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| Laparoscopic Myomectomy for Fibroids |
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 What
are Fibroids? |
| What
are the causes? |
| What
are the symptoms? |
| How
are they diagnosed? |
| What
are the treatment options? |
| What
are the Benefits and Drawbacks? |
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| What
are Fibroids? |
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Fibroids are growths of tissue that are usually found
in the wall of the uterus, or womb. They are made of
a mixture of muscle tissue from the uterus and threadlike
fibres of connective tissue. They are among the most
common tumours in women. These growths aren't associated
with cancer. The Medical names for a fibroid are leiomyoma,
myoma, and fibromyoma.
They are one of the most common tumours found in women
during their reproductive years. As many as three out
of four women have fibroids, but most are unaware of
them. Your doctor may discover them incidentally during
a pelvic exam or prenatal ultrasound. Fibroids cause
symptoms for about one in four women, most frequently
during their 30s or 40s. But surprisingly they are the
single most common cause for hysterectomy, being responsible
for somewhere between 20% and 77% of all hysterectomies
performed.
Uterine fibroids originate from the smooth muscle cells
of the myometrium. A single cell reproduces repeatedly,
eventually creating a pale, firm, rubbery mass distinct
from neighboring tissue. Fibroids range in size from
seedlings, undetectable by the human eye, to bulky masses
that can distort and enlarge the uterus. They can be
single or multiple, in extreme cases expanding the uterus
so much that it reaches the rib cage.
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| Types of fibroids |
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 The
names of fibroids reflect their orientation to the uterine
wall. Basically, fibroids can be classified into four
types. They are:
Intracavitary Myomas- These fibroids are present
inside the cavity of the uterus. They usually cause
bleeding between periods and often cause severe cramping.
Submucous Myomas- They are present partially
in the cavity and partially in the wall of the uterus.
They too can cause heavy menstrual periods as well as
bleeding between periods.
Intramural Myomas- These fibroids are in the
wall of the uterus, and can range in size from microscopic
to larger than a grapefruit. Many of these do not cause
problems unless they become quite large. There are a
number of alternatives for treating these, but often
they do not need any treatment at all.
Subserous Myomas- They are on the outside wall
of the uterus. A fibroid may even be connected to the
uterus by a stalk. These do not need treatment unless
they grow large, but they can twist and cause pain
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| What
are the causes? |
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| A fibroid starts as a single muscle
cell in the uterus. For reasons that are not known, this
cell changes into a fibroid tumor cell and starts to grow
and multiply. Heredity may be a factor. After puberty,
the ovaries produce more hormones, especially oestrogen.
Higher levels of these hormones may help fibroids to grow,
although exactly how this might happen is not understood. |
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| What
are the symptoms? |
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| Surprisingly most fibroids up to
the size of an orange cause no symptoms. Their mere presence
is not a reason to treat them. Only about a quarter of
women with fibroids will experience any symptom. These
may include: |
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- Heavy and painful periods- Periods may last more
than seven days and menstrual flow may be very heavy.
- Pain during sexual intercourse,
- Infertility- Large intramural fibroids may be the
cause of longstanding infertility if all other causes
have been excluded.
- Urinary or bowel symptoms caused by local pressure
due to the fibroids.
- Complications in pregnancy like miscarriage, premature
labour
- Pain in the pelvis-The pressure of large fibroids
on other organs may cause pain in the pelvis. Pain
may also occur if the stalk of a fibroid twists, cutting
off blood supply to the fibroid. Rarely, a fibroid
may become infected and cause pain.
- Very rarely, a fibroid can undergo malignant change,
particularly if the fibroid is very large or rapidly
increases in size.
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| We have already discussed above
the various types of fibroids that can arise. Let us see
separately what kind of symptoms will be presented by
each of them. |
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| Intracavitary Myomas- These
fibroids are present inside the cavity of the uterus.
They usually cause bleeding between periods and often
cause severe cramping. |
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| Submucous: They protrude
into the uterine cavity and cause menstrual cramps, heavy
periods, infertility and repeated miscarriages. The diagnosis
is often missed as the uterus is not enlarged and unnecessary
hysterectomies have been performed for these. The diagnosis
is made by hysterosonography or hysteroscopy. |
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| Intramural: These fibroids
are within the muscle of the uterus and can be very large.
Because they enlarge the cavity of the uterus they can
also cause heavy periods. The most common problem is 'pressure'
symptoms on the bladder and rectum. |
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| Subserous: These are external
to the uterine muscle and are connected by a thin stalk.
They are the least likely to be symptomatic and rarely
need removal. Torsion (twisting) is a very rare complication. |
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| How
are they diagnosed? |
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| One of the most common conditions
confused with fibroids is adenomyosis. This can be a serious
error, as the treatment may be quite different. In adenomyosis
the lining of the uterus infiltrates the wall of the uterus,
causing the wall to thicken and the uterus to enlarge.
This can cause severe pain, and heavy bleeding. Since
they present in the same way as fibroids, they often lead
to wrong diagnosis. So after the gynaecologist takes the
case history, the first step is to do a thorough pelvic
examination. Fibroids may be felt during a pelvic exam,
but many times myomas that are causing symptoms can be
missed if the examiner relies just on the examination.
So after this, the physician may ask the patient to undergo
the following test: |
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| Ultrasound |
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| On ultrasound examination adenomyosis
will often appear as diffuse thickening of the wall, while
fibroids are seen as round areas with a discrete border.
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| Hysteroscopy |
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| Hysteroscopy uses a hysteroscope,
which is a thin telescope that is inserted through the
cervix into the uterus. Modern hysteroscopes are so thin
that they can fit through the cervix with minimal or no
dilation. Because the inside of the uterus is a potential
cavity, like a collapsed air dome, it is necessary to
fill (distend) it with either a liquid or a gas (carbon
dioxide) in order to see. During diagnostic hysteroscopy
the hysteroscope is used just to observe the endometrial
cavity (inside of the uterus.) |
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| MRI scan |
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| The above steps are usually all
that is needed to make an accurate diagnosis and plan
treatment. Sometimes, especially with very large fibroids,
more information is needed. An MRI scan makes detailed
images of the uterus. It can show the location of fibroids.
An MRI can usually tell the difference between adenomyosis
and fibroids. |
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| What
are the treatment options? |
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| There's actually no single-best
approach to treating fibroids. The option that's best
for you depends on many factors. Your plans for childbearing,
how close you are to menopause and your feelings about
surgery may play a role in determining your options. |
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| Watchful waiting |
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| Fibroids that cause no symptoms
may require only "watchful waiting". In this,
your gynaecologist will monitor your condition through
regular pelvic examinations. It is also a good option
if one is approaching menopause.The reproductive hormones
oestrogen and progesterone appears to stimulate fibroid
growth. During menopause, the ovaries stop producing these
hormones and fibroids shrink. Your gynaecologist may decide
to take action if signs and symptoms such as heavy bleeding,
pelvic discomfort and pressure on neighboring organs start
intruding on your life. Treatment depends on the size
and site of the fibroids. The options include: |
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| Drug Therapy |
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| Drug therapy is usually tried first.
This might include: |
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- The use of non-steroidal anti-inflammatory drugs
(NSAIDs) such as ibuprofen (Motrin) or naproxen sodium
(Naprosyn),
- Birth-control pills, or
- Hormone therapy.
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| In some patients, symptoms are
controlled with these treatments and no other therapy
is required. However, some hormone therapies can have
risks and side effects (menopausal symptoms, erratic or
no menstruation, bloating, moodiness) when used long-term,
and generally are used temporarily. Hormonal therapy can
be useful for women who are close to the menopause and
wish to avoid surgery. But hormonal treatment is unlikely
to be of any benefit in women who wish to conceive and
causes unnecessary delays. |
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| A newer group of drugs being used
for fibroids are hormones known as GnRH analogues, which
are administered by injection by the gynecologist. These
synthetic (man-made) hormones act like the hormones that
are naturally produced by the body and reduce the level
of oestrogen. The result is reduced blood flow to the
uterus and, therefore, to the fibroids, decreasing the
size of both. Some physicians recommend these hormones
prior to surgery to reduce the size of the fibroids and
make them easier to remove. The effectiveness of the hormones
is considered temporary as studies show that when the
therapy is stopped, fibroids regrow to their original
size in four to six months. The GnRH hormones also may
cause side effects that mimic menopause, including hot
flashes, vaginal dryness, mood swings and a decrease in
bone density (osteoporosis). |
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| Minimal invasive procedures |
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| Myomectomy is a surgical procedure
that removes visible fibroids from the uterine wall. Myomectomy
is the removal of fibroids without removing the uterus.
This operation preserves a woman's ability to bear children.
There are several ways to perform myomectomy, including
hysteroscopic myomectomy, laparoscopic myomectomy and
abdominal myomectomy. While the first two are minimally
invasive procedures, the latter one is a traditional method.
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| While myomectomy is successful
in controlling symptoms about 80 percent of the time,
the more fibroids there are in a patient's uterus, the
less successful the surgery generally is. In addition,
fibroids grow back several years after myomectomy in 10
percent to 30 percent of cases. |
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| Laparoscopic myomectomy |
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| The surgical removal of fibroids
is called a myomectomy. Laparoscopic myomectomy may be
used if the fibroid is on the outside of the uterus. Intramural
and subserous fibroids up to 10 cm in diameter can be
removed by laparoscopic myomectomy, through two small
incisions 10 mm in length, one in the umbilicus (navel)
and the other a little lower down in the midline of the
abdomen. Two smaller incisions only 5mm in length are
made, one on either side of the abdomen about three inches
from the midline. Presently only a handful of surgeons
in this country offer this procedure which takes much
longer and is more challenging than conventional surgery.
Aastha specializes in such kind of minimal invasive
procedures. Fibroids that are deep in the wall of the
uterus or submucous are most difficult to remove laparoscopically.
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| Hysteroscopic myomectomy |
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 This
procedure is used only for fibroids that are just under
the lining of the uterus and that protrude into the uterine
cavity. Hysteroscopic myomectomy is performed through
the woman's cervical canal and does not involve any abdominal
incisions. During operative hysteroscopy a type of hysteroscope
is used that has channels in which it is possible to insert
very thin instruments. These instruments can be used to
remove polyps, to cut adhesions, and do other procedures.
In many situations, operative hysteroscopy may offer an
alternative to hysterectomy. A device called a resectoscope
cuts away the fibroids or an electrical current "evaporates"
the fibroids. The resectoscope has been used for male
prostate surgery for over 50 years. It has been modified
so it can be used inside the uterus. The resectoscope
is a hysteroscope with a built in wire loop that uses
high-frequency electrical current to cut or coagulate
tissue. The resectoscope has revolutionized surgery inside
the uterus. After a laparoscopic or hysteroscopic myomectomy,
the patient goes home the same day. Most women are back
to normal activities within 7-10 days. |
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| Abdominal Myomectomy |
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| This is a surgical procedure, in
which an incision is made in the abdomen to access the
uterus, and another incision is made in the uterus to
remove the tumor. Once the fibroids are removed, the uterus
is stitched closed. The patient is given general anesthesia
and is not conscious for this procedure, which requires
a several-day hospital stay. Typical recovery is four
to six weeks. |
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| Myolysis |
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| Then, using techniques such as
coagulation or electrosurgery, the fibroids are removed
and the uterine wall repaired. We use a bipolar needle
or laser to perform "myolysis" of the fibroids.
This destroys the fibroids and shrinks the blood vessels
that feed them. A similar procedure called cryomyolysis
uses liquid nitrogen to "freeze" fibroids. So
this does not involve surgically cutting into the uterus,
but instead, it uses techniques to coagulate the fibroids,
which shrink to about half the size after surgery. |
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| Uterine artery embolization |
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| Known medically as uterine artery
embolization, this approach to the treatment of fibroids
blocks the arteries that supply blood to the fibroids
causing them to shrink. It is a minimally-invasive procedure,
which means it requires only a tiny nick in the skin,
and is performed while the patient is conscious but sedated
and feels no pain. Fibroid embolization is performed by
an interventional radiologist, a physician who is specially
trained to perform this and other minimally-invasive procedures.
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Uterine artery Embolization
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| The interventional radiologist
makes a small nick in the skin (less than one-quarter
of an inch) in the groin to access the femoral artery,
and inserts a tiny tube into the artery. The catheter
is guided through artery to the uterus while the interventional
radiologist guides the process of the procedure using
a moving X-ray (flouroscopy). The interventional radiologist
injects tiny plastic particles the size of grains of sand
into the artery that is supplying blood to the fibroid
tumor. This cut off the blood flow and causes the tumor
(or tumors) to shrink. The artery on the other side of
the uterus is then treated. Fibroid embolization usually
requires a hospital stay of one night. Pain-killing medications
and drugs that control swelling typically are prescribed
following the procedure to treat cramping and pain. Many
women resume light activities in a few days and the majority
of women are able to return to normal activities within
one week. |
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| MRI-guided focused ultrasound
ablation |
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 Magnetic
resonance guided focused ultrasound (MRGFU) is a non-invasive
outpatient, procedure that uses high intensity focused
ultrasound waves to ablate the fibroid tissue. During
the procedure, an interventional radiologist uses magnetic
resonance imaging (MRI) to see inside the body to deliver
the treatment directly to the fibroid. The procedure
is FDA approved for treating uterine fibroids, but is
under investigation for the treatment of breast, prostate,
brain and bone cancer.
MRI scans identify the tissue in the body to treat
and are used to plan each patient's procedure. MRI's
provide a three-dimensional view of the targeted tissue,
allowing for precise focusing and delivery of the ultrasound
energy. MRI also enables the physician to monitor tissue
temperature in real-time to ensure adequate but safe
heating of the target. Immediate imaging of the treated
area following MRGFU helps the physician determine if
the treatment was successful. The ultrasound energy
used in MRGFU can pass through skin, muscle, fat and
other soft tissues. High-intensity ultrasound energy
that is directed to the fibroid heats up the tissue
and destroys it. This method of tissue destruction is
called thermal ablation.
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| Hysterectomy |
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| Hysterectomy is the surgical removal
of the uterus (and usually of the cervix as well). It
is the most common treatment for fibroids. In a hysterectomy,
the uterus is removed either in an open surgical procedure
or via laparoscopy. In case an open procedure is performed,
it is considered major surgery and is performed while
the patient is under general anesthesia. It requires an
incision in abdominal wall to remove the uterus. It requires
3 to 4 days of hospitalization and the average recovery
period is about six weeks. Hysterectomy can also be done
laparoscopically provided the uterus is not too bulky
because of fibroids. To know more about laparoscopic
hysterectomy, |
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| What
are the Benefits and Drawbacks? |
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| Today minimal invasive procedures
have created a revolution in the world of surgery. The
reason is that they cause less tissue-damage and scarring.
So the recovery is also faster. Laparoscopy and hysteroscopy
are two very common approaches for removing fibroids (myomectomy).
Until recently, surgical removal of fibroids almost always
involved a large abdominal incision (laparotomy) with
a three-to-five day hospital stay and six-to-eight week
recovery. The advantages of laparoscopic/hysteroscopic
myomectomy are: |
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- shorter hospital stay
- reduced recovery time
- reduced post-operative pain
- smaller incisions
- better cosmetic results
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| Side Effects or Complications
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| Fibroid embolization is considered
to be very safe, however, there are some associated risks,
as there are with almost any medical procedure. Most women
experience moderate to severe pain and cramping in the
first several hours following the procedure. Some experience
nausea and fever. These symptoms can be controlled with
appropriate medications. A small number of patients have
experienced infection, which usually can be controlled
with antibiotics. It also has been reported that there
is a 1 percent chance of injury to the uterus, potentially
leading to hysterectomy. These complication rates are
lower than those of hysterectomy and myomectomy. |
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| Myomectomy and hysterectomy also
carry risks, including infection and bleeding leading
to transfusion. Patients who undergo myomectomy may develop
adhesions causing tissue and organs in the abdomen to
fuse together, which can lead to infertility. In addition,
the recovery time is much longer for abdominal myomectomy,
generally one to two months. |
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