Uterine fibroids (hysteromyoma), also known as uterine smooth muscle tumors, are the most common benign tumors of the female reproductive organs. They are most common in women of childbearing age between 30 and 50 years old, with an incidence rate of 5% to 50%, and even up to 70%. Uterine fibroids are rarely life-threatening like malignant gynecological tumors, most patients have no obvious symptoms and do not affect their lives and work, and they are hormone-dependent diseases, so they do not always require treatment, and those who need treatment do not always choose surgery. However, at present, there are some uterine fibroids that should not be treated, but choose surgery for those that can be treated by other methods, and even remove the organs and other over-treatment phenomenon, or in order to comply with the principle of humane treatment, those who have indications for treatment are not treated, those who have indications for surgery are not chosen, or those who should not keep the uterus Ningxia Medical University General Hospital Gynecology Department Yang Rainbow are given to keep the phenomenon of inadequate treatment. The treatment of fibroids The treatment of uterine fibroids includes: expectant follow-up, surgical treatment and non-surgical treatment (including drugs, radiofrequency, focused ultrasound, uterine artery embolization, etc.). Whether uterine fibroids need to be treated and what treatment method to choose are based on the patient’s age, fertility requirements, size, location, number of fibroids, presence or absence of symptoms, growth rate of fibroids, presence or absence of complications, and personal wishes. In fact, surgery is only one of the treatment methods, and should be considered only when the patient has one of the following conditions: (1) excessive menstruation or even secondary anemia due to fibroids, and drug treatment is ineffective. (2) Myoma causing severe abdominal pain or painful intercourse or chronic abdominal pain, or subplasmalemmal myoma with torsion. (3) When pressure symptoms appear. (4) When the fibroid is determined to be a cause of infertility or recurrent miscarriage. (5) When the growth rate of myoma is accelerated and malignancy is suspected. For those who need treatment but do not have indications for surgery, the following options are available: for those with mild symptoms, near menopausal age, combined with systemic organ insufficiency or unable to tolerate surgery, and without clear indications for surgery, pharmacological treatment (e.g. GnRH-a) can be chosen; for those who have completed childbirth and for some reasons do not want to operate and wish to preserve the uterus, patients with interstitial myomas <10cm can choose For patients with uterine fibroids who do not need to preserve their reproductive function and are unwilling to undergo surgery, uterine artery embolization can be chosen. 2 Choice of surgical scope (procedure) for uterine fibroids For patients with indications for surgery, the choice of surgical procedure and surgical route is involved. In addition to a thorough preoperative examination and careful evaluation, the choice of surgical procedure should be based on what is seen intraoperatively. The basic surgical procedures for uterine fibroids are conservative surgery with preservation of the uterus (myomectomy) and hysterectomy (total hysterectomy, subtotal hysterectomy). The choice of the procedure is based on the patient's age, fertility requirements, the number and size of the fibroids, the condition of the cervix, the combination of other diseases (e.g. adenomyosis) and the patient's wishes. It is inappropriate to perform hysterectomy in young patients with fertility requirements, but it is also inappropriate to perform subtotal hysterectomy in patients with no fertility requirements, multiple fibroids (even dozens), perimenopausal patients, or those who have not yet ruled out cervical lesions, because future recurrence of fibroids, cervical stump lesions, and perimenopausal patients will be faced with uterine hemorrhage and endometrial lesions. This option will be followed by the recurrence of fibroids, cervical stump lesions and perimenopausal hemorrhage and possible endometrial lesions. Myomectomy is suitable for young patients who have not yet had children and need to preserve their reproductive function. There are some patients who do not need to have children but strongly want to keep their uterus. The choice of myomectomy is a psychological one, because the patient believes that menstruation is the basis of health, youth and sex life; if the patient has symptoms, no need to have children, large or more fibroids, or suspected malignant changes, hysterectomy should be performed. The choice of total hysterectomy or subtotal hysterectomy depends on the age of the patient, the condition of the cervix and the patient's wishes: if the patient is young (under 40 years old), if the patient requests it, if cervical lesions can be excluded, or if it is difficult to remove the cervix because of complicated conditions (such as severe pelvic adhesions), subtotal hysterectomy with preservation of the cervix can be considered, otherwise, total hysterectomy should be performed. For special types of fibroids, such as cervical fibroids, it is difficult to preserve the uterus, so total hysterectomy should be performed unless the patient is young and requires fertility. For cervical stump fibroids, the cervical stump should be removed together with the uterus. Broad ligament fibroids can be removed or hysterectomized according to the above-mentioned selection principles. If the fibroids are small, they do not need to be treated and can be maintained until the full term of pregnancy. If the fibroids are red and degenerative, it is better to treat them conservatively first, but if they do not work, surgery can be considered and the pregnancy can be terminated according to the specific situation. The advantages of myomectomy are that it is less invasive, preserves the reproductive organs, does not affect fertility and sexual life, satisfies the patient's psychological needs, and reflects the humanization of treatment, but is prone to recurrence. It has been reported that there is a 50% chance of recurrence after such surgery, and about 1/3 of the patients need to be operated again, and the time of recurrence depends on the patient's age, ovarian function, and the way of the previous surgery, with individual differences. In addition, the preserved uterus is still at risk for menopausal uterine bleeding and endometrial lesions. The advantage of total hysterectomy is the complete removal of the diseased uterus and the avoidance of cervical stump cancer, but the ovarian circulation may be affected to varying degrees, the integrity of the pelvic floor support structures may be compromised, and the chance of vaginal vault prolapse may increase. In addition, the removal of the body and cervix of the uterus may reduce the amount of leukorrhea, which may affect the quality of sexual life. Subtotal hysterectomy preserves the integrity of the pelvic floor and prevents or reduces the occurrence of postoperative fornix prolapse, while the vaginal structure remains intact and has little impact on the patient's sexual function. However, lesions may occur in the preserved cervix, such as cervical stump myoma, cervical endometriosis, and cervical stump cancer. The incidence of cervical stump cancer after subtotal hysterectomy has been reported to be 1%-2%, and stump cancer is difficult to treat with either surgery or radiotherapy. Intrafascial hysterectomy retains the advantages of total hysterectomy and subtotal hysterectomy, and overcomes the problems of cervical stump cancer faced by subtotal hysterectomy and fornix prolapse and impact on sexual quality of life faced by total hysterectomy, and its indications are the same as those of total hysterectomy. There are different opinions on the impact of hysterectomy on women's quality of life and psychological well-being. The results showed that hysterectomy had no significant effect on ovarian function and sexual life of women, and the quality of life of patients improved to varying degrees after surgery. There was no statistically significant difference in the changes of sexual life indicators and sexual life scores between patients with subtotal hysterectomy and total hysterectomy after surgery. Another study showed that hysterectomy may seriously affect women's body image, self-worth, self-esteem and sexual physiological function, that preserving the cervix may reduce women's sense of sexual organ absence, and that preserving the integrity of the cervix, vagina and pelvic floor may help the body retain a good impression of sexual life. Therefore, the pros and cons of uterine preservation should be weighed and the patient should be fully communicated with, and the appropriate surgical approach should be chosen according to the patient's wishes without compromising the treatment.4 Choice of surgical approach for uterine fibroids Each of the above-mentioned surgical approaches can be chosen from different surgical approaches: transabdominal surgery, transvaginal surgery, laparoscopic surgery, hysteroscopic surgery. 4-1 Myomectomy 4-1-1 Transvaginal myomectomy (TVM) is suitable for submucosal fibroids with tissues protruding from the vagina, with a low root position and the tissues palpable in the cervical canal; for fibroids with a loose vagina, no pelvic adhesions and good uterine mobility, with single or less than 3 subplasmal or interstitial fibroids. TVM has the advantage of being minimally invasive compared to laparoscopic myomectomy, and has some of the advantages of transabdominal surgery, i.e., it can be palpated, reduces leakage, and closes the cavity more precisely during suturing. 4-1-2 Hysteroscopic myomectomy is the best treatment for submucosal fibroids. Hysteroscopic surgery is the best treatment for submucosal fibroids. When interstitial fibroids protrude more than 1/2 into the uterine cavity and are not accompanied by fibroids in other areas or small fibroids in other areas can be ignored, hysteroscopic surgery can be chosen. The size of myoma that can be removed by hysteroscopy is not definite, but the depth of invasion of the myometrium is the first factor to be considered. For patients with a diameter >5 cm and a myoma located in >50% of the muscular layer, hysteroscopic resection is difficult.4-1-3 Laparoscopic myoma resection The indications are still not uniform and are closely related to the surgeon’s surgical experience. At present, it is believed that laparoscopic myomectomy is suitable for subplasma or broad ligament fibroids, multiple 3-4 medium-sized (≤6 cm) interstitial fibroids, and single interstitial fibroids of 7-10 cm in diameter. Laparoscopic myomectomy is difficult in patients with interstitial fibroids >10 cm in diameter, more than 4 fibroids or near the submucosa, and cervical fibroids.4-1-4 Transabdominal myomectomy (TAM) is indicated for all young patients with fibroids who wish to have children and have indications for surgery, regardless of the location, size, and number of fibroids, especially in patients with multiple fibroids that are estimated to be difficult to remove by other methods. It is particularly suitable for patients with multiple fibroids that are expected to be difficult to remove by other means, those with a history of multiple pelvic surgeries, those with heavy adhesions, those with a uterine volume larger than 12 weeks of gestation, and those with recurrent fibroids after various routes of resection. Each of these procedures has its own advantages and disadvantages. Transvaginal myomectomy has no scar in the abdomen, little abdominal interference, and few complications, but it is difficult to detect other problems in the pelvic cavity because of the limited operating space, and myomas are easily missed, especially posterior wall myomas, which are difficult to operate and easily cause bleeding and injury, and requires good cathodic surgical skills; hysteroscopy can only remove submucosal myomas and has limited indications; laparoscopic myomectomy 4.2.1 Transvaginal hysterectomy is suitable for patients with no history of multiple pelvic surgeries, no pelvic adhesions and inflammation, no adnexal masses or no need for exploration. There is no mass or no need to explore or remove the adnexa; Individuals with abdominal obesity; Uterus not exceeding the size of a 3-month pregnancy; Medical comorbidities such as diabetes mellitus, hypertension, coronary artery disease, obesity, etc. who cannot tolerate open surgery; The advantages of hysterectomy by the negative route are the same as above, but there is some difficulty in dealing with adnexal problems. The size and mobility of the uterus, the elasticity and volume of the vagina, and the presence of adnexal lesions need to be evaluated before surgery.4-2-2 Laparoscopic hysterectomy is suitable for cases other than those with large tumors (uterine volume greater than 14 weeks of gestation), severe pelvic adhesions, suspected malignant tumors of the reproductive tract, and general contraindications to laparoscopic surgery. It has the advantages of minimally invasive surgery.4-2-3 Transabdominal hysterectomy has good visual exposure and can facilitate the management of difficult surgeries, and it can perform hysterectomy that cannot be done vaginally or laparoscopically, especially in cases of recurrence after myomectomy, suspected malignancy and heavy pelvic adhesions. The disadvantages of this procedure are the large abdominal trauma, interference with the abdominal cavity, and slow postoperative recovery.4-2-4 Laparoscopic-assisted vaginal hysterectomy (LAVH) can overcome the shortcomings of narrow field of view in vaginal surgery, unfavorable treatment of adnexa and separation of pelvic adhesions, and has minimally invasive features, but with the improvement of laparoscopic techniques, LAVH has been reduced and gradually replaced by laparoscopic hysterectomy.4-3 Special Cervical fibroids: laparoscopic and transvaginal are more difficult to perform, but transabdominal complications are relatively minor, if total hysterectomy is chosen, the surgical route can be chosen according to the operator’s ability to perform such complex surgery. Transabdominal surgery is relatively safe because of the history of surgery and the complexity of this procedure, which is prone to collateral damage. The risk of transvaginal surgery is higher in the case of leiomyosarcoma of the broad ligament, so laparoscopic or open surgery is preferred, depending on the operator. In fact, each route has its own indications, and some may be suitable for only one route. When transvaginal, transabdominal and laparoscopic routes are available for myoma surgery, the first choice should be transvaginal, followed by laparoscopic and finally open. Laparoscopic hysterectomy is minimally invasive and has a quick recovery, and laparoscopy provides a clearer picture of the pelvic cavity than transvaginal surgery and a clearer field. However, both laparoscopic and vaginal hysterectomy have certain limitations, especially for more difficult hysterectomies, transvaginal surgery is still a wise choice. It is true that choosing a less invasive and faster recovery surgical route is a humane way of treatment, but the choice of surgical route should be individualized according to the condition and the skill level of the operator. For example, some cases are suitable for minimally invasive surgery, but if the surgeon is not skilled, the minimally invasive surgery may become massively invasive. On the contrary, in some cases where minimally invasive surgery is not fully available, the minimally invasive route can be chosen by experienced and skilled surgeons to minimize patient trauma.5 Ovaries during hysterectomy The ovaries have both reproductive and endocrine functions, and removal of ovaries while removing the uterus for a patient with normal ovarian function who is not yet menopausal is not in accordance with treatment norms. However, for menopausal and even menopausal women without reproductive requirements and/or functions, their endocrine functions are still important for their physical and mental health. Although the ovaries do not ovulate after menopause, their endocrine function can still be maintained for several years. After menopause, the site, type and amount of estrogen secreted by the ovaries are different from those before menopause. After menopause, the ovaries produce very little estradiol, and the estrogen in the body mainly comes from androstenedione produced by the interstitial cells of the ovaries, which is converted into estrone in adipose tissue and can stabilize the autonomic nervous system and regulate the body’s metabolism. Obviously, natural menopause does not mean the complete loss of ovarian function, therefore, it is recommended that, when removing the uterus for uterine fibroids, if both ovaries are normal in women under 50 years of age, they should be preserved as much as possible; in women over 50 years of age, if they are not yet menopausal or if their ovaries are not atrophied, they can also consider preserving both ovaries or one side; if they are menopausal and their ovaries are obviously atrophied, bilateral resection is feasible, but it is still necessary to The patient’s wishes should be respected and informed consent should be obtained.6 Problems to be noted in the selection of uterine fibroid treatment Different surgical routes for uterine fibroids have their own advantages and limitations, and therefore each has its own indications and contraindications, therefore, the selection of surgical route should be considered in terms of effectiveness, safety and invasiveness. At present, there is no single surgical route that can completely replace all other surgical routes. Therefore, when choosing the surgical route, we should take into account not only the advantages and disadvantages of the route itself, but also our own technical proficiency, equipment and conditions, the characteristics and wishes of the patient’s lesion, and health economics. The quality of life of the patient is also taken into account in the choice of the scope of surgery for uterine fibroids. Uterine fibroids are benign tumors, and the incidence of malignant transformation into sarcoma is only 0-4%~0-8%, so the choice of treatment should pay more attention to the quality of life of patients. The aim is to relieve the patient’s pain and improve the quality of life at the same time. At present, hysterectomy has become one of the main treatment methods for uterine fibroids. However, hysterectomy is an organ-destructive surgery. From the anatomical point of view, total hysterectomy, subtotal hysterectomy and intra-fascial hysterectomy, no matter which procedure is chosen, cut off the ovarian branch from the uterine artery, and the blood supply to the ovary is reduced after hysterectomy, or the preserved ovary is twisted or adhered, which reduces the blood supply to the ovary and thus reduces the secretion of ovarian hormones, which may affect This may affect ovarian function. Therefore, there should be strict indications and contraindications for the removal of the uterus to avoid over-treatment in the pursuit of surgical completeness and under-treatment due to excessive emphasis on preservation of sexual organs and humane treatment. Nowadays, with the change of medical model, the surgical procedures for uterine fibroids are also undergoing adaptive changes, such as semi-extraperitoneal hysterectomy, intrafascial hysterectomy, intrafascial hysterectomy with preservation of the superior branch of uterine artery (triangular hysterectomy) and hysterectomy with preservation of endometrium (high hysterectomy), which reflect the concept of human-oriented treatment and will provide individualized, humanized, minimally invasive treatment for uterine fibroids. The proposed procedures, such as hysterectomy with preservation of the endometrium (high hysterectomy), reflect the concept of human-centered treatment and will provide good prospects for the realization of individualized, humanized and minimally invasive treatment of uterine fibroids.