Professor Ghezzi, et al. should be congratulated for their excellent manuscript “Transvaginal Contained Tissue Extraction After Laparoscopic Myomectomy: A Cohort Study”. This is a well-conceived, well-written retrospective cohort study describing operative and peri-operative outcomes for patients who have undergone transvaginal morcellation via a posterior colpotomy. Given the continued controversy regarding electronic power morcellation leading to restriction of use in certain areas, this study is not only impactful, in that it describes an alternative technique with data accumulated over a decade of experience, but it describes a technique of contained morcellation that is neither based on the controversial power morcellation, nor the mini-laparotomy (https://www.fda.gov/medicaldevices/safety/alertsandnotices/ucm424443.htm). The technique, as currently utilized, does have limitations that must be recognized. Fifty-five of the 371 (14.8%) myomectomies performed via a laparoscopic approach had a trans-abdominal extraction of the surgical specimen post laparoscopy secondary to patient virginal status, obliteration of the Pouch of Douglas or surgeon choice. Moreover, the authors really did not study this technique in an obese population. The BMI was 23 Kg/m2 (range: 17–32) and only 41% were obese (class 1). As a physician performing minimally invasive gynecologic surgery for the treatment of symptomatic myomas in Metropolitan Chicago, this weight limit would restrict the majority of my patients from enrolling in a randomized controlled trial similar to the current study. In addition, the mean myomectomy specimen weight was 154 ± 128 g. When patients undergoing abdominal myomectomy were compared to a laparoscopic approach, (36.9% of the patient population) the authors noted a much greater proportion of larger fibroids (≥10 cm: 50% versus 5.4%) and a higher number of removed fibroids ≥ 5 (69% versus 1.3%). The authors unfortunately, do not indicate if the decision, in part, was based on the concern with the ability to complete the extraction through the culdotomy incision. While the authors report no cases of pelvic infection, vaginal dehiscence or complaints of dyspareunia, follow-up was at 30 days. Certainly, especially vaginal dehiscence and complaints of dyspareunia, must be evaluated long term as coitus increases. In fact, I would surmise that the number of patients having intercourse and the frequency of coitus would be relatively low during the first month post-surgery. Finally, it must be recognized that only two centers were involved in the study (Women's and Children Hospital, Varese and Evangelical Hospital Villa Betania, Naples). As both are referral centers for minimally invasive gynecologic surgery, one must question, how translatable this technique is to the average gynecologic surgeon. In addition, this is a retrospective study. In the final analysis, this study by Ghezzi, et al., is an important contribution to our literature regarding safe myoma extraction at laparoscopy. I look forward to a multicenter randomized controlled trial that will be expanded to include obese patients and large & multiple fibroids. None declared. Completed disclosure of interests form available to view online as supporting information. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.
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Oct 5, 2017
K.W Fan + 2
Open Access