Myomectomy during cesarean section or non-caesarean myomectomy in reproductive surgery: this is the dilemma

Abstract

Myomectomy during cesarean section or non-caesarean myomectomy in reproductive surgery: this is the dilemma Andrea Tinelli1,2,3, *, Ceana H. Nezhat4,5,6 , Ivana Likić-Ladjević7,8 , Mladen Andjić8 , Dina Tomašević9 , Dimitrios Papoutsis10 , Radomir Stefanović11, Radmila Sparić7,8 1Department of Obstetrics and Gynecology and CERICSAL (CEntro di RIcerca Clinico SALentino), Veris delli Ponti Hospital, 73020 Lecce, Italy 2Division of Experimental Endoscopic Surgery, Imaging, Technology and Minimally Invasive Therapy, Department of Obstetrics and Gynecology, Vito Fazzi Hospital, 73100 Lecce, Italy 3 Laboratory of Human Physiology, Phystech BioMed School, Faculty of Biological & Medical Physics, Moscow Institute of Physics and Technology (State University), 125009 Moscow, Russia 4Nezhat Medical Center, Atlanta Center for Minimally Invasive Surgery and Reproductive Medicine, Atlanta, GA 30350, USA 5 Training and Education Program, Northside Hospital, Atlanta, GA 30106, USA 6Department of Gynecology and Obstetrics, School of Medicine, Emory University, Atlanta, GA 30307, USA 7 School of Medicine, University of Belgrade, 11103 Belgrade, Serbia 8 Clinic of Gynecology and Obstetrics, University Clinical Center of Serbia, 11103 Belgrade, Serbia 9University Clinical Center of Serbia, 11103 Belgrade, Serbia 10Department of Obstetrics and Gynecology, Shrewsbury and Telford Hospital, NHS Trust, TF1 6 Telford, UK 11Department for Histopathology, University Clinical Center of Serbia, 11103 Belgrade, Serbia *Correspondence: andreatinelli@gmail.com (Andrea Tinelli) DOI:10.31083/j.ceog4806199 This is an open access article under the CC BY 4.0 license (https://creativecommons.org/licenses/by/4.0/). Submitted: 14 May 2021 Revised: 5 July 2021 Accepted: 21 July 2021 Published: 15 December 2021 Nowadays it is quite common to encounter pregnants over 35 years with uterine fibroids (UFs), requiring cesarean section (CS). Large UFs may cause severe complications during delivery, as bleeding and hemorrhage, during vaginal or cesarean delivery. Frequently, the caesarean myomectomy (CM) is recommended, but generally obstetricians are reluctant to perform CM, since literature data do not agree on its surgical recommendation. CM is jet particularly controversial, due to increased risk of perioperative hemorrhage and cesarean hysterectomy, and UFs are often left in situ during cesarean section (CS). CM investigations are generally directed to myomectomy associated issues, whereas CS complications without CM are largely underreported. The risks of leaving UF for an interval myomectomy is underestimated and large UFs, left in uterus during CS, might cause significant early and late postoperative complications, even necessitating a relaparotomy and/or a subsequent hysterectomy. CM would be mandatory in some instances, whatever the UF diameter, to avoid further damage or complications. UFs management prior to CS should include a full counselling on pro and cons on the possible consequences of surgical decisioning. To illustrate what was discussed above, authors performed a narrative review with an expert opinion, reporting a case of a 31-year-old woman with a large UF who underwent a CS without myomectomy. Nine hours after CS, puerpera was submitted, for a massive postoperative hemorrhage and hemorrhagic shock, to an emergency relaparotomy with total hysterectomy without salpingo-oophorectomy. Keywords Uterine fibroids; Myoma; Pseudocapsule; Cesarean myomectomy; Complications; Hysterectomy; Caesarean section