body mass was repaired using an absorbable multifilament thread 1/0 index, indication for surgery, preoperative hemoglobin levels, (Vicryl, Ethicon; Johnson & Johnson) or an absorbable previous myomectomy, previous use of ulipristal acetate (5 mg monofilament thread 1/0 (Biosyn, Covidien). As previously daily for 3–6 months), total number of myomas and the described for the LM group, the uterus was sutured in 1 or 2 diameter and location of the largest myoma as determined by layers, according to the depth of the hysterotomy, with a ultrasound. A preoperative systematic ultrasound examination continuous suture. Frontiers in Surgery 02 frontiersin.org Ordás et al. 10.3389/fsurg.2022.997078 TABLE 1 Patient characteristics of the two groups (laparoscopic myomectomy versus abdominal myomectomy). LM AM Total p (n = 112) (n = 142) (n = 254) Age (years) 35.91 (±5.517) 37.17 (±4.902) 36.60 (±5.244) 0.057 2 BMI (kg/m ) 23.37 (±4.631) 24.30 (±4.800) 23.82 (±4.749) 0.129 Preoperative Hb (g/dl) 13.15 (±1.279) 13.15 (±1.358) 13.15 (±1.328) 0.991 Barriers myomectomy 6 (5.4%) 12 (8.4%) 18 (7.2%) 0.310 Use of ulipristal acetate 15 (13.4%) 18 (12.7%) 33 (13%) 0.935 Indication 0.886 Several vaginal bleeding 35 (31.3%) 50 (35.2%) 85 (33.5%) Abnormal growing 31 (27.7%) 34 (23.9%) 65 (25.6%) Pelvic pain 25 (22.3%) 31 (21.8%) 56 (22%) Infertility 21 (18.8%) 27 (19%) 48 (18.9%) Ultrasound description Number of myomas 1.54 (±1.472) 1.99 (±2.076) 0.022 Largest size (cm) 6.79 (±2.175 8.67 (±2.631) 0.000 Type of the largest 0.567 Pedunculated 15 (13.4%) 10 (7.1%) Subserous 28 (25%) 30 (21.1%) Subserous-intramural 24 (21.4%) 29 (20.4%) Intramural 44 (39.3%) 69 (48.6%) Intramural-submucous 1 (0.9%) 4 (2.8%) Location of the largest 0.791 Anterior 26 (23.2%) 34 (23.9%) Posterior 49(43.7%) 52 (36.6%) Fundus 16 (14.3%) 23 (16.2%) Right 8 (7.1%) 16 (11.3%) Left 9 (8%) 12 (8.4%) Other 4 (3.6%) 5 (3.5%) FIGO type of the largest 0.113 2 0 3 (2.1%) 3 (1.2%) 3 3 (2.7%) 5 (3.5%) 8 (3.1%) 4 27 (24.1%) 20 (14.1%) 47 (18.5%) 5 32 (28.6%) 53 (37.3%) 85 (33.5%) 6 37 (33%) 52 (36.6%) 89 (35%) 7 13 (11.6%) 9 (6.3%) 21 (8.3%) Surgical data Number of myomas removed 1.79 (±1.51) 3.07 (±2.86) 0.006 Size of the largest myoma (cm) 7.55 (±2.73) 10.24 (±5.42) <0.001 (continued) Frontiers in Surgery 03 frontiersin.org Ordás et al. 10.3389/fsurg.2022.997078 TABLE 1 Continued LM AM Total p (n = 112) (n = 142) (n = 254) Procedures to reduce intraoperative bleeding None 65 (58%) – – Uterine artery occlusion (clips) 26 (23.2%) – – Vasopressin 21 (18.8%) – – Uterine cavity disruption 20 (17.9%) 30 (19.7%) 0.559 Operating time (min) 147.38 (±63.79) 95 (±37.47) 0.001 † Additional procedure 19 (17%) 13 (9.1%) 0.450 ‡ Expert surgeon 103 (92%) 48 (33.8%) 0.001 Use of anti-adherents 42 (37.5%) 50 (35.2%) 0.885 Hospital stay (days) 4.57 (±2.1) 5.49 (±1.13) 0.001 Histology 0.278 Typical leiomyoma 106 (94.6%) 138 (97.1%) 244 (96.1%) Leiomyoma with bizarre nuclei 3 (2.7%) 4 (2.8%) 7 (2.7%) Adenomyoma 2 (1.8%) – 2 (0.8%) STUMP 1 (0.9%) – 1 (0.4%) Values are n (%) or mean ± standard deviation. LM, laparoscopic myomectomy; AM, abdominal myomectomy; BMI, body max index; Hb, hemoglobin; STUMP, smooth muscle tumor of uncertain malignant potential. † Including: ovarian cystectomy, salpingectomy, appendectomy, bowel resection for deep endometriosis and resection endometriosis lesions. ‡ >10 years of experience. In both surgical techniques, the pelvis was irrigated with saline Results solution at the end of the procedure. For both groups, the use of absorbable adhesion barrier (oxidized regenerated cellulose; Surgical outcomes Surgicel, Ethicon) and drain was not standardized, and they were placed only if the surgeon considered them necessary. From May 2012 to December 2018, a total of 254 myomectomies were performed (112 [43.9%] LMs and 142 [55.7%] AMs). In 4 (3.6%) cases, the surgery started by laparoscopy and then converted to open surgery; these cases Statistical analysis were therefore assigned to the AM group. In 2 of these cases, the conversion was due to the enormous size of the myoma The statistical analysis was performed using SPSS version (>15 cm), and in the other 2 cases, the conversion was due to 24.0 for Windows (IBM Corp., Armonk, NY, United States). massive blood loss. The quantitative variables are expressed as mean and standard Table 1 summarizes the patients’ preoperative characteristics deviation, and the qualitative variables are expressed as absolute and surgical data, while Table 2 summarizes the intraoperative numbers and percentages. The quantitative variables were and postoperative complications, the latter of which were analyzed between the two groups using Student’s t-test, mostly minor and controllable with no invasive procedures. In whereas the qualitative variables were analyzed using the chi- contrast, 1 patient of the AM group (Table 2) underwent squared test and Fisher’s exact test. To assess the significance emergency abdominal hysterectomy due to uncontrolled of the individual parameters, we performed a bivariate logistic intraoperative blood loss (>1000 ml). One (0.9%) case in the regression analysis. To investigate the combination of LM group and 5 (3.6%) cases in the AM group experienced predictors for the myomectomy route, we conducted a multiple recurrence and required reintervention, a difference that was regression analysis. To assess the degree of agreement between not statistically significant (p = 0.285). the ultrasound examination and the surgery evaluation, we The logistic regression analysis demonstrated that the calculated the intraclass correlation coefficient (ICC). A p-value number of enucleated myomas, the size of the largest myoma <0.05 was considered statistically significant for all variables. and the surgeon’s experience were related to the outcomes and Frontiers in Surgery 04 frontiersin.org Ordás et al. 10.3389/fsurg.2022.997078 TABLE 2 Comparison of the intraoperative and postoperative (15 patients) for suspicious ultrasound findings and 18.6% (11 complications between laparoscopic myomectomy and abdominal myomectomy. patients) for pelvic pain (p < 0.001). Moreover, in the patients whose indication for surgery was infertility, a higher LM AM p pregnancy rate was maintained in the LM group than in the (n = 112) (n = 142) AM group (61.9% [13/21 patients] vs. 37% [10/27 patients]); Intraoperative complications 6 (5.3%) 9 (6.3%) 0.075 however, the difference was not statistically significant (p = † Organ injury 2 (1.8%) 5 (3.5%) 0.087). There was an increase in the overall pregnancy rate Estimated blood loss >1,000 ml 1 (0.9%) 4 (2.8%) 0.559 (33%) for the patients whose largest enucleated myoma was ‡ <8 cm compared with those whose largest myoma was ≥8 cm Postoperative complications 17 (15.2%) 29 (20.4%) 0.336 (20%) (p = 0.022), regardless of surgical approach. There were Grade 1 3 (2.7%) 5 (3.5%) no cases of major maternal or obstetric complications such as Grade 2 11 (9.8%) 20 (14.1%) preterm delivery, placental abnormalities or placental abruption in either group. Grade 3 2 (1.8%) 4 (2.8%) Our series presented a miscarriage rate of 10.2% and an Grade 3a 0 0 overall full-term delivery rate of 88.1%. All deliveries resulted Grade 3b 2 (1.8%) 4 (2.8%) in live births, and there were no cases of uterine rupture or Grade 4 0 0 postpartum hemorrhaging in our series. The pregnancy outcomes of the 2 groups are summarized in Table 3. Values are n (%). LM, laparoscopic myomectomy; AM, abdominal myomectomy. † Including: bowel, uterus, bladder, ovaries, small intestine and ureter. ‡ Clavien-Dindo Classification system. Discussion could predict the success of the surgical approach. Our results Myomas are the most common female benign tumors showed that having more than 3 myomas reduced the and frequently require surgery. Although there are no probability of a successful LM by 69.3% (p = 0.001), which also universally accepted selection criteria for the surgical applied to the size of the largest enucleated myoma. The approach, based on our results, women with 3 or more probability of successful enucleation was 3-fold higher with fibroids and whose largest myoma is ≤9 cm can be laparotomic access than with laparoscopic access for myomas successfully treated through laparoscopy. Our results agree measuring >9 cm [odds ratio 3.24, 95% confidence interval with those of previous studies that showed that the (CI) 1.865–5.656] (p < 0.001). Moreover, the surgeon with number of complications, surgical difficulties and risk of more than 10 years of experience in laparoscopic surgery laparoconversion increase if LM is performed in patients increased the chances of a successful minimally invasive with these characteristics (11, 20–22). surgery of uterine fibroids by 20,431 fold (95% CI 8704–47,956; A preoperative ultrasound evaluation should be p < 0.001). systematically performed to select the most appropriate Lastly, we calculated the ICC to determine whether there surgical approach because ultrasound provides information on was a correlation between the number of myomas observed the number, size, type and location of the fibroids (14, 21). by ultrasound and the number of myomas observed during Frascà et al. (2018) (23) concluded that preoperative the surgical procedure. We obtained an ICC of 0.729 (95% ultrasound can correctly identify the number, type, size and CI: 0.591–0.812; p < 0.001), which indicated “high similarity”. locations of myomas with an accuracy >72%. Our results The dimensions of the major myoma observed in the showed that there was a high correlation between the number preoperative ultrasound showed moderate agreement with and size of the largest myoma observed by ultrasound and those ultimately observed during surgery (ICC: 0.686; 95% CI: those identified during surgery. 0.597–0.756; p < 0.001). Does LM improve surgical outcomes Obstetric outcomes compared with AM? Table 3 shows the obstetric outcomes of the 2 groups, and In our series, the women who underwent LM and open AM Figure 1 summarizes the pregnancy and delivery outcomes. The were comparable in their preoperative characteristics. The overall pregnancy rate (pregnancies with evidence of a viable association between the surgeon’s experience and the fetus) for the patients whose indication for surgery was laparoscopic approach was statistically significant (p < 0.001), infertility was 40% (23 patients), compared with the other with 92% of the laparoscopies performed by expert surgeons indications: 16.9% (10 patients) for vaginal bleeding, 25.4% and 66% performed by training surgeons. The surgeon’s Frontiers in Surgery 05 frontiersin.org Ordás et al. 10.3389/fsurg.2022.997078 TABLE 3 Obstetrics and delivery outcomes according surgical approach. LM AM TOTAL p (n = 36/112) (n = 23/142) (n = 59/254) Pregnancy rate 36 (30.8%) 23 (16.2%) 59 (23.2%) 0.009 Conception method 0.159 Spontaneous pregnancy 26 (72.3%) 13 (56.5%) 39 (66.1%) ART (including IVF or AI) 10 (27.7%) 10 (43.5%) 20 (33.9%) Pregnancy outcome 0.680 Miscarriage 4 (11.1%) 2 (8.7%) 6 (10.2%) Intrauterine fetal death 1 (2.8%) – 1 (1.7%) Full-term delivery 31 (86.1%) 21 (91.3%) 52 (88.1%) Type of delivery 0.074 Vaginal 15 (48.4%) 5 (23.8%) 20 (38.5%) Cesarean 16 (51.6%) 16 (76.2%) 32 (61.5%) GROUP I:LM GROUP II: AM TOTAL p- (n = 31) (n = 21) (n = 52) value Mode of delivery 0.035 Elected cesarean delivery 10 (32.3%) 13 (61.9%) 23 (44.2%) 0.035 Prior myomectomy 8 (80%) 12 (92.3%) 20 (87%) 0.385 Fetal malpresentation 2 (20%) 1 (7.7%) 3 (13%) 0.385 Admitted for TOLAM 21 (67.7%) 8 (38.1%) 29 (55.8%) 0.035 Cesarean delivery during labor 6 (28.6%) 3 (37.5%) 9 (31%) 0.642 Failed induction of labor 1 (16.6%) 1 (33.3%) 2 (22.2%) Failure to progress 1 (16.6%) 1(33.3%) 2 (22.2%) Fetal distress 2 (33.3%) 1(33.3%) 3 (33.3%) Cephalopelvic disproportion 2 (33.3%) – 2 (22.2%) Accomplished vaginal delivery in patients admitted for TOLAM 15 (71.4%) 5 (62.5%) 20 (69%) 0.074 Values are n (%). LM, laparoscopic myomectomy; AM, abdominal myomectomy; ART, assisted reproductive techniques; IVF, in vitro fertilization; AI, artificial insemination; TOLAM, trial of labor after myomectomy. experience continues to be decisive for successful LM (20, 21). specimen retrieval after LM showed comparable results in We therefore found no association between the type of terms of intraoperative complications, hospital stay and myoma and the surgical approach (p = 0.767), given the operative time. Concerning transvaginal extraction of the expert surgeon’s skill in managing different types of myomas. surgical specimen after LM, a large case series by Laganá For the same reason, there was no significant difference in the et al. (27) demonstrated a significant increase in operative estimated blood loss between the groups (p = 0.559). Despite time, intraoperative blood loss and hospital stay with the surgeon’s experience, LM required longer surgical times increasing weight of removed fibroid. (p < 0.001), as previously reported (13, 22). One of the limitations of the laparoscopic approach is the With regard to intraoperative and postoperative inability to palpate the uterus during the intervention, which complications, we found no statistical differences between the can result in persistence of intramural fibroids (22). However, 2 groups, as reported in the literature (13). In our study, this limitation could be overcome by performing an intra- the mean hospital stay was shorter for the LM group than for operative vaginal ultrasound to confirm the presence of any the AM group, corroborating the reports of previous studies intramural fibroids prior to completing the surgery (23). (13, 24, 25), thereby confirming the major advantage of the Studies have established that the recurrence rates for patients laparoscopic approach. Furthermore, a recent meta-analysis who undergo LM are 167% higher than for those who (26) which compared transvaginal retrieval and port-site undergo AM, with a cumulative 5-year recurrence rate of Frontiers in Surgery 06 frontiersin.org Ordás et al. 10.3389/fsurg.2022.997078 FIGURE 1 Flow diagram of study population: pregnancy and delivery outcomes in patients who underwent laparoscopic and abdominal myomectomy. CD, cesarean delivery; TOLAM, trial of labor after myomectomy; VD, vaginal delivery. 57.3%–62.1% for the LM group and 15.4%–62% for the AM group statistically significant, we can speculate that their use in LM (13, 28). Recent studies have reported that although recurrence might prevent adhesions. In a recent review (32), oxidized rates after LM might be high, the number of patients who regenerated cellulose was found to be effective in reducing the require re-operation is low (2.4%) (29, 30). Our study showed total adhesion score during second-look surgery. Laganá et al. different results, given that 5 (3.62%) patients underwent re- (33) showed that the opening of uterine cavity and the operation after AM vs. only 1 after LM (0.9%), although there laparotomic approach represented independent risk factors for were no significant differences, and the reintervention rates were developing intrauterine adhesions, after 3 months from surgery. low in both cases. Lastly, it is important to highlight the effect of Unfortunately, it is difficult to speculate on the relationship additional procedures such as endometriosis on the operative between increased pregnancy rates among patients who time. Although there were no statistical differences in operative underwent LM and those who underwent AM. times between the 2 groups, the association between Numerous studies have shown that pregnancy rates increased endometriosis and myomas is very common. In particular, up to 70% after myomectomy (14) due to various mechanisms, eradication of deep endometriosis could affect surgical times and such as distortion of the uterine cavity, alteration of myometrial could represent a selection bias in our study. contractility and alteration of the tube-ovary anatomic relationship (34). Our data showed a higher pregnancy rate for the patients whose indication for surgery was sterility compared Do obstetric outcomes improve after LM with the other indications (40% vs. <25.4%, respectively; p < compared with AM? 0.001), Furthermore, the gestational rate was higher for the LM group than for the AM group (61.9% vs. 37%), although these Numerous studies have indicated that the cumulative clinical differences were not statistically significant (p = 0.087). pregnancy rate and cumulative live birth rate are similar between Our results showed a higher pregnancy rate (33% vs. 20%) women treated by LM and those treated with AM (30, 31). Our among the patients whose main excised myoma measured study showed a higher pregnancy rate after LM (30.8% vs. <8 cm (p = 0.020), regardless of the surgical approach. Similar 16.8%), which was statistically significant (p = 0.009). Our results results were reported by Kundu et al. (2018) (14), who agree with those of other studies that found that patients who indicated a pregnancy rate of nearly 50% in the group with underwent LM had a higher pregnancy rate than those who removed myomas <8 cm in diameter, dropping to ≤30% when underwent AM, possibly due to a reduced occurrence of the myomas measured ≥8 cm in diameter. postoperative adhesions (14, 21). In our study, anti-adherent With regard to delivery outcomes, the elective caesarean rate barriers were employed in 37.5% of the LM procedures and in was 44.2% in our series, with a higher rate of scheduled 36.2% of the AM procedures. Although these differences are not caesareans in the AM group than the LM group (69.1% vs. Frontiers in Surgery 07 frontiersin.org Ordás et al. 10.3389/fsurg.2022.997078 32.3%; p = 0.035). The main indication for scheduling a more exact data on cofactors that might have influenced the caesarean in our study was opening the uterine cavity and attitude of obstetricians in determining the delivery mode. performing multiple myomectomy (85% of cases) to prevent uterine rupture during labor. Our results agree with those of Gambacorti-Passerini et al. (2018) (15), who also reported a Conclusion higher rate of scheduled caesareans in their AM group (75% vs. 46.7% in the LM group), with the main indication for As an alternative to AM, LM can be considered a safe and caesarean being a previous myomectomy. The authors suitable surgical technique for women of childbearing age, compared the operative findings of the women admitted for although LM requires longer surgical times and should be trial of labor after myomectomy (TOLAM) with those who performed by surgical teams with a high degree of expertise and were scheduled for caesareans and found no significant experience. A preoperative ultrasound evaluation of the size and differences apart from the incidence of entering the uterine number of myomas should be performed for careful patient cavity (33.3%) in the caesarean group compared with the selection. In our practice, LM was successfully performed in patients admitted for TOLAM (1.4%; p < 0.01). cases with ≤3 fibroids in which the largest measured ≤9 cm. The Surprisingly, a recent meta-analysis by Claeys et al. (2014) (35) delivery mode for patients with a prior myomectomy should be demonstrated that LM is associated with a higher rate of elective individually established; however, vaginal delivery after LM caesareans (p = 0.001), which contrasts with our results and should be considered a safe option for these patients, with those of previous studies. The authors attributed the higher rate uterine rupture an extremely rare complication. in the LM group to the surgeon’s concerns that this type of myomectomy has a higher risk of rupture during subsequent pregnancies and labor compared with the open technique. Data availability statement Interestingly, the URIDA (uterine rupture international data The original contributions presented in the study are acquisition) study (19), did not showed any association between included in the article/Supplementary Material, further the incidence of uterine rupture and the number and type of inquiries can be directed to the corresponding author. previous uterine surgeries. This study evaluated 224 patients with previous uterine operations (cesarean section, LM, AM, hysteroscopic myomectomy). In these patients, the mean gestational age at which the uterine rupture was 37.32 ± 5.09 weeks. Ethics statement In our study, 21 (67.7%) patients in the LM group and 8 The studies involving human participants were reviewed (38.1%) patients in the AM group (p = 0.035) were admitted and approved by PI-3661 Hospital la Paz. The patients/ for TOLAM. Fifteen (71.4%) patients achieved a successful participants provided their written informed consent to vaginal delivery after LM, and 5 (62.5%) patients achieved it participate in this study. after AM (p = 0.074). Gambacorti-Passerini et al. (2018) (15) and Claeys et al. (2014) (35) showed similar results, with a vaginal delivery rate of 91.5% for the patients admitted for Author contributions TOLAM, 93% after LM and 88% after AM, with no statistically significant difference between the two surgical All authors listed have made a substantial, direct, and approaches. Although our findings showed a lower percentage intellectual contribution to the work and approved it for of vaginal delivery by the patients admitted for TOLAM in publication. both types of myomectomy than in prior studies, we had no cases of intrapartum complications and a lower rate of caesarean deliveries. Our results are therefore encouraging. Funding Considering the aforementioned data, we believe TOLAM should be considered a feasible and safe option in tertiary This work has been supported by the Carlos III Health level hospitals for patients with a history of myomectomy. Institute and the European Regional Development Fund We had no cases of uterine rupture in our series, a (ERDF) “European Union, A way to make Europe” (PI20/01368). complication that represents the main obstetrical risk for women with a previous myomectomy. Uterine rupture is rare (0.47%–1%) and difficult to predict (15, 20, 36). Conflict of interest The strength of our study was its large patient cohort and the analysis of numerous factors in addition to surgical The authors declare that the research was conducted in the variables. Our study is limited by the retrospective data absence of any commercial or financial relationships that could collection, which might have prevented us from collecting be construed as a potential conflict of interest. Frontiers in Surgery 08 frontiersin.org Ordás et al. 10.3389/fsurg.2022.997078 Publisher’s note affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this All claims expressed in this article are solely those of the article, or claim that may be made by its manufacturer, is not authors and do not necessarily represent those of their guaranteed or endorsed by the publisher. References 1. Donnez J, Bouchard P, Zakharenko NF, Ugocsai G, Bestel E, Loumaye E. 18. Dindo D, Demartines N, Clavien PA. Classification of surgical Ulipristal acetate versus placebo for fibroid treatment before surgery. N Engl J complications: a new proposal with evaluation in a cohort of 6336 patients and Med. (2012) 366(5):409–20. doi: 10.1056/NEJMoa1103182 results of a survey. Ann Surg. (2004) 240(2):205–13. doi: 10.1097/01.sla. 0000133083.54934.ae 2. Jacques D, Janusz T, Francisco V, Philippe B, Boguslav L, Francesco B, et al. Ulipristal acetate versus leuprolide acetate for uterine fibroids. N Engl J Med. 19. Tinelli A, Hurst BS, Hudelist G, Tsin DA, Stark M, Mettler L, et al. (2012) 366(5):421–32. doi: 10.1056/NEJMoa1103180 Laparoscopic myomectomy focusing on the myoma pseudocapsule: technical and outcome reports. Hum Reprod Oxf Engl. (2012) 27(2):427–35. doi: 10.1093/ 3. Sandberg EM, Tummers FHMP, Cohen SL, van den Haak L, Dekkers OM, humrep/der369 Jansen FW. Reintervention risk and quality of life outcomes after uterine- sparing interventions for fibroids: a systematic review and meta-analysis. Fertil 20. Martinez MEG, Domingo MVC. Size, type, and location of myoma as Steril. (2018) 109(4):698–707.e1. doi: 10.1016/j.fertnstert.2017.11.033 predictors for successful laparoscopic myomectomy: a tertiary government hospital experience. Gynecol Minim Invasive Ther. (2018) 7(2):61–5. doi: 10. 4. Cruz MSDDL, Buchanan EM. Uterine fibroids: diagnosis and treatment. Am 4103/GMIT.GMIT_12_18 Fam Physician. (2017) 95(2):100–7. PMID: 28084714. 21. Bean EMR, Cutner A, Holland T, Vashisht A, Jurkovic D, Saridogan E. 5. Laughlin-Tommaso SK, Jacoby VL, Myers ER. Disparities in fibroid Laparoscopic myomectomy: a single-center retrospective review of 514 patients. incidence, prognosis, and management. Obstet Gynecol Clin North Am. (2017) J Minim Invasive Gynecol. (2017) 24(3):485–93. doi: 10.1016/j.jmig.2017.01.008 44(1):81–94. doi: 10.1016/j.ogc.2016.11.007 22. Jansen LJ, Clark NV, Dmello M, Gu X, Einarsson JI, Cohen SL. Perioperative 6. Kroon B, Johnson N, Chapman M, Yazdani A, Hart R. Fibroids in infertility – outcomes of myomectomy for extreme myoma burden: comparison of surgical consensus statement from ACCEPT (australasian CREI consensus expert panel on approaches. J Minim Invasive Gynecol. (2019) 26(6):1095–103. doi: 10.1016/j. trial evidence). Aust N Z J Obstet Gynaecol. (2011) 51(4):289–95. doi: 10.1111/j. jmig.2018.10.022 1479-828X.2011.01300.x 23. Frascà C, Tuzzato G, Arena A, Degli Esposti E, Zanello M, Raimondo D, 7. Williams ARW, Bergeron C, Barlow DH, Ferenczy A. Endometrial et al. The role of pelvic ultrasound in preoperative evaluation for laparoscopic morphology after treatment of uterine fibroids with the selective progesterone myomectomy. J Minim Invasive Gynecol. (2018) 25(4):679–83. doi: 10.1016/j. receptor modulator, ulipristal acetate. Int J Gynecol Pathol. (2012) 31(6):556–69. jmig.2017.08.661 doi: 10.1097/PGP.0b013e318251035b 24. Cicinelli E, Tinelli R, Colafiglio G, Saliani N. Laparoscopy vs 8. Donnez J, Vázquez F, Tomaszewski J, Nouri K, Bouchard P, Fauser BCJM, minilaparotomy in women with symptomatic uterine myomas: a prospective et al. Long-term treatment of uterine fibroids with ulipristal acetate⋆. Fertil randomized study. J Minim Invasive Gynecol. (2009) 16(4):422–6. doi: 10.1016/j. Steril. (2014) 101(6):1565–1573.e18. doi: 10.1016/j.fertnstert.2014.02.008 jmig.2009.03.011 9. Donnez J, Dolmans MM. Uterine fibroid management: from the present to 25. Kim H, Shim S, Hwang Y, Kim M, Hwang H, Chung Y, et al. Is robot- the future. Hum Reprod Update. (2016) 22(6):665–86. doi: 10.1093/humupd/ assisted laparoscopic myomectomy limited in multiple myomas?: a feasibility dmw023 for ten or more myomas. Obstet Gynecol Sci. (2018) 61(1):135–41. doi: 10.5468/ 10. Sandberg EM, Cohen SL, Jansen FW, Einarsson JI. Analysis of risk factors ogs.2018.61.1.135 for intraoperative conversion of laparoscopic myomectomy. J Minim Invasive 26. Laganà AS, Vitagliano A, Casarin J, Garzon S, Uccella S, Franchi M, et al. Gynecol. (2016) 23(3):352–7. doi: 10.1016/j.jmig.2015.10.017 Transvaginal versus port-site specimen retrieval after laparoscopic 11. Vargas MV, Larson KD, Sparks A, Margulies SL, Marfori CQ, Moawad G, myomectomy: a systematic review and meta-analysis. Gynecol Obstet Invest. et al. Association of operative time with outcomes in minimally invasive and (2022) 87(3–4):177–83. doi: 10.1159/000525624 abdominal myomectomy. Fertil Steril. (2019) 111(6):1252–1258.e1. doi: 10.1016/ 27. Laganà AS, Casarin J, Uccella S, Garzon S, Cromi A, Guerrisi R, et al. j.fertnstert.2019.02.020 Outcomes of in-bag transvaginal extraction in a series of 692 laparoscopic 12. Saccardi C, Gizzo S, Noventa M, Ancona E, Borghero A, Litta PS. Limits and myomectomies: results from a large retrospective analysis. J Minim Invasive complications of laparoscopic myomectomy: which are the best predictors? A Gynecol. (2022) 29(12):1331–38. doi: 10.1016/j.jmig.2022.09.009 large cohort single-center experience. Arch Gynecol Obstet. (2014) 290(5):951–6. 28. Kotani Y, Tobiume T, Fujishima R, Shigeta M, Takaya H, Nakai H, et al. doi: 10.1007/s00404-014-3289-2 Recurrence of uterine myoma after myomectomy: open myomectomy versus 13. Cezar C, Becker S, di Spiezio Sardo A, Herrmann A, Larbig A, Tanos V, laparoscopic myomectomy. J Obstet Gynaecol Res. (2018) 44(2):298–302. et al. Laparoscopy or laparotomy as the way of entrance in myoma doi: 10.1111/jog.13519 enucleation. Arch Gynecol Obstet. (2017) 296(4):709–20. doi: 10.1007/s00404- 29. Shiota M, Kotani Y, Umemoto M, Tobiume T, Hoshiai H. Recurrence 017-4490-x of uterine myoma after laparoscopic myomectomy: what are the risk factors? 14. Kundu S, Iwanuk C, Staboulidou I, Garcia-Rocha GJ, Soergel P, Hertel H, Gynecol Minim Invasive Ther. (2012) 1(1):34–6. doi: 10.1016/j.gmit.2012.08. et al. Morbidity, fertility and pregnancy outcomes after myoma enucleation by 003 laparoscopy versus laparotomy. Arch Gynecol Obstet. (2018) 297(4):969–76. 30. Malzoni M, Tinelli R, Cosentino F, Iuzzolino D, Surico D, Reich H. doi: 10.1007/s00404-018-4697-5 Laparoscopy versus minilaparotomy in women with symptomatic uterine 15. Gambacorti-Passerini ZM, Penati C, Carli A, Accordino F, Ferrari L, myomas: short-term and fertility results. Fertil Steril. (2010) 93(7):2368–73. Berghella V, et al. Vaginal birth after prior myomectomy. Eur J Obstet Gynecol doi: 10.1016/j.fertnstert.2008.12.127 Reprod Biol. (2018) 231:198–203. doi: 10.1016/j.ejogrb.2018.10.007 31. Flyckt R, Soto E, Nutter B, Falcone T. Comparison of long-term fertility and bleeding outcomes after robotic-assisted, laparoscopic, and abdominal 16. Van den Bosch T, Dueholm M, Leone FPG, Valentin L, Rasmussen CK, myomectomy. Obstet Gynecol Int. (2016) 2016:2789201. doi: 10.1155/2016/ Votino A, et al. Terms, definitions and measurements to describe sonographic 2789201 features of myometrium and uterine masses: a consensus opinion from the morphological uterus sonographic assessment (MUSA) group. Ultrasound 32. Borghese G, Raffone A, Raimondo D, Saccone G, Travaglino A, Degli Obstet Gynecol. (2015) 46(3):284–98. doi: 10.1002/uog.14806 Esposti E, et al. Adhesion barriers in laparoscopic myomectomy: evidence from randomized clinical trials. Int J Gynecol Obstet. (2021) 152(3):308–20. doi: 10. 17. Munro MG, Critchley HOD, Broder MS, Fraser IS. FIGO Classification 1002/ijgo.13495 system (PALM-COEIN) for causes of abnormal uterine bleeding in nongravid women of reproductive age. Int J Gynecol Obstet. (2011) 113(1):3–13. doi: 10. 33. Laganà AS, Garzon S, Dababou S, Uccella S, Medvediev M, Pokrovenko D, 1016/j.ijgo.2010.11.011 et al. Prevalence of intrauterine adhesions after myomectomy: a prospective Frontiers in Surgery 09 frontiersin.org Ordás et al. 10.3389/fsurg.2022.997078 multicenter observational study. Gynecol Obstet Invest. (2022) 87(1):62–9. doi: 10. 35. Claeys J, Hellendoorn I, Hamerlynck T, Bosteels J, Weyers S. The risk of 1159/000522583 uterine rupture after myomectomy: a systematic review of the literature and meta- analysis. Gynecol Surg. (2014) 11(3):197–206. doi: 10.1007/s10397-014-0842-8 34. Milazzo GN, Catalano A, Badia V, Mallozzi M, Caserta D. Myoma and myomectomy: poor evidence concern in pregnancy: myoma and myomectomy 36. Parker WH, Einarsson J, Istre O, Dubuisson JB. Risk factors for uterine in pregnancy. J Obstet Gynaecol Res. (2017) 43(12):1789–804. doi: 10.1111/jog. rupture after laparoscopic myomectomy. J Minim Invasive Gynecol. (2010) 17 13437 (5):551–4. doi: 10.1016/j.jmig.2010.04.015 Frontiers in Surgery 10 frontiersin.org