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Sir,

We thank Talaulikar and his colleagues1 for their interest in our study and are grateful for the opportunity to respond to their comments.

We use prophylactic perioperative antibiotics for open myomectomy as recommended by Breech and Rock in Te Linde’s Operative Gynecology.2 Like many, we consider this book to be the bible of gynaecological surgery. As far as we know, the appropriate randomised controlled trial has yet to be carried out on the subject, and it is clearly a mistake to interpret this as evidence against the use of antibiotics. For this reason, we refer to the opinion of well respected practising gynaecologists. Indeed, logic states that perioperative antibiotics may well be of benefit with myomectomy because of the likelihood of postoperative oozing from the uterine incision(s), an almost unique circumstance in gynaecological surgery.

We are grateful for the St George’s team pointing out a typographic error in Table 2 of our paper where the data regarding the relative use of transverse and vertical midline incisions have been transposed. To clarify the matter, only four (10%) patients required a midline laparotomy, and not 36 as stated.

Our views regarding the use of GnRH analogues prior to myomectomy are not as extreme, and we believe that these drugs are valuable in certain situations. For instance, we would be reluctant to force a transverse incision on patients when the uterine fundus is both well above the umbilicus and extends to the flanks for fear of being unable to exteriorise the uterus. The fundal height, which is often used as the denominator when describing the size of a fibroid uterus, is actually a poor index of overall uterine volume as it is based solely on assessment of uterus in one plane (S. Sheth, pers. comm.). We are also wary of using a low transverse incision with a very large uterus after previous surgery for fear of having poor access to any fundal or posterior adhesions. Under such conditions, preoperative therapy with a GnRH analogue can make a low transverse incision both appropriate and safe.

We also use GnRH analogues and oral iron to treat preoperative anaemia but rarely prescribe parenteral iron. To quote the British National Formulary, ‘… With the exception of patients with severe renal failure receiving haemodialysis, parenteral iron does not produce a faster haemoglobin response than oral iron provided that the oral iron preparation is taken reliably and is absorbed adequately …’.3 There is also the risk of anaphylactoid reactions with parenteral administration of iron complexes.

Finally, while the value of intramyometrial injections of vasopressin and its derivatives in terms of reducing the need for blood transfusion at myomectomy is debatable,4,5 there is no debate regarding its risks of causing life-threatening complications even when using the dilute solution recommended by Talaulikar et al.1 Furthermore, because of their short half-life, injectable vasoconstrictors can mask bleeding vessels during surgery resulting in suboptimal uterine repair and bleeding after surgery. Tourniquets do not have any of these short comings.

References

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  2. References
  • 1
    Talaulikar V, Gorti M, Manyonda I. Prospective randomised trial comparing gonadotrophin-releasing hormone analogues with triple tourniquets at open myomectomy. BJOG 2009;116:1531.
  • 2
    Breech LL, Rock JA. Leiomyomata uteri and myomectomy. In: RockJA, JonesHWIII, Editors. “Te Linde’s Operative Gynaecology, 9th Edn. Philadelphia, PA: Lippincott & Wilkins; 2003, 75398.
  • 3
    Parenteral iron. British National Formulary 57, March 2009, Section 9.1.1.2.
  • 4
    Kongnyuy EJ, Wiysonge CS. Interventions to reduce haemorrhage during myomectomy for fibroids. Cochrane Database Syst Rev 2007: CD005355.
  • 5
    Hobo R, Netsu S, Koyasu Y, Tsutsumi O. Bradycardia and cardiac arrest caused by intramyometrial injection of vasopressin during a laparoscopically assisted myomectomy. Obstet Gynecol 2009;113:4846.