To the Editor:
I read with great interest Herbert A. Goldfarb and Nicole J. Fanarijan's article (Laparoscopic-assisted vaginal myomectomy: a case report and literature review. JSLS. 2001;5:81–85. The aim of this article was to present a new minimally invasive technique, laparoscopic-assisted vaginal myomectomy (LAVM), used for removing multiple transmural uterine myomas and faciliting uterine suturing. First of all, I would like to congratulate the authors on a successful presentation of the new surgical technique and the instructively written case report with a well-organized discussion. Laparoscopic-assisted vaginal myomectomy seems to be a very promising method, which could expand the spectrum of minimally invasive techniques used for myomectomy.
I think, however, that based on our previous experiences with laparoscopic-assisted myomectomy (LAM) and classic myomectomies performed via a vaginal approach, the LAVM method can be applied only to a select group of patients. We have performed laparoscopic-assisted myomectomies since 1998 after an internship at Stanford University using a method described by Nezhat et al.1 A critical issue of laparoscopic myomectomy (LM) compared with abdominal myomectomy is an impossibility to achieve a perfect suture of the defect after removing the intramural myoma. A combination of laparoscopy and minilaparotomy improves chances of executing a perfect suture. Nevertheless, we know from the literature that even a suture of the uterine wall performed during LAM does not rule out a uterus rupture and resulting pregnancy.2
I consider as unsuitable for LAVM cases with myoma localization in the area of fallopian tube division and near uterine blood vessels. It would also be difficult to remove myomas located on the front uterine wall and in the area of urinary bladder using colpotomy. Another group of problematic indications is composed of women with a large myoma and a poor vaginal access. In our study, criteria for LAM were a myoma larger than 6 cm or numerous myomas requiring extensive morcelation.3 In the study group, the mean weight of the specimen and the mean operative time were 151.7 g (range 90 to 220) and 76 min (range 50 to 90), respectively. The mean leiomyoma weight reported by Nezhat et al is 247 g. Goldfarb and Fanarijan reported the mean size of dominant myoma 6 cm (range 4 to 8 cm) and the mean operative time 93 min (range 60 to 120 ). It would be necessary to test the above mentioned data that can limit indications for LAVM during a larger comparative prospective study. The question is whether the vaginal access allows for safe use of an electro-morcellator, which undoubtedly shortens the surgery time, especially when larger myomas are removed.
It will also be appropriate to study the morbidity of women with LAVM. According to our experience and published studies, myomectomies performed via the vaginal approach are related to an increased rate of occurrence of febrile states and inflammatory complications. At the end of my letter, I should like to ask the authors these questions: How do they interpret an occurrence of postsurgery urine retention in 3 patients (27.3%) in their pilot study and whether antibiotic prophylaxis was performed in their patients?
Sincerely,
References:
- 1. Nezhat C, Nezhat FR, Luciano AA, et al. Operative Gynecologic Laparoscopy: Principles and Techniques. New York: McGraw-Hill Inc; 1995. [Google Scholar]
- 2. Hockstein S. Spontaneous uterine rupture in the early third trimester after laparoscopically assisted myomectomy. A case report. J Reprod Med. 2000; 45:139–141. [PubMed] [Google Scholar]
- 3. Holub Z, Voracek J, Lukac J, Kliment L. Laparoscopically assisted myomectomy: operative technique and indications. Czech Gynaec. 2001; (66:243–274). [PubMed] [Google Scholar]