FALCONE: The management of symptomatic leiomyomas depends on the patient’s desire to preserve her fertility. If she does not have an interest in future fertility and there are no myomas that are largely submucous or pedunculated, then uterine fibroid embolization is the treatment of choice. Many studies have shown an excellent response, few complications, and rapid return to work.
If the woman wants to preserve fertility, myomectomy is the treatment of choice. If there are few myomas of moderate size, laparoscopic myomectomy is as effective as laparotomy in the hands of experienced laparoscopists who have the ability to suture.
HERZOG: I also want to stress that we now have a number of options, including uterine artery embolization, medications, and surgery, available for women with symptomatic fibroids. The surgical approaches are numerous and include hysteroscopic and/or laparoscopic myomectomy with or without morcellation, as well as hysterectomy. The approach should be determined by the symptoms, size, and distribution of the fibroids, as well as by individual patient characteristics such as prior surgeries, body mass index, and so on. Just because a procedure is technically feasible does not mean it is the preferred method, and this tenet certainly applies to morcellation. In some instances, women with very large fibroids may be better served by laparotomy to decrease blood loss and the duration of surgery while optimizing uterine wall reconstruction, especially when future fertility is an important consideration. Once again, proper patient selection is paramount in achieving favorable outcomes, especially for those who may be undergoing morcellation.
LEVY: For women who have completed childbearing and who desire hysterectomy, I always attempt a vaginal approach first. Most uteri, regardless of size, can be safely and efficiently removed vaginally as long as there is access to the uterine vasculature. Morcellation is easily performed vaginally once hemostasis is assured. For the rare patient with a large fundal myoma that cannot be brought into the pelvis for morcellation, minilaparotomy or laparoscopic approaches are appropriate.
KARRAM: I think randomized trials are needed in this area. It is important to remember that most cases performed laparoscopically result in supracervical hysterectomies and that significant costs are accrued from the equipment required for morcellation. These factors need to be weighed against potential advantages over abdominal hysterectomy, which include shorter hospital stay, potentially decreased morbidity, and faster recovery. The only way to make any objective conclusions about the options would be a randomized trial with appropriate power involving surgeons equally skilled in laparoscopic and open techniques.
Are residents adequately trained?
It depends on the program but, on the whole, more concentrated experience in minimally invasive surgery is needed.
KARRAM: Let’s focus on residency training for a moment. We seem to agree there is a lack of it in vaginal hysterectomy. It seems to me that the lack of training increases as time goes on. Because the current generation of gynecologists-in-training is ultimately the next generation of teachers, it bodes ill for the future when they are reluctant to attempt vaginal hysterectomy, except in the simplest and most straightforward cases. The medicolegal climate also plays a role, as Dr. Herzog mentioned.
Any other thoughts?
FALCONE: The training across residency programs is not homogenous. Some institutions promote vaginal hysterectomy as the primary access, and others do not.
HERZOG: I agree that some institutions do provide an adequate volume of cases, but many others offer a paucity of vaginal surgeries. Many reasons have combined to cause this shortage of training cases over the past 15 years, including a decrease in the number of hysterectomies performed overall, thanks to a number of nonsurgical or less radical surgical treatments for the most common indications for hysterectomy. These approaches generally are mandated by third-party payers prior to invasive surgery. These mandates were not as rigidly enforced in the past.
In a survey of gynecologic oncologists—the vast majority of whom were at academic training centers—the consensus was that residents had fewer surgical experiences and were less skillful than their predecessors over a 5-year period. More than 80% of respondents thought residents needed more surgical experience to achieve competence.13
Compounding the problem, resident work hours have been restricted and additional educational objectives and nonsurgical rotations have been added to the curriculum without any lengthening of the residency tenure. The adverse effects of these factors on residency case volume has prompted some educators to propose major changes in the residency curriculum, either by lengthening training or developing distinct tracks that facilitate early concentration on an area of interest, thereby allowing residents who choose a surgical track to gain increased training and volume.