Managing Uterine Fibroids: Alternatives to Hysterectomy

William H. Parker, MD

Disclosures

July 20, 2012

In This Article

Surgical Treatments for Fibroids

Surgical treatment options currently include hysteroscopic myomectomy, abdominal myomectomy, laparoscopic myomectomy, and endometrial ablation. Many women with fibroids can be treated with these procedures and hysterectomy can be avoided.

Serious medical conditions, such as severe anemia or ureteral obstruction, often need to be addressed surgically. Symptoms that compromise quality of life, such as fibroid-associated heavy menstrual bleeding, pelvic pain or pressure, and urinary frequency or incontinence, also may be indications for surgery. Myomectomy has been reported to relieve symptoms in 80% of women with uterine fibroids.[14]

Hysteroscopic Myomectomy

Submucous fibroids, sometimes associated with increased menstrual bleeding or infertility, often can be removed hysteroscopically. A meta-analysis of the effect of fibroids on fertility found that submucous fibroids causing distortion of the uterine cavity reduced ongoing pregnancy/live birth rates by 70% (relative risk 0.32; 95% confidence interval, 0.12–0.85) and that fibroid resection increased ongoing pregnancy/live birth rates.[15]Hysteroscopic resection of submucous fibroids also can significantly reduce heavy menstrual bleeding in 82% of women with submucous pedunculated fibroids (type 0), 86% with sessile fibroids (type 1), and 68% with intramural fibroids (type 2).[16]A study of 285 consecutive women who had hysteroscopic resection of submucous fibroids for heavy menstrual bleeding found that additional surgery was required in 9.5% at 2 years, 10.8% at 5 years, and 26.7% at 8 years.[17]

Endometrial ablation, with or without hysteroscopic myomectomy, also may be considered in women who do not desire future childbearing. One study found that 94% of women had resolution of abnormal bleeding 1-5 years after endometrial ablation, and another found that only 12% eventually had hysterectomy.[18]

A small study of 22 women with known submucous fibroids up to 4 cm that were treated with hydrothermal ablation found that 91% of the women had amenorrhea, hypomenorrhea, or eumenorrhea after a minimum of 12 months of follow-up.[19]In 65 women with heavy menstrual bleeding and type 1 or 2 submucous myomas up to 3 cm in size, treatment with the NovaSure® endometrial ablation device (Hologic; Bedford, Massachusetts) resulted in normal bleeding or amenorrhea in 95% at 1 year.[20]

Abdominal Myomectomy

Case/control studies suggest that the risk for intraoperative injury with myomectomy may be lower than the risk for complications from abdominal hysterectomy. In women who had myomectomy, 5% experienced complications (bladder injury, reoperation for bowel obstruction, and ileus).[21]In contrast, 13% of women who had hysterectomy experienced complications (bladder injury, ureteral injury, bowel injury, pelvic abscess, and ileus). The risks for hemorrhage, febrile morbidity, unintended surgical procedures, life-threatening events, and rehospitalization did not differ between groups.

Blood loss during myomectomy can be limited by the use of tourniquets or vasoconstrictive agents (eg, vasopressin).[22]The use of vasopressin for this indication is off-label, and rare cases of bradycardia and cardiovascular collapse have been reported, so intravascular injection should be avoided and patients should be monitored carefully. A cell saver can reduce the need for preoperative autologous blood donation or heterologous blood transfusion. This device suctions blood from the operative field, mixes it with heparinized saline, and stores the blood in a canister. If blood loss is greater than 300 mL, the collected blood is washed, filtered, centrifuged, and given back to the patient intravenously.

Myomectomy may be considered even for women with large uterine fibroids. After myomectomy in 91 women with uterine size larger than 16 weeks (range, 16-36 weeks), investigators reported 1 bowel injury, 1 bladder injury, 1 reoperation for bowel obstruction, and no instances of conversion to hysterectomy.[23]

Laparoscopic Myomectomy

Currently available instruments make laparoscopic myomectomy feasible, although the wide application of this approach is limited by the size and number of fibroids that can be reasonably removed and by the technical difficulty of the procedure and of laparoscopic suturing. Although microprocessor-assisted (robotic) myomectomy can help the surgeon avoid these technical challenges, the added cost and longer operating times associated with this approach must be considered.

A systematic review of randomized controlled trials of laparoscopic vs abdominal myomectomy found that laparoscopic myomectomy was associated with longer operating times but reduced operative blood loss, less postoperative pain, fewer complications, and more patients who recuperated fully within 2 weeks.[24]

Laparoscopic myomectomy also may be feasible in women with large fibroids. In a series of 332 consecutive women undergoing laparoscopic myomectomy for symptomatic fibroids as large as 15 cm, only 3 required conversion to laparotomy.[25]

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