Fibroid Uterus - MITR

Fibroid Uterus

Fibroids are also known as leiomyoma.They are benign tumor of the uterus. This tumor
arises from the uterine tissue.It is seen in 40-50% of women in their reproductive age group.
Symptoms due to fibroid depend on the location, size and number of the fibroid .Most
fibroids are asymptomatic and need waitful management.
Type of fibroid-Depending on the location they are classified as Subserous ,Intramural and
Submucous fibroid.They can present as a solitary fibroid or can be seen in more numbers and
can present in combination of subserous,intramural and or submucous.
Cause-the exact cause for fibroid is still unknown .
Common complaints seen in Fibroid uterus are – Increased Menstrual flow ,clot,painful
cycles,shortened menstrual cycles.Large fibroid have pressure symptoms and may be the
cause for increased urinary frequency or difficulty in passing urine also sometimes may
complaint of bloating.
Treatment
Waitful management is advised in asymptomatic fibroid.
Medications cannot cure fibroid but they are used in a select few cases .
Surgery – 1.Minimally Invasive Myomectomy
2.Hysteroscopic Myomectomy
3.Minimally Invasive Hysterectomy

Myomectomy– Surgical removal of fibroid while conserving the uterus is done in
myomectomy.Techniques for myomectomy are Laparoscopic myomectomy and Robot
assisted laparoscopic myomectomy.

Laparoscopic Myomectomy.
In this technique General anaesthesia is preferred.Pneumoperitoneum is created in the
abdominal cavity using medical grade gas. Small cut of half centimeter are made on the
abdomen ,3-4 in numbers and one 1cm port is used around umbilicus for introducing
telescope for vision into the pelvis.In this video laparoscopy procedure the surgeon visualises
the operation on a monitor connected to the laparoscope.Energy based device is used for
separation of fibroid which is then put in a endobag in the pelvic cavity and cut into smaller
pieces.The endobag with smaller fibroid pieces is then removed from the pelvis and sent for
examination.The procedure takes from 60 min to 180 minutes depending on the fibroid
numbers and size.

Robot assisted Laparoscopic Myomectomy
In this technique General anaesthesia is used.And similar to Laparoscopy technique 3-4 ports
of less than 1cm are introduced into the abdomen.1visual bed side Robotic units and 3
bedside Robotic units are placed.Surgeon sits on a Robotic console and controls the bedside
units arms for performing the surgery with amplified vision and more precision.

Post-Operative care in Minimally invasive surgery

6hrs after the surgery patient is started on liquid diet and mobilized. Next day catheter
draining the urine is removed and once the bowel activity is resumed soft diet is
started.Discharge is advised on day 2 evening or day 3 morning of surgery.They are advised
to walk and do all their necessary activity depending on the pain tolerance.Antibiotics are
stopped on day 5 of surgery and they are to revisit the consultant .

Hysteroscopic submucous Myomectomy
This procedure can be performed in spinal anesthesia/general anaesthesia.It is performed
through vagina /birth passage without cutting the passage.A Hysteroscope resection assembly
is used to enter the uterine cavity through the vaginal passage .Submucous fibroid is
visualised in the uterine cavity and resected using energy based device. It is a day care
surgery .Post surgery some amount of menstrual spotting/bleeding may continue for a month.

Minimally Invasive Hysterectomy
Laparoscopic Hysterectomy
This technique is performed under General anaesthesia.Medical grade gas is used for
creating pneumoperitoneum into the abdominal cavity.Small cut of half centimeter are made
on the abdomen ,3-4 in numbers and one 1cm port is used around umbilicus for introducing
telescope for vision into the pelvis.In this video laparoscopy procedure the surgeon visualises
the operation on a monitor connected to the laparoscope.Energy based device is used for separation of uterus from its attachments in the pelvis and the organ is delivered through
normal vaginal passage.The procedure takes from 60 min to 180 minutes.

Robot assisted Laparoscopic Hysterectomy
In this technique General anaesthesia is used.And similar to Laparoscopy technique 3-4
ports of less than 1cm are introduced into the abdomen.1visual bed side Robotic units and 3
bedside Robotic units are used during the surgery.Surgeon sits on a Robotic console and
controls the bedside units arms for performing the surgery with amplified vision and more
precision.Uterus is separated from its attachments in the pelvic cavity and delivered
vaginally.

Fibroid (Uterine Myoma)

Fibroid is excessive growth of uterine musculature which forms a localized swelling in the uterus.

Depending on the location, size and site the fibroids are classified as:

1. Subserous fibroid: The location of the fibroid is on the surface of the uterus.
2. Submucous fibroid: The fibroid is situated within the uterine cavity.
3. Intramyometrial fibroid: The fibroid is within the body of the uterus.

Rarely, fibroids of the above mentioned variant may coexist.

Epidemiology: Fibroid is seen in 50% of the reproductive age group of women. It is one of the common causes for infertility in women. The incidence is on the rise due to early menarche, late marriage, poor breast feeding. There is association of genetic inheritance in fibroids.

Symptoms

Abdominal pain and lump in tummy
Menstrual irregularities: heavy painful bleeding, prolonged cycles, clots.
Nausea, vomiting, bowel obstruction symptoms
Urinary complaints: Large fibroids cause pressure symptoms giving rise to frequent urination, retention of urine, descent of reproductive organ.
Dyspareunia (painful intercourse)
Infertility
A large population of women with fibroids is asymptomatic and need no treatment.

Occasionally as the size of fibroid enlarges, it may give rise to severe abdominal pain and surgical diagnostic dilemma.

Investigations

Abdominal sonography is a very reliable tool for the diagnosis of fibroids.
CT scan and MRI are performed in cases where there is diagnostic dilemma.

Treatment

Medical managementfor fibroids is a non-definitive treatment modality and should be exercised only in selective cases.

Surgical management:

The right approach depends on the size, site, and location of fibroid.
When reproductive function is to be preserved, Laparoscopic Myomectomy is performed in subserous and partially intramyometrial fibroid.
Hysteroscopic Myomectomy is performed in submucous fibroid.
In cases of infertility, Diagnostic Hysteroscopy and Laparoscopy both have to be performed and accordingly the fibroid is removed.
Laparoscopic Hysterectomy is performed for multiple fibroids and in whom reproductive function is not desired.

FAQ's

  • What are fibroids?
    Uterine fibroids are non cancerous muscle growths in the uterus. They occur in about 50perrcent of womenin reproductive age group age. Many women who have fibroids are unaware of them because the growths can remain small and not cause a problem. Fibroids however can cause problems due to their size, number and location.them. The procedure is performed through a laparoscope and uses either a laser or electrical or cryo needle that is passed
  • What causes of Fibroids?
    Little is known about what causes them. Few theories put the responsibility on the ,female hormone estrogen.
  • How do I know if my symptoms are due to fibroids?
    Gynecology routine pelvic examination. Other tests that can be used to obtain more information about the fibroid include the following, Sonography.It can identify the site, size, and number of fibroids. Computed Tomography (CT) Scan and Magnetic Resonance Imaging (MRI)are special imaging techniques that may also be used to help visualize the fibroids but are rarely needed.
  • Can fibroids cause infertility?
    Fibroids are not usually a cause of infertility. In order to cause infertility, fibroids must grow very close to and must actually obstruct the uterine openings of the Fallopian tubes, thereby blocking the passage of the egg as it enters the uterus. Both tubes must be blocked, since only one open tube is needed for pregnancy to occur.
  • What is uterine artery embolization procedure for the treatment of fibroids?
    Uterine artery embolization is a fairly new procedure developed to shrink fibroids without surgical removal of them. The procedure, performed by an interventional radiologist, involves injecting the embolizing agent to both uterine arteries (blocking the main blood supply to the uterus), because of which fibroids will die and eventually be absorbed by the body.
  • What is myoma coagulation (myolysis)?
    Myoma coagulation, or sometimes called myolysis, is a laparoscopic procedure developed to shrink fibroids without removing directly into the fibroid to destroy both the fibroid tissue and the blood vessels feeding it.
  • What are its types?
    Uterine fibroids are depending on the size, shape and location may occur inside the uterus, on its outer surface or within the walls. Fibroids can range in size from pea-sized growths to large melon sized growths. As fibroids grow they can disturb the inside as well as the outside of the uterus and can completely fill the pelvis and abdomen. Fibroids can occur singly or in multiples of varying sizes. Growth of the fibroid is unpredictable. They may remain very small for a long time, suddenly grow rapidly, or grow slowly over a number of years.
  • How do I know whether I have fibroids?
    There may not be any symptoms at all. Heavy flow, long and frequent periods, bleeding in between periods and pain –lower abdomen
  • Complications of Fibroids ?
    Bleeding related to it can get the heamoglobin of the pt .down and at times may need blood transfusion.
  • Can fibroids be treated with medication?
    Medication can temporarily reduce the size of the majority of fibroids and decrease the amount of menstrual bleeding, allowing a window time for some women to prepare physically and emotionally for surgery Fibroids may be removed with myomectomy or hysterectomy and the choice usually depends on patient wishes and desire to preserve fertility.
  • Which surgery best suits my fibroid?
    The size, number & location of the fibroids and the first and foremost .Technical skills of the operating surgeon are equally important deciding which surgery is best suited.