Uterine Fibroids, Myomectomy

Michael E. Toaff, MD, MSc

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?

What is the Conventional Treatment for Fibroids?

What Are a Woman's Options If She Wishes to Preserve Her Uterus? (Are there safe and effective alternatives to hysterectomy?)

Changing Attitudes Among Women

A Physician's Response

Effective Treatment for Uterine Fibroids

Myomectomy

The Operation

Laparascopic Myomectomy

Bleeding During Myomectomy

What if Cancer is Found?

What is the Role of Hormone Treatment?

What Kind of Imaging Tests May Be Helpful Prior to Surgery?

Other Alternative Treatment Modalities for Fibroids

Uterine Artery Embolization

Myolysis

Endometrial Ablation

Questions to Ask Before Choosing a Surgeon for Myomectomy

Conclusions

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).

What is the Conventional Treatment for Fibroids?

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

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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Bleeding During Myomectomy

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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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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What is the Role of Hormone Treatment

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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What Kind of Imaging Tests May Be Helpful Prior to Surgery?

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.

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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