Removing Uterine Fibroids Laparoscopically

Before the advent of laparoscopy, uterine fibroids were often removed by surgical hysterectomy. The author describes a number of alternative treatments, including GnRH agonists and laparoscopic coagulation with the Nd:YAG laser and bipolar needles.

 

Over 80% of women between 30 and 50 years of age have uterine fibroids. Depending on their size and location, fibroids can be completely asymptomatic or can cause pelvic pain, dyspareunia, pressure, urinary problems, and recurrent menorrhagia. In general, the larger the fibroid, the more severe the symptoms. Abnormal bleeding is usually caused by fibroids adjacent to the uterine cavity. Patients who have smaller serosal fibroids may be completely asymptomatic or report only one symptom. Less than 1% of fibroids are malignant, and, unless they affect the patient's quality of life, there's no need for treatment.

Current Approaches

Medical therapy may be the best way to treat fibroids causing symptoms in premenopausal women. Synthetic gonadotropin-releasing hormone (GnRH) agonists inhibit estrogen production, causing, the uterine cavity to shrink by 36% within a few months. Fibroids may be reduced by 38% to 90% of their original size. Although these results are impressive, long-term estrogen suppression can cause bone loss. Also, GnRH agonists cannot be taken orally; a long-acting version of the drug requires injection. The drug is expensive and there's no guarantee of continued protection after treatment is stopped. Indeed, fibroids usually return to their original size within 4 months.

Surgical therapy usually involves myomectomy or total abdominal or vaginal hysterectomy (Fig. 2). Some investigators, such as Camran Nezhat, MD, Mercer University, Atlanta, and Harry Reich, MD, The Graduate Hospital, Philadelphia, recommend laparoscopic myomectomy, which requires advanced pelviscopic skill. Selecting the appropriate treatment is controversial. Abdominal or vaginal myomectomy is recommended for women under 40 years of age who wish to have children, and total vaginal or abdominal hysterectomy is suggested for women who have completed their families.

Fibroid uterus is the most frequent diagnosis leading to hysterectomy; this accounts for 37% to 62% of all US hysterectomies performed annually. Out of the estimated half-million hysterectomies performed annually in the US, the overall mortality rate is 12 per 10,000. Major complications, often include wound infection; postoperative bleeding; transfusion; ureteral, bladder, and bowel injuries.

There are several new operative techniques that don't require major surgery. Laparoscopic myoma coagulation - myolysis is an alternative to myomectomy. This procedure can be combined with endometrial ablation for patients who have persistent uterine bleeding. Laparoscopic myomectomy is another alternative to hysterectomy.

Laparoscopic Coagulation

Laparoscopic coagulation uses the Nd:YAG laser or bipolar needles (Reznik Instrument Co., Skokie, Ill., and J.E.M. Davis, Hicksville, N.Y.) to degrade myometrial stroma, denature protein, destroy vascularity, and substantially shrink fibroids. We use 50 to 70 W of continuous, pure cutting power with the Nd:YAG laser to repeatedly pierce and coagulate the fibroid, desiccating a cone of vasculature approximately 3 to 5 mm in diameter around each puncture point. Repeated puncturing effectively destroys the fibroids. We've tried using monopolar electrodes, but consider bipolar current safer. Unipolar energy may increase the size of the holes, but it doesn't increase the efficiency of the energy delivered to the fibroids.

Future research may show that this technique may be used in women who want to maintain fertility, but current experience is based only on women who have completed their families. Anecdotal evidence suggests that myometrial necrosis is counterproductive to childbearing.

In the hundreds of procedures I've performed, and in those performed in Europe, there have been no side effects. Compared with hysterectomy, which requires 5 to 6 weeks recovery, patients are discharged the same day and can return to work within 4 or 5 days. Because the uterus is left intact, hormonal and sexual function is preserved. After following these patients for up to 8 years, we have seen no regrowth of fibroid tumors. This treatment is successful for both serosal and subserosal fibroids and is recommended for women who have symptomatic fibroids that measure 10 cm or less.

Imaging Techniques for Diagnosis

Hysteroscopy, endovaginal ultrasonography, computerized axial tomography, and magnetic resonance imaging will allow you to visualize the interior of the uterine cavity accurately. By evaluating the uterine cavity, you can determine the size, shape, and position of any fibroids. If a myoma is asymptomatic and measures less than 5 cm in diameter, I recommend watchful waiting. However, when a fibroid measures 5 cm or more and continues to grow, I usually recommend a course of action.

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