Fibroids and Minimally Invasive Surgical Techniques
¨ What are fibroids?
Fibroids, also called myomas or leiomyomas, are an abnormal growth of the uterine muscle (myometrium). These benign tumors are not a form of cancer, but they are the most common solid pelvic tumor and are expected to affect 20-25% of reproductive age women. Because not all fibroids cause symptoms, this number might be underestimated as many diagnoses will be missed.
The cause for their growth and development is not completely understood. Several factors might play a role, including genetic predisposition and hormonal exposure. Fifty per cent (50%) of women who have fibroids are symptomatic and the severity of those symptoms depends on the number, size and location of the fibroids.
The three most common types of fibroids are exemplified below: (see picture)
- Intramural fibroid: within the myometrium, inside the uterine wall
- Subserosal fibroid: outside the uterus. Subserosal fibroids can be sessile (with a broad base) or pedunculated (there is a stalk connecting the fibroid to the uterus)
- Submucosal fibroid: inside the uterine cavity. It can also be sessile or pedunculated.
¨ What are the most common symptoms?
Fibroids can be the source of a wide variety of symptoms and cause significant clinical repercussion:
- Heavy, painful or more frequent and irregular period pattern: which can cause mild to severe anemia, feeling constantly tired and demotivated, or with headaches, dizziness, palpitations;
- Pelvic pain, pressure, or “fullness” sensation: which can be unrelated to periods;
- Painful intercourse (dyspareunia) and lower back pain;
- Frequent urination: as the fibroid can compress other organs, including the bladder and the urinary system, which in severe cases can also cause swelling of the kidneys (hydropephrosis);
- Constipation: again due to mass effect in the bowels and rectum;
- Infertility: by altering the normal pelvic anatomy and potentially making it a lot more difficult for sperm to meet egg; and
- Miscarriage: several studies demonstrate the link between fibroids, miscarriage and premature delivery. Fibroids can distort the uterine cavity where the baby grows and can also “steal” the blood supply necessary for the growth of the baby.
Talk to your doctor if you think you might be experiencing any of these symptoms and he/she can help you to get the right treatment for you.
¨ How does the doctor investigate and make the diagnosis of a fibroid?
In general, if you are experiencing any of the above symptoms, your doctor will start the investigation with an abdominal and pelvic exam. Depending on the size and location of the fibroids, they can be palpated through a pelvic exam.
Then, your symptoms will guide the physician in regards to the best tests to order. A basic blood work might be needed to check for anemia, coagulation profile and thyroid function.
The next step would be imaging studies. The most available ones are outlined below:
- Abdominal and/or Transvaginal Ultrasound: it is the most common and available first study to be performed. It is a good diagnostic modality for intramural and subserosal fibroids;
- Saline Sonohysterogram (SIS) or Endosee: the goal here is to visualize what is inside the uterus. Just like a ballon from a kids’ party, the uterus has to be inflated so we can visualize what is inside. We never know if there is a hole in the balloon until we start blowing it up! The uterus is distended with fluid and either ultrasound (SIS) or a small camera (Endosee) is used to look inside of the uterus. This technique works better for diagnosis of submucosal fibroids;
- CT scan and MRI: it can also be ordered, especially if you and your doctor are planning a surgical procedure.
¨ How can fibroids be treated?
There is a wide variety of treatment options for fibroids. The right treatment for you will depend on your age and symptoms, the location of the fibroid(s), your desire for future pregnancies, possible contraindications to medical therapy, and patient preference between hormonal therapy and minimally invasive surgical techniques. Talk to your doctor about the benefits and risks of each treatment option and he/she will guide you towards the best choice for you.
¨ What if I cannot take hormones?
¨ What if I don’t want to take hormones?
¨ What if I want to get pregnant?
If you fall under one of these situations, Minimally Invasive Surgery might be the best treatment for you. We are glad to be able to discuss and offer Minimally Invasive Surgical Techniques at El Camino Women’s Medical Group.
Several decades back, the old-fashioned open surgery (laparotomy) was the only available surgical treatment for fibroids. It would involve an extensive procedure and possible scar (bigger than a c-section scar at times), prolonged hospital stay and difficult recovery time, meaning increased pain, and time away from work and family.
This is not true anymore. With the advance of minimally invasive surgical techniques, very complex procedures can be performed in an outpatient setting through small incisions when in hands of a qualified and trained surgeon.
A minimally invasive surgeon is able to solely remove the fibroids, using laparoscopy or robotic surgery, if conservation of the uterus is desired. His/her cutting-edge surgical skills, enable the surgeon to offer different treatments based on patient’s symptoms and preferences. Some of those treatments will be overviewed below:
- Laparoscopic myomectomy: when small fibroids are removed from the abdomen using 1cm incisions or less;
- Laparoscopic-assisted myomectomy: when large fibroids are removed from the abdomen using a mini-laparotomy incision (3-4cm) and avoiding morcellation (chopping) of the tissue and spreading inside the patient’s abdomen;
- Robotic-assisted myomectomy: when the surgical robot is controlled by the surgeon to assist the fibroid removal;
- Hysteroscopic myomectomy: when the fibroid is removed though the vagina and there are no scars in the abdomen after the procedure is completed;
- Laparoscopic hysterectomy: when the uterus is removed using laparoscopic techniques; and
- Robotic-assisted hysterectomy: when the surgical robot is controlled by the surgeon to assist the removal of the uterus.
Talk to your provider about minimally invasive surgical options if you think it might be an option for you.
El Camino Women’s Medical Group offers the latest Minimally Invasive Solutions for gynecologic problems. Drs. Amy Teng and Erika Balassiano, both members of AAGL (American Association of Gynecologic Laparoscopy) are highly trained and experienced in the field of Minimally Invasive Gynegologic Surgery. Dr. Erika Balassiano is also a graduate of the Minimally Invasive Gynecologic Surgery Fellowship at Stanford University, under the supervision of world-renowned Dr. Camran Nezhat.
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