Outcomes of cesarean myomectomy among pregnant women with uterine leiomyomas: A single tertiary center experience

doi:10.21203/rs.3.rs-2068695/v1

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Outcomes of cesarean myomectomy among pregnant women with uterine leiomyomas: A single tertiary center experience

https://doi.org/10.21203/rs.3.rs-2068695/v1

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Purpose: This study aimed to investigate the surgical outcomes and safety of cesarean section myomectomies.

Methods: This retrospective study was performed between January 2015 and August 2022, at a single university hospital. Pregnant women diagnosed with myoma uteri who underwent C/S (cesarean section) myomectomy and pregnant women without myoma as the control group and only underwent C/S were included in the study. Patients' age, gravida, parity, abortion, body mass index (BMI), delivery week, previous delivery type, myoma size, type, number, localization, preoperative and postoperative hemoglobin (Hb) values and postoperative Hb changes, operation time, hospital stay, blood transfusion need and amount, and postoperative complications were recorded from the hospital archive system. The obtained data were compared between the two groups.

Results: A total of 283 patients underwent C/S myomectomy and 324 patients who did not have myoma underwent only C/S. Duration of operation, length of hospital stay, postoperative blood transfusion need and amount of blood transfusion, preoperative Hb, and change of Hb values were statistically significantly higher in the C/S myomectomy group (p<0.01, p<0.01, p=0.005, p= 0.006, p<0.01, p<0.01, respectively). A statistically significant weak positive correlation was observed between fibroid size and hospital stay (ρ=0.133). There was a statistically significant weak positive correlation between the size of myoma and the amount of blood transfused (ρ=0.120).

Conclusion: Myomectomy during cesarean section has a low complication rate and saves patients from the necessity of a second operation.

Uterine leiomyomas or fibroids are benign neoplasms composed of smooth muscle cells and fibroblasts of the uterus and develop in approximately 20–40% of women of reproductive age [1]. Its incidence in pregnancy is between 3–10% [2]. Although fibroids are mostly asymptomatic, they can lead to various complications such as bleeding, miscarriage, premature birth, premature rupture of membranes, dystocia, and malpresentation due to their growth in size during pregnancy, as they are hormone sensitive.

The presence of leiomyoma is associated with a 6-fold increased risk in cesarean section[3], and fibroids are observed in approximately 11% of all cesarean sections (C/S) [4]. Removal of leiomyomas encountered during cesarean section remains a matter of debate. The reason for removing leiomyomas during cesarean section is to avoid an additional surgical intervention [5]. However, this approach is associated with the risk of major bleeding, increasing postoperative morbidity, and even the need for a hysterectomy [6]. From another point of view, performing a myomectomy during a cesarean section reduces the total cost by lessening the need for a second surgery [7], speeds up puerperal involution, and reduces complications such as postoperative pain, anemia, and bleeding [8].

This study aimed to investigate the surgical outcomes and safety of cesarean section myomectomies in our clinic while cesarean section myomectomy controversies continue worldwide.

This retrospective study was performed between January 1, 2015, and August 1, 2022, at a single university hospital. For the study, approval was obtained from the ethics committee of Necmettin Erbakan University with the decision number 2022/3806 dated 20/05/2022.

Patients diagnosed with myoma uteri during pregnancy who underwent C/S as the delivery method and patients who were incidentally determined to have myoma uteri during C/S operation were included in the study. All patients cannot be included in the study, because the pre-2015 data record cannot be available. Myoma uteri were diagnosed by transabdominal and/or transvaginal ultrasonography, and myoma localization was determined per the FIGO classification system [9]. All patients whose myoma uteri were detected during pregnancy and C/S was planned due to fetal or maternal indications were informed about the cesarean section myomectomy operation before 34 weeks of gestation, and informed consent was obtained. Indications for C/S were C/S delivery history, fetal distress, fetal malpresentation, previous uterine surgery history, fetal macrosomia, non-progressive labor, and maternal anxiety. Cesarean section myomectomy was performed on patients with an operational request (Patients who did not want a second operation for myoma uteri), symptomatic myoma uteri (causing pain due to obstruction, menorrhagia, menometrorrhagia, myoma degeneration during pregnancy), and large myomas localized in the lower uterine segment or multiple myomas preventing vaginal delivery.

All emergency and elective C/Ss were included in the study. All fibroids detected during cesarean section were excised regardless of size, number, and localization. There were no selection criteria for myomectomy. All C/S and cesarean section myomectomy operations were performed by the same surgical team. During the cesarean section, myomectomy was performed by linear incision of the pseudocapsule of the fibroid with electrocautery followed by removal of the fibroid. After achieving hemostasis, the remaining fibroid bed and serosa were closed with absorbable sutures. All fibroid samples were sent for pathological evaluation. Patients with maternal systemic diseases (e.g., chronic hypertension, diabetes mellitus, renal and cardiac diseases), patients with placenta previa or placenta acreata spectrum, and patients with coagulation disorders or using anticoagulant drugs were excluded. The control group was randomly selected from patients without myoma who underwent C/S during the study period. Patients' age, gravida, parity, abortion, body mass index (BMI), delivery week, previous delivery type, myoma size, type, number, localization, preoperative and postoperative hemoglobin (Hb) values and postoperative Hb changes, operation time, hospital stay, blood transfusion need and amount, and postoperative complications were recorded from the hospital archive system. The obtained data were compared between the two groups. The largest diameter of myoma was considered as myoma size. In patients with more than one myoma, the size of the largest myoma was accepted as the size of myoma. The duration of the operation was calculated as the time from the start of the skin incision to its closure (in minutes). The length of stay in the hospital was calculated as the time from the day of operation to the day of discharge (in days).

Statistical Analyses

The SPSS version 22.0 (Chicago, IL, USA) was used to perform the statistical analysis. Initially, the Kolmogorov-Smirnov test and graphical analysis of all data deviation from normality were performed. To compare these groups, normally distributed data were presented as Mean ± SD values, and the Student's t-test was performed. If the data were not parametric, the Mann-Whitney U test was used, and the values were presented as median (minimum-maximum) values. The Chi-square and Fisher's exact tests determined whether categorical variable distributions differed between groups. Pearson correlation analysis was used to investigate the correlations. A p-value of less than 0.05 indicated a significant correlation between parameters. All eligible patients were included in the study. Finally, a power analysis was calculated based on the patients' Hb levels with the G-power program[10]. According to the post hoc analysis of our study, its power was 0.96 (with an effect size of 0.30, α = 0.05).

The data of 283 patients who underwent myomectomy during cesarean section were compared with the control group of 324 patients who did not have myoma but underwent only cesarean section. Demographic data consisting of age, gravida, parity, abortion, delivery week, body mass index (BMI), and previous birth history are summarized in Table 1. When abortion, delivery week, and BMI were examined, there was no statistical difference between the groups. The mean age was statistically significantly higher in the cesarean section myomectomy group (p < 0.01), while gravida and parity were higher in the control group (p < 0.01 and p < 0.01, respectively). Considering the previous birth histories, primigravida was statistically significantly higher in the cesarean section myomectomy group (p < 0.01).

Table 1

Demographic characteristics of patients in both groups
		Control group (n = 324)	Cesarean section + myomectomy (n = 283)	p value
Age(years)*		35,0 ± 6,4	37,9 ± 5,5	,000
Gravida**		3 (1–10)	2 (1–10)	,000
Parity*		1,36 ± 1,22	1,01 ± 1,10	,000
Abortion**		0 (0–8)	0 (0–7)	,141
Delivery week*		36,9 ± 2,38	36,6 ± 2,58	,108
BMI**		27 (18–40)	27 (15–48)	,902
Previous delivery type***	Primigravid	91 (28,1%)ᵃ	128 (45,2%)ᵇ	,000
	Vaginal	46 (14,2%)ᵃ	63 (22,3%)ᵇ
	C/S	187 (57,7%)ᵃ	92 (32,5%)ᵇ
*Values are expressed as mean ± SD, independent samples t-test is used.
**Values are expressed as median (minimum–maximum), Mann–Whitney U test is used.
*** Values are expressed as percentage (%), chi-square test is used.
Bold values represent p value < 0.05.

Myomas were larger than 5 cm in 38.2% of the patients. The most common type of myoma was subserosal (37.2%), and the most common fibroid localization was corpus uteri (94.7%). There was more than one fibroid in 32.2% of the patients. The mean size of myoma in the cesarean section myomectomy group was 4.7 ± 3.5 cm. Characteristics of myomas are presented in Table 2.

Table 2

Characteristics of myomas
Characteristics		Cesarean myomectomy group (n = 283) (n, %)
Size	≤ 2 cm	73 (25,8%)
	2–5 cm	102 (36,0%)
	≥ 5 cm	108 (38,2%)
Type	Subserosal	105 (37,2%)
	Submucosal	57 (20,3%)
	Intramural	91 (32,1%)
	Combined	30 (10,4%)
Number	Single	192 (67,8%)
Number	More than 1	91 (32,2%)
Localisation	Corpus Low segment Lateral wall Cervical	268 (94,7%) 3 (1,1%) 7 (1,8%) 5 (2,5%)

Duration of operation, length of hospital stay, postoperative blood transfusion need and amount of blood transfusion, preoperative Hb, and change of Hb values were statistically significantly higher in the cesarean section myomectomy group (p < 0.01, p < 0.01, p = 0.005, p = 0.006, p < 0.01, p < 0.01, respectively). Considering the postoperative complications, ileus developed in one patient in the cesarean section myomectomy group, relaparotomy due to hematoma was performed in one patient, and hysterectomy was performed in one patient. However, there was no statistically significant difference when compared with the control group (p = 0.06). Intraoperative and postoperative outcomes of all cases are summarized in Table 3.

Table 3

Analysis of surgical data compared across groups
			Control group (n = 324)	C/S + myomectomy (n = 283)	p value
Duration of operation(min)*			59,9 ± 13,5	68,5 ± 19,1	,000
Lenght of hospital stay(hour)**			46 (15–240)	48 (21–192)	,000
Postoperative blood transfusion***		No	306 (94,4%)	249 (88,0%)	,005
Postoperative blood transfusion***		Yes	18 (5,6%)	34 (12%)	,005
Amount of blood transfusion**			0 (0–3)	0 (0–6)	,006
Pre-operative Hb(g/dl)*			12,01 ± 1,42	12,45 ± 1,22	,000
Post-operative Hb(g/dl)(1.day)*			10,44 ± 1,30	10,53 ± 1,24	,379
Change of Hb(g/dl)*			1,56 ± 0,94	1,91 ± 1,10	,000
Type of operation ***	Emergency		55 (17,0%)	37 (13,1%)	,181
Type of operation ***	Elective		269 (83,0%)	246 (86,9%)	,181
Post-operative complication***			0 (0,0%)	3 (1,1%)	,063
*Values are expressed as mean ± SD, independent samples t-test is used.
**Values are expressed as median (minimum–maximum), Mann–Whitney U test is used.
*** Values are expressed as percentage (%), chi-square test is used.
Bold values represent p value < 0.05.

The correlation analysis between myoma size and duration of operation, length of hospital stay, delivery week, and amount of blood transfusion in the cesarean section myomectomy group are indicated in Table 4. A statistically significant weak positive correlation was observed between fibroid size and length of hospital stay (ρ = 0.133, p = 0.025). There was also a statistically significant weak positive correlation between the size of myoma and the amount of blood transfused (ρ = 0.120, p = 0.045).

Table 4

Analyses of correlations with myoma size within the cesarean section myomectomy group.
Parameters	r/ρ	p
Duration of operation & myoma size	,032*	,586
Lenght of hospital stay & myoma size	,133**	,025
Delivery week & myoma size	,078*	,190
Amount of blood transfusion & myoma size	,120**	,045
*Pearson’s correlation coefficient was used. The level of significance was set
at p < 0.05.
**Spearman’s correlation coefficient was used. The level of significance was
set at p < 0.05.

Pregnancies in advanced age have increased rapidly in recent years. Patients who have never been pregnant and learn that they have fibroids before conception do not prefer surgical treatment due to possible risks before pregnancy. Therefore, the possibility of encountering myoma uteri during pregnancy increases.. Although myomectomy during cesarean section is still controversial due to risks such as bleeding and hysterectomy, we believe that it makes the procedure reliable, because it has been done by the same team as our clinic for 25 years. This study revealed that myomectomy during cesarean section is safe, has low complications, and is cost-effective without needing a second operation. In addition, studies have demonstrated that performing a myomectomy during a cesarean section reduces complications such as premature birth, dystocia, and uterine atony in the subsequent pregnancy [11].

Myoma uteri are known to be more common in nulliparous and elderly women [12]. In our study, similar to the literature, the rate of nulliparous patients in the cesarean section myomectomy group was higher than in the control group, and the mean age of this group was higher than the control group. Myoma development is observed with a lower incidence in women who have given several births [13]. In our study, gravida and parity were higher in the control group than in the cesarean myomectomy group, as expected.

The major concern with cesarean section myomectomy is that it can cause massive hemorrhage, leading to postoperative morbidity and even hysterectomy. However, previous studies have reported that cesarean section myomectomy is not associated with significant hemorrhage and postoperative morbidity, although it causes increased operation time and decreased Hb levels [14, 15]. In the study of Kwon DH et al., in which 65 patients with cesarean myomectomy were compared with 96 patients who had only cesarean section, there was no difference between the groups in terms of change of Hb levels, operation time, and surgical outcomes [16]. A meta-analysis of 2301 patients with cesarean section myomectomy and only cesarean section, in which 19 studies were evaluated in 2017, determined a greater decrease in Hb in the group that underwent cesarean section myomectomy and more blood transfusion needed [6]. In the retrospective cohort analysis of Zhao R et al. in 2019 comparing the two groups with cesarean section myomectomy and only cesarean section, no significant difference was observed between the two groups regarding Hb decrease and blood transfusion need [17]. In the study of Kwon et al. in 2021, consisting of 212 patients who underwent cesarean section myomectomy, operative hemorrhage developed in 43 (20.3%) patients. Multiple logistic regression analysis demonstrated that low segmental localization and diameter were independent predictors of hemorrhage after C/S myomectomy. Low segmental position and ≥ 8cm diameter of the myoma yielded a specificity of 88.7% for hemorrhage after C/S myomectomy[18]. Our study determined a higher increase in Hb decrease, blood transfusion requirement, and transfusion amount in the cesarean section myomectomy group compared to the control group.

The present study observed an increase in the operation time of approximately 8.5 minutes in the cesarean section myomectomy group compared to the control group. Another study reported that myomectomy prolonged the operation time by 15 minutes compared to the control group [19]. The same study indicated that the duration of hospital stay was approximately one day longer in the cesarean section myomectomy group, and the reason for this was only to observe the patients more, regardless of any postoperative complications. Our study determined that the length of hospital stay in the myomectomy group was longer than in the control group. Conversely, in their systematic review in 2013, Song et al. did not detect a significant increase in the duration of the operation in myomectomy performed during C/S [20]. We think performing a myomectomy during C/S will prolong the operation time in providing hemostasis, and we believe this additional time is acceptable compared to the patient's need for a second operation.

In a meta-analysis performed in 2013, no significant difference was observed between the two groups with fibroids who underwent cesarean section myomectomy and those who had only cesarean section in terms of operation time or the amount of decrease in postoperative hemoglobin (Hb) levels. This meta-analysis revealed that cesarean section myomectomy might be an acceptable option for patients [21]

Due to the possible risk of hysterectomy during cesarean section, the general belief is that myomectomy should be avoided. In a retrospective cohort study published in 2020 in which 91 patients who underwent cesarean section myomectomy were compared with a control group of 87 patients, the hysterectomy rate was 2.2% (2/91) in the myomectomy group, and 0% (0/87) in the control group and the difference was stated to be statistically insignificant [22]. In their retrospective study, Sakinci et al. determined febrile morbidity in only four patients, associated this with breast engorgement or atelectasis, and stated that no complications such as wound infection or hysterectomy developed in any of the patients [19]. A retrospective cohort study of 212 patients who underwent cesarean section myomectomy by Kwon et al., published in 2021, demonstrated that postoperative ileus or fever developed in only six patients (2.8%) as a complication [18]. In our study, ileus developed in 1 patient in the postoperative period, relaparotomy was performed in 1 patient, and hysterectomy was performed in 1 patient. The difference was not statistically significant when compared with the control group.

Myomectomy can usually be performed with a serosal incision, and the type of operation may vary depending on the location, number, localization, and size of myomas [23]. Endometrial myomectomy, which is less invasive and adhesive, is also among the new approaches [24]. Since the pseudocapsule of myoma in the pregnant uterus is larger than in the non-pregnant uterus, it is more easily excised. In addition, the myometrium in the pregnant uterus is more elastic [25]. Another advantage of cesarean section myomectomy is that myoma can be excised with a smaller incision, and hemostasis can be achieved faster due to postpartum uterine contraction and puerperal involution [25, 26]. This condition reasonably explains the low complication rates observed in cesarean section myomectomy. We believe that performing myomectomy during cesarean section with a multidisciplinary approach by experienced teams will be safe and effective.

There are some limitations of our study. The first was the study's retrospective design, and the control group consisted of cesarean section patients without fibroids. Since our clinic is a tertiary center with experienced surgeons, all fibroids are excised during cesarean section. This situation led us to form the control group from cesarean section patients without fibroids. Another limitation was that we encountered lower complication rates because the operations were performed by an experienced team. Furthermore, patients consisted of a heterogeneous group in terms of myoma type, size, number, and localization.

Our study indicated that myomectomy during cesarean section is safe and has a low complication rate and saves patients from the necessity of a second operation. Complications such as massive hemorrhage and the need for blood transfusion are reduced when cesarean section myomectomy is performed with a multidisciplinary approach by experienced teams. Multicenter studies are needed on this subject.

Acknowledgements: Thanks to all colleagues

Author contribution:

Aslı Altınordu Atcı: Project development, Data Collection, Manuscript writing

Şükran Doğru: Data collection

Fatih Akkuş: Data analysis

Meryem Gümüş: Data collection

Ali Acar: Manuscript writing/editing

Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Conflict of interest: The authors declare no conflict of interest.

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Outcomes of cesarean myomectomy among pregnant women with uterine leiomyomas: A single tertiary center experience

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