An Overview in Gynaecologic Oncology
Uterine fibroids (also termed leiomyomas or myomas) are non-malignant uterine outgrowths that are commonly found in women's reproductive spells, which being benign neoplasms often lead to discomfort/pain and difficulties that require surgical treatment in some instances. This article delves into the various aspects of uterine fibroid surgery within the broader context of gynecologic oncology, offering insights into causes, symptoms, surgical options, risks, and advancements in treatment.
Understanding Uterine Fibroids
Uterine fibroids are derived from the smooth muscle component of the uterus (myometrium) and have considerable variability in size, number, and location. They are also categorised into three broad types according to their location -
- Submucosal Fibroids - It grows beneath the uterine wall and can extend into the intrauterine cavity.
- Intramural Fibroids - Form within the muscular wall of the uterus.
- Subserosal Fibroids - Involve outward growth of the outer surface of the uterus.
While the underlying cause of fibroids is unclear, hormonal imbalances (oestrogen and progesterone) as well as genetic susceptibility and obesity and diet have been suggested to play a role in fibroid formation.
When is Surgery Necessary?
Not all fibroids require surgical treatment, as many women with fibroids usually remain asymptomatic or have slight symptomatic fibroids that can be treated conservatively, but surgery becomes a viable option in the following conditions:-
- There is severe pelvic pain or pressure.
- Heavy and prolonged menstrual bleeding leads to anaemia.
- Fertility is affected by the extent and/or the location of fibroids.
- Rapid fibroid growth raises suspicion of malignancy.
- Non-surgical treatments fail to alleviate symptoms.
Types of Uterine Fibroid Surgery
There are a number of surgical approaches for treating uterine fibroids, which are adapted to the age of the patient, symptoms, the need to maintain future fertility, and general medical condition. Here are the primary types of surgeries:-
Myomectomy -
- A procedure to remove fibroids while preserving the uterus.
- Suitable for women who wish to retain fertility.
Approaches:-
- Hysteroscopic Myomectomy—administered vaginally by means of a hysteroscope; suited for Submucosal fibroids.
- Laparoscopic Myomectomy - Minimally invasive; involves small abdominal incisions.
- Open Myomectomy - Consumes a more extensive abdominal opening; employed in cases with multiple or large fibroids.
Hysterectomy -
- Meant forcomplete removal of the uterus.
- Suggested for women with refractory symptoms who have decided they no longer want to bear children.
Approaches:-
- Total Hysterectomy - Removes the uterus and cervix.
- Subtotal Hysterectomy - Removes the uterus but leaves the cervix intact.
- Radical Hysterectomy - Also involves transcervical uterine body, cervix resection, and a portion of the adjunctive tissues (occasionally required to treat fibroids, but also is useful in oncologic applications).
Uterine Artery Embolisation (UAE) -
- A non-operative technique of constricting blood supply to fibroids resulting in shrinkage of the fibroids.
- For women seeking an alternative to traditional surgery.
Radiofrequency Ablation (RFA) -
- Uses energy to destroy fibroid tissue.
- Minimally invasive and uterus-sparing.
Endometrial Ablation–
- Removes or destroys the uterine lining.
- Highly effective in treating heavy bleeding caused by fibroids, but not in women planning to have future pregnancies.
Risks & Complications of Surgery
Similarly to any surgical operation, uterine fibroid operations have some risk factors, such as:
- Bleeding—Excessive blood loss may occur, particularly in myomectomy.
- Infection - Postoperative infections are rare but possible.
- Adhesions - The formation of scar tissue can cause pelvic pain or problems getting pregnant.
- Damage to Surrounding Organs - As rare event complications, there is injury to the bladder, bowel, or blood vessels.
- Recurrence - Fibroids can recur after myomectomy in some cases.
- Anaesthesia Risks - General anaesthesia carries its own set of potential complications, including allergic reactions.
Advancements in Surgical Techniques
Gynaecologic oncology has undergone major change in the management of uterine fibroids in the operating room, improving its outcomes and reducing complications. Some noteworthy developments include:-
Robotic-Assisted Surgery -
- Higher accuracy and dexterity than the conventional laparoscopic approach.
- Offers shorter recovery times and less postoperative pain.
Minimally Invasive Techniques -
- Minimally invasive (laparoscopic, hysteroscopic) procedures lead to shorter hospitalisations and earlier return to normal activities.
Enhanced Imaging Modalities-
- Better preoperative imaging, e.g., MRI-guided surgery, enables precise identification of the fibroids and modulated interventions for their removal.
Emerging Therapies -
- Focused ultrasound surgery (FUS) and other noninvasive procedures are being considered as viable replacements.
Postoperative Care & Recovery
- Hospital Stay - Minimally invasive surgery is commonly associated with same-day discharge, whereas open surgery may lead to 2-3 days of hospitalisation.
- Activity Restrictions - Patients are also recommended not to engage in heavy lifting and vigorous physical activity for 4-6 weeks.
- Follow-Up - Follow-up visits are important to check the recovery and diagnose any complications.
- Emotional Support - Surgery, especially hysterectomy, can be emotionally challenging. Psychological support and counselling may benefit some patients.
Uterine Fibroids & Cancer
Though fibroids are benign, their presence in the field of gynaecologic oncology underscores the importance of ruling out malignancy. Rarely, fibroids can mimic or coexist with uterine sarcomas, a form of uterine cancer. Excisional surgery enables the histopathological analysis for confirming accurate diagnosis.
Lifestyle Modifications and Preventive Strategies
Although surgery is a useful way of treating fibroids, a good healthy lifestyle can mitigate the chances of fibroids' development/recurrence. Strategies include -
- Moderating diet of fruits, vegetables, and whole grains
- Engage in regular physical exercise for weight control and hormonal therapy.
- Limiting alcohol and caffeine consumption.
- Regular gynaecologic check-ups to detect fibroids early.
Conclusion
Uterine fibroid surgery is a cornerstone of gynaecologic oncology, offering relief to women suffering from debilitating symptoms. Treatment can be tailored by combining a spectrum of surgical approaches, from conservative myomectomy to radical hysterectomy, based on individual preference and goals. Improvements in minimally invasive techniques and also in image guidance have transformed the management of fibroids, providing safer treatment interventions with a concomitant accelerated recovery.
With ongoing research progress, the future of uterine fibroid surgery holds even better accuracy and patient satisfaction. Gynaecologic symptoms should be discussed with an experienced gynaecologic oncologist to discuss all options and make an informed decision on behalf of health.