|Year : 2016 | Volume
| Issue : 1 | Page : 50-54
Surgical management of uterine fibroids at Aminu Kano Teaching Hospital
Ibrahim Garba1, Rabiu Ayyuba1, Tella Monsur Adewale2, Idris Sulaiman Abubakar1
1 Department of Obstetrics and Gynaecology, Bayero University Kano/Aminu Kano Teaching Hospital, Kano, Nigeria
2 Department of Obstetrics and Gynaecology, Aminu Kano Teaching Hospital, P.M.B. 3011, Nigeria
|Date of Web Publication||12-Feb-2016|
Department of Obstetrics and Gynaecology, Bayero University Kano/Aminu Kano Teaching Hospital, P.M.B. 3011
Source of Support: None, Conflict of Interest: None
Background: Uterine fibroid is one of the most common pelvic tumours of the female genital tract. Surgery offers long-term relief of symptoms but is associated with complications, hence, the aversion for it in our environment. Therefore, understanding the factors associated with the complications will help to reduce morbidity and mortality. Objective: To determine the surgical options, socio-demographic characteristics, clinical presentations and post-operative complications associated with uterine fibroids at Aminu Kano Teaching Hospital, Kano. Methods: A retrospective review of case notes of 132 surgically managed cases of uterine fibroids at Aminu Kano Teaching Hospital over the study period. Results: Surgical operations for uterine fibroids constituted 21.4% of all gynaecological operations. Most of the cases were seen in 30–39 age group (41.5%) and 51.2% of them were nulliparous. Menorrhagia (53.7%), infertility (26.3%) and abdominal swelling (40.4%) were the common presenting symptoms. Myomectomy was performed in 75.6% of the cases while abdominal hysterectomy accounted for 24.6% of cases. Anaemia was the most common post-operative complication seen in this study (31.7%). Conclusion: Uterine fibroid is common in our environment. The main-stay of management of uterine fibroid is surgery which is associated with post-operative complications. The surgical options used in the management of uterine fibroids in this study were hysterectomy and myomectomy due to lack of requisite skills for the more technical procedures. Improvements in surgical skill will help reduce the frequency and severity of the complications.
Keywords: Complications, Kano, surgical options, uterine fibroids
|How to cite this article:|
Garba I, Ayyuba R, Adewale TM, Abubakar IS. Surgical management of uterine fibroids at Aminu Kano Teaching Hospital. Niger J Basic Clin Sci 2016;13:50-4
|How to cite this URL:|
Garba I, Ayyuba R, Adewale TM, Abubakar IS. Surgical management of uterine fibroids at Aminu Kano Teaching Hospital. Niger J Basic Clin Sci [serial online] 2016 [cited 2021 Apr 23];13:50-4. Available from: https://www.njbcs.net/text.asp?2016/13/1/50/176207
| Introduction|| |
Uterine leiomyoma (fibroid) is a benign clonal neoplasm arising from the smooth muscle cells in the uterine wall. It is the most common benign tumour affecting women. It represents the most common large solid benign neoplasm being exceeded in size only by giant lipoma.
The incidence of uterine fibroids increases with increasing age among women of childbearing age. It is reported in more than 80% of women at the age of 50 years. It is 3–9 times more common in Blacks than in Caucasians.,, Infertility and nulliparity are also associated with increased incidence of uterine fibroids.,,,
The incidence of uterine fibroids is known to decrease with prolonged use of oral contraceptive pills as well as with increased term pregnancies. It represents 6.5% of gynaecological admissions in Ile-Ife; 9.8% in Enugu, and 13.5% in Ilorin.
The cause of uterine fibroids is not known. However, oestrogens are certainly implicated in the growth of myomas. In addition, progesterone increases the mitotic activity of myomas in young women.
The risk factors for clinically significant fibroids are obesity and positive family history. It is commoner in African racial origin than Caucasians. It is uncommon in pre-pubertal women and regresses after menopause.
Although a significant proportion of women with fibroids are asymptomatic, up to 50% of them do have symptoms. Fibroids may cause menstrual dysfunction, pressure-related symptoms and pains, sub-fertility, recurrent miscarriage and problems during pregnancy.
The typical patient presents with menorrhagia, low abdominal mass, infertility, abdominal pains/discomforts, dysmenorrhoea, irregular vaginal bleeding, urinary symptoms (frequency, urgency) and recurrent abortion.
Due to these varied symptoms associated with uterine fibroids, the quality of life is usually affected in women with uterine fibroids.,
Treatment modalities of uterine fibroids include conservative, medical, surgical techniques that preserve either the uterus or not.
Surgical management which offers long-term relief of symptoms includes hysterectomy and myomectomy. Most gynaecologists would recommend a hysterectomy for women who have completed their families as it is the treatment of choice for them.
The usual method of removal of the uterus is by abdominal hysterectomy. This can be done as a total hysterectomy or as a subtotal hysterectomy. Hysterectomy has a high rate of satisfaction and loss of all menstrual symptoms in women; however, there is appreciable complication rate.
Subtotal or supra-cervical hysterectomy may cause fewer intra-operative complications; however, the long-term complications following a subtotal hysterectomy may negate this benefit. It has been suggested that subtotal hysterectomy may be associated with less impairment of sexual response because the cervix and its associated nerve supply are maintained.
Hysterectomy is, however, not the method of choice in women who wish to conserve their uterus for reproductive or social reasons. The main conservative surgical procedure is myomectomy for women wishing to conserve the uterus. This can be done as hysteroscopic myomectomy for subserous fibroids and myomectomy by laparotomy or laparoscopy.
Not all modalities of managing fibroids are available in our centre due to lack of facility and requisite skill to perform some of the more technical procedures. In addition, the medical options have only limited use in treating symptoms such as menorrhagia and in making myomectomy easier to perform. The cost of Gonadotrophin-releasing hormone analogue is not within the reach of most of the patients and coupled with its limited use. Hence, myomectomy and hysterectomy are the two most commonly performed surgical procedures in our centre for uterine fibroids.
The previous study in this centre has shown that surgical operations for uterine fibroids are safe and that uterine fibroid is associated more with high parity  and dominance of abdominal hysterectomy over myomectomy because early marriage is common in our community.
The purpose of this study, therefore, was to determine the socio-demographic characteristics, clinical presentations and post-operative complications associated with the surgical options of managing uterine fibroids in Aminu Kano Teaching Hospital over the study period, to identify and possibly put in place measures to reduce these complications.
| Materials And Methods|| |
This was a retrospective review of the cases of uterine fibroids managed surgically at Aminu Kano Teaching Hospital from 1st of January, 2009 to 31st of December, 2011. The hospital numbers of all the surgical operations for uterine fibroids during the study period were obtained from the theatre register. The case notes of these patients were then retrieved from the medical records department. Relevant information including socio-demographic characteristics, clinical presentation, type of surgery, operative findings and post-operative complications were extracted. The data were analysed using Epi info software version 3.5.4, 2012 (Centers for Disease Control and Prevention 1600 Clifton Road Atlanta, GA, USA) and presented in the form of tables and charts.
| Results|| |
There were 618 gynaecological operations carried out during the study period, 132 of which were surgeries for uterine fibroids, thus, giving a prevalence of 21.4%. Only 123 case notes were retrieved and analysed, giving a retrieval rate of 93.2%. Ninety-three (75.6%) of the patients had myomectomy while 30 (24.4%) had an abdominal hysterectomy.
[Table 1] shows the demographic characteristics of the patients. The age range was 20–60 with mean age ± standard deviation of 33.2 ± 9.78 The age group 30–39 had the highest frequency representing 41.5% of the cases while 50–59 age group had the lowest (2.4%). The parity ranged from 0 to 7. The majority of the patients were married 93 (75.6%) [Table 1].
Menorrhagia was the most common presentation accounting for 66 (53.7%). Other complaints included lower abdominal swelling 57 (46.3%), infertility 33 (26.8%) and dysmenorrhoea 6 (4.9%). Thirty (24.4%) patients had at least 2 symptoms. This is depicted in [Figure 1].
The uterine size in patients with lower abdominal swelling ranged from 12 weeks to 34 weeks with a mean of 20.7. This is depicted in [Table 2].
The duration of the surgery ranged between 60 min and 205 min with a mean of 138 min. The majority of the surgery (55%) lasted <150 min.
The anatomical location of the fibroids is also shown in [Table 2].
Ninety-three (75.6%) of the patients had myomectomy while 30 (24.4%) had an abdominal hysterectomy. There was no vaginal hysterectomy or laparoscopic surgery.
Ninety (73.2%) cases were done by consultants while 33 (26.8%) were done by senior registrars under the supervision of the consultants. This is shown in the [Table 2].
Anaemia was the most common post-operative complication accounting for 39 (31.7%) of the patients [Table 3]. This was due to intra-operative blood loss. Post-operative pyrexia occurred in 9 (7.3%) while wound infection was seen in 6 (4.9%). Only 12 (9.8%) of the patients had a blood transfusion.
The majority of the patients had a total hospital stay of 5–8 days while 3% had prolonged hospital stay. Forty-eight (39%) had pelvic adhesions.
| Discussion|| |
The prevalence of surgical operation for uterine fibroids in this study was 21.4%. This is slightly lower than the previous study done in Kano where a period prevalence of 24.7% was reported but compares favourably with the finding from the study in Ilorin. This is probably due the number of gynaecological procedures carried out during the study period.
In this study, most of the cases of uterine fibroids (41.5%) were seen in the 30–39 age group. This agrees with the finding of Omokanye et al. in Ilorin. This is probably because symptoms become manifest at this time prompting the need to seek medical intervention.
Most of the patients in this study were of low parity with 51.2% being nulliparous. This is in contrast to the finding in an earlier study carried out in this hospital  but is in keeping with the findings by other workers.,
Up to 75.6% of the women in this study were married indicating that uterine fibroids occur commonly in women of reproductive age group.
The clinical presentations of uterine fibroids are variable. This study showed that menorrhagia was the most common presenting symptoms in patients with uterine fibroids accounting for 53.7%. This is comparable to the finding in Ilesha (52.2%), but lower than that of Ile-Ife (60.2%). The causes of the increased uterine bleeding are not always clear but may be associated with enlargement of surface area of the uterine cavity and hyperplasia of the endometrium; congestion and dilatation of endometrial venous plexuses due to obstruction of veins in the myometrium leading to endometrial venous ectasia, imbalance in uterine prostaglandin productions; disturbances in myometrial contractility, and increased anovulatory cycles.
There were 26.3% cases of associated infertility in this study. This is much lower than 56.2% and 87.2% reported in Ilorin and Zaria, respectively. Fibroids are common and certainly occur in both normally fertile and infertile women and there is no clear evidence that their mere presence is causally linked to infertility. More important is the frequent association between chronic pelvic inflammatory disease and uterine fibroid as a cause of infertility.
This study also shows that the uterine size at presentation ranged from 12 to 34 weeks with size ≥20 weeks accounting for 40.4%. The relatively huge size of the fibroid is probably due to late presentation. Intramural fibroids were the most common as they were found in 58.5% of cases. This is consistent with the findings of Stewart.
This study shows that myomectomy (75.6%) was more commonly performed compared with abdominal hysterectomy (24.4%). This is consistent with the finding from the studies done in Ilorin, Enugu, and Abakaliki. It is, however, in contrast to the findings reported in Ile-Ife by Ogunniyi et al. The reason for this may be because most of the patients are of low parity and still desire fertility or that the fibroids are removed to improve their fertility.
Anaemia was the most common post-operative complication seen in this study, accounting for 31.7%. This agrees with the findings by previous authors , and is probably due to intra-operative blood loss, especially during myomectomy. However, only 9.8% of the patients required blood transfusion.
In this study, 9 (7.32%) of the patient had post-operative pyrexia. This was less than the figure (33.3%) reported by Omole-Ohonsi and Belga  in the previous study. Improvement in surgical procedures, especially in asepsis, the use of pre-operative antibiotics and anaesthetic techniques  over the years might have played a role in the curtailment of infections.
Wound infection was manifest in only 6 (4.88%) of the patients. Aboyeji and Ijaiya  reported wound infection constituting 20.2% of the post-operative morbidities in patients with uterine fibroids. Our figure was less than that. Shorter duration of the period under review (3 years) and improvement in surgical management could be attributed to that.
| Conclusion|| |
Uterine fibroid is a common gynaecological disorder in our environment. Abdominal myomectomy is more commonly performed relative to hysterectomy due to the age at which symptoms become distressing, the association of fibroid with infertility, as well as the desire to preserve fertility. Improvement of surgical skill and training of personnel in the use of endoscopic procedures will help to reduce post-operative morbidity associated with abdominal myomectomy and hysterectomy.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Drinville JS, Memarzadeh S. Benign disorders of the uterine corpus. In: Decherney AH, Nathan L, Goodwin TM, Laufer N, editors. Current Diagnosis and Treatment Obstetrics & Gynaecology. 10th
ed. New York: McGraw-Hill; 2007. p. 639-53.
McIlveen M, Li TC. Myomectomy: A review of surgical technique. Hum Fertil (Camb) 2005;8:27-33.
Lumsden MA. Benign diseases of the uterus. In: Edmonds DK, editor. Dewhurst's Textbook of Obstetrics and Gynaecology for Postgraduates. 7th
ed. London: BlackWell Science; 2007. p. 638-44.
Baird DD, Dunson DB, Hill MC, Cousins D, Schectman JM. High cumulative incidence of uterine leiomyoma in black and white women: Ultrasound evidence. Am J Obstet Gynecol 2003;188:100-7.
Vollenhoven BJ, Lawrence AS, Healy DL. Uterine fibroids: A clinical review. Br J Obstet Gynaecol 1990;97:285-98.
Omu AE, Ihejerika IJ, Tabowei G. Management of uterine fibroids at the University of Benin Teaching Hospital. Trop Doct 1984;14:82-5.
Briggs ND. Common gynaecological tumours. Trop J Obstet Gynaecol 1995;12:62-71.
Anate M. Uterine fibroids in Federal Medical Centre, Lokoja: A five year review 2002-2006. Niger Clin Rev J 2007;1:5-12.
Ogunniyi SO, Fasubaa OB. Uterine fibromyomata in Ilesha, Nigeria. Niger Med Pract 1990;19:93-5.
Emembolu JO. Uterine fibromyomata: Presentation and management in Northern Nigeria. Int J Gynaecol Obstet 1987;25:413-6.
Komolafe JO, Makinde NO, Ajadi AM, Dayo AA. Uterine leiomyomata in Ile-Ife, Nigeria. Trop J Obstet Gynaecol 2004;21:103-6.
Okezie O, Ezegwui HU. Management of uterine fibroids in Enugu, Nigeria. J Obstet Gynaecol 2006;26:363-5.
Aboyeji AP, Ijaiya MA. Uterine fibroids: A ten-year clinical review in Ilorin, Nigeria. Niger J Med 2002;11:16-9.
Ezeama C, Ikechebelu J, Obiechina NJ, Ezeama N. Clinical presentation of uterine fibroids in Nnewi, Nigeria: A 5-year review. Ann Med Health Sci Res 2012;2:114-8.
Parker WH. Uterine myomas: Management. Fertil Steril 2007;88:255-71.
Hrubosová E. Uterine fibroids and their treatment. Ceska Gynekol 2011;76:152-7.
Pai RD, Pai HD. Uterine fibroids and their management. In: Kriplani A, Rozati R, editors. Controversies in Obstetrics, Gynaecology & Infertility. New Delhi: Jaypee Brothers Medical Publishers (p); 2006. p. 125-46.
Clarke-Pearson DL, Geller EJ. Complications of hysterectomy. Obstet Gynecol 2013;121:654-73.
Kwawukume EY. Uterine leiomyomas. In: Kwawukume EY, Emuveyan EE, editors. Comprehensive Gynaecology in the Tropics. Accra: Graphic Packaging Limited; 2005. p. 124-37.
Omole-Ohonsi A, Belga F. Surgical management of uterine fibroids at Aminu Kano Teaching Hospital. Obstet Gynecol Int 2012;2012:702325.
Balogun OR, Nwachukwu CN. Surgical findings at laparotomy for uterine fibroids in University of Ilorin Teaching Hospital. Trop J Health Sci 2006;13:27-30.
Ogunniyi SO, Fasubaa O. Uterine fibromyomata in Ilesha, Nigeria. Niger Med Pract 1990;191:93-5.
Komolafe JO, Makinde NO. Uterine leiomyoma in Ile-Ife, Nigeria. Trop J Obstet Gynaecol 2004;21:103-6.
Lowe DG. Benign tumours of the uterus. In: Edmonds DK, editor. Dewhurst's Textbook of Obstetrics and Gynaecology for Postgraduates. 6th
ed. Oxford, UK: Blackwell Sciences Ltd.; 1999. p. 552-9.
Mohammed A, Shehu SM, Ahmed SA, Mayun AA, Tiffin IU, Alkali G, et al
. Uterine leiomyomata: A five year clinicopathological review in Zaria, Nigeria. Niger J Surg Res 2005;7:206-8.
Stewart EA. Uterine fibroids. Lancet 2001;357:293-8.
Obuna JA, Umeora OU, Ejikeme BN, Egwuatu VE. Uterine fibroids in a tertiary health centre South East Nigeria. Niger J Med 2008;17:447-51.
Yakasai IA, Ibrahim SA, Abubakar IS, Ayyuba R, Mohammed AD, Gajida AU. Surgical procedures in obstetrics and gynecology department of a teaching hospital in Northern Nigeria: A 5 year review. Arch Int Surg 2014;4:104-7.
[Table 1], [Table 2], [Table 3]