Uterine myomas are the most common pelvic tumors in women [1]. The prevalence of myoma increases with maternal age. The incidence of myoma is higher in black women than in white women. Its prevalence increases to 10.7% in the first trimester [2]. However, increased parity and long-term breastfeeding are associated with a decrease in its prevalence [3].

Myomas are usually asymptomatic during pregnancy. The most common symptom is pain [4]. Pregnant women with myomas are at risk of premature birth, premature membrane rupture, fetal malpresentation, placental abruption, low gestational age, low birth weight, and delivery by cesarean section [5]. Myomas have adverse effects on economic costs and quality of life. The surgical approach forms the basis for myoma treatment. Various minimally invasive procedures are applied in treatment in addition to abdominal myomectomy and hysterectomy [6].

Given the increasing age of women at first pregnancy, pregnancy and myoma commonly occur together. Hence, the incidence of myomas and the rate of surgical intervention during cesarean sections are increasing [7].

The general opinion is to avoid myomectomy during cesarean section. However, in recent years, successful results have been reported in selected cases related to cesarean myomectomy [8, 9, 10]. The correct approach remains unclear, and surgeons find difficulties in decision making when encountering myomas during cesarean section. The objective of this study was to share our experience in selected challenging cases and to reduce the possibility of a second myomectomy in the future.

Compared with similar studies, our study involved a higher number of cases. In addition, this study was the first to include large myomas and those with an intramural component. Thus, we obtained data on possibly the worst outcomes.

This study was designed retrospectively and conducted in a single center. We included 99 patients who underwent cesarean section and uterine myomectomy concurrently between December 2015 and September 2020 in our gynecology and obstetrics clinic as the study group. The indications for cesarean section were determined based on obstetric reasons. Cesarean section was indicated when the mass obstructs vaginal delivery. Otherwise, vaginal delivery was preferred in pregnant women with myomas. We included 100 cases who underwent cesarean section between the same dates and had no myoma as the control group. The study population consisted of a total of 199 patients. Patient information was accessed using the files in the archive system of our hospital and the information processing system. Age, gravida, parity, gestational week, indication of cesarean section, previous delivery, preoperative and postoperative hemoglobin (HGB) levels, performance of blood transfusion, operation time, and length of hospital stay were determined from patient files. The number, diameter, location, and type of myoma were determined from ultrasonography reports, surgical notes, and pathology reports.

Myoma types were grouped as subserous, mural, and submucous, and their locations were grouped as fundal, corpus anterior, corpus posterior, and cervical. Pedunculated myomas and myomas less than 4 cm in size were not included in our study. In multiple myoma cases, the largest diameter of myoma nodule was taken as a basis.

The time from the end of the operation until the control hemogram test was taken was planned to be 8 hours on average. The HGB limit for postoperative transfusion was determined to be 8 mg/dL. The measurement of operation time was initiated with the first skin incision.

In patients with pre-eclampsia, the condition may affect the length of hospital stay due to the cesarean section procedure; hence, the lengths of hospital stay in these patients were not included in the calculations of postoperative length of hospital stay. In addition, abruptio placenta, placenta previa, and coagulopathy may affect the amount of bleeding; hence, the amount of bleeding in patients with these conditions was not included in the calculation of the amount of bleeding.

The minimum professional experience of the surgeons operating on the patients in the study and control groups was 5 years. Hysterectomy, need for intensive care, relaparotomy, major organ and vascular injury, and massive blood transfusion were not observed in any patient.

Most women with myomas give birth through vaginal delivery. Standard obstetric indications for cesarean delivery apply to pregnant women with myoma. Delivery by cesarean section can be considered if fetal descent may be prevented by a myoma. Women with retroplacental or anterior lower uterine segment myoma at cesarean delivery are at high risk for intrapartum or postpartum bleeding; therefore, appropriate preparations should be made before the operation [11].

In our study, the mean age of the cesarean myomectomy group was 34 years, which was higher than that of the control group (age = 29, p 0.001). The number of gravida and parity were higher in the normal cesarean group than those in the control group. With the development of auxiliary reproductive techniques, maternal age is increasing worldwide. Increased maternal age increases the incidence of myoma. Parity and breastfeeding have a reducing effect on myomas. This phenomenon may be related to the high level of gravida and parity in the control group [3, 12].

In our study, length of hospital stay, operation time (p 0.001), and number of transfusions (p 0.05) were higher in the cesarean myomectomy group than in the control group. The mean length of hospital stay was 2.4 days in the myomectomy group. Sakıncı et al. [13] reported that the duration of hospital stay and operation time were significantly higher in 83 patients who underwent corporeal myomectomy and 80 patients who underwent corporeal myomectomy. In a retrospective study comparing 212 patients who underwent cesarean myomectomy or normal cesarean section, Şentürk et al. [14] found HGB level, complication rate, and number of transfusions similar in both groups and reported that cesarean myomectomy was a safe procedure, including removal of myomas over 5 cm.

Akbaş et al. [15] reported that 63 patients who underwent myomectomy during cesarean section had longer operative time and higher HGB loss, and this difference increased when involving myomas over 5 cm. El-Refaie and Özcan et al. [16, 17] reported that hospital stay and operation times were significantly longer. In a prospective case control study of 68 patients by Tinelli et al. [18], the mean length of hospital stay was reported to be 5 days. Huang et al. [19] reported in their meta-analysis that cesarean myomectomy cases stayed in the hospital for 0.18 days longer than the control group. The hospital stay rate of 2.4 days in the current study is much lower than the average found in the current literature. The duration of operation was 25 min in the normal cesarean group and 45 min in the cesarean myomectomy group. Our cesarean myomectomy rate was below the average found in the literature [7]. Caesarean section and caesarean section myomectomy volumes were high because the surgeons were in a tertiary center. The short operation time of our patients may be the effect of increased surgical experience.

In our study, the control group had significantly higher postoperative HGB values than the patients who underwent cesarean myomectomy (p 0.05). In a study comparing 47 and 94 patients who underwent cesarian myomectomy and normal cesarean, respectively, Hassiakos et al. [20] did not find a difference in HGB changes between the two groups, although the difference between the preoperative and postoperative HGB mean values of the groups was statistically significant. In their meta-analysis, Pergialiotis et al. [21] reported a relationship between operation time and HGB decrease in patients who underwent cesarean section myomectomy compared with those who underwent only cesarean section delivery; furthermore, no major bleeding or transfusion need was detected. Guler et al. [22] found no significant difference in preoperative, postoperative, and mean HGB between 65 and 82 patients who underwent intramural myomectomy and subserosal myomectomy, respectively.

In our study, 69% of the myomas were anterior, 90% of the myomas were subserosal (FIGO 6 [66.4%] and FIGO 5 [34.5%]), and the mean myoma diameter was 5.9 cm. Consistent with findings in the literature, the myomas in our study were mostly located in the anterior corpus [23, 24]. Sparic et al. [10] reported that corporeal myomectomy did not cause an increase in perioperative morbidity and was safe in patients with anterior myomas. Kaymak et al. [25] compared 40 patients who underwent cesarean myomectomy with 80 patients with myomas as the control group and found that the average myoma size was 8.1 cm. Park et al. [26] warned that the operation time would be longer than usual in myomas exceeding 6 cm. Zhao et al. [27] stated a high risk for postpartum bleeding if cesarean myomectomy was performed in myomas over 5 cm and fetal weight was over 4000 g. Sparic et al. [28] stated that the type and size of myomas and the duration of surgery were related, and the size of the defect caused by myoma enucleation and suture rate had a significant effect on the formation of intraoperative bleeding. Furthermore, surgeons should exercise great care when performing corporeal myomectomy on mothers over 40 years of age [29].

In our study, no hemostatic method (tourniquet, uterotonic drugs, vasopressin, vascular ligation, etc.) was performed. Ehigiegba et al. [30] reported that myomectomy in cesarean section is no longer as dangerous as many people believed with sufficient surgical experience and the use of high-dose oxytocin infusion. In a study where cesarean section myomectomy and abdominal myomectomy were compared, Kanthi et al. [31] reported that the contraction power of a pregnant uterus was effective in reducing blood loss that cesarean myomectomy can be performed safely in single myomas and that it is similar to abdominal myomectomy in terms of blood loss.

The limitations of the study are its retrospective design, all myomectomy operations being performed by experienced surgeons, and the lack of results related to postpartum bleeding. We believe that the size of the patient population and the mean myoma diameter are the strengths of the study.

The safety of cesarean myomectomy remains unclear in the literature. Our experience has shown that it prolongs operation time, blood transfusion rate, and hospital stay. In addition, no hysterectomy, relaparotomy, massive transfusion, or major organ damage was found. Myomectomy performed during cesarean section reduces the possibility of a second surgery. Surgeons should consider all these factors when deciding to perform myomectomy.

ST and MRG conceived and designed the experiments; SA, CA, MRG, and ST performed the experiments; ST and MRG analyzed the data; MRG and ST contributed reagents and materials; CA and ST wrote the paper. All authors read and approved the final manuscript.

All subjects provided their informed consent for inclusion before they participated in the study. The study was performed in accordance with the Declaration of Helsinki and was approved by the Institutional Ethics Committee of Gazi Yasargil Training and Research Hospital (2021/702).

We thank all the peer reviewers and for their opinions and suggestions.

This research received no external funding.

The authors declare no conflict of interest.