Fibroid resection & Myomectomy
What are fibroids?
Fibroids (also known as leiomyomas or myomas) are benign growths of smooth muscle which typically arise from the uterus. 30-40% of women aged 40 or more years will have fibroids. Fibroids rarely develop in prepubertal girls or women after the menopause.
The growth of fibroids is promoted by oestrogen. Known risk factors include:
- African descent.
- Polycystic ovarian syndrome.
- Familial (2.5-fold increase in first degree relatives).
Symptoms of fibroids
Fibroids do not cause symptoms in the majority of women and are often discovered during part of the assessment for another condition. Symptoms include:
- Heavy, long and painful periods.
- Intermenstrual bleeding.
- A mass in the lower abdomen.
- Urinary frequency.
- Feeling of pressure or heaviness in the pelvic area and lower back.
Location of fibroids
- Intramural (in wall of uterus; myometrium).
- Submucous (on the lining of the uterus; endometrium).
- Sub-serosal (on the outer, serosal part of the uterus and can be pedunculated).
- Broad ligament.
- Round ligament.
- Utero-sacral ligament.
- Parasitic (other parts of the body ? related to use of morcellators from previous fibroid surgery).
Complications caused by fibroids
Most of the complications caused by fibroids result from a pressure effect, increase in endometrial surface area or compromise of vascular supply. Complications may include:
- Preterm delivery.
- Hydronephrosis (kidney enlargement).
- Hydroureter (enlarged ureter).
- Urinary retention.
- Red degeneration (in pregnancy).
- Leiomyosarcoma (malignant change).
The investigation and treatment of fibroids will be informed by the clinical findings, the symptoms and the circumstances of the individual patient.
Investigation of fibroids
- Blood tests.
Treatment & management of fibroids
- No action.
- Uterine artery embolisation.
- Hysteroscopic resection.
- Laparoscopic or open resection.
- Laparoscopic or open myomectomy.
This is a calcified submucous fibroid. It was diagnosed at hysteroscopy following an ultrasound performed in a woman reporting intermenstrual bleeding.
Hysteroscopic resection of the submucous fibroid towards the end of the procedure. The tissue removed was sent for histological analysis and no abnormal cells were found.
Laparotomy performed for a large intramural fibroid in a woman giving an 8 month history of very heavy menstrual bleeding who was also found to be anaemic. A myomectomy was performed, leaving the uterus in situ.
Laparotomy performed for a large, multiple fibroid uterus in a woman whose family was complete. Her symptoms included heavy periods, increase urination and feeling of discomfort and pressure in the abdomen. She underwent a hysterectomy with ovarian preservation.
Assessment of a subserosal fibroid indicates that the fibroid is only connected to the uterus by a small amount of smooth muscle and mainly by connective tissue.
The fibroid is elevated through tractiod. Diathermy and sharp dissection are used to resect the fibroid with minimal blood loss.
A GP, attempting to perform a routine Pap smear found this lesion at the cervix. She was found to have a cervical fibroid.
The cervix after the fibroid was resected. The ectocervix (outer part of the cervix) actually looked quite normal as the cervical fibroid had arisen from within the endocervical canal.
It is prudent to perform a hysteroscopy when a cervical lesion is found because in some cases, the fibroid might extend higher up into the cervix and in other situations a separate lesion may be discovered.
An incidental endometrial fibroid polyp is found and this can be removed during the same episode of surgery.
Myomectomy may need to be performed as part of the debulking procedure during a vaginal hysterectomy. Debulking facilitates the vaginal delivery of a uterus that would otherwise be too large to pass through the vagina.
The vascular supply to the uterus has been interrupted by clamping and dividing the uterine arteries. The uterus has been split open, traction applied to the fibroid. It is mobilised away from the myometrium revealing a sizeable, irregular mass.
The uterine cavity is explored for other fibroids and then the alignment of the uterus checked to ensure that the remaining uterine pedicles can be clamped and divided.
The uterine cavity is explored for other fibroids and then the alignment of the uterus checked to ensure that the remaining uterine pedicles can be clamped and divided. Despite the debulking procedure, the uterus is still twice the size of a normal uterus.
A large posterior subserosal fibroid with limited mobility and compressing the Pouch of Douglas resulting in dyspareunia and pelvic pressure.
In this patient, the subserosal fibroid has no obvious calcification, is softer, more vascular and more mobile. It is easily displaced out of the pelvis.