Interventions to reduce haemorrhage during myomectomy for fibroids.

BACKGROUND: Uterine myomas (fibroids) are benign tumours of the uterus. Myomectomy, the surgical removal of myomas, can be associated with life-threatening bleeding and prolonged postoperative stay. Knowledge of the effectiveness of the interventions to reduce bleeding during myomectomy is essential to enable evidence-based clinical decisions. This is an update of the review published in The Cochrane Library Issue 3, 2009.
OBJECTIVES: To assess the effectiveness, safety, tolerability, and costs of interventions to reduce blood loss during myomectomy. SEARCH STRATEGY: Electronic searches were undertaken in the Cochrane Menstrual Disorders and Subfertility Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 3), MEDLINE (1950 to February 2011), EMBASE (1980 to February 2011), CINAHL (1982 to February 2011), and PsycINFO (1801 to February 2011). SELECTION CRITERIA: Only randomised controlled trials (RCTs) that compared the use of interventions to reduce blood loss during myomectomy to placebo or no treatment were included. DATA COLLECTION AND ANALYSIS: The two authors independently selected RCTs for inclusion, assessed the methodological quality of trials, and extracted data. We expressed study results as mean differences (MD) for continuous data and odds ratios for dichotomous data, with 95% confidence intervals (CI). MAIN
RESULTS: Twelve RCTs with 674 participants met our inclusion criteria. The interventions were intramyometrial vasopressin (two RCTs), intravenous oxytocin (two RCTs), peri-cervical tourniquet (two RCTs), and one RCT each for vaginal misoprostol, gelatin thrombin matrix, chemical dissection with sodium-2-mercaptoethane sulfonate (mesna), intramyometrial bupivacaine plus epinephrine, tranexamic acid, and myoma enucleation by morcellation. We found significant reductions in blood loss with misoprostol (MD -149.00 ml, 95% CI -229.24 to -68.76), vasopressin (MD -298.72 ml, 95% CI -593.10 to -4.34; I(2) = 99%), bupivacaine plus epinephrine (MD -68.60 ml, 95% CI -93.69 to - 43.51), tranexamic acid (MD -243 ml, 95% CI -460 to -25.98), peri-cervical tourniquet (MD -289.44, 95% CI -406.55 to -172.32; I(2) = 95%), and gelatin-thrombin matrix (MD -545.00 ml, 95% CI -593.26 to -496.74). There was no evidence of an effect on blood loss with oxytocin or morcellation. None of the interventions significantly increased myomectomy-related complications. The trials did not assess the costs of the different interventions. AUTHORS'
CONCLUSIONS: There is limited evidence that misoprostol, vasopressin, bupivacaine plus epinephrine, tranexamic acid, gelatin thrombin matrix, peri-cervical tourniquet, and mesna may reduce bleeding during myomectomy. Bupivacaine plus epinephrine has limited clinical importance compared with other interventions as the clinical impact was small. There is no evidence that oxytocin and morcellation reduce blood loss. Further well designed studies are required to establish effectiveness, safety and the costs of different interventions for reducing blood loss during myomectomy.