Uterine fibroids are the most prevalent benign tumors in women, with an incidence of 20%-25%, and some reports even up to 70%-80%, and their malignant rate is low, generally 0.4%-1%.
The common symptoms of uterine fibroids are uterine bleeding, anemia, pressure symptoms, etc. They are also one of the main causes of infertility, especially submucosal fibroids, with an incidence of infertility of 25% to 40%. With the improvement of ultrasound technology, more and more uterine fibroids are detected when there are no symptoms, which brings a lot of mental burden to patients.
The uterus is an important reproductive organ of women, and its functions are mainly for menstruation and fetal conception, but also involved in a small part of endocrine function and sexual function. Uterine bleeding is the most common reason for hysterectomy. Given the important physiological functions of the uterus and the high incidence of uterine fibroids, surgery of the uterus not only brings a heavy economic burden to society, but also poses a serious risk to the physical and mental health of the majority of female patients.
The cause of the occurrence of fibroids is mainly related to the estrogen level in the body, and also has a certain relationship with progesterone, immunity, genetics and environment.
Several issues need to be noted when choosing the treatment for uterine fibroids.
1.Is it surgical treatment or conservative treatment?
2.If you choose conservative, will you wait for observation or treat with medication?
3. If you choose surgery, will it be hysterectomy or myoma removal? Is it open surgery or minimally invasive surgery? Is it a hysteroscopic laparoscopic surgery or a transvaginal femoral surgery? 4. For older women, is the uterus removed along with the ovaries?
Doctors need to pay attention to the following bases when choosing a treatment method.
1. the presence or absence of symptoms;
2. the size and location of the fibroid;
3, the patient’s age and fertility requirements;
4. the growth rate of the fibroids and the presence of other diseases;
5, whether the diagnosis is clear. The most important thing is to understand the patient’s wishes and to make an individualized and informed choice. Surgery is recommended for patients with the following conditions.
1.Severe anemia and pressure symptoms such as pain, urinary retention and difficulty in stool;
2. Myoma uterus exceeding 2.5 months of gestation;
3, submucosal fibroids, especially those that have prolapsed into the vagina;
4. Myomas with twisted tissues and infections;
5.Young infertile patients with fibroids;
6.If it is not clear from the ovarian tumor. Sometimes the fibroids are asymptomatic, but the patient still has a heavy mental burden after the doctor’s explanation, so the doctor may also consider to perform surgery according to the patient’s wish. Pre-operative localization of fibroids is important, and 3D vaginal ultrasound, rectal ultrasound or abdominal ultrasound is recommended.
Surgical treatment of fibroids includes hysterectomy and myomectomy. Minimally invasive surgical methods are mostly used nowadays.
The main types of hysterectomy are total hysterectomy, intrafascial hysterectomy and partial hysterectomy.
Total hysterectomy can remove the entire uterus, but the operation is relatively complex and technically demanding, with relatively more intraoperative bleeding and complications, and has a certain impact on the integrity of the pelvic floor, which may affect sexual life when too much vagina is removed. Partial hysterectomy is a relatively simple operation with less bleeding, fewer intraoperative and postoperative complications, and less impact on sexual life and pelvic floor structure; however, inflammation of the cervix still exists or is aggravated, and there is a possibility of cancer in the residual cervix, requiring regular postoperative cervical examination. Intrafascial hysterectomy can preserve the sacral ligament of the uterus and some of the supporting structures of the pelvic floor, with less impact on the bladder and rectum, and removes the migratory zone that is prone to cervical cancer; however, the incidence of cervical cysts is higher after surgery, and the residual endometriosis in the uterosacral ligament can easily cause recurrence or aggravation of postoperative symptoms.
The routes for removal of the uterus are open surgery, laparoscopic surgery, transvaginal surgery, and laparoscopic-assisted transvaginal surgery. Open surgery is the traditional surgical approach, which is widely used at the grassroots level. It has a good field of view exposure and is easy to operate, but it is highly traumatic to the abdomen, interferes more with the abdominal cavity, and the patient’s recovery after surgery is slow; it is suitable for patients with uterine volume greater than 14 weeks of gestation, serious pelvic adhesions or suspected myoma malignancy. Laparoscopic surgery is a minimally invasive surgery with small abdominal incision, enlarged surgical field, clear exposure, good hemostasis, less disturbance to the abdominal cavity, and fast postoperative recovery; however, the cost of surgery is relatively high, the requirements for surgical instruments and surgical techniques are high, and complications are likely to occur in elderly patients with combined cardiovascular and respiratory diseases, increasing the risk of surgery. Transvaginal surgery has no incision in the abdomen, little interference with the abdominal cavity, few intestinal complications, light postoperative pain, fast recovery, and relatively low cost; however, because of the limited operating space in the vagina, the surgery is suitable for patients with small fibroids, combined with uterine prolapse and vaginal wall bulge; transvaginal surgery is not recommended for patients with uterine volume greater than 14 weeks of gestation, pelvic adhesions, adnexal lesions, and suspected fibroid malignancy.
The main ways to remove fibroids with preservation of the uterus are: open surgery, hysteroscopic surgery, laparoscopic surgery, and transvaginal surgery. Open surgery is indicated for all patients who wish to have children and preserve their uterus, but the incision in the abdomen is relatively large. Hysteroscopic surgery is the best surgical procedure for submucosal fibroids and is suitable for patients with submucosal fibroids less than 3 cm in diameter and greater than 50% protrusion of the uterine cavity; patients with fibroids more than 3 cm and less than 50% protrusion have a risk of bleeding, residual and uterine perforation with surgery. Laparoscopic surgery requires higher operator experience and surgical suture technique, relatively longer operation time and more bleeding, and is suitable for subplasma and broad ligament fibroids; multiple interstitial fibroids should not exceed 3 and size should not exceed 6 cm; single interstitial fibroids should not exceed 10 cm in diameter; postoperative complications and pregnancy outcome are the same as open surgery, but the chances of recurrence of fibroids and uterine rupture in second pregnancy are relatively higher after surgery. The postoperative complications and pregnancy outcomes are the same as for open surgery, but the chances of recurrence of postoperative fibroids and uterine rupture in another pregnancy are relatively high.
For postmenopausal patients with ovarian cancer risk factors, it is recommended to remove the ovaries at the same time as the uterus.
Conservative treatments for fibroids include expectant observation, drug therapy, uterine artery embolization, and ultrasound focusing. Conservative treatment is suitable for patients with small fibroids, asymptomatic, requiring fertility, requiring preservation of the uterus, near menopausal age, and having comorbidities that preclude surgery. The duration of observation is usually 3-6 months. Commonly used drugs include: mifepristone, gonadotropin-releasing hormone agonist (GnRHa), androgens, and herbal preparations, etc. All kinds of drugs have the effect of relieving symptoms and reducing the size of fibroids, but have different degrees of side effects and are prone to recurrence after stopping. Uterine artery embolization and ultrasound focusing should be strictly controlled for their indications and preoperative and postoperative precautions.
Minimally invasive is a philosophy, not a certain type of surgery. Any treatment method that can treat the disease to the maximum extent while reducing the trauma to the patient has achieved the effect of minimally invasive. If the indications are not mastered, any method can be turned from minimally invasive to massively invasive.