Prospective Randomized Trial Comparing Gonadotropin-Releasing Hormone Analogues With Triple Tourniquets at Open Myomectomy

Abstract

The primary treatment for preservation of fertility in women with large fibroids―open myomectomy―is complicated by significant intraoperative bleeding. In a recent survey, over 85% of gynecologists in the United Kingdom reported use of gonadotropin-releasing hormone (GnRH) analogues before myomectomy to reduce operative hemorrhage at myomectomy. In contrast to pretreatment with GnRH analogues, less than 25% of gynecologists of the United Kingdom reported use of tourniquets to myomectomy-associated bleeding. Although evidence for reduction of bleeding by pretreatment with GnRH analogues has been shown in many studies, other studies have found no benefit. In a previous randomized, controlled trial, triple tourniquets (tourniquets applied to the uterine and ovarian vessels) were highly effective to temporarily occlude the uterine blood supply and reduce myomectomy-associated bleeding. This randomized, controlled trial compared the effectiveness of triple tourniquets and preoperative treatment with GnRH analogues in reducing blood loss in a population of 40 women undergoing open myomectomy for symptomatic fibroids. The study subjects were randomized to either 3 months pretreatment with a GnRH analogue or intraoperative application of triple tourniquets. To occlude the uterine blood supply, a number 1 polyglactin suture was threaded through the broad ligament incisions on each side and tied around the cervix above the level of the bladder and size 10 suction catheter tubing was also passed through the incisions and tied around the infundibulopelvic ligaments. Women randomized to tourniquets received no pretreatment. No significant differences between the 2 groups were found in the numbers of fibroids removed or in the total weight of fibroids (P = 0.13). Compared with triple tourniquets, intraoperative blood loss was significantly greater with the GnRH analogue group (GnRH analogues: median 2482 mL, 95% confidence level, 1744 to 3151 vs. tourniquets: mean 640 mL, 95% confidence level, 418 to 881, respectively, P < 0.001), and significantly more women in the GnRH analogue group required blood transfusion (70% vs. 30%, P < 0.025). The frequency of postoperative complications was similar among the 2 groups; most were minor. Two women from the tourniquet group sustained major complications that appeared to be unrelated to the use of tourniquets. There was no difference between the 2 groups in the length of the postoperative hospital stay and none of the women in either group was readmitted to hospital in the early postoperative period (<6 weeks). These data are consistent with previous findings that triple tourniquets are more effective than preoperative treatment with GnRH analogues or other available intraoperative techniques at reducing intraoperative blood loss at open myomectomy.