[Current role of conservative surgery]. / Papel actual de la cirugía conservadora.

It is not easy to establish the true impact of fibroids on fertility. Fibroidectomy in sterile patients with subserosal fibroids does not offer the best results for patients with in situ fibroids. Women with intramural fibroids appear to present reduced fertility and increased miscarriage rates, compared with women without fibroids. However, fibroidectomy does not always reverse this effect (does not increase the clinical pregnancy or "take-home baby" rates), but the quality of the studies is still poor. Fibroids with a submucosal component significantly decrease implantation and pregnancy rates with regard to sterile controls. Fibroid exeresis clearly improves fertility results. There is a need for better quality studies aimed at assessing the impact of intramural fibroids, with a special focus on factors such as size, number and proximity to the endometrium. The majority of cases can be treated endoscopically. This procedure needs properly trained teams who monitor their results and who are able to offer the same guarantees that laparotomy affords, both in terms of the surgical technique and the patients' obstetric future. Laparoscopic fibroidectomy offers results comparable to laparotomy and minimizes the formation of adhesions, blood loss, hospital stay and the time to return to work. For sterile patients, laparoscopic fibroidectomy may be the first choice therapy.

Papel actual de la cirugía conservadora / Current role of conservative surgery

No es sencillo establecer el verdadero impacto de los miomas sobre la fertilidad. La miomectomía en pacientes estériles con miomas subserosos no ofrece mejores resultados respecto a pacientes con miomas in situ. Las mujeres con miomas intramurales parecen presentar un descenso en su fertilidad y un aumento de la tasa de aborto, comparadas con mujeres sin miomas. Sin embargo, la miomectomía no siempre revierte este efecto (no aumenta la tasa de embarazo clínica ni de niño vivo en casa), pero la calidad de los estudios aún es pobre. Los miomas con componente submucoso disminuyen significativamente la tasa de implantación y embarazo respecto de controles estériles. Su exéresis claramente mejora los resultados de fertilidad. Son necesarios estudios de mayor calidad, dirigidos a valorar el peso del mioma intramural, con especial atención a factores como el tamaño, el número y la proximidad al endometrio. La mayor parte de los casos se va a poder abordar por vía endoscópica. Para ello son necesarios equipos debidamente entrenados, que monitoricen sus resultados y sean capaces de ofrecer las mismas garantías que la vía laparotómica, tanto en la técnica quirúrgica como en el porvenir obstétrico de las pacientes. La miomectomía laparoscópica ofrece resultados comparables a la laparotómica. Además minimiza la formación de adherencias, la pérdida sanguínea, la estancia hospitalaria y el tiempo de reincorporación laboral. En pacientes estériles, la miomectomía laparoscópica puede ser la primera elección terapéutica (AU)

It is not easy to establish the true impact of fibroids on fertility. Fibroidectomy in sterile patients with subserosal fibroids does not offer the best results for patients with in situ fibroids. Women with intramural fibroids appear to present reduced fertility and increased miscarriage rates, compared with women without fibroids. However, fibroidectomy does not always reverse this effect (does not increase the clinical pregnancy or “take-home baby” rates), but the quality of the studies is still poor. Fibroids with a submucosal component significantly decrease implantation and pregnancy rates with regard to sterile controls. Fibroid exeresis clearly improves fertility results. There is a need for better quality studies aimed at assessing the impact of intramural fibroids, with a special focus on factors such as size, number and proximity to the endometrium. The majority of cases can be treated endoscopically. This procedure needs properly trained teams who monitor their results and who are able to offer the same guarantees that laparotomy affords, both in terms of the surgical technique and the patients’ obstetric future. Laparoscopic fibroidectomy offers results comparable to laparotomy and minimizes the formation of adhesions, blood loss, hospital stay and the time to return to work (AU)