Description

Laparoscopic myomectomy (LM) has become an increasingly preferred surgical option for women with uterine fibroids who wish to preserve their fertility. This minimally invasive technique offers several advantages over traditional abdominal myomectomy (AM), including reduced postoperative pain, shorter hospital stays, and quicker recovery times. However, understanding the impact of LM on subsequent pregnancy outcomes is crucial for informed clinical decision-making. Pregnancy Rates Post-Myomectomy Studies have demonstrated that myomectomy, in general, can enhance fertility outcomes, with pregnancy rates reaching up to 70% post-surgery. This improvement is attributed to the removal of fibroids that may distort the uterine cavity, alter myometrial contractility, or disrupt the anatomical relationship between the fallopian tubes and ovaries. Notably, some research indicates that LM may be associated with higher pregnancy rates compared to AM. For instance, a single-center cohort study reported pregnancy rates of 30.8% in the LM group versus 16.8% in the AM group, suggesting that the minimally invasive approach might reduce postoperative adhesions, thereby enhancing fertility. Influence of Myoma Characteristics The size of the excised myomas appears to influence fertility outcomes. Patients with myomas smaller than 8 cm had higher pregnancy rates (33% vs. 20%) compared to those with larger myomas, regardless of the surgical approach. This finding underscores the importance of early intervention and careful patient selection in optimizing reproductive outcomes. citeturn0search0 Mode of Delivery and Obstetric Outcomes The mode of delivery following myomectomy has been a subject of considerable discussion. Elective cesarean sections are often recommended to mitigate the risk of uterine rupture during labor, especially in cases where the uterine cavity was entered or multiple myomas were removed. In the aforementioned cohort study, the elective cesarean rate was 44.2%, with a higher incidence in the AM group (69.1%) compared to the LM group (32.3%). Conversely, other studies have reported higher rates of elective cesareans in the LM group, possibly due to concerns about uterine integrity post-surgery. Trial of labor after myomectomy (TOLAM) has shown promising results. In the same study, 67.7% of patients in the LM group and 38.1% in the AM group were admitted for TOLAM. Among these, successful vaginal delivery was achieved in 71.4% of LM patients and 62.5% of AM patients, with no reported cases of uterine rupture. These findings suggest that, with appropriate patient selection and monitoring, vaginal delivery can be a safe option after LM. Risk of Uterine Rupture Uterine rupture is a rare but serious complication in pregnancies following myomectomy. The incidence is estimated between 0.47% and 1%, with no significant association between the type of surgical approach and the risk of rupture. Factors such as the method of uterine closure and the extent of myometrial invasion by the fibroids may play a role in this risk. Notably, studies have reported no cases of uterine rupture in their series, highlighting the importance of surgical technique and postoperative care in mitigating this risk. Recommendations for Clinical Practice Based on current evidence, the following recommendations can be made: - Patient Counseling: Women considering LM should be informed about the potential risks and benefits, including the impact on future fertility and the mode of delivery. - Surgical Technique: Adherence to meticulous surgical techniques, such as multilayered closure of the myometrium and minimal use of electrocautery, is essential to preserve uterine integrity. - Delivery Planning: The decision between elective cesarean and trial of labor should be individualized, considering factors like the number and location of fibroids removed and whether the uterine cavity was entered during surgery. In conclusion, laparoscopic myomectomy offers favorable reproductive outcomes for women desiring pregnancy. While the risk of uterine rupture is low, careful surgical planning and individualized obstetric management are crucial to ensure optimal maternal and fetal outcomes.