Dr Ahmed Ismail

Consultant Gynaecologist & Fertility Expert

Queensway Clinic Latest Techniques in Treatment of Intracavitory Fibroid

1.0 Uterine Fibroids ( Leiomyomata )

Fibroid are benign (non-cancerous) tumours, which grow on, or in, the muscle lining of the uterus.

Uterine fibroids (leiomyomata) are the most common benign tumours, occurring in 70% of white women and 80 % of black women by the time they reach 50 years of age and the myomas are clinically apparent in 25% of patients. Smooth muscle tumours of the uterus cover a broad spectrum, from benign leiomyomata to leiomyosarcomata. Within this spectrum lies STUMP- smooth muscle tumours of unknown malignant potential. Leiomyosarcomas account for 3-7% of malignant disease of the uterus. They are found in about 0.5% of women who have hysterectomies for fibroids. They are the most common sarcoma (accounting for 25-36% of uterine sarcomas).

There are three different types of fibroids, submucosal, intramural and subserosal:

Types of Fibroids

Types of Fibroids

Most uterine fibroids are asymptomatic. They are usually only discovered in the course of clinical or imaging investigation of other conditions. There are no confirmed risk factors, however, it is known that

  • Women of Afro-Carribean ethnicity have a higher incidence of fibroids. Recent studies have isolated mutations in two genes, HMGI (C) and HMGI (Y), which appear to have a role in the fibroid information, influencing myometrial response to growth factors and ovarian steroids.
  • Fibroids are common in women of child bearing age (between 25 to 40 years of age).
  • Overweight or obese women are higher risk of developing fibroids.

Symptoms of fibroids can be:

  • Manorrhagia
  • Bleeding between periods

2.0 Hysteroscopic Morcellation

2.1 Definition

Hysteroscopic morcellation is achieved by using a probe with a ‘uterine shaver’. Once placed inside the uterine cavity, the device shaves off and immediately suctions out any excised tissue that might impair visibility. The ability to remove and instantly suction out tissue fragments means the hysteroscope and morcellator are inserted only once, for initial entry.

For the physician, the immediate removal of tissue through the probe makes surgery much simpler to perform and requires less surgical time.

Traditionally, the removal of fibroid has involved a laparotomy under general anaesthesia but this technique is becoming increasingly unpopular and new technological developments now permit the procedure to be performed quickly and safely hysteroscopically under local anaesthesia in an ambulant setting.

2.2 Prevalence/p>

Data from the 2010 Office of National Statistics (ONS) reports that there are 20,500.913 woman aged between 15-64 years of age in the UK. It is estimated that 3.4 million women develop fibroids and 850,000 of these women are anticipated to seek treatment. Taking into account an estimated 22,750 women who undergo major surgery of a hysterectomy directly due to fibroids and discounting a percentage of 55% of hysterectomies performed for intramural fibroids and 40% of subserosal fibroids that cannot be treated by hysteroscopic morcellation, there is an estimated 35,000 woman that could undergo hysteroscopic morcellation with the emphasis to move more minimally invasive procedures to the outpatient environment.

3.0 Treatment Options

In the UK, polyps and small fibroids are commonly treated by Wire Loop resection as it is a cost-effective and multi-use system. Women are most commonly prescribed birth control treatment if suffering from abnormal uterine bleeding, or even referred for a hysterectomy (an estimated 38%of hysterectomies are directly related to fibroids in a clinical study led by Vassey in 1992).

3.1 Hormone Therapy

In mild cases of uterine fibroids, it is common for doctors to prescribe hormone therapy. Altering oestrogen levels with the assistance of medication may reduce fibroid clusters in some women, though this method is not successful with every patient. Also, successful hormone therapy may not be a permanent solution. Many documented cases have indicated a fibroid regrowth shortly after the completion of hormone therapy. Medication can be administered orally or via an intrauterine device.

Endometrial resection can be used to physically remove fibroids. This method of treatment has declined somewhat in popularity due to competition from UAE, which is less invasive.

MyoSure

Forceps and graspers are a cheaper cost option with less equipment required. MyoSure does require inflow/suction while most physicians will blindly go in with forceps to try to remove polyps and small fibroids. But the limitations on these manual instruments is the risk of perforation and the challenge of removing large pathology through the cervix, which could lead to longer, if not incomplete, procedures, in addition to the high percentage of missed pathology.

MyoSure

The bipolar Vaporisation technique is a quicker procedure than the standard mono/bipolar loop. However, it is dependent on the size of pathology and is slow in removing fibroids and larger pathology. Also, as tissue is vaporized, there is no pathology able to be investigated.

5.0 The MyoSure® Hysteroscopic Morcellation System

5.1 Definition

The MyoSure Tissue Removal System is a new and innovative treatment that is designed to provide incision-less, fast and safe removal of intracavitary fibroids and polyps and effective relief of the associated abnormal uterine bleeding symptoms. The MyoSure Tissue Removal System provides a treatment option for women seeking to preserve uterine form and function. The easy-to-use device is designed to provide gynaecologists with confidence and control via a minimally-invasive care option for their patients. Clinical studies show the efficacy rate for hysteroscopic removal is very high at 96.4%of patients of symptom resolution and less than 10% recurrence at five years.

The bespoke polyp and fibroid removal system uses a mechanical mechanism of action and has a proprietary blade, with a unique side window, that simultaneously rotates and reciprocates at 6,000 rotations (1.5g) per minute, enabling fast tissue cutting from any location within the uterus and intact tissue margins on the specimen.

  • MyoSure’s efficient tissue removal means shorter procedure times, that can remove a 3cm fibroid in just 10 minutes.
  • MyoSure requires normal saline and, because of its quick procedure time, minimizes the risk of fluid overload.
  • MyoSure has been especially created for use in an outpatient setting. It is compatible with all fluid management systems.
  • MyoSure contraindications are the same as hysteroscopic myomectomy which include a patient who is pregnant, exhibits a pelvic infection, has cervical malignancies, or has been previously diagnosed with endometrial cancer.

MyoSure

Facilities:

Facilities to perform a morcellation procedure

Necessary equipment and supplies:

  • A MyoSure Control Unit and Foot Pedal MyoSure Operative Hysteroscope (sterilized one per patient), outflow channel, two single-use scope seals and light source adaptor .
  • A MyoSure Tissue Removal Device (sing use, disposable, per patient) Camera, light cable and video monitor
  • Hysteroscopic fluid pump with pump inflow tubing Outflow Y-tubing
  • 2-3 litre collection canisters and tandem tubing A tissue trap

• Performed in an outpatient setting

MyoSure has been especially created for use in an outpatient setting.

• Fluid management systems

MyoSure is compatible with all fluid management systems.

• Efficacy rates for hysteroscopic removal is very high

Clinical studies show the efficacy rate for hysteroscopic removal is very high at 96.4% of patients of symptom resolution and less than 10% recurrence at five years.

Conclusion

  1. Uterine fibroid could be totally Asymptomatic and only diagnosed during routine examination (no action) but advice should be given to the patient to be followed up once every six months.
  2. Uterine fibroid symptomatic majority of symptoms are :
    1. Menorrhagia
    2. Pressure symptoms, on Bladder and rectum or lower abdomen
    3. Recurrent Miscarriages
    4. Infertility

Treatment of all of the above should be conservative, medical, radiological, ssurgical various type of surgical methods using Laser and Hysteroscopic removal using different technique including the latest technique of My-Sure tissue removal (Tissue Morcellation) , Myomectomy of Intramural Fibroid should be avoided in a women trying to conceive or they did not complete their family, but subserous Myomectomy could be removed if it is causing pressure symptoms, but for other symptoms removing subserous fibroid usually do not improve symptoms of menorrhagia or recurrent miscarriage or improve fertility.

We are at Queensway Clinic totally against Myomectomy as we have seen over the years many patients with severe pelvic adhesions, Tubal block, Infertility problems, pelvic pain and deep dyspareunia (Painful Sex) as a result of Surgical Myomectomy .

Fibroid Uterus Operation

Fibroid Uterus

Multiple Fibroid uterus size of twenty weeks or 5 month pregnancy, removed through Bikini incision. 52 years old woman complaining of severe long and heavy period with pressure symptoms. After excluding uterine pathology other than Fibroids, we carried out Subtotal Hysterectomy & Removal of both ovaries and tubes, to be followed by HRT.

Cervix was left on patient’s request for sexual gratification.

Patient will be seen regularly for smear test.

Laparoscopic view of fundal fibroid, patient bleeding heavyily during period, also wish to have a baby and trying for 10 years.

Fibroid Uterus

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