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Fibroids Eliminated without Hysterectomy

Fibroids are benign uterine muscle tumors present in up to 20% of reproductive age women. They are a common cause of heavy, painful periods. They can also dramatically increase the risk for miscarriage and diminish fertility. Sometimes a fibroid will grow larger than a grapefruit. When they grow large they can cause symptoms from pushing on other organs in the pelvis – such as the bowel and bladder. Not all fibroids cause problems or need any treatment. The symptoms depend in large part on the size and location of a fibroid. Fibroids tend to run in families, suggesting a genetic disposition. No one fully understands why some women grow them while others do not. These tumors start to fade away after menopause because they are dependent on the female hormones estrogen and progesterone which drop after the “change of life.”

Treatment for fibroids is only necessary for those women who are bothered by fibroid-related symptoms or for those with fibroids greater than 3-5 cm in size who want to conceive a baby. Fibroids near the inner lining of the uterus can be the cause for heavier than normal menstrual periods and can make a woman bleed in between her regular menses. Those same fibroids are also the worst offenders when it comes to causing a woman to miscarry a pregnancy (esp. when after 10 weeks gestation.) Fibroids larger than 5 cm (regardless of their location) have been definitively linked to impaired fertility and higher miscarriage rates. As fibroids get even larger than 5 cm they commonly cause pain, discomfort, or fullness in the pelvic region. The fibroids can press on other nearby organs such as the bowel or bladder which can cause constipation or the need to urinate frequently. The pain can sometimes be intermittent, yet intense, when a part of the fibroid may “infarct,” which is to say a portion of it can outgrow its supply of blood. At those times the “dying” tissue sends out pain signals.

Surgical Approaches
In the medical field fibroids are called myomas, so the surgery to remove these from the uterus is termed a myomectomy. A hysterectomy is the term for removing the uterus. Thus a hysterectomy can be a solution for fibroids for those women who no longer want to become pregnant. The women suffering with fibroids who want to maintain their ability to bare children can choose a myomectomy. There are at least 3 different surgical approaches by which a myomectomy can be performed. The type of surgical approach depends on the location, size, and number of fibroids present. There are also a couple of non-surgical measures to try to alleviate the suffering from fibroids, though pregnancy is not recommended with the non-surgical methods.

The least invasive surgical approach is through the vagina utilizing a thin lighted scope (hysteroscope) that can slip in through the natural opening in the cervical canal. However, this approach can only access fibroids that are close to 50% or more exposed in the central cavity of the uterus, termed the endometrial cavity. A relatively small proportion of women have their bothersome fibroids limited to only that location, but it is a very satisfying surgery for those candidates as the recovery and return to usual activity from hysteroscopy is generally 3 days.

When fibroids are located in the middle of the muscular uterine wall or even on the outer boundaries of the uterus, an approach through the abdominal skin is necessary. Traditionally this has been done by laparotomy, which means opening the abdomen with a large enough incision for the surgeon to reach in both hands. The recovery includes 2 nights in the hospital and 6 weeks before a return to full physical activity. Fortunately a new revolutionary method is available these days which utilizes a minimally-invasive approach called laparoscopy. The woman typically returns home the same day as the surgery and recovers sufficiently to return to work in 1-2 weeks since the 5 incisions are only as long as the width of their thumbnail. Laparoscopy consists of a lit scope for visualization and narrow instruments which can dissect the fibroids out, repair the uterus with suture, and remove the ground up fibroid material through small keyhole incisions in the abdomen. This is generally performed with the assistance of the da Vinci surgical device (sometimes referred to as “the robot.”) The robot allows the surgeon to manipulate the narrow instruments with much more accurate control than with standard laparoscopy. So the robot allows the surgeon to perform the closure of the uterine incisions with the same strong suturing technique as is used with the open myomectomy, but without the extended post-operative recovery that comes with the larger abdominal incision. Patients usually return home the same day as the surgery. The “robot” holds the camera steady and provides a 3D high definition visualization that is far superior to that of standard laparoscopy. Studies have found that the “Robot-assisted” laparoscopic myomectomies have an even lower risk for poor healing of the surgical incision and loses less blood. This minimally invasive approach is usually an option when there are fewer than 10 fibroids and none exceed 12 cm in size.

Any time that an incision is made fairly deep into a woman’s uterine wall she should have (according to national standards) a C-section delivery when she is 9 mos. pregnant rather than trying to push the baby out in labor. This caution is taken due to concern that her weakened uterus may not hold up to the stress of labor. One potential complication of any abdominal surgery is scar formation involving the pelvic organs, such as the ovaries and fallopian tubes. This scarring could potentially limit fertility unless in vitro fertilization is pursued. To lower the risk for adhesion formation most surgeons place a dissolvable barrier over the uterine scars. Patients who have had a myomectomy should not get pregnant for 3 months after surgery to allow the uterus to heal well.

Non-Surgical Options for Treating Fibroids
Medical therapy (monthly injections for 6 months or so) can induce a temporary menopause to shrink them. The benefit is only transient unless the woman is going to be going through natural menopause soon. This medical therapy is useful to bridge the gap to menopause when the time window is sufficiently narrow. It is also used when the woman’s hemoglobin is so low due to the heavy periods that she is too anemic to be accepted for surgery. Another approach uses an invasive radiology catheterization procedure (Embolization) that blocks the blood supply to the uterus so that the fibroids die off. Occasionally a patient is a candidate for another option that uses high frequency ultrasound to ablate medium and small sized fibroids under MRI guidance (ExAblate). Neither the embolization nor ExAblate therapies are recommended for patients who wish to become pregnant.

The chance for more fibroids to form following removal or ablation of fibroids is approximately 30%, but only about 10% of patients will require another procedure for their recurrent fibroids because of symptoms.

Conclusion
In summary, fibroids in the uterus are relatively common but only sometimes cause sufficient problems, such as uterine bleeding and pain, that they need to be addressed. The entire uterus need not be sacrificed if the woman wants to retain her fertility. Fortunately there is a new minimally invasive surgical procedure that takes advantage of robotic technology to allow removal of the fibroids through keyhole incisions which allows a much shorter and easier recovery than the previous method of surgical removal through a 5 inch incision.



For more information, please call South Jersey Fertility Center at (856) 596-2233 or visit www.sjfert.com.

As seen in:  Burlington County Woman and Camden County Woman (Spring 2012)

 

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