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Myomectomy
for Uterine
Fibroids
Myomectomy
is the surgical
removal of uterine
fibroids without
hysterectomy.
The following
questions and
answers discuss
the issues involved
in this type
of alternative
to hysterectomy.
Uterine
Fibroids
What
Are
Uterine
Fibroids?
What
Symptoms
Do
Fibroids
Cause?
Uterine
Fibroids
What
Are Uterine Fibroids?
Fibroids
are common
benign
tumors
which arise
from the
muscle
tissue
of the
uterus;
they may
be single
or multiple.
About 25%
of all
women over
the age
of 35 have
fibroids;
among African-American
women fibroids
are even
more common.
These tumors
may grow
into the
uterine
cavity
(submucous
fibroids);
they may
be located
in the
uterine
wall (mural)
or protrude
outside
of the
uterine
wall (subserous).
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What
Symptoms
Do Fibroids
Cause?
Submucous
fibroids are the
type that most commonly
cause significant
problems; even small
tumors located in
or bulging into the
uterine cavity may
cause heavy bleeding,
anemia, pain, infertility
or miscarriage. Mural
fibroids (located
in the uterine wall)
and subserous fibroids
(protrude outside
the uterine wall)
may reach a large
size before causing
symptoms. These symptoms
may include pressure
on the bladder with
difficulty voiding
or urinary frequency
and urgency, pressure
on the rectum with
constipation, lower
back and abdominal
pain, as well as
heavy bleeding. .
A large fibroid uterus
may also compress
the ureter as it
enters the pelvis
and lead to hydronephrosis (swelling
of kidneys due to
accumulation of urine
because of obstruction
of ureters) because
of obstructed urine
flow from that kidney.
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What
is the Conventional Treatment
for Fibroids?
Every
year
over
550,000
American
women
undergo
hysterectomy,
the
majority
for
benign
non-life
threatening
conditions.
In
33%
of
all
hysterectomies,
the
reason
for
surgery
is
problems
related
to
fibroid
tumors.
When fibroids
are small and cause
no symptoms, no
treatment is required.
In the presence
of symptomatic or
large fibroids,
a woman who wishes
to preserve her
fertility may be
offered a myomectomy,
an operation which
removes the fibroids while
sparing the uterus. However,
the conventional treatment
for women 40 years of age
and older is hysterectomy
and bilateral oophorectomy
(removal of both ovaries).
Even women younger than 40
who have completed childbearing
are usually offered hysterectomy.
The rationale for this approach
is as follows: hysterectomy
and oophorectomy are viewed
as definitive solutions for
the presenting medical problem
(i.e., bleeding, anemia, pain
etc.) and as preventive measures
against the risk of malignancy
in the pelvic organs. The
prevailing attitude is that
a woman who does not desire
more children no longer "needs
her uterus." Another
justification for the conventional
approach of hysterectomy is
the fact that, depending on
the number, location and size
of fibroids, successful myomectomy
requires more expertise and
surgical skill than hysterectomy.
When performed by a surgeon
without extensive experience,
myomectomy is more likely
to result in prolonged surgery,
significant blood loss requiring
blood transfusion and other
postoperative complications.
Therefore, it is not surprising
that the average gynecologist
tends to offer hysterectomy
as a treatment for fibroids,
rather than myomectomy. Despite
these views we firmly advocate
myomectomy with preservation
of the uterus and ovaries.
The rationale for these will
follow.
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In
recent years, as
more
women have become
better
informed on health
issues,
they have sought
treatments
that preserve the
pelvic
organs, especially
in
the presence of a
benign
disease. In addition,
research has demonstrated
that, while hysterectomy
solves some problems,
it may also lead
to
other
problems. For example,
following hysterectomy,
there is an increased
prevalence of problems
related to sagging
pelvic
organs such as "dropped
bladder" (in
medical terms these
are known as genital
prolapse, such as
vaginal vault prolapse,
enterocele, cystocele
and rectocele). These
conditions may cause
symptoms, such as
urination and defecation
disorders, and may
require surgical
repair. Several studies
suggest that even
without sagging of
the vaginal walls,
about 30% of women
develop urinary leakage,
urinary frequency
or slow transit constipation
after hysterectomy.
It
has
been
shown
that
after
hysterectomy,
even
without
removal
of
the
ovaries
(oophorectomy),
women
tend
to
enter
menopause
earlier,
by
as
much
as
four
years
according
to
one
study.
Estrogen
produced
by
the
ovaries
may
reduce
the
risk
of
coronary
artery
(heart)
disease
and
helps
prevent
osteoporosis
(thinning
and
weakening
of
the
bones).
Studies
indicate
that
hysterectomy
before
natural
menopause,
even
without
oophorectomy,
increases
the
risk
of
heart
disease
(by
up
to
300%,
according
to
one
study)
during
the
remaining
premenopausal
years.
Hysterectomy
with
prophylactic
(preventive)
oophorectomy
eliminates
the
risk
of
death
from
uterine
or
ovarian
cancer
(life
long
probability
of
death
1.3%),
but
increases
the
risk
of
death
from
heart
disease
(life
long
probability
of
death
33%)
and
osteoporosis.
Estrogen
replacement
therapy
may
prevent
the
negative
consequences
of
surgically
induced
menopause.
However,
a
large
proportion
of
women
discontinue
hormonal
replacement
therapy
after
a
few
months
and
therefore
lose
this
protective
effect.
Also
there
is
concern
that
hormone
replacement
therapy
(containing
both
estrogen
and
progesterone)
may
increase
the
risk
of
heart
disease
and
breast
cancer,
and
this
concern
leads
many
women
to
avoid
taking
hormone
replacement.
In
fact,
recently
medical
authorities
recommended
restriction
of
hormone
replacement
therapy
only to
be
used for
relief
of
hot
flashes
and/or
dryness
in
the
vagina
and
discontinuation
of
the
treatment
as
soon
as
possible.
Given
the
new
reality,
it
is
more
important
than
ever
before
to
preserve
ovarian
function
for
as
long
as
possible.
Hysterectomy,
with
or
without
oophorectomy,
shortens
the
functional
life
span
of
the
ovaries
significantly.
Preservation
of
ovarian
function
requires
preservation
of
the
uterus.
The uterus has
great psychological significance
for many women. Although many
women have no emotional difficulties
after surgery, post-hysterectomy
problems such as depression,
anxiety and sexual dysfunction
have been described. Some women
complain of decreased quality
of sexual response after hysterectomy,
specifically, a change in the
quality of orgasm. This change
may be the result of the absence
of rhythmic uterine contractions
during orgasm. Finally, many
women are strongly opposed,
in principle, to the removal
of any organs,
genital or otherwise,
unless absolutely
necessary.
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A
Physician's
Response
My
conviction
as a physician
is to respect
the personal
aspirations
and viewpoints
of every
patient.
If an informed
patient
wishes
to preserve
her uterus
in the
presence
of a benign
condition
and if
her medical
problem
can be
safely
resolved
without
hysterectomy,
the physician
should
comply
with the
patient's
desire,
even if
this involves
referring
her to
another
specialist.
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Myomectomy,
when performed by an expert,
is a safe and effective
alternative to hysterectomy.
This operation can usually
be accomplished with minimal
blood loss. When the operation
is performed with optimal
technique by a highly
experienced surgeon the
need for blood transfusions
is limited to very few
cases. Likewise, in an
expert's hands, it is
rare that a myomectomy
is converted during surgery
to an unplanned hysterectomy
because of uncontrollable
bleeding. The gynecological
surgeon who has extensive
experience with myomectomy
is able to remove all
fibroids regardless of
their location. The successful
myomectomy should result
in resolution of all symptoms
related to fibroids.
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Myomectomy
The
Operation
Depending
upon the
location
of the
fibroid(s),
myomectomy
can be
accomplished
by either
an abdominal
or vaginal
approach.
When the
fibroid
causing
symptoms
is bulging
into the
uterine
cavity
(submucous),
it is usually
possible
to remove
it by using
hysteroscopic
technique.
This technique
involves
using an
operating "telescope" which
is inserted
into the
uterus
through
the vagina.
Hysteroscopic
myomectomy
is performed
on an out-patient
basis;
the short
recovery
period
at home
is 2-3
days before
resumption
of full
activity.
However,
there are
limitations
with hysteroscopic
myomectomy.
If the
submucous
fibroid
is located
mostly
within
the uterine
wall, hysteroscopic
resection
is not
possible.
If, in
addition
to the
submucous
fibroid(s),
there are
other clinically
significant
fibroids
within
the uterine
wall, then
abdominal
myomectomy
is necessary.
In the
presence
of large
fibroids
in the
uterine
wall (mural)
or bulging
out of
the uterus
(subserosal),
abdominal
myomectomy
through
an abdominal
incision
is usually
required.
In most
cases this
can be
accomplished
through
a low horizontal
incision
along the
bikini
line, resulting
in a minimally
visible
scar. Following
an uncomplicated
abdominal
myomectomy,
discharge
from the
hospital
is usually
possible
within
two days.
There is
a variable
recovery
period
at home
of two
to six
weeks depending
upon individual
factors
and lifestyle.
A critical part of successful
myomectomy is optimal
reconstruction of the
uterus after the fibroids
have been removed. The
irregular defects created
in the uterine wall by
the removal of the fibroids
must be meticulously repaired
so that potential sites
of bleeding and/or infection
are eliminated. A poorly
reconstructed uterus may
rupture during a subsequent
pregnancy or delivery.
In this regard, removing
large fibroids through
the laparoscope (telescope
inserted through the navel)
is not advisable in most
cases because optimal
reconstruction of the
uterus is not accomplished
in this manner. Suboptimal
reconstruction may also
lead to post operative
bleeding which may require
emergency hysterectomy
and/or blood transfusions.
In addition, internal
bleeding (with or without
infection) may cause pelvic
adhesions, tubal occlusion
and infertility, and/or
chronic pelvic pain.
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Laparoscopic
Myomectomy
Laparoscopic
myomectomy
entails
the removal
of uterine
fibroids
using a
laparoscopic
technique
instead
of the
traditional
surgical
approach
through
a sizable
incision.
A laparoscope
is a telescope-like
instrument,
which is
inserted
into the
abdominal
cavity,
usually
through
the navel.
The surgeon
uses the
laparoscope
to see
inside
the abdominal
and pelvic
cavity
and perform
surgical
procedures
without
large incisions.
Additional
entry sites
into the
abdomen
are created
through
tiny incisions
in the
lower abdomen.
These additional
tiny incisions
allow for
the introduction
of surgical
instruments
and for
the removal
of the
resected
fibroids
in small
pieces.
A few successful pregnancies
have been reported following
laparoscopic myomectomy. However,
there are also reports of
uterine rupture during pregnancy
following laparoscopic myomectomy.
The rupture is caused by poor
reconstruction of the uterine
wall following the removal
of the fibroids resulting
in a weakened uterine wall.
Adequate reconstruction of
the uterus following myomectomy
demands meticulous placement
of multiple sutures, which
is too time consuming to be
performed through the laparoscope.
Consequently, too few such
sutures are applied during
laparoscopic repair, resulting
in a weakened uterine wall.
It is therefore advisable
to avoid laparoscopic myomectomy
when a future pregnancy is
a consideration.
Another
important
aspect
of uterine
reconstruction
after myomectomy
is the
need to
eliminate
the so-called "dead
spaces" within
the uterine
wall created
by the
removal
of fibroids.
These "dead
spaces" are
potential
sites for
bleeding
during
and after
the operation,
which may
lead to
infection,
pelvic
adhesions,
and early
or late
bowel obstruction.
It is much
more difficult
to achieve
optimal
uterine
reconstruction
during
laparoscopic
surgery.
The main
advantage
of laparoscopic
myomectomy,
the avoidance
of a larger
abdominal
incision,
has to
be weighed
against
the disadvantages
of a prolonged
procedure
time with
more anesthesia,
a much
weaker
uterus,
and a higher
potential
for major
complications.
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There
are numerous surgical
techniques for performing
myomectomy. However, the
important goal common
to all is minimizing blood
loss and other complications.
It is critical to prevent
significant blood loss
during and after surgery,
as this may result in
postoperative complications
such as anemia, fever,
infection, and the requirement
for blood transfusion.
Bleeding and/or infection
may lead to pelvic adhesions
which, in turn, may cause
pain or bowel obstruction
in the short or long term.
The expert in myomectomy
should be able to assure
the patient prior to surgery
that the intended myomectomy
will not turn into an
unplanned hysterectomy
because of uncontrollable
blood loss.
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What
if Cancer is Found?
About
1 in 200 women
with fibroids
is found at
surgery to have
a malignant
tumor of the
uterus (sarcoma).
Therefore, the
preoperative
discussion between
the woman and
her surgeon
should include
consideration
of this unlikely
circumstance.
The patient
should be counseled
regarding the
importance of
hysterectomy
and the removal
of both ovaries
as a life-saving
procedure when
cancer is found
during the operation.
It is important,
however, to
understand that
an "ugly
necrotic"
fibroid is not necessarily
a sarcoma (tumor). Intraoperative
evaluation of suspicious
tumors by "frozen
section" is
required in
order to ensure
that hysterectomy
is performed
only for a malignant
tumor. It is
also important
to understand
that a frozen
section will
not detect all
cases of sarcoma
and that it
is theoretically
possible that
a fibroid which
was negative
on frozen section
is found later,
upon further
studies after
surgery, to
be malignant.
In such a rare
event the patient
may have to
return to the
OR for hysterectomy.
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Some
physicians advocate hormone
treatment with GnRH agonists,
such as Lupron, in preparation
for myomectomy. This treatment
postpones the operation
for 2-4 months. During
this time the fibroids
decrease in size and the
bleeding is markedly reduced.
Although some surgeons
feel that this makes the
operation easier and diminishes
blood loss, many other
experienced surgeons find
this very expensive treatment
unnecessary with a few
exceptions. In fact, this
treatment is often detrimental.
Following GnRH treatment
the fibroids usually become
temporarily smaller. However,
as a result of the GnRH
treatment, the fibroids
also become much more
difficult to separate
from the surrounding uterine
tissue. As a result, myomectomy
is more difficult technically.
Even so, it is generally
agreed that if a woman
is very anemic, hormone
treatment along with iron
supplements is indicated
as it promotes recovery
from the anemia prior
to surgery. Concern has
been raised that GnRH
treatment may shrink small
fibroids which could,
therefore, be missed at
surgery only to enlarge
again and cause problems
later. Recently, it was
reported that the anti-progesterone
agent RU486 (mifepristone)
may shrink fibroids temporarily
in preparation for myomectomy.
The clinical value of
this agent is still under
study.
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The
role of imaging studies
in women with fibroids
is to: a) confirm the
clinically suspected diagnosis
of fibroids, b) exclude
other causes of uterine
enlargement or pelvic
masses such as adenomyosis,
uterine malignancy, and
benign or malignant ovarian
masses, c)identify normal
ovaries in the presence
of an enlarged uterus,
d) examine the kidneys
and urinary tract for
obstruction due to the
pelvic mass, and e) determine
prescisely the number,
size, and location of
the fibroids. The latter
is particularly important
for successful myomectomy
because it helps the surgeon
determine ahead of time
what kind of operation
is required. The type
of imaging test depends
upon the individual findings
in a given woman and the
availability of certain
equipment/techniques.
The tests commonly used
are pelvic ultrasound
(both transabdominal and
vaginal) and x-rays of
the kidneys and urinary
tract (IVP). Newer imaging
modalities which may be
used in selected cases
include MRI and sonohysterography. MRI
helps determine the size
and location of fibroids
in the giant uterus. It
can also detect adenomyosis
as an additional diagnosis
or as the sole diagnosis
instead of fibroids. However,
MRI must follow strict
conditions. This pelvic
MRI is done with IV contrast
medium gadolinium. There
should be 4mm thick contiguous
sections through the uterus. Sonohysterography
is an ultrasound study
performed after the introduction
of saline into the uterine
cavity. It helps define
the location of the cavity
and the presence of submucous
or intracavitary fibroids. Both
pelvic MRI and sonohysterography,
in expert hands, will
generally detect 92% or
more cases of adenomyosis.
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Other
Alternative
Treatment Modalities
for Fibroids
Myolysis
Myolysis
is the
destruction
of fibroids
(necrosis)
by different
methods,
including
coagulation
of the
tumors
with bipolar
or unipolarelectrodes
or laser
beams.
Another
technique
for the
destruction
of fibroids
utilizes
a freezing
probe (cryomyolysis).
The probe
is inserted
into fibroids
through
the laparoscope
and the
electrical,
laser or
freezing
apparatus
is activated,
resulting
in necrosis
of the
affected
portions
inside
the fibroid.
This is
repeated
several
times,
at different
locations
inside
the individual
fibroid,
until the
extent
of the
necrosis
inflicted
in a certain
fibroid
is considered
sufficient.
Such
techniques,
in different
versions,
have been
used since
the early
nineties.
They are
time-consuming
and are
usually
limited
to the
treatment
of moderate-sized
fibroids.
Frequently,
the patient
is first
treated
with Lupron
injections
over several
months
prior to
the procedure
in order
to reduce
fibroid
size and
vascularity
(blood
supply
to fibroids).
The procedure
is performed
through
a laparoscope
so that
no large
abdominal
incision
is required.
Following
the procedure
the holes
created
by the
probe on
the uterine
surface
tend to
ooze sero-sanguinous(blood
stained)
fluid.
This may
lead to
infection
and pelvic
adhesions.
The procedure
may destroy
large portions
of the
uterine
muscle.
Consequently,
a pregnancy
following
myolysis
is ill
advised.
Failure
of the
myolysis
procedure
to solve
abnormal
bleeding,
pain or
other clinical
problems
happens
frequently
and additional
surgery
may then
be required,
usually
hysterectomy.
Prevailing
views today
call for
the abandonment
of myolysis
as a treatment
for fibroids.
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Endometrial
Ablation
Endometrial
ablation
destroys
the endometrial
lining
to varying
extent
(depending
on technique
and skill).
There are
numerous
different
techniques
to achieve
endometrial
ablation
that lead
essentially
to the
same end
result.
These techniques
include
hot water
balloon,
cryo- ablation
(freezing
the endometrium),
laser ablation,
roller
ball cautery
and electric
loop resection
of the
endometrium.
These techniques
destroy
the endometial
lining
and may
reduce
bleeding,
but only
temporarily.
These
procedures
are quite
effective
for the
treatment
of true
functional
uterine
bleeding
(bleeding
due to
hormonal
imbalance
without
the presence
of any
anatomical
abnormality).
However,
in the
presence
of sub
mucous
fibroids,
endometrial
ablation
usually
fails (unless
effective
myomectomy
is also
performed
at the
same time).
Ablation
also fails
when the
bleeding
is caused
by deep
adenomyosis.
Unfortunately,
failure
to recognize
the presence
of adenomyosis
occurs
frequently.
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1.
How often do you perform myomectomy?
2. How
many years
have you
performed myomectomy
and how
many myomectomies
have you
performed?
3.
What
was
the
outcome
of
these
myomectomies:
How
often
was
the
operation
converted
into
hysterectomy?
4.
In what percentage of cases
were blood transfusions required?
5.
How long do your patients
stay in the hospital
after surgery?
These
questions are
important because
they help pinpoint
the experience
and "track
record" of
a doctor. An
experienced,
confident surgeon
will not find
these questions
threatening
and should be
readily forthcoming
with these facts
and figures.
On the other
hand, if a physician's
surgical skill
is limited primarily
to hysterectomy,
these questions
will reveal
inexperience
or poor results
with myomectomy.
For further
reassurance,
consider speaking
with other women
who have undergone
myomectomy by
the surgeon
under consideration.
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Conclusions
As
women become
increasingly
aware of the
important issues
related to fibroids
and hysterectomy,
there is growing
interest in
alternative
treatments.
Many of these
issues are controversial
among both professionals
and lay persons.
The ethical
physician should
inform the patient
of the issues
and options
and, above all,
respect her
convictions
and her right
to make the
ultimate decisions
regarding her
body. I hope
that this presentation
is helpful to
the many women
and their families
who are facing
this common
problem.
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COPYRIGHT 2009 ALL RIGHTS RESERVED
MICHAEL E. TOAFF,
MD, MSc
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