fibroid recurrence

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The following are just a few abstracts from clinical studies and a few

thoughts to chew on about fibroid recurrence with myomectomy. carla

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Title

Long term follow up of hysteroscopic myomectomy assessed by

survival analysis.

Author

Hart R; Moln´ar BG; Magos A

Address

Endoscopy Training Centre, University Department of Obstetrics and

Gynaecology, The Royal Free Hospital,

London, UK.

Source

Br J Obstet Gynaecol, 106(7):700-5 1999 Jul

Abstract

OBJECTIVE: To identify patient characteristics which affect outcome

after hysteroscopic myomectomy for

submucous fibroids. DESIGN: Prospective observational study.

SETTING: A university teaching hospital.

SAMPLE: One hundred and twenty-two consecutive patients treated by

hysteroscopic myomectomy for

submucous leiomyoma over a period of almost eight years. METHODS:

Hysteroscopic electroresection of the

leiomyoama using a continuous flow resectoscope. MAIN OUTCOME

MEASURES: The avoidance of further

surgery and patient satisfaction. RESULTS: The average age of the

patients at the time of their surgery was 42.8

years. A total of 194 fibroids were removed. The mean follow up

period was 2.3 years (range 1-7.6). Of those

asked, 71.4% were satisfied with the results of surgery. Sixteen

women required further surgery for fibroids, and six

ultimately underwent hysterectomy. Survival analysis showed that

the risk of further surgery was 21% at four years

after the myomectomy, and 0% thereafter. Univariate regression

analysis suggested that outcome was significantly

better in older women, and in cases where the uterus was equivalent

in size to < or = 6 weeks of gestation, the

fibroid was < or = 3 cm in diameter and mainly intra-cavitary, and

the procedure time was < or = 20 minutes. The

influence of hormonal pre-treatment and the number of fibroids

excised was not statistically significant. After

multivariate regression analysis, only overall uterine size and the

position of the fibroid being removed were found to

significantly influence the success of surgery. CONCLUSIONS:

Hysteroscopic myomectomy is an effective way to

manage patients with symptomatic submucous leiomyomata,

particularly when the uterus is not grossly enlarged and

the fibroid(s) are mainly inside the uterine cavity.

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Title

Recurrence rate after laparoscopic myomectomy.

Author

Nezhat FR; Roemisch M; Nezhat CH; Seidman DS; Nezhat CR

Address

Stanford University School of Medicine, Department of Gynecology

and Obstetrics, California, USA.

Source

J Am Assoc Gynecol Laparosc, 5(3):237-40 1998 Aug

Abstract

STUDY OBJECTIVE: To determine the recurrence rate of myomas after

laparoscopic myomectomy. DESIGN:

Retrospective review (Canadian Task Force classification II-2).

SETTING: Tertiary referral center. PATIENTS:

One hundred fourteen women (age 25-51 yrs, median 38 yrs) who were

followed for an average of 37 months

(range 6-120 mo). INTERVENTION: Laparoscopic myomectomy.

MEASUREMENTS AND MAIN RESULTS:

Follow-up data were obtained by chart review and from returned

questionnaires. Variables were date of surgery,

first diagnosis of recurrence, and last follow-up visit. There were

38 (33.3%) recurrences after an average interval

of 27 months. Twenty-four of these women did not require treatment.

Eight underwent a second laparoscopic

myomectomy, and one had a third. One patient had myomectomy and

then hysterectomy, and six patients chose

hysterectomy to treat the first recurrence. Cumulative risk of

recurrence (Kaplan-Meier curve) was 10.6% after 1

year, 31.7% after 3 years, and 51.4% after 5 years. CONCLUSION:

Although laparoscopic myomectomy is

associated with less morbidity than removal by laparotomy, our

results suggest that recurrence of myomas may be

higher with the laparoscopic approach. Of 38 women with recurrent

myoma, however, only 14 (36.8%) required

additional surgery.

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Here's just a few questions that studies like the ones above might make

one think about before globally applying these statistics to recurrence

of fibroids with ALL myomectomies:

1. What was the age of patients (median was 38 with youngest being

25!) in the study?

2. What type of myomectomy is being addressed with the study and why

would or would not the information gleaned or statistics calculated be

globabally applicable to all types of myomectomy?

3. Does the study identify/address whether GnRH was used

pre-procedure in any of the patients?

4. How large is the patient sample?

5. Was the study prospective (planned in advance and

surgeons/surgical technique/data collection controlled to some degree)

or retrospective (a collection and review of information

after-the-fact)?

This is only a beginning list of questions that one should start to

think about and critically " eyeballing " when doctors throw out studies

as the basis of their statistical data. Only YOU can determine whether

these statistics and this particular study are " good enough " for

comparative value to your own situation. Personally, I wouldn't quote

from this study and globally apply it to recurrence of fibroids

post-myomectomy for reasons related to all of the questions above and

more. But each person must determine those relevant factors/issues for

him/herself.

The numbers I used previously for fibroid recurrence were comparative

across a broad range of research and number crunched by experts--not

me. Comparative review of a broad range of medical literature and the

numbers identified therein are very good tools for statistically

weighting values and coming up with some sort of mean results. This is

something RAND statisticians are very good at. Still, prospective

TRIALS of myomectomy techniques and comparative recurrence of fibroids

with different techniques are not abundant. STUDIES are simply not the

same thing. But then again, the same could be said of UFE. Only

studies exist in the U.S. No controlled trials have been started yet.

Everything we " know " about UFE and fibroids is based on studies. Not

clinical trials. But then again even yet, most medicine and surgical

techniques used today are based on neither studies nor trials.

That probably clears up just about nothing -- sorry guys. Wish there

was truly more definitive info/stats on this issue. There really just

isn't.

Here's a better idea of what might be included in a review of the

medical literature in an attempt for researchers to draw a broader,

potentially more accurate conclusion -- I think you can get the general

idea behind what I'm trying to explain in terms of how a variety of

studies combined can present a slightly different perspective than a

singular study standing by itself. The RAND review of hysterectomy on

the http://www.rand.org site does the same thing for hysterectomy as

what this study tries to do with myomectomy for

infertility--collect/combine/review/compare data in an attempt to draw

some useful conculsions.

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Title

Abdominal myomectomy for infertility: a comprehensive review.

Author

Vercellini P; Maddalena S; De Giorgi O; Aimi G; Crosignani PG

Address

Clinica Ostetrica e Ginecologica Luigi Mangiagalli, Universit`a di

Milano, Italy.

Source

Hum Reprod, 13(4):873-9 1998 Apr

Abstract

To obtain estimates of the effect of abdominal myomectomy on

infertility, information from studies published in the

English language literature between 1982 and 1996 was retrieved.

Articles were identified through hand and

computerized searches using Medline. A total of 27 trials, all

published in peer-reviewed journals, was identified, of

which four were excluded from the analysis because of

methodological limitations. All studies were non-comparative

and only nine were prospective. The sample size was generally

limited, the mean number of patients included being

49 and the mean number of infertile subjects 26. All patients were

followed for at least 12 months after surgery in 12

studies. The combined estimate of pregnancy rates across

prospective studies based on a total of 138 observed

subjects was 57% [95% confidence interval (CI), 48-65%]. Time to

conception varied from a mean of 8 to 20

months. Survival analysis was used in only three studies, with

cumulative rates ranging from 57 to 67% at 1 year,

and 63% at 5 years. The overall conception rate among seven

prospective studies in which only women with

otherwise unexplained infertility were recruited was 61% (95% CI,

51-70%) compared with 38% (95% CI,

20-59%) in two prospective studies that included patients with

causes of infertility in addition to myomas (chi2(1) =

4.25, P = 0.04; mean difference = 23%, 95% CI, 1-43%; OR = 2.47,

95% CI, 1.03-5.94). The conception rate

ranged from 58 to 65% in the three studies of women with only

intramural and/or subserous fibroids and were

respectively 53 and 70% in the two that considered only patients

with submucous myomas. Data on recurrence

after myomectomy were reported in 13 articles, with rates varying

from 4 to 47%. According to the available

evidence, slightly less than two-thirds of women with uterine

leiomyomas and otherwise unexplained infertility

conceived after myomectomy. However, comparison with expectant

management is needed before drawing

definitive conclusions on the effectiveness of this time-honoured

conservative surgical procedure.