1. MINIMAL INVASIVE SURGERY
or LAPROSCOPIC REMOVAL OF FIBROID OF UTERUS AND
2. HYDROTHERMAL ABLATION
Every Gynecologist carries a laproscope, this being the popularly chosen method today.
Study published by
S N Mukherjee©
ALTERNATIVE SURGICAL METHODS
1. Myomectomy —
Abdominal or open myomectomy is a standard and accepted form of treatment of symptomatic fibroids in women who wish to retain their uterus and reproductive function. With technical advances in minimal access surgery, myomectomy can now be performed laparoscopically for intramural and subserous fibroids. Although laparoscopic myomectomy is technically difficult and takes more operating time, it offers significant benefits of less postoperative pain and shorter recovery time in comparison to open myomectomy. Recurrence of fibroids after laparoscopic myomectomy remains a concern. Hysteroscopic resection of submucous fibroid is indicated in symptomatic women presenting with heavy bleeding or reproductive failure. It is a day care procedure with very little risk.
2. Laparoscopic myolysis —
The procedure can be used as a minimally invasive alternative treatment to myomectomy in women who do not wish to have children and have large symptomatic fibroids. The procedure involves laparoscopic use of neodymium: yttrium-alluminium-garnet (ND : YAG) laser to coagulate the myoma. Alternative energy sources have subsequently been used, such as diathermy, and a cryoprobe has been used to carry out myolysis.
3. Uterine artery embolisation (UAE) —
It is rather a popular alternative treatment to myomectomy/hysterectomy. It has been observed to be safe and effective, has fewer major complications and a shorter hospital stay. The technique involves percutaneous insertion of an angiography catheter via a femoral artery into the ipsilateral or contralateral uterine artery, by an interventional radiologist assisting the gynaecologist. Polyvinyl alcohol particles 300-500 mm in size are injected into the vessel until blood flow ceases. Embolisation may affect myometrial integrity leading to uterine rupture during pregnancy.
4. Magnetic resonance guided percutaneous laser ablation —
It is a promising alternative minimally invasive therapy for fibroids. Under local anaesthesia, four magnetic resonance-compatible 18-gauge needles are placed within the target fibroid under MRI guidance. Laser fibres are threaded into the outer needle sheath until the laser tips are within the fibroid substance. An infrared di-iode laser is used for thermal ablation of the fibroid. A 41% reduction in mean fibroid volume was observed at 12-month follow-up. The quality of life and satisfaction scores were similar to those seen in women after hysterectomy.
5. Interstitial laser photocoagulation —
The principle is the same as for magnetic resonance guided laser ablation, but the laser fibres are placed in the fibroids under laparoscopic guidance. It can be performed by any gynaecologist-laparoscopist without the need for expensive equipment to monitor thermal changes.
6. High intensity focussed ultrasound (HIFU) energy —
This non-invasive approach of treatment of symptomatic fibroids has generated great interest. Under MRI guidance, an ultrasound beam of approximately 1.0-1.5 mHz delivered the energy directly to the targeted tissue for fibroid ablation. HIFU has an excellent safety profile. In contrast to more diffuse necrosis caused by UAE, the targeting ability of HIFU produces few adverse effects.
Hydrothermal ablation methods, based on their safety and efficacy, are being used as an alternative to hysterectomy in selected women presenting with heavy periods, provided future fertility is no longer an issue.
First generation methods —
These are endometrial resection, rollerball coagulation and endometrial ablation. These approaches afford shorter hospital stay, faster recovery and financial savings. Transcervical resection of endometrium (TCRE) using electrical or laser energy and a rectoscope is a simple procedure under local, epidural or general anaesthesia. The rollerball ablation is tried with a roller of 2 mm diameter sphere on the rectoscope wire which can roll freely on its axis and a unipolar coagulating current is applied to the endometrium21. Laser vaporisation with Nd: YAG laser is used to systematically destroy the superficial layers of endometrium. In expert hands, the results are impressive with a success rate of 93%, 74% become amenorrhoeic and 14% reported satisfactory results.
Second generation methods —
These techniques aim to induce permanent thermal damage to basal endometrium by applying heat/cold from a variety of sources eg, heated fluid, microwave, radiofrequency, cryocautery or laser energy. Hydrothermal ablation devices, introduced in 1994, have undergone several modifications. These devices are less operator-dependent and easier to use than first generation techniques.
DGO, MD, FACS, FAMS, FICOG, FICMCH, Senior Consultant Obstetrician and Gynaecologist, New Delhi 110092 and Ex-Professor and Head of the Department of Obstetrics and Gynaecology, JIPMER, Pondicherry 605006, Indira Gandhi Medical College, Simla 171001, UCMS and Safdarjung Hospiral, New Delhi 110095, Maulana Azad Medical College and LNJPN Hospital, New Delhi 110002
[J Indian Med Assoc 2008; 106: 232-6]©
Dr. Ashok Koparday
MBBS, FC SEPI
Center for Therapy, Education, Research in
Sex, Marriage, Relationships
Ex. Teaching Faculty
Seth G. S. Medical College and K. E. M. Hospital and
Grant Medical College and Sir J. J. Group of Hospitals
University of Mumbai, India