Comparison of safety and efficacy between laparoscopic myomectomy and traditional laparotomy for patients with uterine fibroids and their effect on pregnancy rate after surgery

  • Authors:
    • Xueqiao Kan
    • Xiaoxia Shen
    • Li Feng
    • Yuqing Hu
    • Jiadong Yu
    • Xiaoju Yang
  • View Affiliations

  • Published online on: June 29, 2021     https://doi.org/10.3892/etm.2021.10345
  • Article Number: 913
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Abstract

The aim of this retrospective study was to compare the safety and efficacy between laparoscopic myomectomy and traditional laparotomy for patients with uterine fibroids and determine their effect on the pregnancy rate after surgery. In total, 86 cases with uterine fibroids were selected among patients who were admitted in the Zhangqiu District Maternal and Child Health Care Hospital during the period of April, 2016 to April, 2017. Patients who underwent laparoscopic myomectomy were enrolled in group A (n=42), and those who underwent traditional laparotomy were placed in group B (n=44). The general linear data and the operative indicators were compared. The VAS scores, serum IFN‑γ, IL‑6, VEGF levels and clinical efficacy of the two groups were also compared one week after surgery. Postoperative pregnancy rates and complications in both groups were also compared. No significant differences were observed in general data between the two groups (P>0.05). The intra‑operative blood loss in the group A was lower than that in group B (P<0.05), the average time of operation, hospital stays (days), and anal exhaust time in group A were shorter than those in group B (P<0.05). The pain degrees at 3, 6 and 18 h after surgery for patients in the group A were significantly lower than those of the group B (P<0.05). There was no significant difference IL‑6 and VEGF levels in the serum between groups A and B before and after surgery (P>0.05); however, the level of IFN‑γ expression, one week after surgery, in group B was significantly higher than that in group A (P<0.05). The pregnancy rate in the experimental group was higher than that in the control group (P<0.05), and the incidence rate of complications in group A was significantly lower than that in group B (P<0.05). Results presented in the present study suggested that compared to traditional laparotomy, laparoscopic myomectomy is a more advantageous method in terms of safety, efficacy and pregnancy rate after surgery.

Introduction

Uterine fibroid is a common tumor in women with a relatively high prevalence rate in infertile patients (1). The tumor has smooth muscle and fibroblast components besides a large amount of extracellular matrix, which has an important influence on this disease. This is considered as a type of common clonal tumor and is also known as liomyoma or leiomyoma (2). Prior studies have shown that estrogen and progesterone can increase the growth rate of the tumor (3), while causing a series of grave and chronic symptoms. Excessive menstruation is the most common symptom, which can lead to anemia, fatigue and pain. In some cases, it may cause aperiodic pain, abdominal protrusion or pelvic pressure, which affects intestinal function and causes constipation (4). In addition, uterine fibroids have a great influence on the pregnancy rate of women (5,6).

Traditionally, surgery for uterine fibroids, such as hysterectomy (7), requires open surgery. Although these treatments are of great benefit in the treatment of patients with uterine fibroids, these operations can easily lead to a series of complications such as urinary tract infection and pain (8). In recent years, more laparoscopic therapies, such as laparoscopic myomectomy, have been widely used for the treatment of these patients. Laparoscopic myomectomy technique has surpassed laparotomy and become the treatment option for many medical institutions worldwide. Compared with traditional laparotomy, laparoscopic myomectomy has several advantages. Some studies showed that laparoscopic myomectomy reduced morbidity and hospital stays compared with traditional surgical methods (9-12).

In this study, we compared the safety and efficacy of the two methods of surgeries and their influence on the pregnancy rate after surgery.

Materials and methods

General information

This is a retrospective study. In total, 86 cases with uterine fibroids were selected among patients who were admitted in Zhangqiu District Maternal and Child Health Care Hospital during the period of April, 2016 to April, 2017. Patients who underwent laparoscopic myomectomy were enrolled in group A (n=42), and those that underwent traditional laparotomy were included in group B (n=44). Patients in group A were 26-46 years of age, with an average age of (35.59±4.02) years, and patients in group B were 28-44 years, with an average age of (36.01±3.97). Inclusion criteria were: i) Patients diagnosed with uterine fibroids after gynecological examination. ii) Family members were informed about this study. Exclusion criteria were: i) Age (<25 or ≥50); ii) primary ovarian insufficiency or tubal infertility; iii) a history of hemorrhagic diseases.

This study was approved by the ethics committee of the Zhangqiu District Maternal and Child Health Care Hospital. Patients signed the informed consent.

Methods

Patients in group A (n=42) were treated with laparoscopic myomectomy. Abdominal endoscopy was performed using a 10-mm endoscope equipped with a camera and a high-resolution monitor (Storz-France).

The following instruments were used: Atraumatic graspers, Semm fibroids for thermal coagulation, monopolar hooks, Semm needle holders and suture forceps, pelvicleaner (Storz-France). The instrument was introduced through three suprapubic puncture sites (diameter, 5 mm). Laparoscopic myomectomy was performed in all cases according to the principle of non-invasive infertility surgery: Enlargement, careful hemostasis and irrigation with saline. Prior to surgery, the patient was required to first empty the bladder, then undergo general anesthesia, select the bladder lithotomy position and indwelling catheter. A 1-cm incision was made in the skin of the umbilicus margin, and a pneumoperitoneum needle was inserted to construct a carbon dioxide pneumoperitoneum with a pressure of 12-14 mmHg. Subsequently, a laparoscopy device was inserted. Laparoscopy can prevent myometrial fragmentation after interstitial myomectomy or prevent the risk of large area (>1 cm2) adhesion after myomectomy by suturing a fine-closed uterine incision. The uterus was cut into one or two layers according to the depth of the incision, interrupting or running 3-0 Vicryl (Polyglactine 910, 20 mm needle; Ethicon) or 4-0 PDS (Polydioxanon, 20-mm needle; Ethicon) suture. After enlarging the incision (20 mm) with a single tooth retractor, myoma was removed through the suprapubic puncture site. The uterine incision was transparently closed using a classic needle hub placed via the suprapubic incision under laparoscopic control. In all cases, the peritoneal cavity was flushed with saline solution after the surgery was terminated.

Patients in group B (n=44) were treated via traditional laparotomy. For laparoscopic myomectomy, the patient took the supine position after anesthesia, and a longitudinal incision was made in the middle of the lower abdomen. After slow injection of 20 ml of normal saline + 6 U of pituitrin into the myometrium, blunt separation was performed along the surface of the myoma capsule until reaching the area with more basal blood vessels. The myoma was then removed after clamping, and the myometrium and serosa were sutured.

Birth control lasted for 1 year for patients with large and frequent fibroids who underwent the intrauterine operation. This period was 6 months for those who did not undergo the intrauterine operation, and 3 months for patients without obvious uterine fibroids under the serosa.

Observation indicators

There were six observation indicators: i) The general linear data and operative indicators were compared. No significant differences were observed in the general data between the two groups (P>0.05). The operative indicators of patients in groups A and B, including average time of operation, intraoperative blood loss, hospital stays and anal exhaust time was also compared.

ii) The pain levels of patients in the two groups were compared at 3, 6 and 18 h after surgery. The pain levels of the two groups were compared using the Visual Analogue Scale/Score (VAS) (13), with a score range of 0-10 points, and the score was proportional to the pain level.

iii) One week following surgery, the expression levels of IFN-γ, IL-6 and VEGF in the serum were compared., between the two groups.

iv) The total effective rate was compared between the two groups. Evaluation criteria were: Markedly effective, uterine fibroids were completely excised without complications; effective, uterine fibroids were basically excised with no complications or complications could be recovered; ineffective, could not meet the effective standard. Total effective rate was calculated as marked efficiency + effective rate.

v) Comparison of the pregnancy rate after surgery between the two groups. Since the patients were childbearing age, the pregnancy rate after surgery between the two groups was compared. In order to investigate their pregnancy rate, follow-up visits were made after 6, 12, 18 and 24 months following the surgery.

vi) Complications observed in both groups were compared: There were three common postoperative complications after uterine fibroids and other laparoscopic surgery and laparotomy, i.e., urinary tract infection (14), incision pain (15), and pelvic adhesions (16). The complications were investigated and the incidence of complications was counted.

Statistical analysis

SPSS 19.0 (Asia Analytics Formerly SPSS) was used for statistical analysis of comprehensive data. The measurement data were expressed as mean ± standard deviation. Independent samples t-tests was performed, and multiple group comparisons were performed using analysis of variance followed by LSD test. The count data were expressed by rate and composition ratio, and the Chi-square test was performed. P<0.05 indicated a statistically significant difference.

Results

Comparison of the general clinical baseline data of the two groups

There was no statistically significant difference in the general clinical baseline data including age, hypertension, hyperlipidemia, diabetes, personal hobbies such as smoking and drinking, between the groups (P>0.05) (Table I).

Table I

General clinical baseline data of groups A and B [n (%)] (mean ± SD).

Table I

General clinical baseline data of groups A and B [n (%)] (mean ± SD).

VariableGroup A (n=42)Group B (n=44)t/χ2P-value
Age (years)35.59±4.0236.01±3.970.490.63
Unfertile phase (month)44.57±20.6741.99±20.170.590.560
Body mass index (kg/m2)19.04±3.1819.15±2.640.170.862
Total number of myomas2.75±1.982.94±1.530.500.619
Total number of large myomas1.12±0.331.09±0.290.450.655
Size of large large myomas (cm)7.47±2.607.07±2.540.720.473
Smoking  0.180.673
     Yes23 (54.76)24 (54.55)  
     No19 (45.24)20 (45.45)  
Drinking  0.190.666
     Yes22 (52.38)21 (47.73)  
     No20 (47.62)23 (52.27)  
Obesity  0.050.825
     Yes20 (47.62)22 (50.00)  
     No22 (52.38)22 (50.00)  
History of hypertension  0.160.685
     Yes23 (54.76)26 (61.90)  
     No19 (45.24)18 (38.10)  
History of diabetes  0.400.526
     Yes21 (50.00)25 (56.82)  
     No21 (50.00)19 (43.18)  
Location of myomas of patients  0.680.711
     Subserous myomas (%)11 (25.00)12 (27.27)  
     Intermural myomas (%)29 (69.05)28 (63.64)  
     Intra-uterine myomas (%)2 (5.95)4 (9.09)  
Comparison of the surgical indicators of patients between the two groups

The average time of operation, hospital stays, intra-operative blood loss, and anal exhaust time in the group A were (70.21±7.83) min, (8.12±2.01) days, (44.4±5.82) ml, and (13.21±4.13) h, respectively. The average time of operation, intra-operative blood loss, hospital stays, and anal exhaust time in the group B were (100.23±38.34) min, (16.01±2.44) days, (79.22±7.53) ml, and (29.25±5.37), respectively. By comparing the post-treatment surgical indicators in the two groups, it could be concluded that patients in group A were significantly better than those in group B and the results were statistically significant (P<0.001) (Table II).

Table II

Comparison of surgical indicators of patients between groups A and B.

Table II

Comparison of surgical indicators of patients between groups A and B.

VariableGroup A (n=42)Group B (n=44)tP-value
Average time of operation (min)70.21±7.83100.23±38.344.98<0.001
Average length of stay (days)8.12±2.0116.01±2.4416.32<0.001
Average intra-operative blood loss (ml)44.4±5.8279.22±7.5323.91<0.001
Average anal exhaust time (h)13.21±4.1329.25±5.3715.47<0.001
VAS score after surgery

The pain scores of group A were (4.21±0.83), (2.56±0.67), (1.63±0.55) 3, 6 and 18 h after surgery, respectively, while the pain scores of group B were (8.23±0.94), (5.54±0.85) and (3.70±0.61) at T0, T1 and T2 after surgery, respectively. As for intra-group comparison, the VAS score of the two groups decreased from T0 to T2, and the difference was statistically significant (P<0.05). As for comparison among groups, the VAS scores of group A at different time points were significantly lower than those of group B (P<0.05). More details are presented in Table III.

Table III

Average VAS score tables of patients in groups A and B at different time periods after surgery.

Table III

Average VAS score tables of patients in groups A and B at different time periods after surgery.

VariableGroup A (n=42)Group B (n=44)tP-value
Three hours after surgery4.21±0.838.23±0.9420.98<0.001
Six hours after surgery2.56±0.675.54±0.8518.000<0.001
Eighteen hours after surgery1.63±0.553.70±0.6116.500<0.001
F149.40337.10  
P-value<0.001<0.001  
Levels of serum related inflammatory factors in the two groups IFN-γ

Before and after treatment, the expression levels of IFN-γ in group A were (12.39±1.20) µg/l and (12.18±1.01) µg/l, respectively, while the expression levels of IFN-γ in group B were (12.76±1.09) µg/l and (15.67±1.02) µg/l, respectively. There was no significant difference between the two groups prior to treatment (P>0.05). There was no significant difference in group A before and after treatment (P>0.05). However, the expression level in group B after treatment was higher than that before treatment (P<0.05). After treatment, the expression level in group B was higher than that of group A (P<0.05). More details are shown in Fig. 1.

IL6 (pg/ml)

Before and after treatment, the expression levels of IL6 in group A were (6.97±2.20) pg/ml and (9.16±1.29) pg/ml, respectively, and the expression levels of IL6 in group B were (7.28±2.41) pg/ml and (9.37±1.22) pg/ml, respectively. There was no significant difference between the two groups before treatment (P>0.05). The expression levels in both groups after treatment were higher than those levels measured before treatment (P<0.05). Nevertheless there was no significant difference between the groups after treatment (P<0.05). More details are shown in Fig. 2.

VEGF (pg/ml)

Before and after treatment, the expression levels of VEGF in group A were (946.42±104.76) pg/ml and (547.36±57.67) pg/ml, respectively, and the expression levels of VEGF in group B were (946.55±104.91) pg/ml and (548.18±58.08) pg/ml, respectively. There was no significant difference between the two groups prior to treatment (P>0.05). The expression levels in the two groups after treatment were higher than those levels registered before treatment (P<0.05). There was no significant difference between the groups after treatment (P<0.05). More details are presented in Fig. 3.

Total effective rate of patients in the two groups

Among the patients in group A, the total effective rate was: In 22 cases, markedly effective; in 18 cases, effective while 2 cases were ineffective. The overall total effective rate in group A were 95.24%. In group B, 18 cases were markedly effective, 15 cases were effective while 11 cases were ineffective. The overall total effective rate in group B was 75.00%. The total effective rate of group A was significantly higher than that of group B, and the difference was statistically significant (P<0.05). More details are shown in Table IV.

Table IV

Total effective rate of patients in the two groups.

Table IV

Total effective rate of patients in the two groups.

EfficacyGroup A (n=42)Group B (n=44)χ2P-value
Markedly effective22 (52.38)18 (40.91)--
Effective18 (42.86)15 (34.09)--
Ineffective2 (4.76)11 (25.00)--
Total effective rate (%)40 (95.24)33 (75.00)6.860.009
Comparison of the pregnancy rate after surgery between the two groups

In group A, 9 patients were pregnant at 6 months after surgery, with a pregnancy rate of 21.43%; 20 at 12 months after surgery, with a pregnancy rate of 47.62%; 29 at 18 months after surgery, with a pregnancy rate of 69.05% and 38 were pregnant at 24 months after surgery, with a pregnancy rate of 90.48%. In group B, 2 patients were pregnant at 6 months after surgery, with a pregnancy rate of 4.55%; 10 at 12 months after surgery, with a pregnancy rate of 22.73%; 19 were pregnant at 18 months after surgery, with a pregnancy rate of 43.18%, and 26 at 24 months after surgery, with a pregnancy rate of 59.09%. The pregnancy rate of group A was significantly higher than that of group B at these four time points. The difference was statistically significant (P<0.05). More details are shown in Table V.

Table V

Comparison of pregnancy rates between groups A and B.

Table V

Comparison of pregnancy rates between groups A and B.

VariableGroup A (n=42)Group B (n=44)χ2P-value
Six months after surgery9 (21.43)2 (4.55)5.130.024
Twelve months after surgery20 (47.62)10 (22.73)5.860.015
Eighteen months after surgery29 (69.05)19 (43.18)5.830.016
Twenty-four months after surgery38 (90.48)26 (59.09)11.120.001
Comparison of the complications of the two groups

The postoperative complications including infection, incision pain and pelvic adhesion were studied in both groups. In group A, there was 1 case of infection, 1 case of incision pain and 2 cases of pelvic adhesion, with a total incidence rate of complications of 9.52%. In group B, there were 4 cases of infection, 6 cases of incision pain and 4 cases of pelvic adhesion, with a total incidence rate of complications of 31.82%. The incidence rate of complications after surgery in group A was significantly lower than that of group B, with significant difference (P<0.05). More details are presented in Table VI.

Table VI

Comparison of complications of patients between the two groups.

Table VI

Comparison of complications of patients between the two groups.

VariableGroup A (n=42)Group B (n=44)χ2P-value
Urinary tract infection1 (2.38)4 (9.09)--
Incision pain1 (2.38)6 (13.64)--
Pelvic adhesion2 (4.76)4 (9.09)--
Incidence rate of complications4 (9.52)14 (31.82)4.270.039

Discussion

Uterine fibroids are very common in gynecology, and they have adverse effects on women and pregnancy (17,18). However, it is very important to choose an effective therapy that can effectively and safely treat uterine fibroids. The focus of the present study was to compare laparoscopic myomectomy with traditional laparotomy methods for treating uterine fibroids.

In this study, the average time of operation, blood loss, hospital stays and exhaust time of groups A and B were compared, and results showed that laparoscopic therapy had significantly shorter time of operation, less blood loss and significantly less hospital stays and average exhaust time. Results obtained from prior studies revealed that laparoscopic myomectomy could simply lead to serious blood loss, resulting in severe problems such as increased incidence rate of postoperative illnesses (19,20). However, the blood loss in the laparoscopic myomectomy method is less than that of laparotomy. Previous findings showed that compared with laparotomy, laparoscopic myomectomy method significantly reduced blood loss (21,22). In addition, compares to laparoscopy, patients treated with laparoscopic myomectomy recover faster and better from laparoscopy. Patients treated with laparoscopic myomectomy also had a shorter hospital stay (23,24). All these observations could explain the reason for the average time of operation, blood loss and hospital stays of laparoscopic myomectomy surgery being better than those of laparotomy.

Compared with laparotomy, laparoscopic myomectomy could reduce postoperative pain by effectively reducing the oxidative stress reaction of postoperative uterine fibroids (25). Results obtained from comparing the VAS scores between the two groups after 3, 6 and 12 h, demonstrated that patients in group B had a higher pain VAS score. Bhave Chittawar et al reported that laparoscopic myomectomy was a less painful surgery compared with traditional laparotomy (26). Results showed that laparoscopic surgery caused less postoperative pain compared to traditional transabdominal surgery.

In the present study, we compared the levels of serum IFN-γ, IL-6 and VEGF in both groups one week after surgery, and found that the expression level of IFN-γ in group B after treatment was significantly higher, while the levels of IL-6 and VEGF between the two groups were not significantly different after treatment. Prior findings showed that IFN-γ could inhibit tumor level in uterine fibroids. High expression level of IFN-γ can inhibit gonadotropin synthesis and affect the normal body function. However, the expression level of IFN-γ after surgery in laparoscopic myomectomy was lower than that in traditional laparotomy, indicating that laparoscopic myomectomy could improve IFN-γ and the efficacy was more significant than that of traditional methods (27). By comparing the postoperative serum factors such as IFN-γ and the total effective rate of the disease in the two groups, it was shown that laparoscopic hysteromyoma surgery has better efficacy than traditional laparotomy.

The pregnancy rate for patients with uterine fibroids is usually very low (28), and this problem can be alleviated only through surgery. After comparing the pregnancy rates of the two groups at different time points (6, 12, 18 and 24 months) after surgery, we found that the pregnancy rate after laparoscopic myomectomy was higher than that of the alternative method. Results obtained from prior studies indicated that uterine rupture caused by myomectomy was particularly risky to pregnancy (29). Koo et al reported that the uterine rupture caused by laparoscopy was a rare event (30) with minimal effects on pregnancy rate. Shen et al also showed (31) that the pregnancy rate was higher after laparoscopic myomectomy.

Sheyn et al reported that, compared with traditional abdominal myomectomy, laparoscopic myomectomy had a lower incidence rate of complications (32). The results of the present study showed that the incidence rate of complications in patients treated with laparoscopic myomectomy were significantly lower than that of traditional laparotomy. Our findings are in accordance with previous reports.

Other studies have reported a close association among the size of fibroids, number of fibroids and the risk of complications (33). We also should not underestimate the importance of traditional laparotomy for patients with numerous large fibroids (34,35).

From the incidence of these complications, combined with the previous inflammatory factors, surgical indicators, VAS scores, and pregnancy rate, patients who underwent laparoscopy have smaller wounds, less bleeding volume, less inflammation, and less pain than traditional open surgery. In this way, patients have fewer postoperative complications and can recover faster. Owing to its less pain and faster recovery, patients' quality of life is less affected, which can be very beneficial to their chance for future pregnancies. In the clinical study of Gueli Alletti et al (36) on ovarian cancer, it was found that if a patient needs to get a good recovery, he has to stay positive, and negative emotions are likely to aggravate the patient's condition. Therefore, it is necessary to avoid such negative emotions in the clinical practice. The same is true for the treatment of uterine fibroids. The use of laparoscopy is currently a trend. If surgical methods are modified to reduce their risks, the use of laparoscopy will be more widespread in the future. In this case, the effect becomes higher, and it is more beneficial for women's pregnancy rate.

There were some shortcomings associated with this study, for example the variety of uterine fibroids was limited, there were no patients with large myoma, and finally our sample size was small. In summary, laparoscopic myomectomy on uterine fibroids has advantages over traditional laparotomy. At the same time, in the future research and treatment, the existing laparoscopic therapy remains to be ameliorated, the risk of surgery reduced and the efficacy of surgery should be improved.

Acknowledgements

Not applicable.

Availability of data and materials

The datasets used and/or analyzed during the present study are available from the corresponding author on reasonable request.

Authors' contributions

XK and XS conceived and designed the study and drafted the manuscript. LF and YH collected, analyzed and interpreted the experimental data. JY and XY analyzed data and revised the manuscript for important intellectual content. XK wrote the manuscript. XK and LF are responsible for confirming authenticity of the data. All authors read and approved the final manuscript.

Ethics approval and consent to participate

The study was approved by the Ethics Committee of Zhangqiu District Maternal and Child Health Care Hospital. Patients signed the informed consent.

Patient consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

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September-2021
Volume 22 Issue 3

Print ISSN: 1792-0981
Online ISSN:1792-1015

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Spandidos Publications style
Kan X, Shen X, Feng L, Hu Y, Yu J and Yang X: Comparison of safety and efficacy between laparoscopic myomectomy and traditional laparotomy for patients with uterine fibroids and their effect on pregnancy rate after surgery. Exp Ther Med 22: 913, 2021
APA
Kan, X., Shen, X., Feng, L., Hu, Y., Yu, J., & Yang, X. (2021). Comparison of safety and efficacy between laparoscopic myomectomy and traditional laparotomy for patients with uterine fibroids and their effect on pregnancy rate after surgery. Experimental and Therapeutic Medicine, 22, 913. https://doi.org/10.3892/etm.2021.10345
MLA
Kan, X., Shen, X., Feng, L., Hu, Y., Yu, J., Yang, X."Comparison of safety and efficacy between laparoscopic myomectomy and traditional laparotomy for patients with uterine fibroids and their effect on pregnancy rate after surgery". Experimental and Therapeutic Medicine 22.3 (2021): 913.
Chicago
Kan, X., Shen, X., Feng, L., Hu, Y., Yu, J., Yang, X."Comparison of safety and efficacy between laparoscopic myomectomy and traditional laparotomy for patients with uterine fibroids and their effect on pregnancy rate after surgery". Experimental and Therapeutic Medicine 22, no. 3 (2021): 913. https://doi.org/10.3892/etm.2021.10345