terinUe fibroids are benign tumors arising from the uterine muscle (myometrium). They occur in 25-30% of women. However only a small percentage of these women require surgery to treat symptoms arising because of uterine fibroids (also called leiomyomas)
The common symptoms of leiomyomas include:
- Pain: Large tumors stretch the uterine muscle and cause pain and dysmenorrhea (painful menstruation). These tumors, by virtue of their size and compression of adjacent structures such as intestines and urinary bladder, may cause pain.
- Menstrual disturbances: Fibroids usually cause heavy and regular menses. However, a fibroid encroaching upon the cavity of the uterus may cause heavy as well as painful and irregular menstruation.
- Infertility and recurrent pregnancy loss: Large fibroids inside the uterine muscle (intramural fibroids), fibroids entering the cavity of the uterus (submucous fibroids) and fibroids compressing the Fallopian tubes can cause infertility (inability to conceive) and recurrent miscarriage.
- Other symptoms: Extremely large fibroids may press upon the rectum and cause difficulty in passing stools. They may press upon the urinary bladder and may cause increased feeling of passing urine or difficulty in passage of urine. They may compress the ureter (tubes taking urine from the kidneys to the bladder) and cause their dilatation. Part of the fibroid may die out due to reduced blood supply (necrosis and degeneration) and cause fever and intense pain. A fibroid lying on the outer surface of the uterus (subserosal fibroids) may have a thin attachment(pedicle) to the uterus (pedunculated fibroids) and undergo twisting (torsion) of the pedicle. This causes severe pain and requires emergency laparoscopic surgery.
Laparoscopic surgery is the gold standard for management of uterine fibroids. The following surgeries may be performed by laparoscopy:
- Laparoscopic myomectomy: This involves incision of the uterine wall, enucleation of the fibroid, and suturing of the uterine wall with sutures which get absorbed in three months. This is a technically challenging procedure requiring great skill and expertise. The blood loss in surgery may be significantly reduced by instilling a drug called vasopressin in the uterine wall or occluding a few blood vessels which supply the uterus prior to removal of the fibroids. Following surgery, a membrane of oxidized cellulose is placed on the uterus to prevent the intestines from sticking to the uterine incision (adhesions). Broad ligament fibroids (fibroids on the side wall of the uterus) can be challenging procedures since they require careful isolation of structures lying along the side wall of the pelvis (ureters and pelvic blood vessels). The fibroid is removed through the tiny laparoscopic incision by a instrument called as a morcellator which shreds the fibroid into narrow strips.
- Laparoscopic hysterectomy: In women who are elderly and do not desire future pregnancy, laparoscopic removal of the uterus (hysterectomy) is the procedure of choice for symptomatic fibroids. Surgery requires expertise since one has to maneuver instruments in the narrow space of the pelvis.
- Hysteroscopic myomectomy: Hysteroscopic myomectomy involves removal of fibroids with a telescope and an electrode through the uterine cavity. Any fibroid which even partially comes into the uterine cavity can be removed by hysteroscopy. Even fibroids which extend into the muscle (type1) or up to the outer surface (type 2) of the uterus can be removed by hysteroscopy. However these and multiple fibroids may require additional sittings to complete the surgery.
Advantages of laparoscopic and hysteroscopic myomectomy include:
- Lesser tissue handling with reduced chances of adhesions and better healing
- Less pain
- More cosmetic
- Hysteroscopic myomectomy does not damage the uterine wall hence maintains its strength and integrity
- Excellent pregnancy rates and outcomes