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Fibroids
Fibroids
 

Fibroids are benign growths of the muscle of the womb; they are very common especially in older women. After the age of 35yrs, 25% of women have fibroids. Many women who have fibroids are fertile and have no problems with keeping the pregnancy. However, if the fibroid significantly distorts the cavity of the womb, it may interfere with embryo implantation. Also fibroids can displace the Fallopian tubes and ovaries. Fibroids can cause excessive menstrual bleeding, pain or no symptoms at all, presenting only as a mass arising from the pelvis on a routine examination.

The risk of cancer in a fibroid is estimated to be less than 1 in 500. Once fibroids are removed those particular fibroids cannot grow back. There can be tiny fibroids that cannot be seen or felt, and therefore cannot be removed. These fibroids that are left behind can grow, and new ones can form. Recurrence is least likely in women with one or a few large fibroids than with multiple small ones.

Decapeptyl depot is a medication given by injection that induces temporary menopause. This causes modest and temporary shrinkage to 50% of their size but the fibroids never go away - on stopping medication the fibroid regrows to its original size. It is not a long term solution (there are no drugs to permanently get rid of fibroids). The medication is used for 1-3 months prior to surgery to reduce the size and blood supply to the fibroids and consequently the blood loss during surgery.

Uterine artery embolization ( UAE) is a new procedure in which tiny particles are injected through blood vessels to block the arteries supplying fibroids. This causes degeneration of the fibroids and decrease their size and symptoms; the average reduction in volume of fibroids being 50%. This procedure is not advised for patients who are interested in future childbearing.

Hysterectomy - the removal of the uterus - is a reasonable option for women who do not want to remain fertile.  Hysterectomy is the only treatment with the guarantee that there will be no further menstrual bleeding and no recurrence of fibroids.

Myomectomy is the surgical removal of the fibroids from the uterine muscle leaving the uterus, tubes and ovaries behind. It is a specialised operation done by reproductive surgeons who have considerable experience in preserving the uterus for future fertility. The purpose of myomectomy is to restore the uterus to normal function.

Fibroids can be removed by Operative Hysteroscopy, Operative Laparoscopy or an Abdominal Myomectomy (open surgery).

Fibroids are classified by their location, the symptoms they cause and how they can be treated.

Submucous myomas  (fibroids that are inside the cavity of the uterus) will usually cause infertility, excessive bleeding and severe cramping. These fibroids can usually be easily removed by a method called hysteroscopic resection, which can be done through the cervix without the need for an incision.

Subserous myomas (fibroids) are on the outside wall of the uterus. A fibroid may even be connected to the uterus by a stalk (pedunculated myoma)These do not usually need treatment unless they grow large, but they can twist and cause pain. This type of fibroid is the easiest to remove by laparoscopy. The fibroid can be cut up into small pieces with a specially designed instrument called a morcellator and brought out of the abdomen through a small incision.

Intramural myomas (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 two surgical alternatives for treating these – laparoscopic and abdominal myomectomy.

The advantage of a laparoscopic myomectomy over an abdominal myomectomy is that several small incisions are made on the abdominal wall rather than one larger incision. Postoperative recovery is also faster.

Some of the issues are :

  1. how safe will the surgery be in terms of blood loss, time of anesthesia, and risk of injury to other organs,
  2. strength of the repair of the uterus if fertility desired, as it is more difficult to perform.

The limits to laparoscopic myomectomy depend on a number of factors - the size, number and position of the fibroids and whether future fertility is desired.

The larger the number of fibroids or deeper the fibroid into the uterine muscle wall ,the more difficult it is to remove and suture to repair the muscle wall of the uterus. It may not be done as satisfactorily through the laparoscope as by an abdominal myomectomy.

Also, when there are multiple fibroids there is the risk of leaving smaller myomas behind as often, it is necessary to feel the uterus with your hands, to find the smaller myomas.

If future fertility is desired, then the strength of the uterine wall repair is important. If there is going to be a large area of the wall that needs to be repaired and it is near the uterine cavity, then the repair is stronger if done through an abdominal incision with standard surgical instruments. If future fertility is not desired, then laparoscopic surgery can be performed.

Other considerations regarding position include how close the fibroids are to the fallopian tubes (if fertility is desired) or to the uterine blood vessels, and whether there is any risk of damage to these areas.

We recommend the type of surgery that will obtain the best results. If positive results can be obtained by removing the fibroids through the laparoscope we do the Myomectomy laparoscopically. If the surgery can be done better through a regular incision, then we recommend that approach -the quality of surgery inside is far more important than recovering 1 or 2 weeks earlier.

 

 

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