leiomyomas
LEIOMYOMAS

Leiomyomas or uterine fibroids are benign tumors of the uterus that consist of smooth muscle and extracellular matrix collagen and elastin.

Most common solid pelvic tumors and one of the most frequent clinical conditions encountered in gynecologic practice.

They tend to grow during the reproductive years and usually regress during menopause.

 

Surgical Intervention

Type of surgery will depend on patient’s age, symptoms, and preference, position, size, and number of fibroids and patient’s desire to retain reproduction potential. Asymptomatic leiomyomas do not usually need surgery.

Indications for Surgical Treatment

  • Unresponsiveness to medical treatment
  • Worsening vaginal bleeding or anemia from abnormal uterine bleeding
  • Chronic pain (severe dysmenorrhea, dyspareunia or lower abdominal pressure/pain)
  • Acute pain (prolapsing submucosal leiomyoma or torsion of pedunculated leiomyoma)
  • Infertility with fibroids as the only abnormal finding
    • Treatment of interstitial or intramural fibroids does not improve fertility 
  • Compression symptoms or discomfort from enlarged uterus
  • Urinary symptoms (hydronephrosis after complete evaluation)
  • Rapidly enlarging fibroids in the premenopausal patient or after menopause; enlarging myoma raises the risk of leiomyosarcoma even though it remains very rare
    • Other risk factors for leiomyosarcoma are increasing age, pelvic radiation and Tamoxifen use

Hysterectomy

  • Treatment of choice for patients who have completed childbearing and do not wish to retain their uterus and fertility or when leiomyosarcoma is detected
  • May be considered in women with severe symptoms uncontrolled by other therapies and informed perimenopausal women with symptomatic fibroids
  • The least invasive approach must be chosen for patients who will be undergoing hysterectomy
  • Increases the risk for urinary stress incontinence and pelvic prolapse
  • Hormone therapy is needed to prevent premature menopause

Abdominal Hysterectomy

  • Subtotal hysterectomy (uterus removed and cervix preserved) is a potential alternative to total hysterectomy (both uterus and cervix are removed) because of reduced complications
  • Associated with prolonged hospital stay

Laparoscopic Hysterectomy

  • Preferred over laparotomy for fibroids appearing typical on imaging
  • Benefits include less postoperative pain and faster recovery
  • Use of laparoscopic power morcellation should be limited to reproductive-aged women who cannot undergo en bloc uterine resection
    • Inform patient about the risks and complications of the procedure including spread of cancer from a rare fibroid with an unexpected malignancy

Vaginal Hysterectomy

  • Has less blood loss and shorter surgery time, paralytic ileus time and hospitalization as compared with laparoscopically assisted vaginal hysterectomy or total laparoscopic hysterectomy 
  • Use is limited by the size of the myomatous uterus

Myomectomy

  • Recommended in symptomatic women who wish to preserve fertility or symptomatic women who do not wish preservation of fertility but want to preserve the uterus 
  • Size and location of fibroids determine the most appropriate approach
  • Approximately 10% of women treated with myomectomy would eventually undergo hysterectomy within 5-10 years
  • Leiomyomas in pregnancy are not an indication for myomectomy
    • Exception are women who have had a previous pregnancy with complications related to fibroids

Abdominal Myomectomy

  • Used to remove large or multiple fibroids that have grown deep into the uterine wall
  • Requires the longest hospital stay and recovery time

Laparoscopic Myomectomy

  • May be used to remove isolated fibroids ≤8 cm in diameter that have grown on the outside of the uterus
  • Preferable over abdominal myomectomy in women who wish to preserve their reproductive potential
  • Provides more rapid recovery and less postoperative complications
  • No significant difference is noted in the reproductive outcomes when laparoscopic and abdominal myomectomy are compared 

Hysteroscopic Myomectomy

  • Preferred therapy to remove fibroids that have grown from the uterine wall into the uterine cavity or submucosal fibroids <4 cm in length in women who want to preserve their fertility
  • Least invasive and has the shortest recovery time
Myolysis and Cryomyolysis
  • Considered a uterine-sparing alternative to myomectomy in select patients ≥40 years who do not desire future fertility
  • Myolysis employs a high-frequency electric current while cryomyolysis uses extreme cold to destroy the blood supply to the fibroids
    • Recent development is the ultrasound-guided radiofrequency myolysis for myoma treatment 
  • Cannot be performed if leiomyomas are >10 cm or <3 cm

Endometrial Ablation

  • Surgical procedure to destroy the entire uterine lining with electricity, laser, freezing, microwaves or radiofrequency energy; needs surgical priming
  • Second generation techniques may be used to treat submucosal fibroids
  • May be employed when abnormal uterine bleeding is the main symptom with uterine fibroids <3 cm and fertility is no longer desired

Other Interventional Therapies

Uterine Artery Embolization (UAE)

  • Percutaneous procedure that involves no general anesthesia or surgical incision
  • Option for symptomatic women of reproductive age who are not interested in childbearing but wish to preserve the uterus and/or avoid surgery
  • May be offered to patients as a validated option to hysterectomy and myomectomy
  • Action: Occlusion of uterine arteries disrupts the blood supply to fibroids leading to infarction
  • Effects: Improvement in fibroid-associated symptoms, preservation of the uterus and obviation of the potential complications and lengthy recovery associated with surgery
    • Studies with patient follow-up after 5-7 years have shown that UAE provides durable symptom relief and improves quality of life
Magnetic Resonance-Guided Focused Ultrasound Surgery (MRgFUS)
  • Uses focused high-energy ultrasound waves to destroy fibroid tissue
  • A noninvasive approach with shorter recovery time 
  • Volume reduction is less than the mean levels seen after both myomectomy and UAE
  • May be considered in symptomatic women who do not wish preservation of fertility but want to preserve the uterus

All surgical alternatives to hysterectomy allow the formation of new leiomyomas and rapid growth of preexisting leiomyomas, which may eventually require hysterectomy

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