Herbert A. Goldfarb, MD

More than 99 percent of fibroid tumors of the uterus are         benign, and most require no treatment. However, if these growths get         very large, they can become uncomfortable, enlarge the abdomen and bring         on loner, heavier menstrual periods. Even some tiny fibroids can cause         abnormal bleeding. Until recently, a woman with troublesome fibroids         almost always ended up with a hysterectomy.         

Most women don't know they have fibroids until a gynecologist make         the discovery in a routine pelvic examination. However, fibroids are         very common: About 25 percent of women over 35 have them. Fibroids range         in size from microscopic to giant masses that fill the pelvis and         abdominal cavities." explains Charles M. March, M.D., professor of         obstetrics and gynecology at the University of Southern California         School of Medicine. No one knows what causes hem, but they seem to need         estrogen to grow." Since the fibroids usually shrink after         menopause, when estrogen production declines, many doctors advise         against treatment when a women is approaching menopause.

While hysterectomy has been the most commonly performed treatment for         troublesome fibroids, occasionally an abdominal operation, called         myomectomy, is done to remove just the fibroids, leaving the uterus         intact. Traditionally, myomectomy has been reserve for young women who         have not had children or for those who have trouble conceiving because         fibroids obstruct the path sperm must travel to meet the egg.

The good news is that new treatments for fibroids may mean fewer         hysterectomies. These include some new drugs which can shrink fibroids,         at least temporarily. One, Lupron, suppresses estrogen production, thus         depriving fibroids of the hormone that seems to nourish them.         Unfortunately, Lupron causes hot flashes, vaginal dryness and more         seriously, bone loss that lead to osteoporosis. Because the of the bone         loss, you cannot take Lupron indefinitely; once you stop, the fibroids         begin to grow. Another disadvantage; Lupron must be given by injection.         Still, the drug is useful since shrinking fibroids prior to surgery make         myomectomy more feasible.

Doctors can now remove small fibroids that are the source of bleeding         problems with the aid of the hysteroscope-resectoscope, an instrument         that is inserted into the uterus via the vagina. Using this instrument,         doctors can examine the inside of the uterus and excise these small         fibroids.

The surgery takes about 30 minutes and can be done on an outpatient         basis. A hysterectomy usually requires spending five to seven days in         the hospital and six weeks recuperating at home. So far, the new         procedure is routinely available only at a few major medical centers in         big cities but most gynecologists can arrange it for any woman who         requests it.

Another surgical innovation, called myoma coagulation, spares the         patient major surgery and works on the theory that fibroids need         estrogen and constant supply of blood to survive. "Cutting off         these two vital elements will cause a fibroid to wither and die,"         explains Herbert A. Goldfarb, M.D., director of the Department of         Gynecology at Montclair Community Hospital in N.J., who pioneered the         method. This strategy first requires three of four monthly injections of         Lupron to shrink the fibroids. Then, a small incision is made in the         abdomen to permit insertion of a laparoscope, a long, thin instrument         with a tiny viewing scope and laser attachment. The laser pierces the         fibroid to destroy its blood vessels.

Because long-term effects on fertility are not known, myoma         coagulation is considered suitable only for women in their forties who         don't want more children and whose fibroids are less that 10 centimeters         in size. Myoma coagulation, done as an outpatient procedure, is now         generally available.

The laparoscope also enables surgeons to remove small fibroids not         accessible via the hysteroscope. Because the required incision is so         small, women usually spend only one night in the hospital.

Removing large fibroids still requires major surgery, however there         is no limit to the size or number of fibroids that can removed via         myomectomy. However, because this operation often entails blood loss         that may require multiple transfusions, many doctors opt of hysterectomy         when fibroids are very large.

Dr. Herbert A. Goldfarb is the         director of the 

 and an advocate of         alternative solutions to hysterectomy.

Articles

More than 99 percent of fibroid tumors of the uterus are benign, and most require no treatment. However, if these growths get very large, they can become uncomfortable, enlarge the abdomen and bring on loner, heavier menstrual periods. Even some tiny fibroids can cause abnormal bleeding. Until recently, a woman with troublesome fibroids almost always ended up with a hysterectomy.

Curing Fibroids Without Hysterectomy

Before the advent of laparoscopy, uterine fibroids were often removed by surgical hysterectomy. The author describes a number of alternative treatments, including GnRH agonists and laparoscopic coagulation with the Nd:YAG laser and bipolar needles.

Over 80% of women between 30 and 50 years of age have uterine fibroids. Depending on their size and location, fibroids can be completely asymptomatic or can cause pelvic pain, dyspareunia, pressure, urinary problems, and recurrent menorrhagia. In general, the larger the fibroid, the more severe the symptoms. Abnormal bleeding is usually caused by fibroids adjacent to the uterine cavity. Patients who have smaller serosal fibroids may be completely asymptomatic or report only one symptom. Less than 1% of fibroids are malignant, and, unless they affect the patient's quality of life, there's no need for treatment.

Medical therapy may be the best way to treat fibroids causing symptoms in premenopausal women. Synthetic gonadotropin-releasing hormone (GnRH) agonists inhibit estrogen production, causing, the uterine cavity to shrink by 36% within a few months. Fibroids may be reduced by 38% to 90% of their original size. Although these results are impressive, long-term estrogen suppression can cause bone loss. Also, GnRH agonists cannot be taken orally; a long-acting version of the drug requires injection. The drug is expensive and there's no guarantee of continued protection after treatment is stopped. Indeed, fibroids usually return to their original size within 4 months.

Surgical therapy usually involves myomectomy or total abdominal or vaginal hysterectomy (Fig. 2). Some investigators, such as Camran Nezhat, MD, Mercer University, Atlanta, and Harry Reich, MD, The Graduate Hospital, Philadelphia, recommend laparoscopic myomectomy, which requires advanced pelviscopic skill. Selecting the appropriate treatment is controversial. Abdominal or vaginal myomectomy is recommended for women under 40 years of age who wish to have children, and total vaginal or abdominal hysterectomy is suggested for women who have completed their families.

Fibroid uterus is the most frequent diagnosis leading to hysterectomy; this accounts for 37% to 62% of all US hysterectomies performed annually. Out of the estimated half-million hysterectomies performed annually in the US, the overall mortality rate is 12 per 10,000. Major complications, often include wound infection; postoperative bleeding; transfusion; ureteral, bladder, and bowel injuries.

There are several new operative techniques that don't require major surgery. Laparoscopic myoma coagulation - myolysis is an alternative to myomectomy. This procedure can be combined with endometrial ablation for patients who have persistent uterine bleeding. Laparoscopic myomectomy is another alternative to hysterectomy.

Laparoscopic coagulation uses the Nd:YAG laser or bipolar needles (Reznik Instrument Co., Skokie, Ill., and J.E.M. Davis, Hicksville, N.Y.) to degrade myometrial stroma, denature protein, destroy vascularity, and substantially shrink fibroids. We use 50 to 70 W of continuous, pure cutting power with the Nd:YAG laser to repeatedly pierce and coagulate the fibroid, desiccating a cone of vasculature approximately 3 to 5 mm in diameter around each puncture point. Repeated puncturing effectively destroys the fibroids. We've tried using monopolar electrodes, but consider bipolar current safer. Unipolar energy may increase the size of the holes, but it doesn't increase the efficiency of the energy delivered to the fibroids.

Future research may show that this technique may be used in women who want to maintain fertility, but current experience is based only on women who have completed their families. Anecdotal evidence suggests that myometrial necrosis is counterproductive to childbearing.

In the hundreds of procedures I've performed, and in those performed in Europe, there have been no side effects. Compared with hysterectomy, which requires 5 to 6 weeks recovery, patients are discharged the same day and can return to work within 4 or 5 days. Because the uterus is left intact, hormonal and sexual function is preserved. After following these patients for up to 8 years, we have seen no regrowth of fibroid tumors. This treatment is successful for both serosal and subserosal fibroids and is recommended for women who have symptomatic fibroids that measure 10 cm or less.

Hysteroscopy, endovaginal ultrasonography, computerized axial tomography, and magnetic resonance imaging will allow you to visualize the interior of the uterine cavity accurately. By evaluating the uterine cavity, you can determine the size, shape, and position of any fibroids. If a myoma is asymptomatic and measures less than 5 cm in diameter, I recommend watchful waiting. However, when a fibroid measures 5 cm or more and continues to grow, I usually recommend a course of action.

Before treatment, always perform a pelvic examination including ultrasound examination to determine the size and location of the fibroid. If it measures 10 cm or less and responds to treatment with GnRH agonists, you may consider laparoscopic coagulation. Hysteroscopy with endometrial biopsy will help you identify submucosal and intrauterine fibroids, and rule out endometrial hyperplasia and premalignant or malignant conditions. Because the procedure shrinks the uterine cavity and may leave adhesions, it should be performed only on women who are no longer interested in conception.

To maximize fibroid shrinkage before laparoscopic surgery, I suggest pretreating patients with depot leuprolide acetate, a synthetic pituitary hormone. A monthly injection (3.75 mg) given at the onset of menses for at least 3 months will reduce estrogen production and promote fibroid atrophy.

Laser coagulation proceeds as follows: To begin, inject 5 mL to 10 mL of 10% vasopressin solution directly into the serosa of the uterine fibroid to eliminate hemorrhagic diathesis. It is critical to measure the desired depth of penetration that will thoroughly coagulate the myoma. By placing the Nd:YAG laser fiber against the fibroid, you will be able to visualize it in relation to the surrounding tissue. After determining the desired depth of penetration, puncture the fibroid contiguously using a drilling technique.

To totally coagulate the fibroid, repeat drilling with the bare fiber tip at multiple, concentric sites. Fluid may bi used to cool the fiber tip. Because each puncture coagulates a diameter of 5 mm surrounding the puncture, it takes ten punctures per diameter, or a total of 50 to 75 punctures, to totally coagulate a 5-cm fibroid. The coagulation dispersion of the Nd:YAG laser fiber at 5-mm intervals creates a contiguous core of coagulation.

To protect the rectum, bladder, and uterine blood vessels, it is extremely important to visualize the fibroid's posterior surface during the entire procedure. A uterine grasper inserted through the suprapubic puncture will elevate the uterus and help protect against posterior perforation of the rectum. I suggest a suprapubic steerable laser probe to obtain right-angle punctures for an anterior fibroid; for a posterior fibroid, you can achieve a horizontal approach by using an operative laparoscope with a 50-cm guide. The entire procedure takes about 25 to 30 minutes. In my experience, minimal - if any-bleeding - has occurred and transfusions haven't been necessary. After 4 hours of recovery from anesthesia, the patient is discharged.

We've performed over 800 procedures without any serious complications. One patient developed symptoms of fibroid degeneration and was treated successfully with analgesics, bed rest, and tetracycline. We follow up all patients with endovaginal ultrasound. There has been no residual fibroid exceeding 5 cm, and, since October 1990, no patient has exhibited any fibroid regeneration nor required a second procedure.

 Because many hospitals do not have access to an Nd:YAG laser, we have developed a bipolar needle instrument. Laparoscopic coagulation of subserosal fibroids using a newly developed bipolar needle produces the same effects as the Nd:YAG laser. The bipolar instrument has two, 5-cm steel needles connected to a standard bipolar generator that procluces 70 to 120 W. Two forms of bipolar needles have been used to puncture uterine myomas and obtain multiple cores of coagulation: a 30-cm instrument with a 5-mm probe, and a 45-cm probe attached to the operating laparoscope, which provides a horizontal approach for posterior fibroids. When placed through a 5-mm suprapubic puncture, the bipolar needles develop a core of coagulation and effectively destroy the vasculature of the uterine myoma (Figure 4). After the tissues are lavaged, there is minimal bleeding. Using this technique, a 7-cm myoma can be thoroughly coagulated in 20 minutes. After 18 months, we have seen fibroid reduction comparable with that achieved by laser laparoscopic coagulation.

When patients are treated with depot leuprolide, fibroids are reduced to about 20% to 50% of pretreatment size. Laparoscopic coagulation reduces fibroid size by another 50%. For example, an 8-cm myoma reduced to 4 cm before the procedure, typically measures 2 cm at 2 months after myoma coagulation (Tables 1 and 2). We perform vaginal ultrasound after 6 months, 1 year, and 2 years and have seen no uterine or myoma regrowth.

A majority of our patients afflicted with fibroids also have persistent uterine bleeding. We treat these patients with a combination of myoma coagulation and endometrial ablation. Good candidates for endometrial ablation are women who have persistent abnormal uterine bleeding whose preoperative uterine size measures between 5 cm and 10 cm. You can use the Nd:YAG laser for endometrial ablation, but it has a small field of focus, requires at least I hour to ablate a small uterus, and it costs the hospital more than $100,000. Ablation can also be performed with a continuous flow resectoscope fitted with a roller-bar electrode at 75 to 100 W of coagulating current (some physicians recommend cutting current). Results with the roller electrode are comparable with those achieved by the Nd:YAG laser.

To dilate the cervix, insert laminaria tents the night before surgery. This dilation prevents cervical spasm during the procedure, facilitates the insertion of a 27F-continuous flow resectoscope, and allows fluid to circulate easily, thus preventing excessive intrauterine pressure and fluid absorption. The loop electrode is used to shave intercavity or submucosal fibroids, Once this is accomplished, use the roller-bar electrode to coagulate the entire uterine cavity. Combining this technique with myoma coagulation allows you to treat serosal and submucosal fibroids simultaneously.

The results of endometrial ablation with the Nd:YAG laser or roller-bar electrode show that uterine hemorrhage is controlled in 95% of patients and uterine size is reduced more than 50%. Amenorrhea rates vary, depending on the technique used and the size of the uterine cavity. In patients whose preoperative uterine cavity measures 7 cm or less, amenorrhea rates are about 60%. This rate decreases to 30% when the uterine cavity measures between 10 cm and 15 cm (Tables 3 and 4). Since October 1990, when we performed the first myoma coagulation procedure in the US, we have seen no recurrence of abnormal uterine bleeding nor has any patient required a second procedure.

Although evaluation is necessary to confirm long-term fibroid suppression (more than 2 years), the immediate benefits of the Nd:YAG laser and bipolar needles include same-day surgery, avoidance of hysterectomy, and elimination of abnormal bleeding.

Abdominal myomectomy is considered a complicated procedure because of technical difficulties inherent in removing large fibroids from the abdominal cavity, controlling bleeding, and suturing the uterine defect. GnRH analogs are used preoperatively to reduce fibroid size and vascularity, and eliminate the need for transfusion. Laparoscopic myomectomy is a relatively new technique that treats symptomatic fibroids and avoids the complications associated with laparotomy and hysterectomy. This technique should be performed by advanced pelviscopic surgeons who have mastered techniques of laparoscopic suturing and tissue removal.

When fertility is an issue, we restrict laparoscopic myomectomy to pedunculated and superficial serosal fibroids, and those in which the uterine cavity is not compressed. Because of the potentially destructive impact on the uterine cavity, I don't recommend laparoscopic myomectomy for deep intramural fibroids in women who want to have children. The experience of the operator, blood loss, and safety are the criteria that determine the appropriateness of the procedure when fertility isn't an issue.

Before laparoscopic myomectomy, perform an endometrial biopsy and a diagnostic hysteroscopy to evaluate the uterine cavity. Exclude women with malignant or premalignant conditions. Pretreatment with leuprolide therapy for 3 to 5 months will shrink fibroids by 30% to 50%.

First, inject the fibroid with 5 mL to 10 mL 10% vasopressin solution of vasoconstriction. We inject the fluid immediately under the serosa. We incise the fundus of the uterus in the anterior-posterior plance, using a knife electrode at 100W of cutting power. A suction lavage instrument helps evacuate smoke as well as prode adequate lavage. A 1-mm corkscrew is inserted into the fundus of the the myoma to aid in the dissection process. As soon as a bleeding point is found, we coagulate it with the knife electrode, using 100 W cutting power. This power level provides effective cutting as well as excellent coagulation.

The combination of the knife electrode, the suction lavage instrument, and the corkscrew allow adequate dissection of the fibroid. Be careful to keep the knife electrode away from the intestines, and use caution when cutting. We repeat this dissection procedure until the root of the fibroid is exposed and can be incised. After the excess blood is suctioned and the tissue thoroughly lavaged, we coagulate oozing points, and then place the myoma in the cul-de-sac.

In the past, we performed suturing intracorporeally by stitching the wound inside the abdominal cavity. Because this was time consuming and awkward, we now use an extracorporeal suturing technique, which shortens the procedure considerably.

Using a .00 PDS CT.2 needle placed through a 10-mm trocar, we position the needle inside the abdomen with the help of two needle-holders. One needle-holder (Wolf Castroviejo) is placed through the 10-mm trocar and is used to grasp the needle; the other needle-holder is used for manipulation. After suturing, we withdraw the needle through the 10-rnm trocar. We tie the knots extracorporeally in a double surgeon's knot and use a knot-pusher to secure them. Three knots are made for each suture before cutting. This process is repeated as often as necessary to adequately close the uterine defect. Bleeding is minimal and there has been no need for transfusion. The area is then thoroughly lavaged.

To remove the myoma from the abdominal cavity, we expand the trocar to 20 mm, using the Semm tissue removal system. The procedure requires 30 to 40 minutes for a large myoma, and is an alternative to colpotomy, which is also an effective method of removal. Once the myoma is completely removed, tissues are thoroughly lavaged with 2,000 mL to 8,000 mL of warm lactated Ringer's solution. Another 1,500 mL of Ringer's irrigation are left in the pelvic cavity for hydroflotation and adhesion prevention. It is very important to close the fascia and peritoneal surfaces of the trocar sites of 10 mm or more so that a loop of intestine cannot isolate itself. This entire procedure can be successfully completed in approximately 2 hours and provides an excellent, but highly technical, alternative to open abdominal surgery.

The use of hysterectomy to treat myomatous conditions in post-reproductive women is no longer acceptable to increasing numbers of patients. Learning these alternative laparoscopic options requires diligence and dedication, but allows us to provide patients with alternatives to major surgery.


Dr. Herbert A. Goldfarb M.D. F.A.C.O.G. F.A.C.S.
The Montclair Reproductive Center
29 The Crescent
Montclair, New Jersey 07042
973-744-7470

For the New York Office call (212) 585-4400



 is a full-service gynecological and reproductive center specializing in the treatment of women's disorders where caring goes hand-in-hand with treatment. Queries may be faxed to the Montclair Reproductive Center at 973-744-1274 or phone us at 973-744-7470.

Hysterectomy is no longer the only treatment for uterine fibroids. Now, GnRH agonists and laparoscopic coagulation with lasers and bipolar needles are treatment options.

Removing Uterine Fibroids Laparoscopically

From the Montclair Reproductive Center, Department of OB/GYN,         Mountainside Hospital

Approximately 750,000 hysterectomies are performed         annually in the United States, with a mortality rate of about 12 per         10,000 operations.1 Costs to consumers and insurers have been estimated         at approximately $1.7 billion per year.2 Thus, alternative procedures         that are safer and less invasive, preserve the uterus, and cost less are         increasingly in demand. In recent years, several such techniques have         been introduced.         

Endometrial ablation was first performed in 1981 by Goldrath and         colleagues, using the Nd:YAG laser.3 Vancaille subsequently published a         report of rollerball ablation in 1989.4 Amenorrhea rates following         ablation have been 25 to 84%,3,5-14 with patient satisfaction reported         at up to 80% after 1 year.6,7,15 However, a study by Unger and Meeks16         indicated that as many as 34% of women required hysterectomy within 5         years of ablation, a number that increased with time. A recent report by         Martyn and Allan17 on long-term follow-up of 301 patients having         endometrial ablation revealed that after 5 years 27% had required         further surgery because of bleeding, and 38% because of pain.

In 1990, the author first reported the technique of myoma coagulation         (myolysis) in the United States.18 It was combined with endometrial         ablation in patients who had symptomatic fibroids and also exhibited         excessive and recurrent uterine bleeding refractory to medical therapy.         The procedure was first performed with the Nd:YAG laser,19 but in 1992         the technique was altered by the use of a 5-cm modified bipolar needle         (B. Resnick & Company, Skokee, IL, and J.E.M.D. Medical, Hicksville,         NY) to pierce the myoma, using bipolar current at 50 to 75 watts.20

Patients in this study were selected from the author's private         practice, and complained of abnormally heavy, recurrent uterine         bleeding. All wished to preserve the uterus, and most had uterine         fibroids. Those presenting between 1986 and 1990 (Table 1) were         considered for ablation with or without resection, while those seen         between 1990 and 1995 were offered the same procedure with the addition         of myoma coagulation. Otherwise the two groups were entirely         homogeneous.

All women were given a preoperative evaluation consisting of medical         history, physical and pelvic examination, as well as abdominal and         vaginal ultrasound scan, endometrial biopsy, and hysteroscopy to         determine uterine pathology.21 Patients were considered surgical         candidates if the biopsy revealed no hyperplastic tissue, if fibroids         measured no more than 10 cm, and if they were premenopausal.

Women meeting these criteria and providing informed consent were         given a trial of gonadotropin-releasing hormone (GnRH) agonist in depot         form 10 to 14 weeks prior to surgery as a therapeutic test. Surgery was         conducted only on those having a good response to the GnRH agonist         (i.e., symptoms disappeared and myoma volume was reduced 30 to 40%).

Various endometrial ablation techniques were employed, including the         Nd:YAG laser and the resectoscope; these have been described         elsewhere.6,22 Myoma coagulation was performed using either the Nd:YAG         laser or bipolar needles, as previously described.20,23,24 Resection of         submucosal myoma was also performed as previously described.10

Amenorrheic patients were encouraged to return yearly for vaginal         ultrasound, to ensure that hematometra was not present. Patients who did         not return at least twice postoperatively were considered lost to         follow-up.

The primary end point of this study was adequate relief of symptoms         following the initial procedure. In addition, menstrual outcome and         complication rates were assessed in both groups.

These 52 patients were followed for an average of 47 months (range, 2         to 105 mo). Mean age at the time of surgery was 43.5 years, and mean         parity was 1.87 children. Postoperatively, 19 women (36%) became         amenorrheic, and 12 (23%) had bleeding within the normal range. Thus,         59% experienced improvement in bleeding severity. However, 20 women         (38%) developed heavy bleeding during the period of observation, and         required subsequent surgery, five of them (9.6% of the total) undergoing         hysterectomy.

Serious complications were experienced by four patients (7.7%),         including: pulmonary congestion, hyponatremia, and degenerating myoma;         fever, endometritis, and bleeding at 1 month postablation; uterine and         intestinal perforation secondary to attempted fundal submucosal         resection early in the series (repaired by laparotomy); and peritonitis,         hyponatremia, fluid overload, and pleural effusion. One woman became         pregnant 17 months after surgery.

These 116 patients were followed for a mean of 25 months (range, 4 to         65 months). Mean age at the time of surgery was 45 years, and mean         parity was 1.35 children.

Following surgery, 55 women (47%) were amenorrheic, 51 (44%) had         normal menstrual levels, and 10 (8.6%) had continued heavy bleeding. In         all, 16 (13.8%) elected to undergo subsequent procedures due to         inadequate control of symptoms with myoma coagulation plus endometrial         ablation. Six of these 16 women (5.2% of the total) underwent         hysterectomy. The other procedures included one case each of         laparoscopic myomectomy; myomectomy performed hysteroscopically to         remove a prolapsed fibroid; hysteroscopy and lysis of adhesions; repeat         ablation, laparoscopic myomectomy, and bilateral salpingectomy for myoma         degeneration and continued heavy bleeding; repeat endometrial         coagulation and hysteroscopic resection of a submucosal leiomyoma; and         five cases of repeat ablation due to pain, hematometria, and/or fibroid         growth.

Volumetric analysis was performed in 43 patients (37%). In 30 of         them, preoperative fibroid size ranged from 12 to 630 cm3 with a mean of         230 cm3 and a median of 205 cm3. Following treatment with the GnRH         agonist and surgery, fibroids ranged in size from 3 to 483 cm3, with a         mean and median of 103 and 81 cm3 respectively. The 30 patients         experienced an average 54.5% reduction in fibroid size, with half the         group having a shrinkage of at least 68%.

Complications occurred in 16 of the 116 women (13.8%) and included         one case each (0.8%) of pelvic infection, uterine perforation, bladder         perforation, bacteremia, and fibroid prolapse; two cases (1.7%) of         urinary tract infection; four cases (3.4%) of fever; and five cases         (4.3%) of hematometra.

The incidence of hysterectomy in the ablation alone group (5 of 52 =         9.6%) was somewhat higher than that in the myolysis group (6 of 116 =         5.2%). When all subsequent surgical procedures including hysterectomy         were evaluated, the incidence in the ablation group (20 of 52 = 38%) was         significantly higher than that in the myolysis-ablation group (16 of 116         = 13.8%) (X2N = 116 = 13.84 p < 0.01).

Survival analyses were carried out for both possible end points:         hysterectomies (Table 3), and subsequent surgical procedures (Table 4),         in order to observe the yearly incidence rates, and to determine if         there were differences between them. The incidence of hysterectomies in         the ablation-only group appeared to be fairly uniform over the first 4         years, at roughly 4% yearly. The rates in the myolysis-ablation group         also appeared quite uniform, at about 2.5% yearly.

When Life Table analysis was carried out using all subsequent         surgical procedures as the end point (Table 4), the difference between         ablation alone and myolysis-ablation was striking. For ablation only,         the yearly rate was roughly 10% for at least 9 years, whereas for         myolysis-ablation the yearly rate was only 3% for the first 3 years.         These analyses correct for length of participation, and confirm that the         difference between ablation only and myolysis-ablation is significant (p         < 0.05).

In a series of 52 patients who underwent ablation alone, 38% required         at least one repeat surgery. The hysterectomy rate was 9.6%. The length         of follow-up available for the myolysis group is 6 years, and if data         for the ablation-only group are considered only for the same 6-year         period, just three women had hysterectomy beyond the sixth year. The chi         square analysis remains unchanged, however, with the significance still         < 0.05.

In a similar series of patients treated with rollerball ablation by         Unger and Meeks,16 some 14 of 41 women (34%) underwent hysterectomy         within 5 years of the surgery. (No other type of repeat surgery was         permitted by their study protocol.) They reported that the decision for         hysterectomy following ablation was associated with continued abnormal         bleeding and menstrual pain as well as gross abnormalities such as         uterine myoma. Seven (70%) of 10 women with severe menstrual pain and         probable adenomyosis underwent hysterectomy. It should also be noted         that all 14 of the women who had hysterectomy had significant pelvic         disease; 10 had myoma, adenomyosis, or endometriosis. Additionally,         Unger and Meeks reported a linear relationship between hysterectomy and         time, projecting that all of their ablation patients would undergo         hysterectomy within 13 years of the initial procedure.

A comparison of the current data with those of Unger and Meeks is         provided in Table 1. In the current series, the majority of women         undergoing ablation and all of those in the myolysis group had uterine         fibroids. Resection was performed when submucosal myomas required         significant resculpturing of the endometrial cavity.

An important point to consider is the motivation of the patient and         the physician. Those women with continued abnormal bleeding usually had         migration of intramural or submucosal myomas to the uterine or         submucosal areas. In the current study, these patients were offered         repeat ablation or resection and even myomectomy as an alternative to         hysterectomy, and were encouraged to choose whichever one they         preferred. This contrasts with the series by Unger and Meeks, in which         only hysterectomy was offered as a second procedure.

Those authors also noted that because the uterine cavity may be         scarred by the procedure and no longer patent with the vagina, any         subsequent menstrual flow may be forced into the fallopian tubes,         causing pain and endometriosis. In this study, cavity patency was         maintained by performing an endometrial endosuction 1 month after         surgery; also, amenorrheic patients were followed with yearly vaginal         ultrasound examinations to ensure that hematometra had not developed.

A comparison of our data across patient groups reveals that the         addition of myolysis to ablation increased the rate of postsurgical         amenorrhea from 36 to 47% and reduced the rate of continued heavy         bleeding from 38 to 8.6% (Table 2). Second procedures including         hysterectomies were reduced from 38 to 13.7%, and the hysterectomy rate         from 9.6 to 5.2%.

Although ablation as a single procedure was performed several years         earlier than the combination, patients appeared to be fairly well         matched with regard to demographic variables. It should be noted that a         variety of techniques was used in performing ablation, and that two         different techniques were used in performing myoma coagulation. In         addition, duration of follow-up varied across the two patient groups.

This article represents the author's experience with several recently         developed surgical techniques that are successful in relieving symptoms         related to leiomyomas and menorrhagia, while leaving the uterus in place         and reducing recovery time.

Physicians should note that myolysis performed on an extremely         enlarged uterus (fibroids >10 cm or 14 weeks gestation) is unlikely         to succeed. Similarly, myolysis probably will not have a satisfactory         outcome in patients with disseminated leiomyomatosis. Endometrial         ablation alone should be reserved for those women with persistent         abnormal bleeding refractory to medical therapy and who are without         significant fibroids or adenomyosis; submucosal and intrauterine myomas         must be identified and resected. The addition of myolysis to endometrial         ablation or resection in patients with fibroid tumors markedly improves         the success rate of these minimally invasive alternatives to         hysterectomy.

The author wishes to thank Dr. Charles Lockwood, professor and chair,         Department of Ob/Gyn at New York University School of Medicine, New         York, NY, for his manuscript review and invaluable suggestions. The         author also thanks Stephanie L. Grasso, BS, for assistance with data         collection, Aenov Lance for assistance with manuscript preparation, and         Patrick Ross, PhD, for performing the statistical analysis.

Dr. Herbert A. Goldfarb is the director of the  		

 and an advocate of alternative solutions to         hysterectomy.

Pokras R, Hufnagel VG. Hysterectomy in the United States: 1965-84. Am J Public Health 78:852-3, 1988

New York State Department of Health. Hysterectomies in New York State: A statistical profile. Albany, NY: Information Systems and Health Statistics Group, June 1988

Goldrath MH, Fuller FA, Segal S. Laser photovaporization of the endometrium for the treatment of menorrhagia. Am J Obstet Gynecol 140:14-9, 1981

Vancaille T. Electrocoagulation with a ball and resectoscope. Obstet Gynecol 74:425, 1989

Garry R, Erian J, Grochmal SA. A multi-centre collaborative study into the treatment of menorrhagia by Nd-YAG laser ablation of the endometrium. Br J Obstet Gynaecol 98:357-62, 1991

Townsend DE, Richart RM, Paskowitz RA, Woolfork RE. "Rollerball" coagulation of the endometrium. Obstet Gynecol 80:329-32, 1992

Daniell JF, Kurtz BR, Ke RW. Hysterectoscopic endometrial ablation using the rollerball electrode. Obstet Gynecol 80:329-32, 1992

Fraser IS, Angsuwathana S, Mahmoud F, Yezerski S. Short and medium term out-comes after rollerball endometrial ablation for menorrhagia. Med J Aust 158:454-57, 1993

Rankin L, Steinberg LH. Transcervical resection of the endometrium: A review of 400 consecutive patients. Br J Obstet Gynaecol 99:911-14, 1992

Wortman M, Daggett A. Hysteroscopic endomyometrial resection: a new technique for the treatment of menorrhagia. Obstet Gynecol 83:295-8, 1994

Magos AL, Bauman R, Lockwood GM, Turnbull AC. Experience with the first 250 endometrial resections for menorrhagia. Lancet 337:1074-8, 1991

Dwyer N, Hutton J, Stirrat GM. Randomized controlled trial comparing endometrial resection with abdominal hysterectomy for the surgical treatment of menorrhagia. Br J Obstet Gynaecol 100:237-43, 1993

Approximately 750,000 hysterectomies are performed annually in the United States, with a mortality rate of about 12 per 10,000 operations.1 Costs to consumers and insurers have been estimated at approximately $1.7 billion per year.2 Thus, alternative procedures that are safer and less invasive, preserve the uterus, and cost less are increasingly in demand. In recent years, several such techniques have been introduced.

Does Combining Myoma Coagulation with Endometrial Ablation Reduce Subsequent Surgery?

Laparoscopic myomectomy (LM) is a minimally invasive surgical         procedure for the removal of uterine myomas. It was first described in         the late 1970s by Semm. Subsequently, equipment has been developed to         enhance the procedure. LM requires advanced laparoscopic skill and         expertise in suturing and tissue removal. Laparoscopic assisted         myomectomy (LAM), a procedure that combines operative laparoscopy and         minilaparotomy, was described by Nezhat et al in 1994.

The procedure was initially developed to remove single and multiple         large myomas. Nezhat reports that in addition to providing a route (via         the minilaparotomy incision) for removal of the myoma(s), LAM is         "technically less difficult than <LM>, allows better closure         of the uterine defect, and may require less time to perform ."         Goldfarb and Pelosi, independently, have worked on a variant of this         procedure in which the dominant myoma is removed laparoscopically and         the uterus is delivered (via colpotomy) into the vagina for removal of         secondary uterine myomas and uterine closure. Pelosi’s         laparoscopic-assisted transvaginal myomectomy (LATM) was described in         1997 . This paper discusses Goldfarb’s laparoscopic assisted vaginal         myomectomy (LAVM) technique.

During a visiting professorship, Goldfarb was asked to demonstrate         the myolysis procedure . The patient was 26 years old (g 2, p 1) and         complained of menorrhagia. A transvaginal ultrasound revealed three         transmural myomas; the dominant myoma measured 7cm. Because the patient         was attempting pregnancy, myomectomy, rather than myolysis, was deemed         the appropriate procedure . A routine laparoscopic myomectomy was         performed. A macro-morcellator was not available.

Therefore, the decision was made to remove the myoma by colpotomy. A         5mm myoma screw was inserted into the myoma and a grasper with locking         mechanism was placed on the inferior edge of the wound. The myoma screw         was used to direct the myoma toward the cul-de-sac. A colpotomy was then         performed in the routine manner. The myoma was grasped with a tenaculum         and removed vaginally. During this part of the procedure, it was noted         that the dominant myoma extended into the uterine cavity, the uterus was         mobile, and the vagina was parous. A 5mm laparoscopic grasper was used         to guide the uterus to the colpotomy site. T-clamps were placed on the         edges of the wounds and the fundus of the uterus was delivered, via the         colpotomy incision, into the vagina. The two additional myomas were         palpated digitally and removed transmurally by electrocautery and sharp         dissection. The uterus was sutured in three layers (endometrial,         myometrial and serosal). The repaired uterus was returned to the         abdominal cavity, and the colpotomy incision was sutured. The abdomen         was re-explored laparoscopically and thoroughly lavaged. An oxycellulose         barrier (Interceed) was placed on the uterus.

Since this case, Goldfarb has performed 11 additional LAVM         procedures. The indications and outcomes are listed in Table I. Four         patients experienced minor post-operative complications-three patients         had urinary retention (Foley catheter remained in place for one week)         and one patient was febrile (additional antibiotics were prescribed).         One patient had a follow-up laparoscopy which revealed minimal         adhesions. Follow-up has not been long enough to discuss fertility.

Dubuisson et al cautions that LM can be a lengthy and difficult         procedure, reserved for experienced surgeons with a thorough familiarity         with endoscopic sutures. Parker , suggests that not all women with         symptomatic myomas are candidates for LM. He notes that the procedure,         in some cases, results in excessive blood loss, prolonged operating time         and/or the need to convert to laparotomy. In addition, it has been         reported that laparoscopic suturing of the myometrium may contribute to         uterine dehiscence. Parker suggests the following criteria in deciding         whether a patient is likely to be managed successfully by LM: (1) No         individual myoma should be larger than 7cm; (2) If there are multiple         myomata, the uterine size should not be greater than 14 weeks; (3) No         myoma should be near the uterine vessels or tubal cornua. At least 50%         of the myoma should be subserosal. Operative hysteroscopy is the         preferred procedure for removal of submucous myomas. For success with         LAVM, we suggest surgeons consider the following: (1) Removal of the         dominant myoma must render the uterus mobile enough to be delivered to         the colpotomy site; and (2) The vagina and cul-de-sac must be ample         enough to allow for generous colpotomy (parous preferred). Literature         Review

Prior to Semm’s description of laparoscopic myomectomy, laparotomy         or hysterectomy were the main treatment options for uterine myomas.         Since Semm, several clinicians , , have reported success with LM. Nezhat         et al report that "laparoscopic myomectomy can be a safe and         cost-effective alternative to laparotomy when performed by a skilled         operative laparoscopist." In this series, 154 women, with         symptomatic uterine leiomyomata, underwent laparoscopic myomectomy. In         total, 347 intramural or subserosal leiomyomata were removed, ranging in         size from 2 to 15 cm.

The majority of the myomas were morcellated and removed through a         10-mm suprapubic anterior abdominal wall trocar incision or the         operating channel of the operative laparoscope. In about 20% of the         cases, the myomas were removed from the abdominal cavity via posterior         colpotomy. The procedure ranged from 50 to 190 minutes (with a mean of         116 minutes), the blood loss was estimated at between 10 and 600 cc, and         the duration of hospitalization ranged from 7 to 48 hours (with a mean         of 19.6 hours).

The authors report two major perioperative complications. One patient         developed fluid overload postoperatively. The authors attribute this to         the hysteroscopic portion of the procedure. The other patient had         intra-abdominal bleeding which resulted from laceration of the         epigastric vessels.

The authors note that the damaged vessels were near the left         suprapubic puncture, the site used for removal of the myoma. Other         important findings are that "sutured sites of intramural or deep         subserosal leiomyomata healed more completely than the unsutured sites,         but were associated with a greater incidence of adhesion         formation."

The authors conclude that, in selected patients (i.e., those with few         and relatively small myomas), LM can replace laparotomy for the         treatment of uterine myomas. They caution that (1) LM can be a difficult         endoscopic procedure, (2) the strength of the uterus following LM         remains unknown, and (3) post-operative adhesion formation may impair         fertility. Comparison between LM and Laparotomy In addition to Nezhat ,         several clinicians, have compared LM to laparotomy, noting the         advantages of the laparoscopic procedure.

Stringer et al compare the results of 49 open myomectomies (OM) with         those of 49 laparoscopic myomectomies (LM). They report that uterine         size at surgery ranged from 12 to 14 weeks in 43% of the OM group and 9         to 11 weeks in 51% of the LM group. The mean operating time for OM was         133 minutes as compared to 264 minutes for LM. Mean blood loss and         hospital stay were 340 ml/5.6 days and 110 ml/0.6 days, respectively.         The overall frequency of adhesions was lower in the LM group.

The authors conclude that LM has a lower morbidity, shorter hospital         stay and fewer complications than OM. Adhesion Formation

In response to concerns about post-operative adhesions following LM,         Bulletti et al conducted a case-control study, with 32 patients, to         compare the frequency of adhesion formation after LM with that of         laparotomy. The mean size of myomas was 7.4 cm for laparotomy versus 7.3         cm for laparoscopy. The authors found that the number of incision sites         free of adhesions and the extent of adhesions were significantly lower         in women who underwent laparoscopy. In addition, they found that         suturing myomas with depth of myometrial penetration of less than 50%         provided no advantage over not suturing them (i.e., adhesion formation         was not significantly reduced by suturing).

In 1994, Nezhat et al describe laparoscopically assisted myomectomy         (LAM), a procedure which combines operative laparoscopy and         minilaparotomy for the removal of single and multiple large leiomyomas.         In this retrospective study of 57 patients, with uteri ranging from 8 to         26 weeks’ gestational size and myomas ranging from 28g to 998g, the         authors report that operative time ranged from 40 to 285 minutes (mean         127 minutes) and blood loss ranged from 50ml to 1,600 ml (mean 267 ml).         They conclude that LAM is a safe alternative to myomectomy by         laparotomy. In addition, as compared to LM, they conclude that LAM is         technically less difficult, allows better closure of the uterine defect         and may require less time to perform.

Uterine Dehiscence and Laparoscopic Suturing

Uterine dehiscence during pregnancy is a concern after LM. Harris was         the first to suggest this complication. He reports that a 24-year-old         woman, who conceived after laparoscopic myomectomy, experienced uterine         dehiscence at 34 weeks’ gestation. He notes that with laparoscopic         suturing it is more difficult to reapproximate the layers of the uterus.         This likely creates a weak spot in the uterus, which if stressed, as in         pregnancy, causes the uterus to rupture.

Since Harris, at least three other authors , , have reported cases of         uterine dehiscence following LM. In the most recent case report, Pelosi         and Pelosi suggest that electrosurgical dissection, because it disrupts         blood flow to the wound site, may also contribute to suboptimal healing         of the myomectomy site, weaken the uterus and lead to dehiscence. They         suggest that electrosurgical dissection be used sparingly and sharp         dissection used instead. In addition, they advance the use of endoscopic         suturing or suturing by minilaparotomy or colpotomy.

Also, since Harris, more sophisticated laparoscopic suturing tools         (e.g., Endo Stitch laparoscopic suturing device , and laparoscopic         cannula cone ) have been developed to aid surgeons in reapproximating         the uterine layers and preventing the complication of uterine         dehiscence.

In a retrospective chart review of 50 laparoscopic myomectomies,         Stringer et al report that the Endo Stitch Laparoscopic Suturing Device         (Auto Suture Company, division of US Surgical Corp, Norwalk, CT)         combined with a running, locked suture technique enables the surgeon to         achieve a secure multiple-layer closure of deep defects via laparoscopy.         The authors suggest that repairing the uterine defect this way reduces         the likelihood of uterine rupture.

In 1997, Pelosi and Pelosi described Laparoscopic-Assisted         Transvaginal Myomectomy. In their retrospective chart review, the         authors report 21 cases in which they combine traditional laparoscopic         myomectomy with posterior colpotomy. They conclude that this combination         allows for digital repair and inspection of the uterus while maintaining         the benefits of minimally invasive surgery.

The LAVM procedure offers advantages over both the LM and the LAM.         Compared to the LM, LAVM provides the control and safety of direct         suturing along with the advantages of digital palpation to detect and         remove smaller, less obvious myomas. In comparison with the LAM, the         LAVM requires a smaller incision and avoids cutting through several         layers of fascia and muscle. It is less traumatic and requires less         recovery time than LAM. In addition, the literature reports , fewer         post-surgical adhesions following laparoscopy as compared with         laparotomy.

As Pelosi points out in an 1996 editorial , "operative colpotomy,         an easily performed surgical option, in combination with laparoscopy         permits a much greater number of patients to benefit from both minimally         invasive surgery and a traditional layered uterine repair. The technique         requires only standard laparoscopic and transvaginal         instrumentation." Goldfarb agrees-colpotomy, rather than         minilaparotomy, is a better way to remove large transmural myomas,         inspect the myoma cavity and repair the uterine defect. Furthermore,         transvaginal uterine repair results in minimal blood loss because of the         acute angulation of uterine blood vessels.

Requests for reprints should be addressed to: Montclair Reproductive Center

Dr. Herbert Goldfarb, is the director of the 

 and an advocate of alternative solutions to hysterectomy.

Laparoscopic myomectomy (LM) is a minimally invasive surgical procedure for the removal of uterine myomas. It was first described in the late 1970s by Semm. Subsequently, equipment has been developed to enhance the procedure. LM requires advanced laparoscopic skill and expertise in suturing and tissue removal. Laparoscopic assisted myomectomy (LAM), a procedure that combines operative laparoscopy and minilaparotomy, was described by Nezhat et al in 1994.

Herbert A. Goldfarb, MD

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Does Combining Myoma Coagulation with Endometrial Ablation Reduce Subsequent Surgery?

Laparoscopic Assisted Vaginal Myomectomy