Treatment of large uterine fibroids



It is a pity that in the commentary on the treatment of large uterine fibroids (Vol 103, June 1996)1 Chris Sutton dismisses the option of vaginal hysterectomy in two paragraphs and proposes that only abdominal hysterectomy or the experimental procedure of laparo scopic myolysis±hysteroscopic resection should be considered when it comes to surgery. This ignores the published evidence which clearly shows that vaginal hysterectomy is both feasible and safe when it comes to removing the moderately enlarged uterus. As an example (Table 1), I have summarised the results of four series published in the last 10 years, involving over 900 patients including our own2–5. It is evident that with proper patient selection, vaginal surgery is usually successful and associated with a low complication rate, particularly since the incidence of pelvic sepsis has been reduced with the widespread introduction of prophylactic antibiotics. The rate of complications in this situation compares favourably with the classic survey of vaginal and abdominal hysterectomy by Dicker et al. referred to in the commentary. Not only that, but Kovac2 and Mazdisnian et al.4 also provide comparative data showing that outcome after vaginal hysterectomy for the large uterus, whether involving coring or morcellation, differs little from ‘nonenlarged’ cases or those treated by abdominal hysterectomy save for the well established advantage of a faster recovery after vaginal surgery2,4.

Table 1.  Treatment of large uterine fibroids. Values are given as n (%), arithmetic mean [range or SD] or geometric mean {95% CI}. NA = not available
 Kovac1Grody2Mazdisnian et al3Magos et al4
  1. §Antibiotic prophylaxis not used for first 9 years of 14 year review period

  2. * Antibiotic prophylaxis not used routinely for first 10 years of the 25 year review period

  3. **Includes four further patients not included in the main descriptive series. Uteri described as ‘oversized’

  4. Uterine weights described as > 300 g and < 1000 g

  5. A11 cases include macroscopic haematuria which cleared up within 24 hours of surgery

No. of cases5543243714
Uterine weight (g)163 [100-750]400 [195-810]459 [SD 142]639 [380-1100]
Operating time (min)40 [15-110]NA127 {114-141}84 [30-150]
Estimated blood loss (mL)NANA416 {321-539)296 [100-800]
Blood transfusion16 (2.9)37 (14)3 (8.1)1 (7.1)
Laparotomy3 (0.5)1 (0.3)1 (2.7)0
Cuffccllulitis47 (8.5)§(14-16)*3 (8.1)0
Bladder injury9 (1.6)01 (2.7)6 (42.9)
Ureteric injury0000
Bowel injury0000
Conversion to abdominal hysterectomy04/328 (1-2)**5 (13.5)0
Hospital stay (days)4 [2-17][2-6]2.2 {1-9.26}3.7 [2-9]

Why is it then, that despite the evidence so few gynaecologists carry out vaginal hysterectomy for large uterine fibroids? Indeed, why are so few hysterectomies performed by the vaginal route for anything other than uterovaginal prolapse? The answer cannot be explained because of an inferior operation as the truth is the exact opposite. The likely explanation is that vaginal hysterectomy is conceptually and technically a more difficult procedure, with the result that abdominal hysterectomy is taught first and learnt first. Not surprisingly, it becomes the preferred option for most gynaecologists. The absolute application of relative contraindications, such as increased uterine size, merely fuels this self—fulfilling prophesy. The rapid uptake of laparoscopic hysterectomy and its many derivatives is a good example of an operation which has been welcomed because of this fear of vaginal surgery. And yet, with adequate training, the vast majority of hysterectomies for benign indications could be performed more quickly, more cheaply and just as safely by the vaginal route. Techniques for dealing with the enlarged uterus in the absence of uterovaginal prolapse is one of the clinical situations which should be mastered (the other is performing oophorectomy) if we are to fully exploit the benefits of vaginal surgery.

By all means, let us look for new ways to help our patients. Myolysis may well prove to be a major advance in the management of fibroids, but the evidence is in its infancy. We need more data, particularly regarding long term outcome, remembering that recurrence of fibroids is relatively common even after myomectomy, a more radical procedure than myolysis. Until we know, we should temper our enthusiasm. Conversely, we should not ignore the pioneers of gynaecological surgery, but learn from them. I suspect that the vaginal hysterectomy rate in Britain would be far from the ‘miserable’ 3.9% (for fibroids) and 11.9% (overall)6 if a quarter of the time we are currently spending on laparoscopic hysterectomy was spent training our juniors vaginal surgery. Maybe then our patients would not be denied the advantages of vaginal hysterectomy for large uterine fibroids.