Laparoscopic Myomectomy Treatment for Fibroids | Obstetrics Surgical Treatment | Gynaecology Surgical Treatment | Aastha Healthcare | Super Speciality

What are Fibroids?

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.

Types of fibroids

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

What are the causes?

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.

What are the symptoms?

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:

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.

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.

Intracavitary Myomas- These fibroids are present inside the cavity of the uterus. They usually cause bleeding between periods and often cause severe cramping.

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.

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.

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.

How are they diagnosed?

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:

Ultrasound

On ultrasound examination adenomyosis will often appear as diffuse thickening of the wall, while fibroids are seen as round areas with a discrete border.

Hysteroscopy

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.)

MRI scan

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.

What are the treatment options?

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.

Watchful waiting

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:

Drug Therapy

Drug therapy is usually tried first. This might include:

The use of non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (Motrin) or naproxen sodium (Naprosyn), Birth-control pills, or Hormone therapy.

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.

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).

Minimal invasive procedures

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.

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.

Laparoscopic myomectomy

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.

Hysteroscopic myomectomy

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.

Abdominal Myomectomy

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.

Myolysis

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.

Uterine artery embolization

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.

Uterine artery Embolization

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.

MRI-guided focused ultrasound ablation

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.

Hysterectomy

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,

What are the Benefits and Drawbacks?

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:

shorter hospital stay reduced recovery time reduced post-operative pain smaller incisions better cosmetic results

Side Effects or Complications

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.

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. For more information, kindly visit : http://www.aasthahealthcare.com/Laparoscopic-Myomectomy-Fibroids-Treatment.htm ------------------------------------