BACKGROUND: Uterine myomas (fibroids) are benign tumors of the uterus. Myomectomy, the surgical removal of the myomas, is an important treatment option especially for women who desire to preserve their uteri. The major problem with myomectomy is excessive bleeding from increased uterine blood supply, and this can be life-threatening and prolong postoperative stay. Knowledge of the effectiveness of the interventions used to reduce blood loss during myomectomy is essential to enable evidence-based clinical decisions.
OBJECTIVES: To assess the effectiveness and safety of interventions (other than GnRH analogues) to reduce blood loss during myomectomy.
SEARCH STRATEGY: Electronic searches were undertaken in the Cochrane Menstrual Disorders and Subfertility Group specialized register, CENTRAL (Cochrane Library Issue 1, 2006), MEDLINE (1966 to March 2006), EMBASE (1980 to March 2006), Current Contents (1993 to March 2006), the National Research Register, and the National Library of Medicine’s Clinical Trial Register (up to March 2006).
SELECTION CRITERIA: Only randomized controlled trials (RCTs) that compared interventions to reduce blood loss during myomectomy to placebo or no treatment were included.
DATA COLLECTION AND ANALYSIS: The two authors independently selected RCTs for inclusion, assessed the methodological quality, and extracted data. We expressed study results as weighted mean differences (WMD) for continuous data and odds ratios for dichotomous data.
MAIN RESULTS: Eight RCTs met the inclusion criteria: two on intramyometrial vasopressin and analogues, and one each on vaginal misoprostol, intravenous oxytocin, pericervical tourniquet, chemical dissection with mesna, intramyometrial bupivacaine plus epinephrine, and the enucleation of myoma by morcellation while it is attached to the uterus. We found significant reductions in blood loss with misoprostol (WMD –149.00 mL, 95% confidence interval [CI] –229.24 to –68.76), vasopressin and analogues (WMD –298.72 mL, 95% CI –593.10 to –4.34), bupivacaine plus epinephrine (WMD –68.60 mL, 95% CI –93.69 to –43.51), and pericervical tourniquet (WMD –1,870.00 mL, 95% CI –2,547.16 to –1,192.84). There was no evidence of effect in blood loss with myoma enucleation by morcellation and oxytocin. The trials did not assess the tolerability and costs of different interventions.
AUTHORS’ CONCLUSIONS: There is limited evidence from a few RCTs that misoprostol, vasopressin, bupivacaine plus epinephrine, tourniquet, and mesna may reduce bleeding during myomectomy. There is no evidence that oxytocin and morcellation have an effect on intraoperative blood loss. There is need for adequately powered RCTs to shed more light on the effectiveness, safety, and costs of different interventions in reducing blood loss during myomectomy.
Kongnyuy EJ, Wiysonge CS. Interventions to reduce hemorrhage during myomectomy for fibroids. Cochrane Database of Systematic Reviews 2007, Issue 1. Art. No.: CD005355. DOI: 10.1002/14651858.CD005355.pub2. Copyright The Cochrane Collaboration, reproduced with permission.