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Patients should understand risks in uterine fibroid surgery

Women dealing with problems from uterine fibroids should be informed of recent developments in screening and surgical procedures for treatment. In response to an April 2104 notice from the FDA over a common surgical technique, gynecologist associations are working to raise awareness and deepen research on the issue so that patients can make informed choices on their options.

What are uterine fibroids?

Uterine fibroids are benign tumors that grow in the smooth muscles of the uterus.  Many women have them (the lifetime risk for a woman to develop uterine fibroids is between 40 and 70 percent) but don’t realize it.  Symptoms of uterine fibroids include pain, irregular or abnormal bleeding, and pressure on adjacent organs that can cause bladder issues or painful bowel movements.  Some fibroids can be treated with medication. More advanced cases may require surgical treatment.

How has the surgical treatment of uterine fibroids changed?

“Forty years ago the way to treat fibroids was to make an incision – like a C-section or an up and down incision – and most of the time, remove the uterus,” said Dr. Richard Farnam of the Texas Urogynecology and Laser Surgery Center. “If you were younger and wanted to preserve reproductive ability you might wait, but that wasn’t the best option because fibroids can interfere with fertility.”

Another procedure available was the open myomectomy, which also involves a large incision for a surgeon to remove the fibroids and leave the uterus. But, because of an increased risk of blood loss and other complications, this procedure requires a surgeon with advanced skill. Many physicians who lack experience performing myomectomies often opt to perform complete hysterectomies.

Laparoscopic hysterectomy was introduced in 1989 and led to more minimally invasive procedures for the treatment of uterine fibroids, which have led to less blood loss, shorter hospital stays and a quicker return to normal activities.

“It was a huge win because now women wouldn’t have to have a two month recovery and they could be back to work in two weeks,” Farnam said.

For the last 20 years, hundreds of thousands of women have benefited from surgical alternatives to open abdominal hysterectomy, with a lower risk of complication and death. Robotic options like the da Vinci system help surgeons operate through small incisions, similar to traditional laparoscopy, with  increased precision and minimal scarring. Minimally invasive procedures can include myomectomy, which removes fibroids and leaves the uterus intact, or several types of hysterectomy.

When fibroids or the uterus are too large to remove vaginally, a surgical technique called  laparoscopic power morcellation mechanically fragments the tissue to facilitate removal. The U.S. Food and Drug Administration (FDA) approved the first electromechanical morcellation device in 1995.

Understanding risks and benefits of Open Power Morcellation in treating uterine fibroids

While thousands of women benefit from minimally invasive surgery for fibroids, the use of power morcellation to fragment tissue specimens should only be considered in women at low risk for malignancy after a thorough assessment, according to the American Association of Gynecologic Laparoscopists.

The FDA in April issued a notice discouraging the use of power morcellation due to the risk of spreading  undiagnosed cancerous tissue, which could accelerate the disease. However, several major gynecological  associations cautioned that not allowing the technique could eliminate safer alternatives to open abdominal hysterectomy for women with benign tumors. The American  Congress of Obstetricians and Gynecologists warns that patients who undergo abdominal hysterectomy have three times the risk of mortality than those who have laparoscopic hysterectomy.

At issue is the weak data available for determining the risk of uterine leiomyosarcoma (uterine muscle wall cancer).  Most  endometrial and cervical cancer cases can be diagnosed with imaging and endometrial sampling before surgery. However, uterine leiomyosarcoma is rare, aggressive and difficult to detect. Estimates of risk range from 1 in 1,000 to 1 in 350 based on limited studies.  Also of concern with the use of the device is the dissemination of benign tissue or injury to nearby organs, such as the bowel.  This is why it is important to know your doctor’s training and skill because a higher volume of experience performing advanced surgeries is linked to better outcomes.

In response to the FDA advisory, several medical organizations have issued statements calling for improved research, such as a national registry, to better assess risk and to improve surgical techniques and tools, such as improved imaging studies.

“We should take heed and work on improving the technology for diagnosis and treatment,” Dr. Farnam said, “But we should not abandon a highly effective surgical technique and put more women at risk.”

Learn about your options for uterine fibroid treatment

If you are a candidate for fibroid surgery, it is important to communicate with your doctor. Your physician should be committed to providing safe, high-quality care and be able to provide you with the latest information on this topic.

  • Choose a surgeon with a large amount of experience to determine what the appropriate treatment is for you – which sometimes is open surgery.
  • Be aware of the risks and pick a surgeon with the most experience. You deserve to know what your risks are, and you deserve to be informed of all the options to help make your decision.

 Assessing risk

Uterine sarcomas are rare and difficult to detect.  You should talk with your doctor about any symptoms, such as abnormal bleeding or discharge, which are usually caused by other conditions. 

Other procedures to help in evaluation:

  • Endometrial biopsy – performed in-office before surgery removes a bit of endometrium for examination under a microscope to see if cancer is present. Unfortunately, the fibroid is inaccessible in most cases because it is buried in the uterine wall, so it can’t usually be biopsied.
  • Hystereoscopy - examining the uterus and removing polyps for sampling.
  • Blood tests for signs of cancer.
  • Imaging Studies - Magnetic resonance imaging (MRI) may be helpful in some cases, but  it doesn’t provide a definitive diagnosis.

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Categories: Minimally Invasive Surgery

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