Minimally Invasive Techniques To Treat Fibroid Tumors
Women who undergo minimally invasive fibroid treatment procedures generally experience shorter hospital stays, less pain, faster recovery times and less scarring with a quicker return to normal activities than women who have traditional surgery. Such treatment is performed with the intention of enabling a woman to preserve her uterus and possibly, in some cases, to give her the opportunity to bear children in the future. Sometimes, however, fibroid removal may leave a woman’s ability to conceive and bear children impaired.
With minimally invasive surgery fibroid sufferers have reported the following advantages:
• Significantly less pain
• Less blood loss and need for transfusion
• Lower risk of infection
• Shorter hospital stay
• Quicker recovery and return to normal activities
• Small incisions for minimal scarring
• Better outcomes and greater patient satisfaction in many cases
Minimally Invasive: uterine artery embolization/uterine fibroid embolization
This procedure, known as UAE or UFE, is a non-surgical technique that shrinks fibroids without removing them. It is generally performed in the radiology department of a hospital. With this procedure you will not require general anesthesia, but sedating medications (conscious sedation) will be given by vein to help you relax during the procedure, which is generally one to two hours in duration. A local anesthetic will be applied to the skin around your groin to numb the area so that you do not feel discomfort. A small (one-inch or less) incision is made in the groin directly over the artery carrying blood to the leg. In most cases UAE will be done in both the left and the right uterine arteries. While monitoring the process by X-ray, the doctor, an interventional radiologist by training, guides a long thin catheter tube into the blood vessels that supply the uterus. Small plastic or gelatin particles are pushed through the catheter until they form a block to blood flowing to the uterus. After the procedure you will be asked to lie flat for four to six hours to recover.
Fibroids have only a limited supply of blood vessels; therefore, with the blood flow blocked, the fibroid cells soon start to die off. The surrounding normal uterine muscle, which has a better blood supply, is able to survive the procedure. Deprived of blood, nutrition and oxygen, fibroids then shrink for the next three to six months following minimally invasive embolization, during which time symptoms caused by the fibroids often lessen as well.
does not require general anesthetic and is associated with a shorter hospital stay and a more rapid recovery time compared to conventional surgical procedures. After UAE most women are able to go home the next day and, once released from the hospital, need to take only oral pain and anti-inflammatory medications for the next few days. As with all medical procedures, the recovery varies from woman to woman. Most women, though, feel back to normal within a few days and return to regular activity within a week or so. Fibroid size reduction of 40 to 60% commonly occurs within four months; menorrhagia improvement is reported in up to 85% of all cases. Uterine artery embolization provides excellent relief for abnormal bleeding, pelvic pain and bulk-related symptoms. Early reports show that uterine artery embolization subsequently can result in normal reproductive and obstetric functions. Studies suggest that for many women fibroids are not likely to grow back after embolization. In fact over 85% of patients report significant improvement in symptoms, even up to five years after treatment. More extended research is needed though to establish definitive, long-term results.
some interventional radiologists do not recommend uterine artery embolization for very large fibroids because of concern that the procedure is not likely to be completely successful. Women with submucosal fibroids are not good candidates for this minimally invasive procedure since treatment failure is high and there is some risk of developing a serious infection. Also patients who have a large subserosal fibroid on a narrow stalk (pedunculated fibroid) are not good candidates. After embolization blocks the blood supply to the fibroids, the cells of the fibroid start to die off immediately. The dying cells release toxins that irritate the surrounding tissue and cause pain and inflammation. Almost all women experience moderate to severe pain along with nausea or vomiting for the first day or so after uterine artery embolization and are, therefore, usually kept in the hospital for a day or even longer if necessary. Hospitalization assures that the woman can be given narcotic pain medication when needed. Pelvic cramps, especially common for the first 24 hours after the procedure, can be severe and may last more than six hours at a time for as long as two weeks. After the procedure anti-inflammatory medications (NSAIDs) are administered to minimize inflammation in the uterus. Tylenol, too, may be given for the fever that commonly follows this procedure. Some women experience pain or discomfort that persists for more than a week; consequently such individuals might not get back to normal activity for a few weeks or, rarely, even months. The treated fibroid tissue may pass out of the body through the vagina. Research has shown that up to 30% of women who undergo the UAE procedure subsequently need to have it repeated within one or two years and/or have a hysterectomy performed within five years after the procedure. With this technique, too, there may be some risk for early onset of menopause, but more study is needed for a final conclusion about such jeopardy. Women who may want to become pregnant in the future probably should not undergo this procedure because obstetric complications, including abnormalities of the placenta attaching to the uterus, may be increased. The full effects on subsequent fertility are not yet clear.
Minimally Invasive: myolysis
A needle is inserted into the fibroids, usually guided by laparoscopy, and electric current or freezing is used to destroy the fibroids. In myolysis, which is minimally invasive, surgical instruments are inserted through a tiny, laparoscopic incision in the abdomen; then a high frequency electrical current is administered directly to the fibroid. The electrical current causes blood vessels to constrict or close down, cutting off blood flow to the fibroids. The fibroids remain in place and are not surgically removed. Without a blood supply, the fibroids eventually die and shrink just as they would with uterine artery embolization.
Cryomyolysis is a similar minimally invasive procedure, except that it “freezes to death” the fibroids. Instead of an electric current, liquid nitrogen (at -180 degrees C) is applied through a cryoprobe while a doctor monitors the freezing process using ultrasound.
In order to maximize the potential shrinkage that results from this procedure, the patient is generally requested to undergo GnRH therapy for three to six months as a precursor to treatment. Hopefully the medication will cause fibroids shrink somewhere in the 50% range, thus making the procedure easier to perform and maximizing subsequent shrinkage of fibroids with the myolysis/cryomyolysis procedure.
advantage over myomectomy is that here no suturing is required. It is generally easier to do than a myomectomy, and recovery from this minimally invasive procedure is usually rapid with fibroid shrinkage up to 70% by 12 months. The procedure itself takes only about one hour. Afterwards the patient is observed in a recovery room for approximately another three hours and then discharged directly to home. Total recovery from this procedure usually takes about one week.
general anesthetic is required. Fibroids that are too large, too small or too numerous could complicate the procedure. Neither myolysis nor cryomyolysis can be performed on very large fibroids (anything over 10 cm pre-administration of GnRH agonists is considered “very large”), nor can either one be performed if there are more than four fibroids, each with a volume of up to 5 cm. Also, any fibroid less than 3 cm in size is too small to qualify for this procedure. Only those doctors who are thoroughly experienced laparoscopical operators should attempt this procedure because both extensive skill and special equipment are required for success. Pre-treatment with Lupron GnRH agonist is also somewhat controversial because of its possible side effects. Fibrous pelvic adhesions may occur after treatment. Destruction of the fibroid can result in formation of significant scar tissue and a possibly weakened uterine wall. There is conflicting opinion on the issue of fertility after myolysis with some experts cautioning against subsequent conception because of the unknown strength of the uterine wall after myolysis and the possible presence of scar tissue formed around the uterus. Both of these situations could pose serious risk of the uterus tearing during labor.
Minimally Invasive: laparoscopic or robotic myomectomy
Both laparoscopic myomectomy and robotic myomectomy are considered minimally invasive surgery. They both are performed through small (approximately 1/2 inch) incisions as an outpatient procedure with a short recovery time (typically about 14 days). During laparoscopic myomectomy the surgeon uses special instruments to remove the fibroids and then sutures the uterus. The robotic procedure uses similar instruments, but in this case the instruments are remotely controlled by the surgeon who sits at a console a few feet away from the operating table.
usually performed as minimally invasive out-patient surgery under general anesthesia with only a short hospital stay and quick recovery. The procedure is considered safe and effective when performed by a properly trained physician. The technique continues to evolve as new instruments are developed to allow a more precise removal of the fibroids. It may cause fewer adhesions than abdominal surgery. Following laparoscopic myomectomy, most women are able to leave the hospital the same day as surgery. Because the incisions are small, recuperation is usually associated with minimal discomfort. Since the abdominal cavity is not opened to air, bacteria are less likely to reach the area of surgery; therefore, the risk of infection is very low. The intestines are not exposed to the drying effect of air or to irritation from the sterile gauze sponges used to hold the bowel out of the way during abdominal surgery. As a result the intestines usually begin to work normally again immediately after laparoscopic surgery allowing you to avoid the one- or two-day delay before you are able to eat that would otherwise result from conventional abdominal surgery. Laparoscopic myomectomy is associated with faster postoperative recovery and also could potentially reduce the risk of postoperative adhesions when compared with laparotomy. After laparoscopic myomectomy most women can walk the day of surgery, drive in about one week and return to normal activity, work and exercise within two weeks. Procedure generally results in high patient satisfaction with the symptomatic improvement.
laparoscopic or robotic myomectomy may not be possible if the fibroid is so large that there is insufficient room to fit the necessary instruments into the abdomen. The size, number and position of the fibroid(s) must be carefully considered; the skill and experience of the surgeon may also limit the use of this technique. Spontaneous uterine rupture, although uncommon after laparoscopic myomectomy, is still a concern. The risk of recurrence seems to be higher after laparoscopic myomectomy than after myomectomy performed by laparotomy. Without the proper experience, a physician might find this procedure harder to perform than abdominal surgery because it takes more skill and training. Laparoscopic suturing with small instruments, in particular, requires special training and expertise. If future fertility is desired, the procedure is controversial. Since a myomectomy may result in a buildup of scar tissue, fertility may be impaired even though infertility is sometimes helped with the procedure. Further study is needed to clarify this issue. Future pregnancy, if it does occur, often requires Cesarean delivery.
Minimally Invasive: hysteroscopic myomectomy
A minimally invasive surgical procedure to remove fibroids without removing the healthy tissue of the uterus, myomectomy has traditionally been performed through a large abdominal incision. Advances in technology, however, now allow this less invasive alternative using a vaginal approach. Such a procedure may be more time consuming for the surgeon, but it affords patients an opportunity to remain fertile.
A hysteroscopic myomectomy removes fibroids through the vagina. It is a technique that can be performed when fibroids are located within or bulging into the uterine cavity (submucosal). Anesthesia is needed because the surgery may take one to two hours and would otherwise be very uncomfortable. A small telescopic instrument, the hysteroscope, is passed through the cervix so that the inside of the uterine cavity can be seen. A small camera, attached to the telescope, projects the image onto a video monitor. This technique allows magnification of the picture and also enables the doctor to perform surgery while sitting in a comfortable position. Electricity passes through the thin wire attachment at the end of the hysteroscope so that the instrument can cut easily through the fibroid. As the tissue is shaved out, heat from the instrument sears blood vessels.
often the best procedure for women who wish to have children after treatment or who wish to keep their uterus for other reasons. The blood loss is usually minimal. Submucous or intracavitary myomas are easily visualized and can be resected or removed using a wire loop or similar device. This procedure is performed as outpatient surgery without any incisions and virtually no postoperative discomfort. Women usually go home the same day, and recovery is remarkably fast. The hospital stay can last from 30 minutes to two hours with most patients being able to go back to normal activity, work and exercise within one or two days. When fibroids are the cause of infertility, pregnancy rates following hysreroscopic myomectomy have been about 50%. When performed for heavy bleeding, nearly 90% of women have a return of normal menstrual flow.
general anesthetic is required. Only fibroids that are small and accessible through the cavity can be treated this way; therefore, effectiveness may be mostly limited to treatment of submucosal fibroids.
Minimally Invasive: endometrial ablation
An outpatient treatment for uterine fibroids, especially effective to stop or decrease bleeding from the uterus. The traditional method of performing endometrial ablation uses electrical energy passed into the uterine cavity at the end of a telescope in order to cauterize and destroy the lining of the uterus. An alternative minimally invasive procedure, called Hydrothermal Ablation (HTA), uses hot water circulated inside the uterus to destroy the lining cells. The fibroids remain inside the uterus but shrink in size.
technique is very effective and destroys fibroid tissue without harming surrounding normal uterine tissue. With HTA the ablation device is specially engineered to keep the water at a low pressure so that it cannot escape through the tubes. If the device senses a leak, it automatically shuts off. Because the water circulates freely throughout the entire uterine cavity, the shape of the cavity does not affect the results; consequently this technique is very effective for the fibroid sufferer who has an enlarged uterine cavity. Hydrothermal Ablation takes only about ten minutes and results are almost always excellent. Procedure is performed as outpatient surgery. Patients usually go home the same day once they have recovered from anesthesia and typically return to work within three to five days. It varies woman to woman as to when results are seen; however, symptomatic relief of pelvic pain and pressure is typically seen shortly after the procedure is performed. Heavy bleeding is noticeably improved within three to six months, sometimes as soon as the first subsequent menstrual period. After endometrial ablation the ovaries continue to make normal amounts of hormone for the rest of the body, but without uterine lining cells, bleeding cannot occur. Generally a woman treated with endometrial ablation can look forward to the rest of her life without the fatigue and inconvenience associated with heavy bleeding.
requires special training and skill on the part of the doctor. Many doctors who never learned how to perform endometrial ablation do not offer the procedure to their patients as a minimally invasive alternative to hysterectomy. Endometrial ablation should only be performed for women who do not wish to have more children. Because the lining cells of the uterus are destroyed, there is no safe place for a developing fetus to attach. Even so, it is still strongly recommended to use some form of contraception after the procedure because there does exist, even if only rarely, the possibility of an unplanned, excessively risky pregnancy.
For more comprehensive information about advantages and limitations for other approaches to treatment for uterine fibroid tumors, please visit the Vitamin Insider website and select the topic: “Pros and Cons of Fibroid Treatment Options.”
Note also in Vitamin Insider that a wider variety of subjects about fibroid tumors — everything from causes and risk factors to diagnosis and prognosis — can be found among the topics there.