UTERINE FIBROIDS
TRADITIONAL SURGICAL APPROACHES
If a patient has too large or too many fibroids, or if a patient has contraindications that prevent her from having non-invasive procedures, such as prior abdominal surgeries or coagulative disorders, traditional procedures can be considered. While these procedures are more invasive, they do eliminate the fibroids with less risk of recurrence.
Myomectomy (laparoscopic, hysteroscopic, abdominal)
A myomectomy is a procedure during which the uterine fibroids are surgically removed while the uterus itself is left intact. The myomectomy can be performed laparoscopically, vaginally or abdominally. During a laparoscopic myomectomy, small incisions are made in the perineum with a sharp instrument called a trocar, and laparoscopic instruments such as a microscope, camera and probe are then inserted. The uterine fibroids are destroyed with the probe and transported out of the body through a small cannula. If the fibroids are too large, they can be cut into pieces (morcellation) before being removed. The small incisions of laparoscopic myomectomies have the advantage of less downtime after the procedure and less scarring. However, as with all laparoscopic procedures, there is an increased risk of organ or blood vessel perforation and bleeding. During a hysteroscopic (vaginal) myomectomy, operative instruments are inserted though the vagina and cervix to remove the fibroids. However, this is a treatment option only for fibroids that are located inside of the uterus, as extra-uterine fibroids cannot be reached through the vagina and cervix. Both procedures can be performed either in and outpatient, and if a hospital stay is required, it is usually not longer than 1-3 days and a few weeks of reduced activity. An abdominal myomectomy is an open procedure where a long "C-Section"-like incision is made in the lower abdomen to remove the fibroids. This kind of procedure may be necessary with larger or deeper fibroids, or for women with large numbers of fibroids, where the only other alternative would be a hysterectomy. The advantage of this procedure is that the uterus is preserved and future pregnancies are possible. However, due to the large scar, a C-Section may be necessary.
Hysterectomy (laparoscopic, hysteroscopic, abdominal)
A hysterectomy is the surgical removal of the uterus. Like a myomectomy, it can be performed laparoscopically, hysteroscopically or abdominally. It can be either partial (only removing part of the uterus), full (removing the whole uterus) or radical (removing the uterus, fallopian tubes, ovaries, cervix and upper part of the vagina).
Hysterectomies come with their own set of advantages and disadvantages. On the upside, because the uterus is removed, the fibroids will be removed in their entirety and won't be able to regrow anywhere. On the downside, the removal of the uterus can lead to a slight shift of the remaining organs in the pelvic cavity, mainly the large and small intestines, which will rearrange themselves to take up the space previously occupied by the uterus. This repositioning, although slight, can cause pelvic floor disorders such as fecal incontinence and constipation. (It should be noted though, that this has been somewhat contested in the literature and some have claimed that disorders such as fecal incontinence and constipation are the result of aging rather than hysterectomy.)
Moreover, any type of hysterectomy is effectively a sterilization, because the uterus (or parts thereof) are removed. Therefore, women after hysterectomy don't usually experience menstrual bleeding because there simply is no more lining of the uterus to be shed during the menstrual period. (Partial hysterectomies can be an exception to this, when only part of the uterus is removed.) Because a radical hysterectomy also removes the ovaries, where estrogen and progesterone are produced, radical hysterectomies cause the onset of menopause. Therefore, some women with radical hysterectomies benefit from taking menopausal medication.