Cause / Condition
Uterine fibroids are round balls made up of fibrous and muscular tissue that are embedded within the muscle of the uterus, or may be attached to the uterus by a stalk. They may also protrude into the cavity of the uterus when they are called “submucous fibroids”. Uteri that have fibroids can enlarge to fill the whole abdominal cavity up to the chest, but this is a rare occurrence in a modern country with readily available medical care.
Large fibroids cause pressure symptoms on the bladder resulting in frequency of urination. Pressure on the rectum causes difficulty with bowel movement. The overall weight of the fibroid uterus in the lower pelvis causes a feeling of heaviness and congestion and may also cause backache. Heavy periods may also occur and this is particularly true in cases of submucous fibroid.
Large intramural (in the muscle) fibroids are thought to be responsible for infertility when all other tests are normal. The submucous fibroid causes recurrent miscarriage in up to 70% of pregnancies.
A rare cancer called a sarcoma may develop when fibroids grow rapidly.
The cause of fibroids is unknown and has to do with disturbed metabolism at the genetic level. Estrogens make the fibroids grow and in the menopause, shrinkage is possible to about half its maximum size.
Myomectomy is the term given to the surgical technique of removing the fibroids and repairing the uterus. At our institute, fibroids up to 20-weeks may be treated by laparoscopy. An incision of ½-inch is made in the belly button with two other incisions of ¼-inch and a fourth incision of ½-inch which admits a morcellator. This is an electric device that breaks up the fibroids into small pieces for removing through the small incision. Very large fibroids or numbers in excess of three or four are better treated by an open incision in order to avoid unduly prolonging the surgery.* In women wishing to maintain their reproductive capacity, these operations should be done by an infertility expert who is called a reproductive surgeon. It is always possible to perform a myomectomy.
If the fibroid is only submucous, removal is performed by shaving off bits until the total fibroid is removed. This is accomplished by putting a hysteroscope through the vagina into the uterus. No abdominal incisions are performed in this procedure.
When fertility is not an issue, a laparoscopic hysterectomy may be the best solution for older women with extensive fibroids and previous surgeries.
* We perform a mini-laparotomy in these cases.
All patients undergoing hysteroscopic surgery go home the same day and may return to work in as little as two days. With laparoscopic myomectomy, discharge from the hospital may be the same day, overnight, or after two nights depending on the extensiveness of the operation. Return to work within two weeks is usual.
Expectations / Experience
In the literature, pregnancy rates of about 50% within the year may be expected after myomectomy for infertility. For submucous fibroids, treatment reduces miscarriage rates to almost normal (20%+). Symptoms of pressure and bleeding are also improved in the majority. Recurrence of fibroids is really new fibroids forming, as the ones removed don’t return. After myomectomy the recurrence rate in five years is 20-30%. Not all recurrences require surgery. Obviously with a hysterectomy the recurrence rate is zero.
Myomectomy operations may occasionally require blood transfusion and the use of preoperative Lupron injections may reduce this likelihood. Other complications are more generic, related to surgery in general or laparoscopy.
For more information on laparoscopic treatment for Uterine Fibroids contact:
The Milwaukee Institute of Minimally Invasive Surgery
Columbia St. Mary's Hospital Milwaukee
2301 N. Lake Dr.
Milwaukee, WI 53211