Overview of Fibroids Surgery

Uterine fibroids, also referred to as leiomyomas or myomas, are growths in the uterus or on the uterine wall. They vary in size from smaller than a pinhead to the size of a watermelon or bigger. The vast majority of uterine fibroids are benign (not cancerous).

Fibroids are fairly common, affecting up to 80% of people with uteruses by 50 years of age.

While fibroids are often asymptomatic and do not require attention, symptoms are present in 20%–50% of cases and may require treatment.

While surgery is an option for the treatment of fibroids, not everyone who needs or wants treatment for fibroids has to have surgery. Other less-invasive options are available.

This article discusses surgery options for uterine fibroids.

When Surgery Is Necessary

When determining treatment options and whether surgery is necessary, some important factors need to be considered, including:

• A person's age
• The severity of their symptoms
• Where their fibroids are located
• How many fibroids they have

The National Institute for Health and Care Excellence (NICE) recommends that hysterectomy should be considered only when:

• Other treatments have not worked or are unable to be used.
• The person with fibroids wants to end menstruation.
• The person with fibroids has been fully informed about the procedure and the risks involved and requests the surgery.

A myomectomy is an option for surgery that retains fertility but may be considered too complex or risky if the fibroids are large or there are too many of them.

In cases of severe, life-threatening bleeding that is not responding to other treatments, an emergency hysterectomy may be the only option.

Types of Fibroid Surgery

Hysterectomy, which is surgery to remove a woman's uterus, is the only treatment option that guarantees full removal of fibroids and the symptoms that come with them. Hysterectomy guarantees they won't return. It has a high success rate.

Myomectomy removes the fibroids instead of shrinking them or destroying them. This procedure can be used as an alternative to hysterectomy for people who want to preserve their uterus. It can also be a more complicated surgery and carries a risk of fibroids returning.

Myomectomy

During a myomectomy, the fibroids are removed, but the uterus is left intact and repaired.

After a myomectomy, the uterus usually returns to functioning normally, including with regards to menstruation. Menstrual bleeding may be lighter than it was before surgery.

Pregnancy is possible after a myomectomy, but the pregnancy may need to be monitored for possible risks. Pregnancy outcomes will depend on how deep the fibroids were and if any spanned a large part of the uterine wall.

There are four main types of myomectomy.

Open Myomectomy

Open myomectomy, also known as abdominal myomectomy, is a procedure to remove subserosal fibroids (those attached to the outside wall of the uterus) or intramural fibroids (those embedded in the wall of the uterus.

This surgery is reserved for very large fibroids of 4 inches in diameter or larger or for when there are numerous fibroids, fibroids in an area of the uterus that’s difficult to access, or when cancer is suspected.

This surgery involves:

•  Removing the fibroids through an incision in the abdomen
•  Using either a horizontal or vertical incision
•  Putting the patient under with general anesthesia
•  Hospitalization of a few days, followed by six to eight weeks of full recovery

Standard Laparoscopic Myomectomy

Standard laparoscopic myomectomy is surgery that requires the insertion of a laparoscope (a small, lighted telescope) through the abdomen, near the navel. Several other small incisions are also required to allow special instruments to be inserted to remove the fibroids. Some surgeons also use a robotic machine to precisely control the movement of the instruments.

 In this procedure, fibroids may also be removed through the vagina. Other facts to know about this procedure include that it is:

• Used when the uterus is no larger than it would be at a 12- to 14-week pregnancy
• Used when there are a small number of subserosal fibroids
• Performed under general anesthesia
• Has a short recovery time (up to one week)
• Easier on the body than an open myomectomy

Single-Port Myomectomy

A single-post myomectomy uses only one opening near the navel for all the instruments but requires a fairly large incision. It's performed under general anesthesia.

It typically has a quicker recovery time (up to a week) and is easier on the body than an open myomectomy.

Hysteroscopic Myomectomy

A hysteroscopic myomectomy is used for submucosal fibroids (found in the uterine cavity) and requires no incisions.

A camera with a specialized attachment is placed through the vagina into the uterus to remove fibroids.

This is performed under general or regional anesthesia.

Hysterectomy

During a hysterectomy, the uterus is removed, permanently ending menstruation, the ability to become pregnant, and the chance that fibroids will return.

There are three types of hysterectomies:

• Total hysterectomy: Removal of uterus and cervix
• Subtotal: Also called supracervical hysterectomy—removal of the uterus without the removal of the cervix
• Radical: Removal of uterus, cervix, both ovaries, both fallopian tubes, and nearby tissue

Other procedures that may be performed at the same time as a hysterectomy include:

• Oophorectomy: Removal of an ovary
• Bilateral oophorectomy: Removal of both ovaries
• Bilateral salpingo-oophorectomy: Removal of the fallopian tubes and ovaries

Types of hysterectomy procedures include:

Total Abdominal Hysterectomy

Total abdominal hysterectomy is the traditional hysterectomy procedure. It is invasive surgery that requires an incision of five to seven inches in the lower abdomen. The incision may be vertical or horizontal.

A horizontal incision is made just above the pubic bone, in what’s known as a bikini cut. It heals faster and is less noticeable than a vertical cut. A vertical incision is used for more complicated cases or for the removal of very large fibroids.

Total abdominal hysterectomy also:

•  Is performed under general anesthesia
•  Requires a hospital stay of one to three days
•  Allows for full recovery in about four to six weeks

Vaginal Hysterectomy

Vaginal hysterectomy is recommended as the first choice, when possible, by the American College of Obstetricians and Gynecologists (ACOG) and requires only a vaginal incision through which the uterus (and often the cervix) is removed.

This procedure requires a hospital stay of one to three days and rest for two weeks.

Laparoscopically Assisted Vaginal Hysterectomy (LAVH)

Laparoscopically Assisted Vaginal Hysterectomy (LAVH) uses several small abdominal incisions through which the surgeon divides the attachments to the uterus and—if needed—the ovaries. Part of the procedure is completed vaginally.

This procedure has shorter hospital stays, and faster recovery times than abdominal hysterectomy.

Total Laparoscopic Hysterectomy

Laparoscopically Assisted Vaginal Hysterectomy (LAVH) is recommended by the ACOG as the second choice for minimally invasive procedures.

This procedure uses a laparoscope (a thin, flexible tube through which a tiny video camera and surgical instruments are inserted).

Typically, there are shorter hospital stays and faster recovery times than abdominal hysterectomies.

Robotic-Assisted Laparoscopic Hysterectomy

This is a type of laparoscopic hysterectomy in which the surgical instruments are attached to a robot and the surgeon uses a computer console in the operating room to control the robot's movements.

The ACOG indicates that robotic hysterectomy is best suited for complex hysterectomies, so it is important to find a surgeon who has extensive training and experience in this technique.

The use of robotic-assisted laparoscopic hysterectomy increased exponentially in popularity between 2005 and 2015. In fact, up to 9.5% of hysterectomies were done with the assistance of a robot in research looking back at previously recorded data involving 264,758 cases.

Some things to consider:

• Studies have shown longer operation times.
• One study showed greater blood loss than standard laparoscopic myomectomy.
• The American Association of Gynecologic Laparoscopists (AAGL) states that, at this time, robotic surgery offers no significant advantage in benign gynecological surgery.
• It costs more than conventional laparoscopic surgery.

Benefits and Disadvantages

Benefits

Myomectomy

• Uterus usually returns to normal functioning.
• Pregnancy is possible.
• Menstrual periods either return or remain.
• The disappearance of bleeding symptoms in 90% of cases after a mean follow-up of 17 months

Hysterectomy

• Permanently gets rid of fibroids and symptoms
• Fibroids never return.
• Can help relieve severe symptoms that are greatly negatively impacting quality of life

Disadvantages

Myomectomy

• Higher risk of blood loss than with a hysterectomy
• Longer operating time than with a hysterectomy
• May cause surgery-related complications
• Fibroids have a 15% chance of returning.
• About 10% of people who have a myomectomy will require a hysterectomy within five to 10 years.
• If any of the fibroids spanned a large part of the wall of the uterus or were deeply embedded, a cesarean section may be needed for future pregnancies.

Hysterectomy

• It is major surgery.
• Requires anesthesia
• May cause surgery-related complications
• Has a recovery period of two to six weeks, depending on the type of hysterectomy
• Increased risk of urinary incontinence
• People who have had hysterectomies reach menopause an average of two years earlier than those who have not had a hysterectomy.
• Stops menstruation
• Permanently ends fertility (the ability to get pregnant)
• May experience a numb feeling around the incision and down the leg, usually lasting about two months
• If ovaries are removed, menopause begins.
• It can have a negative psychological impact, such as a sense of loss or depression.

Complications/Risks

Complications from these surgeries are similar to those of any major surgery. They may include:

• Infection
• Fever
• Bleeding (may require transfusion)
• Damage to nearby organs
• Problems with anesthesia
• Urinary tract infections
• Blood clots
• Bowel (obstruction) blockage
• Urinary tract injury

Surgical Alternatives

Nonsurgical treatment options for fibroids are also available.

Watchful Waiting

Fibroids that are not causing problems or bothersome symptoms do not necessarily need treatment. A wait-and-see approach may be appropriate in these cases.

With watchful waiting, the fibroids are monitored for changes and growth through regular pelvic exams and/or ultrasounds.

Medications

Some medications used to treat fibroids include:

• Tranexamic acid (TXA)
• Combined oral contraceptive pills
• Progestin-releasing IUD (intrauterine device)
• Progestin pills (synthetic progesterone)
• Gonadotropin-releasing hormone (GnRH) agonists
• NSAIDs (nonsteroidal anti-inflammatory drugs)

Medical Procedures

Uterine Artery Embolization (UAE)

Uterine artery embolization (UAE)—also called uterine fibroid embolization (UFE) shrinks fibroids by cutting off their blood supply. Things to note about this procedure:

• Person remains conscious but sedated
• Takes around 60–90 minutes
• A catheter is placed through a small incision in the groin and threaded into the uterine artery.
• Small plastic particles are injected into the artery to block the blood supply to the tiny arteries that feed fibroid cells.
• Recurrence rate of more than 17% at 30 months

Radiofrequency Ablation

Radiofrequency Ablation is a minimally invasive laparoscopic procedure that uses heat to destroys fibroids, generated by high-energy waves. It uses ultrasound to verify the correct placement of the radiofrequency device within each fibroid before ablation is performed. This to note about this procedure:

• Usually performed as an outpatient procedure
• Considered a safe and relatively low-risk alternative to hysterectomy

Magnetic Resonance Imaging–Guided Focused Ultrasound (MRgFUS)

Magnetic resonance imaging–guided focused ultrasound (MRgFUS) is a noninvasive procedure that uses high-intensity ultrasound waves to generate heat and destroy fibroids. The procedure is performed with a device called the ExAblate, which combines magnetic resonance imaging (MRI) with ultrasound.

It is a three-hour procedure where a person lies in an MRI machine while conscious but given a mild sedative. A radiologist uses the MRI to target the fibroid tissue and direct the ultrasound beam.

Things to note about this procedure include:

• Only appropriate for people who do not intend to become pregnant
• Cannot treat all fibroids or those near the bowel and bladder, or outside of the imaging area
• Long-term results are not available because the procedure is relatively new.
• Requires an extensive period of time inside MRI equipment
• Not covered by many insurance policies
• Currently available evidence suggests that the procedure is moderately effective.
• UAE may be more effective, with fewer treatment failures and the need for more procedures.

Endometrial Ablation

Endometrial ablation destroys the endometrium (the lining of the uterus). This procedure is typically used to stop heavy menstrual bleeding and for removing small fibroids. It's not useful for large fibroids or for fibroids that have grown outside of the interior uterine lining.

Endometrial ablation usually stops or significantly reduces monthly menstruation and can significantly decrease the likelihood of pregnancy. Things to note about this procedure include:

• Recovery typically takes a few days
• Increases the risks of complications (such as miscarriage or ectopic pregnancy) if pregnancy does occur
• People who choose this procedure must take steps to prevent pregnancy
• May delay or make it more difficult to diagnose uterine cancer in the future
• People who have this procedure should continue to have recommended Pap tests and pelvic exams.

Frequently Asked Questions:

What size fibroids need surgery?

There isn’t a specific size of fibroid that would automatically determine a need for its removal. The need for treatment is largely based on symptoms, not size.

How do you get rid of fibroids without surgery?

Nonsurgical options for fibroid treatment include:

• Medication
• Uterine artery embolization (UAE)
• Radiofrequency ablation
• Magnetic resonance imaging–guided focused ultrasound (MRgFUS)
• Endometrial ablation

How does a doctor determine if surgery is necessary for uterine fibroids?

Healthcare providers take a number of factors into account when deciding on treatment for fibroids, including surgery. Some things they consider include:

• Patient's age and overall health
• Type of fibroids
• Size, location, and number of fibroids
• The symptoms and the severity of the symptoms
• Patient's desire for future pregnancies
• Patient's desire for uterine preservation