The Importance of Uterine Tumors in the Day-to-Day Practice of the General Surgery Department of Ignace Deen National Hospital ()
1. Introduction
Globally, the incidence of uterine tumors varies from one country to another and constitutes a major public health problem. Annual incidence is estimated at 570 new cases, and mortality at 372,000 deaths. The incidence rate standardized on the world population is 6.00 per 100,000 people/year. The worldwide standardized mortality rate is 1.7. Geographical distribution is highly heterogeneous, with 80% of deaths occurring in developing countries [1].
Benign uterine tumors are the most frequently found tumors, especially leiomyomas, which affect 20 to 25 women of childbearing age and are 3 to 9 times more common in black women than in white women. They tend to appear after the age of 30 [2].
Risk factors include papilloma virus, herpes viral simplex, mycoplasma and chlamydia. Other risk factors are also known. These include hormonal disturbances, trauma, estrogen-progestogen therapy and environmental and constitutional genetic factors [2].
Diagnosis is essentially clinical. Menorrhagia and metrorrhagia are often the first signs. They may be associated with other signs, depending on the site of the tumor and the anatomo-clinical picture. These include hydrorrhea and pelvic masses. Physical signs are often poor and delayed. They depend on the cause. Radiological examinations are an invaluable aid to diagnosis, with endo-vaginal ultrasonography helping to identify the tumor and its location, and to assess whether it is malignant or benign. CT scanning is a more effective imaging technique, enabling early detection of the tumor [3]. Anatomopathological examination is an essential part of the diagnosis, enabling tumor confirmation, definition of the histological character of the tumor, tumor behavior and determination of the histoprognosis [3].
In Africa: In 2004, cervical cancer occurred in women of low socio-economic status between the ages of 30 and 49 [4].
In Tunisia: In 2014, a retrospective study demonstrated that uterine sarcomas are rare tumors, accounting for 3% to 5% of malignant tumors of the uterus. Prognostic factors include stage, grade and age [1].
In Guinea, it accounts for 50% of all cancers. One of the characteristics of these cancers in Africa is that patients are seen at advanced stages, which implies heavy, costly treatment that is sometimes limited to palliative care [4].
The relatively high frequency of uterine tumors in the General Surgery Department of the Ignace DEEN National Hospital in Conakry and the difficulties associated with cancer management; were the reasons for choosing the present theme, the general aim of which was to contribute to improving the management of uterine tumors in the department.
2. Methodology
The general surgery department of the Ignace Deen National Hospital was used as the setting for this study. It is a benchmark department.
This was a retrospective descriptive study lasting five (5) years, from January 1, 2011 to December 30, 2015.
The study material consisted of patients’ medical records; consultation registers; hospitalization registers; operative report registers and a pre-established individual data collection sheet.
The study population consisted of all patients with uterine tumors treated in the department during the study period.
We excluded all incomplete records of patients admitted and managed in the department for uterine tumors and untreated patients.
Epidemiological, clinical and therapeutic variables were used.
3. Results
During the study period, we collected 3200 surgical cases, of which 82 or 2.56% were uterine tumors.
According to gestational status, nulliparous were the most represented with 74% (n = 61), see Table 1. As for the reason for consultation, abdomino-pelvic pain was the most represented with 98.78% (n = 81), see Table 2.
Table 1. Distribution of cases according to gravidity.
Gravida |
Headcount |
Percentage |
Nulligravida |
61 |
74 |
Multigravida |
16 |
20 |
Primigravida |
5 |
6 |
Total |
82 |
100 |
Table 2. Frequency of cases by reason for consultation.
Reason for consultation |
Count |
Percentage |
Abdominal pain |
81 |
98.78 |
Metrorrhagia |
77 |
93.90 |
Menorrhagia |
77 |
93.90 |
Hypermenorrhoea |
67 |
81.71 |
Dysmenorrhoea |
34 |
41.46 |
Leukorrhoea |
26 |
31.71 |
Secondary amenorrhoea |
6 |
7.32 |
Abdominal mass |
49 |
59.76 |
Asthenia |
68 |
82.93 |
Anorexia |
52 |
63.41 |
Cervical cancer was the most common diagnosis in this study with 30.49% (n = 25), see Table 3. Myomectomy was performed in most cases (62.20%, n = 51), see Table 4.
Table 3. Distribution of cases by clinical diagnosis.
Clinical diagnosis |
Count |
Percentage |
Cervical cancer |
25 |
30.49 |
Uterine fibromyoma |
53 |
64.64 |
Uterine tumor |
4 |
4.87 |
Total |
82 |
100 |
Table 4. Distribution of cases according to procedure.
Surgical procedure |
Count |
Percentage |
Myomectomy |
51 |
62.20 |
Subtotal hysterectomy |
08 |
9.75 |
Colpo-hysterectomy + lymphadenectomy + lymph node dissection |
23 |
28.05 |
Total |
82 |
100 |
Based on macroscopic appearance, we recorded 20.73% (n = 17) of ulcerating tumors; see Table 5.
Table 5. Distribution of cases according to macroscopy.
Appearance |
Count |
Percentage |
Ulcerative budding |
17 |
20.73 |
Nodular |
53 |
64.64 |
Infiltrative |
12 |
14.63 |
Total |
82 |
100 |
According to histopathological findings, squamous cell carcinomas of the uterine cervix were the most represented with 20.73% (n = 17), see Table 6. Post-operative management was straightforward in 70.73% (n = 58); however, we did record complications such as hemorrhage, surgical site infection and evisceration. See Table 7. The average length of stay was 14.24 days, with extremes of 7 and 36 days.
Table 6. Distribution of cases according to elementary histopathological lesions.
Histological lesions |
Count |
Percentage |
Squamous cell carcinoma of the uterine cervix |
17 |
20.73 |
Adenocarcinoma of the uterine cervix |
08 |
9.76 |
Uterine sarcoma |
05 |
6.10 |
Uterine leiomyoma |
48 |
58.53 |
Endometrial adenocarcinoma |
04 |
4.88 |
Total |
82 |
100 |
Table 7. Distribution of cases according to postoperative follow-up.
Post-surgery follow-up |
Count |
Percentage (%) |
Simple |
58 |
70.73 |
Complications |
Bleeding |
07 |
8.54 |
Surgical site infection |
13 |
15.86 |
Evisceration |
04 |
4.87 |
Total |
82 |
100 |
4. Discussion
The difficulties experienced during the course of this study were inadequate reporting of data on the anatomopathological study of surgical specimens and poor archiving of patient records.
Regarding the insufficient reporting of data on the anatomopathological study of surgical specimens, it should be noted that our country only has one anatomy-pathology department (laboratory) and two specialists in anatomy-pathology. So this promotes an overload of activity which is the cause of non-notification or realization of the anatomy pathology in certain cases; but also due to the fact that the costs of processing the parts fall on the patients, who most often have very limited financial means.
Due to poor archiving of patient files, our hospital does not have digital archives. Patient files are all archived in a room which serves as an archive. Sometimes we notice a deterioration of certain files.
During the study timeframe, we recorded a non-negligible frequency of uterine tumors in our department.
This relatively low frequency could be explained by the presence of two gyneco-obstetrics and general surgery departments in our C.H.U. on the one hand, and on the other, by the overall drop in patient attendance at our health facilities, in connection with the country’s socio-political events. Since 2011, our country has been marked by a series of street demonstrations of a political nature (post-election) and social complaints such as union strikes and demands for electricity and water. Also, our country (Guinea) was hit by the Ebola virus epidemic, which lasted for 3 years.
Generally speaking, we noted an increasing proportion of patients admitted to the department during the period covered by the study, which proves that our study site plays a significant role in the management of uterine tumors. We noted a predominance of young adults.
Our results were comparable to those noted by Messaoudi C [5] in Algeria in 2014, who reported an age range of 40 - 50 years with a frequency of 42.93% and extremes of 18 and 66 years. Our result is in line with literature data. Thus, young adults constitute a layer of predilection for uterine tumors.
Gestational factors play a decisive role in the genesis of uterine tumors. In our series, nulligravida were the most affected. Nulligravida women have factors incriminating in the occurrence of uterine tumors in women.
The clinical pattern was dominated by abdominal pain, which was the main reason for consultation, followed by menorrhagia and metrorrhagia.
Raza Findra Bejab in the Maghreb noted a predominance of haemorrhage, pelvic pain and infertility as the main circumstances for the discovery of fibromyoma [6].
Pain is the reason for consultation in most pelvic pathologies.
The approach was surgical (Pfanenstiel or median subumbilical incision) in all cases. In addition to this conventional approach, Mahbouli S. used an endoscopic approach, hysteroscopy in 13.8% and laparoscopy in 5.3% [7].
Myomectomies were the most common surgical procedures performed during the study period, followed by subtotal hysterectomies and colpohysterectomy + lymphadenectomy.
Macroscopically, uterine tumors were nodular in most cases.
These results show that tumors with different appearances were collected in varying proportions. These appearances depended on the histological lesions and topography of the tumor, as epithelial lining tumors are generally ulcerating and mural or parietal mesenchymal tumors can be nodular and infiltrative. Our results are similar to those of Sophie Taieb et al. [8] who reported in a study of uterine sarcomas that the infiltrative and poorly limited aspect was found in all patients (100% of cases) and Frédérique P et al. [9] who noted that the aspects of endometrial cancers observed were ulcerative-budding in 83.2% of cases,
Uterine leiomyoma was the most frequent histological form, followed by squamous cell carcinoma of the cervix. Our figures were lower than those reported by Girandet G et al. [10], who reported in their research that uterine leiomyomas or fibromas were the most common, accounting for 65.2% of cases.
Post-operative follow-up was generally satisfactory. However, we did record complications such as surgical site infection and haemorrhage.
We did not record any in-hospital deaths. This may be explained by the fact that most of our patients had benign tumors.
The average length of stay was long in our series. Our result was comparable to that of Doumbia Y, et al. who reported a length of stay varying from 3 to 11 days [11].
Follow-up of patients after treatment consisted of clinical and paraclinical examinations at an interval of 4 to 6 months during the 1st year, then once a year. The follow-up results were comparable to those of Georges P [12], who observed a mean follow-up time of 9.54 months, with an extreme range of 0 and 68 months.
5. Conclusion
Uterine tumors are common in our context. Their diagnosis is based on clinical and paraclinical arguments, and the management of uterine tumors is a major public health problem. Information, communication and education of all socio-professional groups; as well as the carrying out of other studies involving gyneco-obstetrics services seem necessary to improve the management of uterine tumors.