A number of energy sources including bipolar electrosurgery, Nd:YAG laser and cryogenic probes were used under laparoscopic direction to reduce fibroid size by means of fibroid destruction and interference with local vascular supply (134). Although uterine and fibroid volumes decreased by approximately 50%, there were dense adhesions to the uterine serosa in 6 of 15 (53%) women undergoing subsequent laparoscopic evaluations for other reasons (135). Myolysis is not recommended for women who wish future fertility.
Adhesion formation after myomectomy is well documented (136). A Cochrane review found that Interceed reduced the incidence of adhesion formation, both de novo and reformation, at laparoscopy and laparotomy (137). Data were insufficient, however, to support its use to improve pregnancy rates. There was limited evidence of effectiveness of Seprafilm (Genzyme, Cambridge, MA) in preventing adhesion formation in a prospective study that randomized 127 women undergoing abdominal myomectomy to treatment or no treatment with Seprafilm (127). During second-look laparoscopy, women treated with Seprafilm had significantly fewer adhesions and lower adhesion severity scores than untreated women. This study and others find an increased incidence of adhesions with posterior uterine incisions compared to anterior incisions (138).
Submucous fibroids, sometimes associated with increased menstrual bleeding or infertility, often can be removed hysteroscopically. Classification of submucous fibroids is based on the degree of the fibroid within the cavity; class 0 fibroids are intracavitary; class I have 50% or more of the fibroid within the cavity; and class II have less than 50% of the fibroid within the cavity (60) (Fig. 15.6). A meta-analysis of the effect of fibroids on fertility found that submucous fibroids with distortion of the uterine cavity decreased ongoing pregnancy/live birth rates by 70% (RR 0.32; 95% CI, 0.12–0.850) and resection increased ongoing pregnancy/live birth rates (RR 1.13; 95% CI, 0.96–1.33) (66).
No meta-analysis of the association of submucous fibroids and abnormal uterine bleeding was performed. However, most studies show a reduction in bleeding following resection. Using pictorial assessment to estimate menstrual blood loss prior to and for 41 months following hysteroscopic resection of submucous fibroids, a significant decrease in bleeding was reported in 42 of 51 (82%) women with submucous pedunculated (type 0), 24 of 28 (86%) with sessile (type I), and 15 of 22 (68%) with intramural fibroids (type II) (140). A study of 285 consecutive women with menorrhagia or metrorrhagia who had hysteroscopic resection of submucous fibroid(s) found that additional surgery was required for 9.5% at 2 years, 10.8% at 5 years, and 26.7% at 8 years (141).
Figure 15.5 Laparoscopic myomectomy. A. 7 cm. posterior intramural fibroid. B. Transverse incision through myometrium until fibroid reached. C. Traction on fibroid and counter-traction on myometrium to tease fibroid away from myometrium.
Figure 15.5 (Continued) D. Adherent attachments to myometrium are cut. E. Minimal use of bipolar electrosurgery to control larger vessels. F. Three layer suture close of myometrium.
Figure 15.5 (Continued) G. Morcellator used to remove fibroid from abdominal cavity.
H. Pelvis irrigated and suctioned. I. Adhesion barrier placed over uterine incision.