Alternative Procedures to Hysterectomy:

In order to operate on the uterus, the surgeon may choose to reach the area through a wide abdominal incision (laparotomy) or use less invasive measures with the use of endoscopy. The decision is usually based on the severity of the case. Women should discuss all options very carefully and be sure that their surgeons have had experience with any procedure they choose.

Laparotomy. Laparotomy is the standard abdominal surgical procedure. It is invasive and usually requires a wide abdominal horizontal incision right above the pubic bone, the so-called bikini incision.

Endoscopy. Endoscopic techniques used for uterine disorders are hysteroscopy and laparoscopy. Endoscopic techniques are used increasingly to replace conventional surgical techniques for many disorders. A common factor in all endoscopic procedures is the use of a fiberoptic scope and tubes, tiny camera lenses, and minuscule surgical instruments. Any incisions made are very small, Band-Aid size.

• Operative Hysteroscopy. In this procedure, the cervix is dilated, which requires either a local or general anesthetic. A device called a hysteroscope is inserted up through the vagina and cervix into the uterine cavity. It contains tiny surgical instruments as well as a mini-camera and light source to view images of the uterus, which are transmitted to a video monitor. This approach is becoming increasingly common. Complication rates include excessive fluid absorption, infection, and uterine perforation.
• Laparoscopy. This procedure uses two or more small incisions, one at the navel, and one or more in the lower abdomen. Carbon dioxide gas is injected into the abdomen, distending it and pushing the bowel away. A laparoscope is inserted through the navel incision and a probe is inserted through a second incision above the pubic hairline. The probe allows the doctor to directly view the abdominal cavity, including the outer walls of the uterus, fallopian tubes, and ovaries. The doctor manipulates surgical instruments that are passed through additional small abdominal incisions, using the image of the uterus on the video monitor as the guide.

Preoperative Hormone Treatment

GnRH agonists, usually depo-Lupron or Synarel, are often used for 2 - 3 months before many uterine surgical procedures.

These drugs may help by:

• Reducing the volume of fibroids by 40 - 60%, in some cases to the extent that a less invasive procedure may be performed
• Reducing the risk of bleeding
• Shortening surgical time
• Reducing postoperative symptoms

Treatments may not be useful, however, for small fibroids, which may shrink to the point that they are no longer visible at the time of surgery. Since fibroids regrow after treatment, the problem would recur.

There has also been some question whether these drugs provide any additional advantages for myomectomies that use conventional surgical techniques. Ultrasound may be useful in helping to detect fibroids most likely to benefit from GnRH agonists before such a procedure.

Myomectomy

A myomectomy surgically removes only the fibroids and leaves the uterus intact, often preserving fertility. Myomectomy may also help regulate abnormal uterine bleeding caused by fibroids. Not all women are candidates for myomectomy. If the fibroids are numerous or large, myomectomy can become complicated, resulting in increased blood loss. If cancer is found, conversion to a full hysterectomy may be necessary.

To perform a myomectomy, the surgeon may use standard surgical approaches (laparotomy) or less invasive ones (hysteroscopy or laparoscopy).

• Laparotomy. Laparotomy uses a wide abdominal incision and conventional surgery. It is used for subserosal or intramural fibroids that are very large (usually more than 4 inches), that are numerous, or when cancer is suspected. Using this approach, the doctor may be able to feel the fibroids, particularly intramural types, which can be missed during laparoscopy or hysteroscopy. (The doctor can view only the uterine cavity or outside surface with these latter procedures.) After the fibroids are removed, careful reconstruction of the uterine wall is critical in both laparotomy and laparoscopy, so that bleeding and infection do not occur. While complete recovery takes less than a week with laparoscopy and hysteroscopy, recovery from a standard abdominal myomectomy takes as many as 6 - 8 weeks. It also poses a higher risk for scarring and blood loss than with the less invasive procedures, a concern for women who want to retain fertility.
• Hysteroscopy. A hysteroscopic myomectomy may be used for submucous fibroids found in the uterine cavity. With this procedure, fibroids are removed using an instrument called a hysteroscopic resectoscope, which is passed up into the uterine cavity through the vagina and cervical canal. Standard endometrial resection uses an electrosurgical wire loop to surgically remove the lining. With endometrial ablation, uterine tissue is usually vaporized using a thin powerful laser beam or high electric voltage. These procedures are useful for women with severe heavy menstrual bleeding, including some with fibroids. They are generally not useful for large fibroids.
• Laparoscopy. Women whose uterus is no larger than it would be at a 6-week pregnancy and who have a small number of subserous fibroids may be eligible for treatment with laparoscopy. Laparoscopy requires incisions, but they are much smaller than with laparotomy. As with hysteroscopy, thin scopes are used that contain surgical and viewing instruments. In centers with extensive experience, laparoscopy has fewer complications, and also shorter recovery time and lower costs than laparotomy. On the other hand, compared to the invasive surgery, laparoscopy has a greater chance for fibroid recurrence (over 16% at 5 years in one study), and a greater danger for a weakened uterine wall, which could threaten pregnancies.

Complications and Postoperative Factors. Any procedure for myomectomy is very complex. To reduce the risk for complication, patients should seek a surgeon experienced in myomectomies. Complications that occur during a myomectomy from any procedure include:

• Excessive blood loss (occurs more often with laparotomy)
• Uterine weakening and rupture during pregnancy (more of a concern with laparoscopy)
• Development of scar tissue called adhesions (more common with laparotomy)
• Infection
• Damage to the bowel or bladder (more common with laparotomy)

Pregnancies after Myomectomy. Studies suggest that pregnancy is possible in more than half of women after the procedure. In appropriate candidates, there appears to be no differences in fertility rates and pregnancy complications between laparotomy and laparoscopy. The best candidates for retaining fertility include women with pedunculated and superficial serosal fibroids (stalk-like fibroids that grow out from the uterine surface). Women with deep intramural fibroids are at higher risk for infertility after myomectomy.

Although studies indicate that 40 - 58% of women become pregnant after myomectomy, only about a quarter of the women carry their babies to term. Women who become pregnant face a higher risk for cesarean section or miscarriage. It is unclear whether laparoscopic myomectomy weakens the uterine walls and poses a higher risk for rupture during pregnancy than laparotomy.

Recurrence of Fibroids and Recurrent Surgeries. The recurrence rate for fibroid growth after myomectomy is high. Between 11 - 26% of patients will have recurring fibroids that are severe enough to need additional treatment.

Uterine Artery Embolization

Uterine artery embolization (UAE), also called uterine fibroid embolization (UFE), is a relatively new way of treating fibroids. UAE deprives fibroids of their blood supply, causing them to shrink. UAE is a minimally invasive radiology treatment and is technically a nonsurgical therapy. It is much less invasive than hysterectomy and myomectomy, and involves a shorter recovery time than the other procedures. The patient remains conscious, although sedated, during the procedure, which takes around 60 - 90 minutes.

The procedure is typically performed in the following manner:

• The patient receives a sedative to cause drowsiness, and a local anesthetic is applied to the skin around the groin.
• An interventional radiologist makes a small quarter-inch incision in the skin and inserts a catheter (a thin tube) into the femoral artery. The femoral artery is a large artery that begins in the lower abdomen and extends down to the thigh. The radiologist then threads the catheter into the uterine artery.
• Small plastic particles are injected into the artery. These particles block the blood supply to the tiny arteries that feed fibroid cells, and the tissue eventually dies.
• Patients usually stay in the hospital overnight after UAE and are given pain medication. Pelvic cramps are common for the first 24 hours after the procedure.
• It takes 1 - 2 weeks for the patient to recover from the procedure and return to work. It may take 2 - 3 months for the fibroids to shrink enough so that symptoms improve.

Effect on Fertility. In general, UAE is considered an option for only those who have completed childbearing. Although UAE may protect fertility in many women, the procedure does pose some risk for ovarian failure and infertility. In 2004, the American College of Obstetricians and Gynecologists issued an opinion statement advising women who wish to have children that it is not yet known how this procedure affects their potential for becoming pregnant. A 2005 British study of 671 women who underwent UAE found that the procedure did not interfere with fertility. The study did find a slight increase in caesarean section delivery.

Complications and Postoperative Effects. UAE has a lower rate of complication than hysterectomy and myomectomy and a shorter hospital stay. Compared to other procedures, women who have UAE miss fewer days of work. Serious complications occur in fewer than 0.5% of cases, and no deaths have been associated with the procedure.

• Pain. Abdominal cramps and pelvic pain after the procedure are nearly universal and may be intense. Pain usually begins soon after the procedure and typically plateaus by 6 hours. On-demand painkillers may be required. The pain usually improves each day over the next several days. A low-grade fever is also common in the first week after the procedure.
• Fibroid slough. Around 2 - 3% of patients pass small fragments of fibroid tissue during the first few days after UAE. This can cause intense labor-like pain and also increase the risk for infection. Some women may need dilation and curettage (D&C) to make sure that infection does not develop.
• Early menopause. Most women who have UAE will continue to have normal menstrual periods. Around 1 - 5% of women, however, go through menopause after the procedure. Menopause is more likely to occur in women over age 45 who have UAE.

Success Rates. Studies on uterine artery embolization show high patient satisfaction (over 90%) and low complication rates. Uterine artery embolization is effective for a large majority of patients. Around 10% of women who have UAE may need a repeat procedure (embolization or hysterectomy) during the first year, and another 10% after the first year. Several studies, including randomized controlled trials, have shown that 20 - 30% of women need hysterectomy within 5 years of having the procedure.

For around 10 - 20% of women, symptom control fails or fibroids reoccur. Some studies suggest that women with large fibroids are not good candidates for UAE.

Myolysis (Laparoscopic Leiomyoma Coagulation)

Myolysis, or laparoscopic leiomyoma coagulation, uses either lasers or electrosurgery to heat, coagulate, and destroy the fibroid tissue. This approach may prove to be beneficial for women with fibroids that measure a diameter of 10 cm (about 4 inches) or less and that respond to hormone treatments with GnRH agonists.

Myolysis uses a needle or a Nd:YAG laser that rapidly punctures a number of holes in the fibroid, heating and destroying the tissue in various locations. This widespread destruction cuts off the blood supply and shrinks the fibroid over ensuing months. The uterus is left intact, but tissue destruction makes childbearing unlikely.

In most cases, patients return home the same day and can return to normal activities within a week. There are few side effects. However, as the fibroids degenerate over time, many women report considerable pain.

Magnetic Resonance Guided Focused Ultrasound (MRgFUS)

MRgFUS is a non-invasive procedure that uses high-intensity ultrasound waves to heat and destroy (ablate) uterine fibroids. This “thermal ablation” procedure is performed with a device that combines magnetic resonance imaging (MRI) with ultrasound. The Food and Drug Administration approved this device, the ExAblate 2000 System, in 2004.

During the 3-hour procedure, the patient lies inside an MRI machine. The patient receives a mild sedative to help relax but remains conscious throughout the procedure. The radiologist uses the MRI to target the fibroid tissue and direct the ultrasound beam. The MRI also helps the radiologist monitor the temperature generated by the ultrasound.

MRgFUS is appropriate only for women who have completed childbearing or who do not intend to become pregnant. The procedure cannot treat all types of fibroids. Fibroids that are located near the bowel and bladder, or outside of the imaging area, cannot be treated.

However, this procedure is new and long-term results are not yet available. Likewise, it requires an extensive period of time involving MRI equipment. Many insurance companies do not pay for this treatment.