Anterior and Posterior Vaginal Myomectomy: a New Surgical Technique

Roberto Carminati, MD; Antonio Ragusa, MD; Raffaella Giannice, MD, PhD; Francesco Pantano, MD, PhD

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In This Article

Introduction

Up to 50% of uterine fibroids cause symptoms severe enough to warrant therapy. The surgical therapy, depending on the type of myoma, may consist of myomectomy and hysterectomy (by abdominal, laparoscopic, or vaginal route), myolysis, or hysteroscopic resection. In recent years, gynecologists have become increasingly interested in minimally invasive surgery, which has led to a shift toward the laparoscopic approach for surgical therapy.[1] Notwithstanding its advantages (eg, minimal scarring, minimal surgical trauma, minimal adhesions, and minimal postoperative pain and postoperative stay), the laparoscopic approach is less cost-effective than the laparotomic route because of the prolonged operative time and costly instruments.[2] Furthermore, in cases of enlarged, numerous, and intramural fibroids, laparoscopy does not allow easy removal of the myoma; nor does it allow optimal suturing of the uterine wall, unless it is performed by a skilled laparoscopic surgeon.[3,4]

Recently, minilaparotomy has been proposed as an alternative to the laparoscopic approach for minimally invasive surgical treatment of benign gynecologic disease.[5] Severe obesity (body mass index [BMI] > 35) and the desire for pregnancy, however, may be regarded as possible contraindications to minilaparotomy. In the first case, the laparotomic incision may have to be extended; and in the second case, tissue trauma to the reproductive organs may be greater than that caused by the laparoscopic approach.[5]

A third possible alternative route for the surgical treatment of benign uterine pathologies, is the vaginal approach (Figure 1). Davies and colleagues[6] first described the surgical technique of vaginal posterior myomectomy in a series of patients and reported no severe drawbacks. In 1998, Bessenay and colleagues[7] reported on 26 women who underwent vaginal myomectomy after culdotomy, which in some cases was laparoscopically assisted. In 1995, we had already described a cystectomy of dermoid ovarian cysts performed through a laparoscopic-assisted posterior culdotomy in a series of 18 patients, with no report of increased morbidity.[8] More recently, we performed a retrospective comparison of total laparoscopic (56 cases) and direct vaginal (30 cases) removal of ovarian dermoids, and we showed few but significant advantages of vaginal removal, particularly in relation to operating time and postoperative outcome.[9]

The illustration shows the anterior and posterior access to the uterine wall.

Having achieved encouraging results in these studies, we designed a pilot study to evaluate the surgical safety and feasibility of vaginal myomectomy. In this study, we describe the surgical technique of vaginal myomectomy for posterior and anterior (Figures 1A and 1B) uterine fibroids, and we report on surgical data and morbidity in patients who underwent this treatment.

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