Myomectomy. Our experience in Namibia

1. Dr. Romelio R. de la Paz Muñiz Obs& Gyn Consultant Myomectomy. Our experience in Namibia

2. Introduction: Uterus: Fundamental in the Reproduction. Important role in sperm transport, embryo implantation, development of the future Foetus and the process of Delivery.

3. Uterine Myomatosis One of the Most frequent conditions in the Gynaecological Practice. The most frequent solid pelvic tumour appearing in 2o-40 % of women in reproductive age. 5th most frequent cause of hospitalisation non related with pregnancy The most frequent cause for hysterectomy(more than 200 000 cases per year only in USA)

4. Uterine Myomatosis Frequently associated with Infertility in Reproductive Age African Women 2-3 times more risk of presenting Myomas and diagnosis done at early age. In 1,7 million Hysterectomies in USA 1988-1990, 61% were African American and 29% white women

5. Objectives General: To improve the Reproductive Health of the Namibian Women Specifics To identify the Myoma as a frequent cause of surgery in our Obs&Gyn Department To evaluate the effectiveness of myomectomy To describe different surgical procedures to do the myomectomy To assess the safety of this operation in our setting

6. Method • Sample: 54 patients operated of Myomectomy in WCH and KSH • Data obtained from Registry Book from theatre and Medical personal files. • Factors: Age of the Pt., Parity, Previous Operation, Number of Myomas, Surgical Procedures performed, Complications

7. Myomectomy By this term, it is called, the surgical procedure designed to excise the Myomas from the uterine wall, leaving the organ free of these benign tumours and offering the possibility for a future successful pregnancy.

8. 4 Combination of Techniques • Myomectomy. To excise the Myomas using as less incisions on the uterus as possible. Most of the time one incision is used for the excision of various Myomas. • Myomectomy + ligation of internal iliac arteries. This is a method used by the Author since 2003 as an alternative and complementary measure to guarantee the haemostasis after massive myomectomy in Uterus with strong likelihood for postoperative bleeding. Was presented in an International Obs&Gyn Scientific Event in Cuba in 2004.

9. Cont. • Myomectomy + Autologue Anterior Rectal Muscle and Omentum Transplantation. A Method developed by the Late Professor and PhD P Aleman taking advantage of the high potential of regeneration and stem cells of the Omentum, particularly used when large sections or an entire Uterine aspect are removed with the Myomas(5). • Myomectomy +Autologue Anterior Rectal Muscle and Omentum Transplantation + ligation of the internal iliac arteries. When all these techniques are combined to assure a successful post-op period and a good reproductive outcome after the surgery.

10. Table # 1. Age of the Pt

11. Table#2 Parity

12. Table# 3 Previous Operations

13. Table# 4 Number of Myomas

14. Table# 5 Surgical Procedures

15. Table# 6 Complications

16. Conclussions • Most of the patients who were operated of Myomectomy are included in the group between 20 to 39 years of age, in coincidence in the main reproductive age of the woman. • The Uterine Myomatosis and thus, the Myomectomy is evidently a condition that affects Nulliparous Women though can be found in patients with low parity rate. • The Majority of patients of our series had no previous operation but is significant the number of previous caesarean section and myomectomy operated patients.

17. Conclussions (cont) • The greatest amount of patients reported between 1 to 10 Myomas removed in the operation. • The myomectomy as unique procedure was the most widely used though each patient requires an individual evaluation and management according with the extension and the area of the Uterus which is affected during the operation, deciding other alternative surgical solutions. • The Anaemia was the most frequent complication in our series which is associated with the Blood Loss during the operation.

18. Recommendations Taking into account the results of our investigation, we recommend to develop at the level of the primary health care, the consciousness and perception of identifying women without children among the communities, with clear features of Infertility as this is the kind of patient with strong likelihood to have a myomatous Uterus and as early we can initiate Health Actions over this patient, as successful will be the outcome. The diverse surgical procedures to do Myomectomy and the consequent conservative surgery over the Uterus must be important piece in the surgical skills of any Gynaecologist assigned to work in this setting.

19. Bibliography • Baird D, Dunson D, Hill M, et al. High Cumulative incidence of uterine Leyomyoma in black and white women: ultrasound evidence. Am J Obstet Gynecol. 2003; 188:100-7 • Wallach E E, Vlahos N F. Uterine Myomas: an overview of development, clinical features and Management. ObstetGynecol 2004; 104:393-406 • Farquhar C, Sleiner C. Hysterectomy Rates in United States 1990-1997. ObstetGynecol 2002; 99: 229-34 • Aboyeji A, Iyaiya M. Uterine Fibroids: a ten-year clinical review in Ilorin, Nigeria. Niger J Med 2002; 11: 16-9 • Aleman Ramirez P. Autologue Rectal Muscle and Omentum Transplantation in Massive Myomectomy. Thesis for Ph D. Villa Clara, Cuba. 2004 • Heinemann K, Thiel C, Mohner S, et al. Benign Gynecological Tumours: estimated incidence results of the German Cohort Study on Women’s Health. Eur J ObstetGynecolReprodBiol 2003; 107: 78-80 • Olufowobi O, Sharif K, PapaionnouS,et al. Are the anticipated benefits of the Myomectomy achieved on Women on Reproductive age? A 5-year review of the results at a UK Tertiary Hospital. J ObstetGynecol 2004;12:177-95

20. Pictures

23. Myomas

24. Autologue transplantation of rectal muscle + Omentum

31. Thank you