Surgical Alternatives to Hysterectomy:

Myomectomy

A myomectomy surgically removes only the fibroids and leaves the uterus intact, often preserving fertility. Myomectomy may also help regulate abnormal uterine bleeding caused by fibroids. Not all women are candidates for myomectomy. If the fibroids are numerous or large, myomectomy can become complicated, resulting in increased blood loss. If cancer is found, conversion to a full hysterectomy may be necessary.

To perform a myomectomy, the surgeon may use a standard "open" surgical approach (laparotomy) or less invasive ones (hysteroscopy or laparoscopy).

• Laparotomy. Laparotomy uses a normal abdominal incision and conventional "open" surgery. It is used for subserosal or intramural fibroids that are very large (usually more than 4 inches), that are numerous, or when cancer is suspected. While complete recovery takes less than a week with laparoscopy and hysteroscopy, recovery from a standard abdominal myomectomy takes as many as 6 - 8 weeks. It also poses a higher risk for scarring and blood loss than with the less invasive procedures, a concern for women who want to retain fertility.
• Hysteroscopy. A hysteroscopic myomectomy may be used for submucous fibroids found in the uterine cavity. With this procedure, fibroids are removed using an instrument called a hysteroscopic resectoscope, which is passed up into the uterine cavity through the vagina and cervical canal. Standard resection uses an electrosurgical wire loop to surgically remove the fibroid.
• Laparoscopy. Women whose uterus is no larger than it would be at a 6-week pregnancy and who have a small number of subserous fibroids may be eligible for treatment with laparoscopy. As with hysteroscopy, thin scopes are used that contain surgical and viewing instruments. Laparoscopy requires only tiny incisions, and has a much faster recovery time than laparotomy.

Complications. The risks for myomectomy are generally the same of those for other surgical procedures, including bleeding and infection.

Recurrence of Fibroids. Myomectomy is not necessarily a permanent solution for fibroids. They can recur after these procedures.

Uterine Artery Embolization

Uterine artery embolization (UAE), also called uterine fibroid embolization (UFE), is a relatively new way of treating fibroids. UAE deprives fibroids of their blood supply, causing them to shrink. UAE is a minimally invasive radiology treatment and is technically a nonsurgical therapy. It is much less invasive than hysterectomy and myomectomy, and involves a shorter recovery time than the other procedures. The patient remains conscious, although sedated, during the procedure, which takes around 60 - 90 minutes.

The procedure is typically performed in the following manner:

• The patient receives a sedative to cause drowsiness, and a local anesthetic is applied to the skin around the groin.
• An interventional radiologist makes a small quarter-inch incision in the skin and inserts a catheter (a thin tube) into the femoral artery. The femoral artery is a large artery that begins in the lower abdomen and extends down to the thigh. The radiologist then threads the catheter into the uterine artery.
• Small plastic particles are injected into the artery. These particles block the blood supply to the tiny arteries that feed fibroid cells, and the tissue eventually dies.
• Patients usually stay in the hospital overnight after UAE and are given pain medication. Pelvic cramps are common for the first 24 hours after the procedure.
• It takes 1 - 2 weeks for the patient to recover from the procedure and return to work. It may take 2 - 3 months for the fibroids to shrink enough so that symptoms improve.

Effect on Fertility. In general, UAE is considered an option for only those who have completed childbearing. Although UAE may protect fertility in many women, the procedure does pose some risk for ovarian failure and infertility. The American College of Obstetricians and Gynecologists advises women who wish to have children that it is not yet known how this procedure affects their potential for becoming pregnant.

Complications. UAE has a lower rate of complication than hysterectomy and laparotic myomectomy and a shorter hospital stay. Compared to other procedures, women who have UAE miss fewer days of work. Serious complications occur in fewer than 0.5% of cases. Postoperative effects may include.

• Pain. Abdominal cramps and pelvic pain after the procedure are nearly universal and may be intense. Pain usually begins soon after the procedure and typically plateaus by 6 hours. On-demand painkillers may be required. The pain usually improves each day over the next several days. A low-grade fever is also common in the first week after the procedure.
• Fibroid slough. A small percentage of patients pass small fragments of fibroid tissue during the first few days after UAE. This can cause intense labor-like pain and also increase the risk for infection. Some women may need dilation and curettage (D&C) to make sure that infection does not develop.
• Early menopause. Most women who have UAE will continue to have normal menstrual periods. Some women, however, go through menopause after the procedure. Menopause is more likely to occur in women over age 45 who have UAE.

Success Rates. Studies on uterine artery embolization show high patient satisfaction (over 90%) and low complication rates. Uterine artery embolization is effective for a large majority of patients. However, some women may have fibroid recurrence and may need future procedures (repeat embolization or hysterectomy).

Some studies suggest that women with large fibroids are not good candidates for UAE.

Endometrial Ablation

Endometrial ablation destroys the lining of the uterus (the endometrium) and is usually performed to stop heavy menstrual bleeding. It may also be used to treat women with small fibroids. It is not helpful for large fibroids or for fibroids that have grown outside of the interior uterine lining. For most women, this procedure stops the monthly menstrual flow. In some women, menstrual flow is not stopped but is significantly reduced.

Endometrial ablation procedures use some form of heat (radiofrequency, heated fluid, microwave) to destroy the uterine lining. The procedure is typically performed on an outpatient basis and can take as few as 10 minutes to perform. Recovery generally takes a few days, although women experience watery or bloody discharge that can last for several weeks.

Endometrial ablation significantly decreases the likelihood a woman will become pregnant. However, pregnancy can still occur and this procedure increases the risks of complications, including miscarriage. Women who have this procedure must be committed to not becoming pregnant and to using birth control. A main concern of endometrial ablation is that it may delay or make it more difficult to diagnose uterine cancer in the future. [For more information, see In-Depth Report #100: Menstrual disorders.]

Magnetic Resonance Guided Focused Ultrasound (MRgFUS)

MRgFUS is a non-invasive procedure that uses high-intensity ultrasound waves to heat and destroy (ablate) uterine fibroids. This “thermal ablation” procedure is performed with a device that combines magnetic resonance imaging (MRI) with ultrasound. The Food and Drug Administration approved this device, the ExAblate 2000 System, in 2004.

During the 3-hour procedure, the patient lies inside an MRI machine. The patient receives a mild sedative to help relax but remains conscious throughout the procedure. The radiologist uses the MRI to target the fibroid tissue and direct the ultrasound beam. The MRI also helps the radiologist monitor the temperature generated by the ultrasound.

MRgFUS is appropriate only for women who have completed childbearing or who do not intend to become pregnant. The procedure cannot treat all types of fibroids. Fibroids that are located near the bowel and bladder, or outside of the imaging area, cannot be treated.

However, this procedure is new and long-term results are not yet available. Likewise, it requires an extensive period of time involving MRI equipment. Many insurance companies do not pay for this treatment.