CHANGE OF THE SPECTRUM OF UTERUS-PRESERVI NG MYOMA SURGERY

Objective: On the basis of the evaluation of 300 patients who underwen t myoma surgery with the desire for uterus preservation at the Departm ent of Obstetrics and Gynaecology of Heidelberg University, a manageme nt scheme including endoscopic techniques was developed. Method: Despi te the patients' wish for organ preservation, in 12 cases (family plan ning complete, therapy-resistant sterility, no desire for a child) wit h an extremely large uterus (20th-24th week of gestation) or a degener ated, intramural myoma (a sarcoma not being excluded), a primary hyste rectomy had to be performed. Overall, 37.9% of patients underwent conv entional, 42% laparoscopic and 20.1% hysteroscopic surgery. Additional ly, to objectify the role of a pretreatment with GnRH analogues (GnRHa ), the following control parameters were examined in 128 patients with and 160 patients without pretreatment: rate of primary laparotomies, conversion, secondary hysterectomy, intraoperative bleedings, amount o f distension medium and percentage of repeat interventions. Results: N o significant differences in the study parameters between study and co ntrol groups could be found in the patients treated by laparoscopy. In the hysteroscopy group, conversion rate (13.3 vs. 7%), operation time (35 vs. 21.9 min), rate of severe intraoperative bleeding (33.3 vs. 9 .3%), amount of distension medium necessary (difference 2.1 litres) an d rate of repeat interventions (40.4 vs. 16.3%) differed significantly between study and control groups. Conclusion: In the operative manage ment, the key question is when to perform an invasive procedure. The s econd question should be which access route is the most convenient. Th e decision whether to give GnRHa pretreatment is also an individual on e, especially in cases of a conventional or laparoscopic operative pro cedure. A preoperative GnRHa therapy is mandatory before hysteroscopy for submucous myoma.