Perioperative Interventions To Minimize Blood Loss At The Time Of Hysterectomy For Uterine Leiomyomas: A Systematic Review And Meta-Analysis

Almost 70% of white and more than 80% of black premenopausal women are affected by uterine leiomyomas. Medical or conservative procedures can manage many leiomyoma-related symptoms. However, hysterectomy remains the most definitive option available for women who fail medical or conservative procedural therapy, do not desire future fertility, or are not candidates for uterine-sparing surgery.There is significant morbidity including blood loss among women with uterine leiomyoma(s) treated by hysterectomy. A number of studies have investigated different interventions that have the direct or indirect potential to reduce or stop blood flow to the uterus and allow safe completion of a hysterectomy, minimizing blood loss. In a systematic review, hormonal medications were effective for minimizing blood loss during hysterectomy for uterine leiomyomas. The impact of interventional nonhormonal medications, procedural tools, and devices during hysterectomy for large uteri has been investigated in multiple small studies, but has not been systematically evaluated.The primary aim of this systematic review and meta-analysis was to identify perioperative nonhormonal interventions, peri-operative surgical interventions, and devices that minimize blood loss at the time of hysterectomy for leiomyoma. A search was conducted of EMBASE, MEDLINE, Web of Science, Scopus, Cumulative Index to Nursing and Allied Health Literature, and Cochrane databases to identify articles published from 1946 to 2018 with hand-guided updates. The search and search terms were guided by a medical librarian. Relevant articles chosen reported on blood loss outcomes in hysterectomy of all routes (laparotomic abdominal, vaginal, and laparoscopic abdominal/laparoscopic-assisted vaginal) for uterine leiomyoma(s). Articles were excluded that only compared the route of hysterectomy without any additional interventions, morcellation, vaginal cuff closure, perioperative hormonal medications, and vessel sealing devices for vaginal hysterectomy and case reports or case series with fewer than 10 patients.Primary outcomes were surgical blood loss and postoperative hemoglobin (Hb) drop. Secondary outcomes included hemorrhage, transfusion, and major and minor complications. All outcomes were analyzed and aggregated in meta-analyses for comparable studies in each category. Among the 2016 unique studies identified in the initial search, 33 met inclusion criteria, and 22 were used for quantitative synthesis. Compared with placebo control, the perioperative use of misoprostol in abdominal hysterectomy was associated with a lower drop in postoperative Hb (0.59 g/dL; 95% confidence interval [CI], 0.39-0.79; P < 0.01) and lower intraoperative blood loss (-96.43 mL; 95% CI, -153.52 to -39.34; P < 0.01). Compared with securing uterine vessels only at the uterine isthmus, securing the uterine vessels at their origin was associatedwith no significant change in the postoperative drop in Hb (0.24 g/dL; 95% CI, -0.31 to 0.78; P = 0.39), but was associated with decreased intraoperative blood loss (-69.07mL; 95% CI, -135.20 to -2.95; P = 0.04). Early uterine artery ligation in LH before dissecting the ovarian/utero-ovarian vessels was associated with lower surgical blood loss compared with late ligation (-27.72 mL; 95% CI, -35.07 to -20.38; P < 0.01).With respect to surgical devices, the postoperative Hb drop was not significantly less with use of a bipolar electrosurgical device in TAH compared with suturing (0.26 g/dL; 95% CI, -0.19 to 0.71; P = 0.26). No significant difference was found between an electrosurgical bipolar vessel sealer (EBVS) and conventional bipolar electrosurgical devices in the postoperative Hb drop (0.02 g/dL; 95% CI, -0.15 to 0.20; P = 0.79) or blood loss (-50.88 mL; 95% CI, -106.44 to 4.68; P = 0.07). Comparing the LigaSure (Medtronic, Minneapolis, Minn) impedance monitoring EBVS with competing EBVS systems monitoring impedance or temperature showed that blood loss in total laparoscopic hysterectomy was not decreased (2.00 mL; 95% CI, -8.09 to 12.09; P = 0.70). There were no significant differences in hemorrhage, transfusion, or major complications for all interventions. \These data show that perioperative misoprostol in abdominal hysterectomy results in a reduction in surgical blood loss and postoperative Hb drop (moderate level of evidence by Grading of Recommendations, Assessment, Development and Evaluation guidelines), but this has limited clinical benefit. Although the remaining interventions appear promising, only low-quality evidence supports their use at this time.There is relative paucity of high-quality trials to guide clinical practice with respect to use of perioperative nonhormonal medications, perioperative procedures and techniques, and surgical devices to reduce blood loss at the time of hysterectomy for leiomyomas. Larger well-designed randomized trials are needed to establish the optimal set of perioperative interventions to reduce the blood loss associated with use of hysterectomy for leiomyomas.