MYOMECTOMY

The non medical treatment of uterine fibroid is either surgical or radiologic. The surgical options of treatment for fibroid include; hysterectomy, myomectomy, endometrial ablation and myolysis. The radiologic options include; uterine artery embolization and Magnetic Resonance-guided high intensity focused ultrasound. Patient who are not fit to undergo surgery can be offered medical treatment while they are been optimize.

NON MEDICAL TREATMENT OF UTERINE FIBROID- SURGICAL

Myolysis is a procedure which incite death of the fibroid tissue by the application of heat (electrocautery) or extreme cold (cryotherapy) to the fibroid.

Endometrial ablation involves the removal or destruction of the inner lining of the womb called the endometrium. This is done via the vaginal route and meant for fibroid in the inner lining of the womb called submucous fibroid. This also help to treat heavy menses due to the fibroid in that location. The procedure makes use of heat energy, microwave and cryosurgery (extreme cold).

Hysterectomy is the definitive treatment for fibroid, it is considered for women who no longer want more children. It involves removal of the womb. This is done in the operating room under anaesthesia. It can be done through the abdomen or by minimal access surgery called laparoscopy. The laparoscopic approach is costlier but is associated with less pain and short hospital stay after surgery. The abdominal route is associated with longer hospital stay about 3 to 5days. The possible complications of hysterectomy include; damage to the bladder, ureter, gut, excessive bleeding necessitating blood transfusion and complication of anaesthesia.

Myomectomy is a fertility preserving surgery for fibroid where the fibroid tissue is removed from the womb. The approach use depends on the location, size and number of the fibroid. The common approach use is the open abdominal approach as fibroid in all location can be reached. The vaginal approach by hysteroscopy is meant for fibroid in the cavity of the womb. The laparoscopic approach is for fibroid in the outer and muscle layers of the womb. Large size and high number of fibroid in the womb limit the use of the laparoscopic approach. Complication of myomectomy include adhesion formation and recurrence; the recurrence is from very small seedlings that could not be seen during the surgery.

PREGNANCY AFTER MYOMECTOMY

After removal of fibroid, it is advisable to wait three to six months before attempting to get pregnant. For some women who are unable to conceive with fibroid, removal of the fibroid increase the chance of pregnancy. Fibroid removal operation is considered a scar on the womb similar to that of caesarean section. When the removal is considered extensive or when the endometrium is bridged, delivery in the next pregnancy should be by caesarean section as vaginal delivery is associated with rupture of the womb. Do well to remember this after the post operation briefing. You might not have your antenatal care in the same facility where the operation was done. Do not forget to inform your doctor if you were told your fibroid removal was extensive or the endometrium was bridged.

UTERINE ARTERY EMBOLIZATION(UAE)

This is an interventional radiologic procedure that delivers certain material into both uterine arteries. The procedure involves passing a device call a catheter into the femoral artery which is then directed into the uterine artery before introducing a substance that will block blood flow. Sealing the uterine artery blood flow result in blockade of blood supply to the fibroid. This will result in the death of the fibroid tissue thereby reducing the fibroid size.  Women whose symptoms persist significantly with medical treatment will benefit from UAE where available. A myomectomy or hysterectomy were applicable is considered where UAE is not feasible.

Before UAE, a thorough evaluation will be carried out to rule out the possibility of cervical cancer, endometrial cancer and sexually transmitted infections such as gonorrhea and chlamydia.There are reports of patient satisfaction with UAE and symptom improvement compared with myomectomy and hysterectomy. The challenge with this is the non-availability of experts skilled in this procedure in certain region or countries. Where there are experts, the equipment to perform it might not be available. After the procedure, admission for a day or two might be necessary.

ABSOLUTE CONTRAINDICATIONS TO UAE

• Pregnancy
• Active uterine or adnexal infection
• Suspected reproductive tract cancer; cervical or endometrial cancer

RELATIVE CONTRAINDICATIONS TO UAE                                                                  

• Coagulopathy (abnormality of blood clot formation)                                                                        
• Renal impairment.                                                       
• Severe contrast allergy.                                            
• Desire for future fertility
• Uterine size >20–24 weeks                                      
• Prior salpingectomy or salpingo-ophorectomy (removal of the fallopian tubes or both tubes and ovaries)                                     
• Prior pelvic radiation                                                
• Large hydrosalpinx: fluid in the fallopian tube.                                                    
• GnRH agonist use

COMPLICATIONS OF UAE

• Post embolization syndrome; this is characterized by malaise, fever, nausea and pelvic pain.
• Groin hematoma
• Permanent loss of menses
• Subsequent Pregnancy complication
• Rarely necrosis of the uterus, adnexa and bladder
• Some patients will require subsequent procedure

MAGNETIC RESONANCE GUIDED FOCUSED ULTRASOUND

This is also called Magnetic Resonance-guided high intensity focused ultrasound (MR-HIFU). It involves the use of ultrasound energy which is focused to heat and incite tissue death in selected myomas. Concurrent Magnetic Resonance imaging enables precise targeting and provides real-time tissue temperature feedback to prevent heat injury to the surrounding tissues. A session can last for 2 to 3hours. A urethral catheter will also be pass for continuous emptying of the bladder. The major challenge is the non-availability of resources in certain regions and countries in term of skill and equipment. The selection criteria for patient include;

• fibroid size 4-10cm,
• completed family size
• perimenopausal.

CONTRAINDICATIONS TO MRgFUS

• Pregnancy
• Energy path obstructions such as abdominal wall scars or foreign bodies
• Future fertility desires
• Current pelvic infection
• Other uterine pathology
• Menopause
• Myoma size >10 cm, and uterine size >24 weeks.

ADVANTAGES OF MRgFUS

•   Noninvasive
•   Requires only conscious sedation
•   Rapid recovery and return to daily activities

DISADVANTAGES OF MRgFUS

•   Symptoms relief wanes with time, and
•   Some patient might seek alternative procedures for their symptoms, including hysterectomy.

COMPLICATIONS OF MRgFUS

• Skin burn
• Adjacent tissue injury
• venous thromboembolism.