Interest of Cervical Withers in Reducing Blood loss during Myomectomy at the Military Hospital of Ouakam (Senegal)

Myomectomy is associated with a high risk of bleeding. In Senegal and in most developing countries, where the means of prevention as arterial embolizationdoes not exist, this procedure is associated with significant morbidity. To overcome this, we experimented cervical-isthmus withers and appreciated its impact on the reduction of blood loss during myomectomy to the Military Hospital of Ouakam (Senegal).


Introduction
Myomectomy is associated with a high risk of bleeding. In Senegal and in most developing countries, where the means of prevention as arterial embolizationdoes not exist, this procedure is associated with significant morbidity. To overcome this, we experimented cervical-isthmus withers and appreciated its impact on the reduction of blood loss during myomectomy to the Military Hospital of Ouakam (Senegal).

Patients and Methods
It was a prospective and comparative case-control study conducted over a period of 15 months from May 1st 2013 to August 31st 2014 at Ouakam Military Hospital. The cases consisted of patients who under went myomectomy by laparotomy after insertion of the cervical withers which is made by a Foley probe or a sterile glove placed at the level of the uterine isthmus and taking the uterine arteries ( Figure 1). It was left in place for the duration of the surgery. Each case was matched to a control consisting of myomectomy by laparotomy performed just after without cervical withers.

Journal of Gynecology and Women's Health
Blood loss was estimated by evaluating hemoglobin rates on the day of surgery and 48 hours later. The parameters studied were: age, parity, reasons for consultation, indications of myomectomy, number of fibroids, weight of fibroids, duration of the intervention, length of hospital stay and blood loss. The data was analyzed using SPSS software version 13.0 and the Fischer test was used to compare the two groups with a significance level of 0.05.

Patients characteristics
The patients were between 24 and 47 years old, with an average of 38 years. Fifty-eight of them (46%) were over 40 years old. Parity ranged from 0 to 7, with an average of 1. Ninetyfour patients were nulliparous (74.6%). They were married in 96% of cases.

Reasons for consultation
They were dominated by cycle disorders such as menorrhagia, menometrorrhagia and infertility in 72%, 21% and 54% of cases, respectively.

Indications of myomectomy
A patient could have several indications but only the main indication was retained. They are summarized in Table 1. Abdominal-pelvic mass with compression signs 8 6,3 Total 126 100

Surgical characteristics
The mean number of fibroids, the mean fibroid weight, the duration of surgery and the hospital stay are summarized in Table 2. For these different parameters, the two groups were comparable, there was no statistically significant difference.

Evaluation of blood loss
On the day of the surgery, the mean hemoglobin rates were comparable in the two groups: 12g/dl for the "withers" group against 12.5g/dl for the controls.
Blood loss was greater in the control group with a statistically significant difference (p = 0, 0001) ( Table 3).

Characteristics of the patients
Our patients were between 25 and 36 years old, with an average of 37 years. This age is comparable to the average age of occurrence of fibroids found in the Wathie series [1]. The average age of fibroid onset, its rate of growth over time, and its single or multiple character remain controversial [2,3]. Parity ranged from 0 to 5, with an average of 1. Nulliparous and primiparous women accounted for 80% of our sample. Lumbiganon [4] found that with more than 5 deliveries, the risk decreases with OR = 0.21 (95%, CI = 0.12-0.35). According to Parazzini [5], the late age of the last pregnancy decreases the risk with OR = 0.5 (0.3-0.8). Thus, pregnancy is a protective factor, as is the high number of gestation [6]. The predominance of nulliparas confirms the role of the estrogen in the genesis of uterine fibroids through exposure to prolonged hyperestrogeny. Our results confirm the hypothesis of Lumbiganon [4] who argues that the risk reduction of uterine fibroids is linked to parity and that this risk decreases with the number of pregnancies.

Reduction of blood loss
Myoma's surgery is very hemorrhagic, especially myomectomy. The first intervention to reduce blood loss and intraoperative complications is the correction of preoperative anemia. In our study, mean hemoglobin rates on the day of surgery were 12g/dl for the "withers" group and 12.5g/dl for controls.
The correction of preoperative anemia requires a martial supplementation or IV iron cure.
Several studies have shown that the administration of LHRH analogues for 3 months preoperatively assists in the correction of anemia by decreasing bleeding, and decreases the size of fibroids [7]. Reducing fibroid volume may help to avoid laparotomy by simplifying vaginal or laparoscopic procedures. LHRH analogues are also associated with decreased operative time, blood loss, postoperative pain and length of hospital stay [8][9][10]. Some authors, however, report a change in the consistency of fibroids, making the dissection plan more difficult.
Regardless of the approach, preoperative embolization with resorbable particles (48 hours to 3 hours before surgery) reduces blood loss and facilitates uterine suture [11]. It finds its place for patients who have no desire for pregnancy and have a high risk of bleeding: multiple myomectomy, fibroma >5cm, transfusion difficulties, haemostasis disorder.
In our developing countries, there is a low socio-economic standard of living for patients making it difficult for them to access LHRH analogues and a limited technical platform in our hospitals. Indeed, in Senegal, arterial embolization is not available in any public hospital. Also, patients consulting late for lack of funds and this delay in the consultation explains that it is most often carried out polymyomectomies.
Thus, in our developing countries, an alternative to the above-mentioned measures for the reduction of blood loss during myomectomy would be the establishment of a cervical withers before the surgery.
This technique would have several advantages: a.
Its low cost compares with those of LHRH analogues and arterial embolization Indeed, it requires only a Foley probe or a sterile glove in addition to the classical myomectomy equipment; b.
The bloodlessness of the procedure that allows the surgeon to make good uterine sutures to avoid postoperative hemorrhages and uterine rupture; c.
The preservation of fertility, indeed, this technique could reduce the number of hemostasis hysterectomy for uncontrolled intraoperative bleeding. In our series we did not perform any hemostasis hysterectomy; d.
The reduction of per and postoperative blood loss as evidenced by our results with an average decrease of hemoglobin of 0.6g/dl in the "withers" group against 2.4g/dl for controls.

Conclusion
In our developing countries where arterial embolization is not available and LHRH analogues are not always available to patients, use of the cervical withers is an effective alternative for reducing blood loss during myomectomy.