SURGICAL MANAGEMENT OF UTERINE FIBROIDS AT THE UNIVERSITY OF ILORIN TEACHING HOSPITAL: A 5 YEAR REVIEW

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1 Global Research Journal of Medical Sciences Vol.2(2) pp June 2012 Available online Copyright 2012 Global Research Journals Review. SURGICAL MANAGEMENT OF UTERINE FIBROIDS AT THE UNIVERSITY OF ILORIN TEACHING HOSPITAL: A 5 YEAR REVIEW Omokanye L.O 1, Salaudeen G.A 2 Saidu R 1, Jimoh A.A.G 1, Balogun O.R 1 1. Department of Obstetrics and Gynaecology, University of Ilorin Teaching Hospital, Ilorin, Nigeria. 2. Department of Epidemiology and Community Health, University of Ilorin Teaching Hospital, Ilorin, Nigeria. Corresponding Author s omostuff1111@yahoo.com Accepted 28 th June 2012 Uterine fibroid is a cause of significant morbidity in women of reproductive age group and could lead to death. This was a retrospective review of the case notes of all surgically treated cases of uterine fibroids at the University of Ilorin Teaching Hospital from the 1 st of January 2006 to the 31 st of December The results show that uterine fibroids constituted 3.0% of new gynaecology admissions. More than one- third of the patients (39.6%) were within the years age-group and 62% occurred among women with the parity of 0 and 1. The majority (42.9%) of the women were nulipara. Infertility (78.4%), menstrual disturbances (70.5%) and abdominal swelling (52%) were common presenting features. Evidence of pelvic inflammatory disease in association with uterine fibroids was demonstrated in 58.8% of the patients. Abdominal Myomectomy was the commonest method of treatment in 60.4% of patients; the choice mainly based on age, parity and patient s desire to maintain her reproductive potential. Anaemia occurred in 40.7% of patients mainly due to intraoperative heamorrhage. Sarcomatous change in the fibroids was present in two (0.6%) of the patients. Surgical operations for uterine fibroids are common kind of gynaecological operations at the University of Ilorin Teaching Hospital. It is therefore suggested that administration of vasopressin into the myoma bed will go a long way to reduce intraoperative haemorrhage. Key words: Uterine fibroids, Ilorin, Nigeria, surgical treatment, review. INTRODUCTION Uterine fibroid is the commonest tumour of the female genital tract (Lowe, 1999) it is estimated that 20% - 45% of women above the age of 30 years have uterine fibroids (Akinyemi et al., 2004). Fibroids are common in black women than in their Caucasian counterparts (Oguniyi and Fasuba, 1990). In Nigeria, uterine fibroids have been reported to account for % of new gynaecological cases (Aboyeji and Ijaiya, 2002; Otolorin et al., 1987). They also accounted for about 68.1% hysterectomy cases (Aboyeji and Ijaiya, 2002; Otolorin et al., 1987). Fibroids are often detected in women undergoing infertility evaluation in many black communities. An incidence of 17.9% - 26% has been found at laparoscopy in some Nigerian studies (Sagay et al., 1998; Vollenhoven et al., 1990) which is much higher than 11% reported in Europe and United States (Ogedengbe, 2003). The exact aetiology of uterine fibroids is uncertain, however clinical and epidemiological surveys have shown that these tumours are 3 9 times commoner in the Negroes than in Caucasians (Ogunbode,1981). This has been attributed to myometrial irritation caused by pelvic infections, which was found to be prevalent in black women (Gross et al., 2000). A positive family history of fibroids was also found to be common in patients who develop the tumours and the presence of a gene encoding for fibroid development has been suggested (Gross et al., 2000). Attempts are now being made to identify these susceptibility genes for fibroids, which may lead to innovative treatments in the future (Okoronkwo, 1999). It is known that fibroids occur and increase in size during the reproductive years but regress after the menopause. Continuous oestradiol secretion, uninterrupted by pregnancy or lactation is therefore thought to be a risk factor in the development of these tumours (Al-Taher and Farguharson, 1993). Uterine fibroids tend to give symptoms from the age of 30 years till the women s reproductive life (Lowe, 1999; Otolorin et al., 1989). Infertility rates of between 38% (Emembolu, 1989) and 87.2% (Lumsden and Wallace, 1998) have been reported in our environment, while studies from developed countries give lower rates

2 019 Glo. Res. J. Med. Sci. of between 2.4% and 2.7% (Sutton, 1996). Pelvic inflammatory disease has been found to be frequently associated with uterine fibroids in this environment contributing significantly to infertility in our patients (Gross et al., 2000). Various studies have found rates of pelvic inflammatory disease association with fibroids in this environment to range from 28.2% to 68% (Vollenhoven et al., 1990; Gross et al., 2000). Menstrual abnormalities viz-a-vis irregular menstrual bleeding (Lumsden and Wallace, 1998) and menorrhagia (Sutton, 1996) have been reported in women with fibroids. Other associated complications of fibroids occurred due to the pressure effect on surrounding tissues and organ (Lowe, 1999; Akinyemi et al., 2004: Aboyeji and Ijaiya, 2002). Age, parity, pregnancy status, associated symptoms and the reproductive potentials of the couples are the usual factors that influence the management of women with uterine fibroids. Hysterectomy is the definitive treatment for symptomatic fibroid (Ogunbode, 1981). It has been noted that uterine fibroid form the bulk of indication for hysterectomy in most countries particularly among the postmenopausal women (Gehlbach et al., 1993). Myomectomy is usually reserved for women who are under 40 and desire to maintain their fertility. This also depends on the fact that the procedure is surgically feasible (Lowe, 1999, Otolorin et al., 1987; Ogunbode, 1981, Otolorin et al, 1989; Gehlbach et al., 1993). Newer techniques for the treatment of uterine fibroids include the use of laser for abdominal myomectomy and laparoscopic myomectomy with or without morcellation. Other methods include the use of gonadotrophin releasing hormone analogue to shrink the tumour and reduce the bulk. Uterine artery embolisation a procedure that should be popular in developing countries (where the culture often makes women resent surgery especially when it involves losing their uterus) is not common (Ogunbode, 1981). However uterine artery embolisation requires high-technology which may out of the reach of most developing countries. It is evident that the determining factors in the management of uterine fibroids and the outcome of treatment vary widely in different communities. Therefore the purpose of this study was to determine the prevalence, presenting features and factors that influence the surgical management of uterine fibroids in Ilorin, Nigeria. MATERIALS AND METHODS A retrospective study of case note of patients who had operation for uterine fibroids at the University of Ilorin Teaching Hospital between the 1 st January 2006 and 31 st December The hospital is located in the Ilorin metropolis which is the capital of Kwara State in North Central, Nigeria and serves as a major referral centre for all areas in Kwara State and parts of the five neighbouring states of Kogi, Ekiti, Osun, Oyo and Niger. The patients identification data were retrieved from the gynecological ward admission and discharge record books and theatre s operation register. Their case notes were retrieved from the Medical Records Department and analyzed for incidence, age, parity, clinical presentation, presence of pelvic adhesions, type of surgical treatment, and postoperative complications. Intraoperatively, tourniquet was applied around the lower uterine segment and below the fibroids, to achieve mechanical vasoconstriction on the ascending uterine artery bilaterally. A tourniquet time was kept, and the tourniquet was released after 30 minutes and reapplied after 5 minutes to reestablish blood flow and prevent irreversible damage to the uterine muscle cells. The tubal patency test was carried out using methylene blue. Postoperatively, a packed cell volume of less than 30% was considered as anemia, a temperature of 38 C or more on two consecutive days after the first post operative day was considered as pyrexia. Three hundred and ninety-five (395) patients were treated, of these 366 case files had adequate information for analysis. The data obtained were recorded using tables. Statistical analysis was done using a commercial statistical package (SPSS/PC version 11.0, SPSS Inc., Chicago, Ill, USA). RESULTS There were 15,061 new patients who attended the gynaecology clinic in the study period, 449 cases of uterine fibroid were diagnosed clinically giving an incidence of 3.0%. The age and parity distribution of the patients is shown in Table 1. The highest incidence (39.6%) was seen in the years age-group. One hundred and fifty seven (42.9%) were nulliparous, while 33.9% were of parity one and two and 5.5% were grand multiparous. Infertility, which was the commonest complaints, occurred in 287 (78.4%) patients. A history of abdominal pain was reported by 171 (46.7%) patients while 72 (19.7%) of them presented with anaemia. There was history of one or more previous spontaneous abortions in 99 (27.1%) patients. The most frequent physical finding was abdominal swelling in 52% patients. Associated pelvic adhesions was found in 151 (41.3%) of patients at laparotomy. Tubal occlusion was found complicating uterine fibroids in 11.8% of patients. Eight patients (2.2%) were found to have had a previous unilateral salpingectomy possibly due to previous ectopic pregnancy. Ovarian cysts were discovered in 13.9% of cases (Table 2).

3 Omokanye et al., 020 Table 1: Age and Parity distribution of patients Age <20 2 (0.5) (14.5) (39.6) (38.8) (6.6) Parity (42.9) 1 70 (19.1) 2 54 (14.8) 3 38 (10.4) 4 27 (7.4) >5 20 (5.5) The types of surgical operation and additional surgical procedures performed on the patients are shown in Table 3. Abdominal myomectomy was performed in 60.4% cases. One hundred and thirty six (37.2%) patients had total abdominal hysterectomy while vaginal hysterectomy with pelvic floor repair was the procedure performed in 2.4% of patients, who presented with first or second degree utero-vaginal prolapse in addition to a small size fibroid uterus. The additional surgical procedures that were performed include; adhesiolysis (22.1%), salpingostomy (15.3%), ovarian cystectomy (12%) and salpingo-oophorectomy (4.7%). The choice of surgical procedure was influenced by the women s parity. Abdominal myomectomy (77.1%) was commonly performed in nulliparous patients, while hysterectomy was preferred in grandmultiparous patients. Most of them (75%) had hysterectomy instead of myomectomy. Generally, myomectomy was the Table 2: Clinical presentation and pelvic findings at laparotomy (n=366) Primary infertility 192 (52.4) Secondary infertility 95 (26.0) Menstrual abnormalities 258 (70.5) Abdominal swelling 190 (52.0) Lower abdominal pain 171 (46.7) Dysmenorrhea 132 (36.1) Prev. spontaneous abortion 99 (27.1) Asymptomatic 83 (22.7) Anaemia 72 (19.7) Vaginal mass 9 (2.5) Acute urinary retention 5 (1.4) Pelvic findings Healthy 92 (25.1) Pelvic adhesion 151 (41.3) Ovarian cyst 51 (13.9) Bilateral tubal blockage 43 (11.8) Tubo-ovarian complex 21 (5.7) Previous salpingectomy 8 (2.2) commonest method of treatment of uterine fibroids (60.4%). Anaemia necessitating blood transfusion was the most common postoperative complication occurring in 149 (40.7%) of patients. This was mainly due to intraoperative blood loss. Post-operative pyrexia occurred in 24.3% of patient while wound infection and postoperative haemorrhage were recorded in 3.7% and 7.7% of patient respectively (Table 4). All the patients had prophylactic antibiotics, while the majority of them had 2 units of blood transfused. Leiomyomata was confirmed histologically in all the specimens. The associated histopathological findings are shown in Table 4. Degenerative changes were found in 2.2% of specimens while sarcomatous changes occurred in 0.6%, carcinoma of the endometrium was associated in 1.4% of the patients. Table 3: Types of surgical operation and additional surgical procedures Myomectomy 221 (60.4) Total abdominal hysterectomy 136 (37.2) Vaginal hysterectomy with pelvic Floor repair 9 (2.4) Procedure (n= 198) Adhesiolysis 81 (22.1) Salpingostomy 56 (15.3) Ovarian cystectomy 44 (12.0) Salpingo-oophorectomy 17 (4.6) Total 198 (54.1)

4 021 Glo. Res. J. Med. Sci. Table 4: Post-operative morbidity and histological findings (n= 366) Complications Anaemia 149 (40.7) Pyrexia 89 (24.3) Bleeding per vaginam 28 (7.7) Urinary tract infection 26 (7.1) Abnormal vaginal discharge 10 (2.7) Upper respiratory tract infection 17 (4.6) Wound infection 13 (3.7) Wound dehiscence 3 (0.8) Histological findings Degenerative change 8 (2.2) Carcinoma of endometrium 5 (1.4) Sarcomatous change 2 (0.6) DISCUSSION The incidence of uterine fibroids among gynaecological patients during the period of the study was 3.0%. This is similar to the findings from other studies (Sagay et al., 1998; Vollenhoven et al., 1990) but lower than 3.2% and 7.6% obtained in Sagamu and Ife (Akinyemi et al., 2004; Ogunniyi, 1990). The low incidence may be due to the fact that this centre, which serves a primary, secondary and tertiary institution in the state, handles as high as 3000 new gynaecology cases every year. In this study, uterine fibroids occurred most (78.4%) in the 30 and 49 years age-group. This figure compares favourably with findings from other centres (Akinyemi et al., 2004, Aboyeji and Ijaiya, 2002; Sagay et al., 1998: Vollenhoven et al., 1990). The high incidence during this period is probably related to the finding that uterine fibroids tend to give symptoms from the age of 30 years and that prolonged periods of infertility are common among the patients (Sagay et al., 1998, Otolorin et al., 1989: Olatinwo and Offiong, 2000). The majority of the patients were of low parity (0-2) with 42.9% being nulliparous. This agrees with the findings of earlier workers (Otolorin et al., 1987; Ogunbode, 1981: Gross, 2000) that fibroid is a disease of the relatively infertile women. Uterine fibroids have been found to be associated with infertility among the black race (Ogunbode, 1981; Gross, 2000; Lumsden and Wallace, 1998) although there is no clear evidence that the mere presence of fibroids is causally linked to infertility especially when they are small and are not impinging on the uterine cavity or fallopian tubes (Ogedengbe, 2003; Ogunbode, 1981: Emembolu, 1989). This tends to suggest that uterine fibroids alone does not cause of infertility and only 2% of patients undergoing myomectomy have absence of other possible causes of infertility (Ogedengbe, 2003). In this environment chronic pelvic inflammatory disease is frequently (26.6% - 68%) found in patients with uterine fibroids and infertility rates are therefore higher (up to 84%) (Sagay et al.,1998; Vollenhoven et al., 1990: Gross, 2000), with associated tubal occlusions being commonly found. These figures are however higher than those reported from Caucasian population. It is not surprising therefore that 2.2% of the patients were found to have had a previous unilateral salpingectomy for ectopic pregnancy. The rate of previous abortion of 27.1% recorded in this study is similar to that found by other authors in Nigeria (Akinyemi et al., 2004; Aboyeji and Ijaiya, 2002: Olatinwo and Offiong, 2000) and abortion may be complicated with sepsis resulting in tubal damage. Myomectomy (60.4%) was the commonest method of treatment of uterine fibroids in our centre. Hysterectomy was performed in 39.6% of cases most of whom were multiparous and postmenopausal. This figure while in agreement with findings from Ibadan and Port- Harcourt (Akinyemi et al., 2004; Aboyeji and Ijaiya, 2002: Otolorin et al., 1987) vary widely with figures obtained from other centres where hysterectomy was a commoner method of treatment (Oguniyi and Fasuba, 1990: Otolorin et al., 1989). It is to be noted that 36 patients in this study had hysterectomy even though they were nulliparous. These patients were among those who presented late with both symptoms of infertility and life threatening menorrhagia. They were also perimenopausal and were found to have giant uterine fibroids making myomectomy not feasible. Post-operative morbidity, due to pyrexia and wound infection were common in this study despite the prophylactic use of antibiotics. This may be due to the known reactionary pyrexia following myomectomy, due to bleeding into the cavities and peritoneum, so effort must be made to obliterate all dead spaces at surgery. In conclusion, abdominal myomectomy is the most common surgical operation reported in this study. The choice of this operation is influenced by the desire to preserve reproductive potential of the patients. More than two- thirds (40.7%) of the patients had anaemia due to intraoperative bleeding. The intraoperative administration of vasopressin is suggested to compliment the haemostatic effect of tourniquet. 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