GYNAECOLOGYLaparoscopic Versus Abdominal Myomectomy: Practice Patterns and Health Care Use in British Columbia
Section snippets
INTRODUCTION
Fibroids (leiomyomata) are benign tumours that are common in women of reproductive age, affecting nearly 80% of premenopausal women.1 Symptoms of fibroids include heavy menstrual bleeding and increased abdominal pressure, causing significantly decreased quality of life.2 Surgical treatments for uterine fibroids tend to be invasive and expensive, but they are associated with increased quality of life.3 While hysterectomy remains the definitive treatment for fibroids, myomectomy is the preferred
METHODS
We conducted a study of all women undergoing laparoscopic or abdominal myomectomy for a benign indication between April 1, 2007, and September 15, 2012, in any hospital within the regions of British Columbia serviced by the Vancouver Coastal Health and Providence Health Care authorities. Together, these health authorities serve more than one million people (more than one quarter of the provincial population) and cover urban and rural geographic areas that include the city of Vancouver,
RESULTS
Of 436 women undergoing myomectomy, 88 cases (20.2%) were laparoscopic, 342 (78.4%) were abdominal, and 6 (1.38%) were laparoscopic with conversion to laparotomy.
Within the eight hospitals in the Vancouver Coastal Health and Providence Health Care regions that offered gynaecologic surgery, myomectomies were performed at five hospitals, all of which were located in the metropolitan area of Vancouver. Among the five hospitals, the proportion of myomectomies performed by laparoscopy ranged from 0%
DISCUSSION
Our study showed that between 2007 and 2012, approximately 20% of myomectomies for benign fibroids in the Vancouver Coastal Health and Providence Health Care regions of British Columbia were performed by laparoscopy. Most myomectomies occurred in hospitals within urban and metropolitan areas in British Columbia; such centralization of surgery for myomectomy may be appropriate, because the morbidity associated with myomectomy, compared with other gynaecologic procedures, increases the need for
CONCLUSION
Myomectomies are mostly performed in urban metropolitan hospitals in British Columbia. Approximately 20% of myomectomies are performed by laparoscopy, and these procedures are performed at a few centres of surgical expertise. Compared with abdominal myomectomy, laparoscopic myomectomy in pre-selected patients is not associated with increases in need for operating time or for emergency or hospital resources. Instead, laparoscopic myomectomy is associated with a decreased length of hospital stay.
ACKNOWLEDGEMENTS
We are grateful to the Vancouver Coastal Health Authority Decision Support and Providence Health Care Decision Support for providing the data used in this study. Innie Chen is supported by a Frederick Banting and Charles Best Canada Graduate Scholarship Award from the Canadian Institutes of Health Research, and K.S. Joseph is supported by a Chair in maternal, fetal, and infant health services research from the Canadian Institutes of Health Research.
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Cited by (13)
Technicity in Canada: A Nationwide Whole-Population Analysis of Temporal Trends and Variation in Minimally Invasive Hysterectomies
2021, Journal of Minimally Invasive GynecologyCitation Excerpt :Although we did find that some provinces with higher technicity indices also had higher hysterectomy rates than the national average (Saskatchewan, Prince Edward Island, and Alberta), we also found some provinces with lower technicity indices despite higher hysterectomy rates (New Brunswick, Newfoundland and Labrador, Nova Scotia, and Manitoba), as well as the example of British Columbia with a high technicity index and low hysterectomy rate. One explanation for the regional variation in hysterectomy rates may be the geographic differences in patient preference regarding a desire for future fertility or definitive surgical treatment [29,30], with provinces with lower fertility rates also seeming to have lower hysterectomy rates (Ontario and British Columbia), and provinces with higher fertility rates having higher hysterectomy rates (Saskatchewan and Manitoba). Another reason for the observed regional variation may be the differences in patient physical characteristics.
Risk of uterine rupture after myomectomy by laparoscopy or laparotomy
2020, Journal of Gynecology Obstetrics and Human ReproductionCitation Excerpt :As the rate of caesarean deliveries in the US has decreased or stayed constant in most states since 2009 [10], any change in the uterine rupture rates could be attributed to the shift in trends of the different myomectomy approaches, either by laparotomy (also known as open) or laparoscopy. Compared to open myomectomy, laparoscopic myomectomy is associated with shorter hospital stay, decrease post-operative pain and increase patient satisfaction [11]. Yet, the warning issued by the Federal and Drug Administration (FDA) against morcellation of uterus and fibroids has discouraged some surgeons from performing myomectomy by the minimally invasive approach and may have led to a decrease in the rate of laparoscopic myomectomy [12,13].
The Effectiveness of Tranexamic Acid at Reducing Blood Loss and Transfusion Requirement for Women Undergoing Myomectomy: A Systematic Review and Meta-analysis
2019, Journal of Obstetrics and Gynaecology CanadaCitation Excerpt :Additionally, this lack of breadth in available research reflects the limited number of randomized trials in this area. Further, despite the increase in use of minimally invasive techniques for myomectomy,27 we did not find any studies describing laparoscopic or robotic myomectomy for inclusion in this review, thereby limiting the generalizability of our findings to these procedures. On the basis of a limited number of studies, among women undergoing abdominal myomectomy, TA was effective at reducing perioperative blood loss compared with no treatment or placebo, and non-significant trends were observed for reduction in need for blood transfusion.
Hospital-associated Costs of Chronic Pelvic Pain in Canada: A Population-based Descriptive Study
2017, Journal of Obstetrics and Gynaecology CanadaCitation Excerpt :These are national hospital administrative databases with capture of consecutive patients using consistent data collection procedures that undergoes routine validation and quality control.20 The use of these systems for reproductive health research has been reported previously.4,21,22 However, as the province of Quebec uses a different data system, data from this province is not captured in our study, leading to underestimation of national costs.
Incidence of Tissue Morcellation During Surgery for Uterine Sarcoma at a Canadian Academic Centre
2015, Journal of Obstetrics and Gynaecology CanadaCitation Excerpt :The removal of large tissue specimens through a minimally invasive approach often requires the fragmentation of tissue through morcellation, either with a laparoscopic power morcellator or a scalpel.4 While uterine fibroids are a common reason for uterine surgery, uterine sarcomas are by contrast relatively infrequent; the annual incidence of uterine leiomyosarcomas is approximately 0.64 per 100 000 women.4-6 It is generally not possible to distinguish between uterine fibroids and sarcomas preoperatively, and it has been estimated that approximately one in 350 to 500 women undergoing uterine surgery for presumed fibroids will have an unsuspected sarcoma.7-11
Myomectomy to Conserve Fertility: Seven-Year Follow-Up
2015, Journal of Obstetrics and Gynaecology CanadaCitation Excerpt :Finally, in this multi-year review and follow-up that included both AM and RM surgical approaches to myomectomy for symptomatic fibroids in women who desired future fertility, we found no differences in the occurrence of pregnancy or in obstetrical outcomes. While some will see this as further reason to champion minimally invasive surgery for everyone, the approximately three fourths of gynaecologic surgeons that continue to use traditional open procedures for myomectomy may feel vindicated by these data.20 Prospective, randomized controlled trials that address the patient (time to full activity), societal (cost of technology/ cost of care/cost of missed productivity), and obstetrical (live born) outcomes, along with medical confounders (size and location of tumours), surgical confounders (cavity entry), secondary diagnoses (infertility, endometriosis), and other related factors confounding outcomes are needed before any surgeon can claim real insight.
Competing Interests: None declared.