Laproscopic Myomectomy (Keyhole, Minimally Invasive procedure to remove fibroids)

Whatare Uterine Fibroids?

Fibroids are Tumors that arise within the muscle of the uterus forming round masses. Some women have single fibroids as large as a football, others have multiple (up to 20 or more) which vary in size from a peanut to golf balls and larger. Fibroids are named according to their position in relation to the uterine muscle and cavity. 1) Intramural fibroids are located within the wall of the uterus and are the most common type; unless large, they may be asymptomatic. It may cause heavy bleeding with clots. With time, intramural fibroids may expand inwards, causing distortion and elongation of the uterine cavity. 2) Subserosal fibroids are located on surface of the uterus and can become very large. They can cause pressure over bladder and rectum producing urgent urination and constipation with back pain. 3) Submucosal fibroids are located in the muscle beneath the endometrium of the uterus and distort the uterine cavity; even small lesion in this location may lead to bleeding and infertility. 4) Cervical fibroids are located in the wall of the cervix (neck of the uterus.

What Problems do Fibroids Cause?

1) No Symptoms : most fibroids up to the size of an orange (12 weeks pregnancy) cause any symptoms. Their mere presence is not a reason to treat them.

2) Submucus : They protrude into the uterine cavity and cause menstrual cramps, heavy periods, infertility and repeated miscarriages. The diagnosis is often missed as the uterus is not enlarged and unnecessary hysterectomies have been performed for these. The diagnosis is made by hysterosonography or hysteroscopy.

3) Intramural : These fibroids are within the muscle of the uterus and can be very large. Because they enlarge the cavity of the uterus they can also cause heavy periods. The most common problem is PRESSURE symptoms on the bladder and rectum.

4) Subserous : These are external to the uterine muscle and are connected by a thin stalk. They are the least likely to be symptomatic and rarely need removal. TORSION (twisting) is a very rare complication.

5) Degeneration : Rarely there is liquifaction and bleeding within the center causing pain and fever. Infection may also occur. The most common occurrence is during pregnancy. Treatment is never surgery but conservative with fluids, pain medication and antibiotics.

Laproscopic(Minimally Invasive) Fibroids Treatment - Uterine Fibroids Surgery at WorldClass Hospitals in India

1) Fibroids shrink at the menopause to 50% of their size but never go away.

2) GnRh agonists e.g. Lupron, Synarel, Busarelin are medications given by injection or nasal spray that create a temporary menopause allowing shrinkage.

3) However on stopping medication the fibroid regrows to its original size.

4) Therefore long term treatment is not indicated as these drugs cause severe menopausal symptoms and osteoporosis.

5) They are used for 1-3 months before surgery to reduce the blood loss of surgery.

Surgical Treatment : 1) The treatment for removing the fibroids from the uterine muscle is known as MYOMECTOMY. 2) It is a specialized operation where the uterus is preserved for future fertility and only fibroids are removed. 3) This operation is traditionally done through a LAPAROTOMY via a 'bikini' or 'up and down' incision. 4) When the fibroids are less than 5 and less than 18 weeks size LAPAROSCOPIC myomectomy can be performed. Laproscopic Myomectomy (Keyhole, Minimally Invasive procedure to remove fibroids) Myomectomy is the most suitable surgery option for women who have fibroids but wish to retain their uterus. Laproscopic Myomectomy : The advantage of this is that patients can go home the same or next day and be back to work in 1-2 weeks. We use laser, harmonic scalpel, knife or electro surgery to remove the fibroids. The skill of the surgeon is paramount to results. Minilap Myomectomy : This is another technique pioneered at our center where large multiple (up to 24 weeks) can be removed through a 2-inch bikini incision. Patients can go home the next day after surgery. Hysteroscopic Myomectomy : Submucus fibroids are removed by inserting a hysteroscope (small camera passed through the Vagina) and an electrical loop is used to remove the protruding part. This is rapid and effective surgery without the need of laparoscopy. Estrogen is used after surgery to promote uterine lining re growth. Total Laparoscopic Hysterectomy : When the family is complete and patient has a symptomatic fibroid, the whole Uterus is removed via only four small holes in the tummy using laparoscopic technique.

Laproscopic Myomectomy has many Advantages over the abdominal (open) approach :- ·  Minimal Pain ·  Minimal Blood Loss ·  Early Post Operative Recovery ·  No Scar ·  Faster Recovery ·  A shorter hospital stay ·  Decreased Adhesion formation ·  Better chances of post surgery pregnancy

Non-Surgical Treatment for Uterine Fibroids

Fibroids are growths enclosed in capsules in the wall of your womb. They don't spread to other parts of your body, except in very rare circumstances.

 Fibroids are very common – around one in two women will be affected at some point in their lives. However, most don't ever get any symptoms. You may have only one fibroid or you may have many fibroids of different sizes. Fibroids can range from being very small to around the size of a basketball.

Uterine fibroids or myomas are the most common tumours to affect women, and are present in up to 40% of women in the reproductive age group. Not all of these women are symptomatic, and they usually do not require any treatment for these fibroids. Occasionally, the fibroids can cause pain, heavy menstrual as well as inter-menstrual bleeding, and pressure effects such as frequency of urination due to the size of the fibroid. In a small number of cases, fibroids can be a cause of infertility.

Fibroids are traditionally known to grow very slowly throughout the reproductive life of a woman, and they exhibit a growth spurt during pregnancy. After menopause, a fibroid typically begins regressing in size, and at this stage, fibroids rarely need to be treated.

Attempts at symptomatic relief through medications have largely been unsuccessful, leaving the patient suffering from fibroids no option other than surgery.

The mainstay of treatment of symptomatic fibroids has been surgery, which could be either myomectomy (removal of the fibroid), or hysterectomy (removal of the uterus). Of these, only hysterectomy ensures that the patient will never suffer from fibroids again, but is a rather radical option for a benign tumour that only requires symptomatic relief. Also, a hysterectomy is followed by a lengthy recovery period before the patient returns to normal activities. Both hysterectomy as well as myomectomy can also be done laparoscopically (key-hole surgery), dramatically reducing the post- operative morbidity. However, even these are invasive techniques, and the risks and possible complications of surgery and anesthesia remain a constant threat.

The search for non-invasive techniques to provide the patient with relief from this otherwise non- threatening illness led to other minimally invasive options like Uterine Artery Embolisation, and Radio- Frequency Ablation which however had limited efficacy, and considerable adverse effects like excruciating post-treatment pain.

How can Fibroids be treated in a non invasivemanner?

MRI guided HIFU or Magnetic Resonance Imaging- guided High Intensity Focused Ultrasound is an innovative mode for genuinely non-invasive treatment of fibroids. Under MRI guidance, sound waves are passed into the body and focused into the fibroid to heat and coagulate the tissues.

As fibroids are almost always benign, with a neglible percentage (0.07% of operated patients - Parker W, Berek J, Fu YS., Obstetrics and Gynecology 1994; 83:414-8) showing the presence of a sarcoma (malignancy),fibroids only require treatment for the alleviation of symptoms due to the fibroid.

 

How MRI does guided HIFU work?

The MRI acquires high resolution 3-D images of the fibroid and surrounding structures. These images are used for accurate planning and mapping of the treatment. During treatment, the HIFU transducer focuses the ultrasound beam into the fibroid as per the planned areas (cells) and heats the tissue up to 65 degree Celsius, coagulating it. This is called sonication.

Sonalleve MRI guided HIFU ensures patient safety by having a number of safety mechanisms built into the system. All of these ensure that apart from the tissue being targeted, no other organ or tissue is affected by the treatment.

During treatment, the MRI plays an important role by monitoring temperatures within the treatment areas as well as in the surrounding tissues. The recorded temperatures are then superimposed in the form of colour coded maps on the 3-D images that are being used for the treatment monitoring.

The real-time feedback loop ensures that adequate heating takes place, treating every bit of tissue that has been targeted and volumetric ablation (a Philips proprietary technology) helps treat larger volumes efficiently and quickly.

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Major Effects of Fibroids on Women's Fertility – Fibroids Treatment in India

Fibroids are common benign tumors of uterine origin that may develop as variably sized solitary tumors or as aggregated clusters. They occur predominantly in premenopausal women, and their growth appears to be hormone (estradiol, progesterone) dependent. They may grow towards the uterine cavity (submucous) or towards the abdominal cavity (subserosal), or they may be located within the uterine wall (intramural). Fibroids may be asymptomatic or could be associated with a variety of complaints. Symptoms, such as menometrorrhagia, pressure, urinary frequency, constipation, and pain, are associated with size, number, and location of the fibroids.

Fibroids are very common – around one in two women will be affected at some point in their lives. However, most don't ever get any symptoms. You may have only one fibroid or you may have many fibroids of different sizes. Fibroids can range from being very small to around the size of a basketball.

Fibroids are named according to where they are found in your womb.

·         Intramural fibroids grow within the muscular wall of your womb.

·         Subserous fibroids grow from the outside wall of your womb into your pelvic cavity. They can become very large.

·         Submucosal fibroids grow from the inner wall of your womb into the space inside your womb.

·         Pedunculated fibroids grow from the outside of your womb. These fibroids are almost free of the wall of your womb and are only attached by a narrow stalk.

It has long been suspected that fibroids that distort the uterine cavity are associated with infertility and miscarriages. The association between fibroids and reproductive failure (infertility, pregnancy loss) has been studied by several groups. The majority of these studies are affected by the same problems: small sample size, no or inappropriate controls, and a retrospective design. The use of a meta-analysis may remedy the shortcomings of individual studies. In addition, few studies have addressed the benefits of treatment in a well-designed manner. To further complicate the issue, several treatment options -- medical, surgical, radiologic -- are available, but their effects would need to be assessed separately.

This analysis is based on the results of 23 studies and is an update of a previous review  Fibroids in general, regardless of location, were associated with a 15% reduction in pregnancy rates, a 30% reduction in live birth rates, and a 67% increase in miscarriage rates when compared with controls without fibroids. The effect was especially pronounced when submucous fibroids were analyzed (64% reduction in pregnancy rates, 69% reduction in live birth rates, and 67% increase in miscarriage rate). The effect of intramural fibroids was significant but less pronounced (22% decrease in live birth rates, 89% increase in miscarriage rates). Subserous fibroids did not affect pregnancy rates or pregnancy outcome. The analysis did not demonstrate a consistent effect on pregnancy rates and outcomes.

Myomectomy was associated with improved pregnancy outcome when submucosal myomas were evaluated. The pregnancy rate was significantly higher after myomectomy when compared with women with fibroids left in place. On the basis of a small number of cases, the removal of intramural fibroids was not associated with improved pregnancy outcome.

Although fibroids are one of the most common benign tumors that affect reproductive-age women, studies are few and have been poorly designed to assess their effect on reproduction. A cause-and-effect relationship seems obvious between submucosal fibroids and reproductive failure. This association is supported by this current review as well. In these cases, myomectomy does improve outcome. The association between intramural fibroids and lower pregnancy rates seems to be supported as well, but the effect of treatment is not obvious. In these cases, treatment needs to be individualized on the basis of the outcome of previous pregnancies, the number of previous surgeries, comorbidities, and the number and size of fibroids when treatment is offered. In the future, studies will have to evaluate the benefits of treatment of intramural myomas.

Fibroid Embolization 

It is a minimally invasive procedure, which means it requires only a tiny nick in the skin. It is performed while the patient is conscious but sedated - drowsy and feeling no pain. Fibroid embolization is performed by an interventional radiologist, a physician who is specially trained to perform this and other minimally invasive procedures. The interventional radiologist makes a small nick in the skin (less then ¼ of an inch) in the groin and inserts a catheter into an artery. The catheter is guided through the artery to the uterus while the interventional radiologist guide the progress of the procedure using a moving X-ray (fluoroscopy). The interventional radiologist injects tiny plastic particles the size of grains of sand into the artery that is supplying blood to the fibroid tumor.

 This cuts off the blood flow and causes the tumor (or tumors) to shrink. The artery on the other side of the uterus is then treated. Embolization preparation: A tiny angiographic catheter is inserted through a nick in the skin in to an artery and advanced into uterus. 

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Complete solution for Uterine Fibroids – Diagnosis and Treatment

Fibroids are growths enclosed in capsules in the wall of your womb. They don't spread to other parts of your body, except in very rare circumstances.

 Fibroids are very common – around one in two women will be affected at some point in their lives. However, most don't ever get any symptoms. You may have only one fibroid or you may have many fibroids of different sizes. Fibroids can range from being very small to around the size of a basketball.

Fibroids are named according to where they are found in your womb.

·         Intramural fibroids grow within the muscular wall of your womb.

·         Subserous fibroids grow from the outside wall of your womb into your pelvic cavity. They can become very large.

·         Submucosal fibroids grow from the inner wall of your womb into the space inside your womb.

·         Pedunculated fibroids grow from the outside of your womb. These fibroids are almost free of the wall of your womb and are only attached by a narrow stalk.

Fibroid growth is very slow and can be stimulated by hormones – especially oestrogen. Fibroids tend to become smaller and reduce in number when your oestrogen levels fall, such as after the menopause.

Symptoms of fibroids :-

Fibroids don't usually cause symptoms. However, you may get one or more of the symptoms listed below, often depending on where the fibroid is within your womb. You may:

·         have heavy periods, sometimes leading to anaemia

·         feel pain in your tummy (abdomen)

·         have swelling in your pelvic area

·         pass urine more often than normal, or feel an urgent need to pass urine – this happens if a fibroid is pressing on your bladder

    have constipation – this happens if a fibroid is pressing on your bowel

Diagnosis of fibroids :-

Most women with fibroids have no symptoms, so they often go undetected. Sometimes they are found during a routine gynaecological (vaginal) examination. If you have symptoms, such as pain or heavy periods, your doctor may do the following tests.

·         An internal examination to check the size of your womb. This is because having an enlarged womb indicates that you may have fibroids.

·         An ultrasound scan. This uses sound waves to produce an image of part of your womb and can confirm if you have fibroids.

·         An MRI scan. This uses magnets and radiowaves to produce images of the inside of your womb.

·         Hysteroscopy. This is a test that involves your doctor putting a small camera into your vagina to look inside your womb.

·         Blood tests to check for anaemia.

Minimally Invasive Surgery for Fibroids at World Best Hospitals in India - No Cuts , No Pain 

Fibroid Embolization

It is a minimally invasive procedure, which means it requires only a tiny nick in the skin. It is performed while the patient is conscious but sedated - drowsy and feeling no pain. Fibroid embolization is performed by an interventional radiologist, a physician who is specially trained to perform this and other minimally invasive procedures. The interventional radiologist makes a small nick in the skin (less then ¼ of an inch) in the groin and inserts a catheter into an artery. The catheter is guided through the artery to the uterus while the interventional radiologist guide the progress of the procedure using a moving X-ray (fluoroscopy). The interventional radiologist injects tiny plastic particles the size of grains of sand into the artery that is supplying blood to the fibroid tumor.

Advantages of Nonsurgical Fibroid Embolization

On average, 85-90 percent of women who have had the procedure experience significant or total relief of heavy bleeding, pain and/or bulk-related symptoms. Requires only a tiny nick in the skin (No surgical incision of abdomen). Recovery is shorter than from hysterectomy or open myomectomy.

All fibroids are treated at once, which is not the case with myomectomy. There has been no observed recurrent growth of treated fibroids in the past 9 years.

 - Uterine fibroid embolization involves virtually no blood loss or risk of blood transfusion.

 - Many women resume light activities in a few days and the majority of women are able to return to normal activities (including exercise) within a week. If the presenting complaint was excess vaginal bleeding, 87-90% of cases experience resolution within 24hours.

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