Myomectomy: rational management of the perioperative period and long-term treatment outcomes
Objective - to study the influence of various surgical approaches on the outcomes of myomectomy and to determine the optimal strategy of postoperative management of patients of childbearing age with uterine fibroids. Patients and methods. A retrospective study included 145 patients who had uterine fibroids with a total increase of 480560 cm3, with the intramural component not less than 55% of the total volume. Patients of group 1 (n = 62) underwent classical laparoscopic myomectomy. Patients of group 2 (n = 48) had surgery supplemented by temporary reduction of arterial perfusion by temporary clipping of the uterine or internal iliac arteries. Robot-assisted myomectomy was performed in 34 patients of group 3. The comparison group comprised 54 women with uterine fibroids of the same sizes who did not undergo operative treatment, and the control group consisted of 36 healthy women. Results. After myomectomy, the progesterone/oestradiol receptor ratio in the endometrium increased from 1.8 to 4.6 and from 1.6 to 2.7 in patients who suffered from primary or secondary infertility before surgery. After surgery, the expression of НОХА- 10 became higher in the epithelium and pinopodes of patients of both groups. But the positive response of the stromal cells was obtained only in women who had pregnancies before surgery. The expression of the proto-oncogene bcl-2 after myomectomy decreased in patients of all groups in both the stroma and epithelium, but it was more pronounced in women with primary infertility. Changes in the endometrium occur irrespective of the type of operative intervention. Taking into account the fact that temporary cessation of arterial perfusion in the uterus does not worsen endometrial receptivity but allows a 5-fold reduction of intraoperative blood loss, this technique might be regarded as one of the most effective for prevention of intra- and postoperative complications. The incidence of pregnancy following myomectomy was 84.7% among women who planned conception, whereas among women with myoma it was only 18.9%. The number of pregnancies after assisted reproductive technologies amounted to 19.4% of the total number of patients. Conclusion. Surgical treatment of uterine fibroids makes it possible to improve a reproductive prognosis and achieve a pregnancy in 85% of cases, which, among other factors, is due to improvement of endometrial receptivity.