Factors Associated with the Complications of Hysteroscopic Myomectomy

A cross-sectional study with women with submucous myomas. The dependent variables were the complete myomectomy performed in a single hysteroscopic procedure, and the presence of early complications related to the procedure.

Results

We identified 338 women who underwent hysteroscopic myomectomy. In 89.05% of the cases, there was a single fibroid to be treated. According to the classification of the International Federation of Gynecology and Obstetrics (Fédération Internationale de Gynécologie et d’Obstétrique, FIGO, in French),most fibroids were of grade 0 (66.96%), followed by grade 1 (20.54%), and grade 2 (12.50%). The myomectomies were complete in 63.31% of the cases, and the factors independently associated with complete myomectomy were the diameter of the largest fibroid (prevalence ratio [PR]: 0.97; 95% confidence interval [95%CI]: 0.96-0.98) and the classification 0 of the fibroid according to the FIGO (PR: 2.04; 95%CI: 1.18-3.52). We observed early complications in 13.01% of the hysteroscopic procedures (4.44% presented excessive bleeding during the procedure, 4.14%, uterine perforation, 2.66%, false route, 1.78%, fluid overload, 0.59%, exploratory laparotomy, and 0.3%, postoperative infection). The only independent factor associated with the occurrence of early complications was incomplete myomectomy (PR: 2.77; 95%CI: 1.43-5.38).

Conclusions

Our results show that hysteroscopic myomectomy may result in up to 13% of complications, and the chance of complete resection is greater in small and completely intracavitary fibroids; women with larger fibroids and with a high degree of myometrial penetration have a greater chance of developing complications from hysteroscopic myomectomy.

Keywords:
uterine myomectomy; leiomyoma; myoma; uterine hemorrhage; intraoperative complications

Characteristics	Total	%
Age (years)
< 40	87	25.74
40–59	192	56.80
> 60–69	59	17.46
Skin color*
White	246	73.43
Non-white	89	26.57
Body mass index (kg/m²)
< 18.5	4	1.18
18.5–24.9	82	24.26
25–29.9	138	40.83
> 30	114	33.73
Number of pregnancies
0	47	13.90
1	59	17.46
≥ 2	232	68.64
Number of cesarian sections
0	180	53.25
1	82	24.26
≥ 2	76	22.49
Number of vaginal deliveries
0	151	44.67
1	61	18.05
≥ 2	126	37.28
Menopausal status
Premenopausal	220	65.09
Postmenopausal	118	34.91
Menopausal hormone therapy^a
Yes	6	5.22
No	109	94.78
Combined hormonal contraceptives
Yes	70	20.71
No	268	79.29
Progesterone-only contraceptives
Yes	56	16.57
No	282	83.43
Gonadotrophin-releasing hormone analogues
Yes	10	2.96
No	328	97.04
Hypertension*
Yes	119	35.31
No	218	64.69
Diabetes mellitus
Yes	42	12.43
No	296	87.57
Multimorbidity
Yes	52	15.38
No	286	84.62

Characteristics	Total	%
Main indication
Bleeding	266	78.70
Incidental finding	65	19.23
Infertility	4	1.18
Pain	3	0.89
Number of fibroids
1	301	89.05
2	29	8.58
≥ 3	8	2.37
FIGO classification^a,b
0	225	66.96
1	69	20.54
2	42	12.50
Location^a,c
Posterior wall	89	25.95
Anterior wall	98	28.57
Lateral wall	153	44.61
Cervical	3	0.87
Misoprostol
Yes	156	46.15
No	182	53.85
Anatomopathological finding
Leiomyoma	286	84.62
Adenomyoma	33	9.76
Lipoleiomyoma	3	0.89
Endometrium	1	0.30
No material	15	4.44

	Complete myomectomy - mean (standard deviation)		p-value*	Early complications - mean (standard deviation)		p-value*
	Yes	No		Yes	No
Age (years)	49.64 (11.13)	44.83 (11.66)	< 0.01	47.93 (12.44)	47.87 (11.43)	0.72
Pregnancies	2.85 (2.05)	2.19 (1.92)	< 0.01	2.05 (1.84)	2.69 (2.04)	0.02
Vaginal deliveries	1.66 (1.94)	1.10 (1.75)	< 0.01	0.98 (1.73)	1.53 (1.91)	0.02
Weight (kg)	74.12 (14.63)	71.62 (16.87)	0.04	72.16 (15.98)	73.36 (15.47)	0.64
Number of fibroids	1.09 (0.34)	1.24 (0.63)	< 0.01	1.20 (0.51)	1.14 (0.47)	0.25
Mean diameter of the largest fibroid (mm)	21.66 (12.29)	36.15 (15.84)	< 0.01	32.02 (15.78)	26.22 (15.18)	0.02
Duration of the procedure (minutes)	29.36 (13.16)	33.73 (14.95)	< 0.01	33.00 (18.18)	30.66 (13.25)	0.55
Volume of the distension media (ml)	102.80 (1024.90)	689.52 (2587.20)	< 0.01	647.73 (2591.50)	268.71 (1631.4)	0.20

	Complete myomectomy (%)		n	p-value	Early complication (%)		n	p-value
	Yes	No			Yes	No
FIGO classification of the largest fibroid*				< 0.01^a				0.96^a
0	71.56	28.44	225		13.33	86.67	225
1	53.62	46.38	69		13.04	86.96	69
2	33.33	66.67	42		88.10	11.90	42
Anterior-wall fibroid*				0.04^a				0.62^a
Yes	56.12	43.88	98		10.20	89.80	98
No	67.90	32.10	215		12.09	87.91	215
Anatomopathological finding				< 0.01^b				0.40^b
Leiomyoma	63.63	36.37	286		11.19	88.81	286
Adenomyoma	93.94	6.06	33		9.09	90.91	33
Other	5.26	94.74	19		47.37	52.63	19
Combined hormonal contraceptives				< 0.01^a				0.96^a
Yes	47.14	52.86	70		12.86	87.14	70
No	67.54	32.46	268		13.06	86.94	268
Misoprostol				0.33^a				0.23^a
Yes	66.02	33.98	156		15.38	84.62	156
No	60.99	39.01	182		10.99	89.01	182
Progesterone-only contraceptives				0.17^a				0.04^a
Yes	55.36	44.64	56		21.43	78.57	56
No	64.90	35.10	282		11.35	88.65	282
Gonadotrophin-releasing hormone analogue				< 0.01^b				0.62^b
Yes	0.00	100.00	10		20.00	80.00	10
No	65.24	34.76	328		12.80	87.20	328
Menopausal status				< 0.01^a				0.37^a
Postmenopausal	75.42	24.58	118		15.25	84.75	118
Premenopausal	56.82	43.18	220		11.82	88.18	220
Hypertension				0.02^a				0.40^a
Yes	71.43	28.57	119		15.13	84.87	119
No	59.17	40.83	218		11.93	88.07	218
Excessive bleeding				0.01^a				–
Yes	33.33	66.67	15		–	–	–
No	64.71	35.29	323		–	–	–
Uterine perforation				0.02^a				–
Yes	35.71	64.29	14		–	–	–
No	64.51	35.49	324		–	–	–
Fluid overload				< 0.01^b				–
Yes	0.00	100.00	6		–	–	–
No	64.46	35.54	332		–	–	–
Early complication				< 0.01^a				–
Yes	34.09	65.91	44		–	–	–
No	67.69	32.31	294		–	–	–
Complete myomectomy				–				< 0.01^a
Yes	–	–	–		7.01	92.99	214
No	–	–	–		23.39	76.61	124

	Categories	p-value	PR	95%CI (PR)
Complete myomectomy^a a PR, prevalence ratio for complete myomectomy (n = 105 no; n = 208 yes). Largest fibroid diameter	Continuous variable (mm)	< 0.01	0.97	0.96–0.98
FIGO classification	2 (ref)	—	1.00	—
	1	0.10	1.68	0.91–3.10
	0	0.01	2.04	1.18–3.52
Early complications ^b b PR, prevalence ratio for early complications (n = 277 no; n = 36 yes); 95%CI PR = 95% confidence interval for the prevalence ratio. Stepwise criteria for variable selection.
Complete myomectomy	Yes (ref)	—	1.00	—
Complete myomectomy	No	< 0.01	2.77	1.43–5.38

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[1] Address for correspondence Luiz Francisco Baccaro, MD, PhD, Rua Alexander Fleming 101, Cidade Universitária Zeferino Vaz, Campinas, SP, 13083-881, Brazil (e-mail: baccaro@unicamp.br).