Uterine Fibroids

Over the past few months I have seen a higher number of patients with uterine fibroids. Over the course of my practice and fellowship, I have treated one fibroid that reached a patient's liver. I recently removed 4 fibroids from a patient who still desired the possibility of having children in the future. Fibroid surgeries can be difficult, but there are many benefits that laparoscopy and robotics offer.

Uterine Fibroids or "leiomyomas" are growths of uterine muscle that often form in a circular or ball shape. They can be small or very large. On patient may have a single fibroid or many within the uterus. Honestly, most patients with fibroids don't have any symptoms. They are often diagnosed during a yearly exam when the uterus seems larger than normal or has an irregular or "bumpy" shape to it.

When fibroids do cause symptoms, some of the common ones are heavy bleeding with periods, a fulness or pressure feeling, or feeling a hard mass or ball in the low belly. Fibroids that are located deep inside the uterus next to the internal lining or cavity are the most likely to cause abnormal bleeding. Some fibroids ban be in the middle of the uterine muscle and some can be on the outside of the uterus almost like they are "attached" to the uterus. These latter two types are ones that can cause the pressure or fulness feelings when they become large or if there are multiple fibroids. The symptoms are mostly due to the bulk or size of the uterus with the fibroids. Occasionally fibroids can become painful if they outgrow their hormone or blood supply. When this happens, the inner cells start to die and pain results. This is more common during pregnancy when fibroids tend to increase rapidly in size.

Fibroid tumors are generally benign or non-cancerous. There are rare types that are cancerous but these are usually present less than 0.1% of the time. Concerning features are very large fibroids or very rapid increase in size outside of pregnancy. Also menopausal patients with an enlarging fibroid should be evaluated for the cancerous type of fibroid.

There are many options for treatment. Often the most appropriate option is observation. As fibroids are generally benign, they do not need to be treated or removed just because they are there. If there are no symptoms, it is often appropriate to check them with a periodic ultrasound and examination. When fibroids need to be treated there are a few options.

Uterine artery embolization (EUA) is a radiology procedure where the blood vessels that feed the fibroids are closed off with small particles or gel. This causes the fibroids to die and shrink down. It does not make the fibroids go away, but can decrease their size and symptoms. Care must be taken with this approach in patients who are not done with child bearing as there have been reports of the ovarian blood supply being cut off as well.

Gynecologists often treat fibroids by removing them. This is called myomectomy. Fibroids that are in the muscle portion of the uterus or toward the outside can be removed by making a cut in the uterus over the fibroid then removing the fibroid and sewing the uterus closed. This is a surgery that very often can be done without a large incision on the abdomen, just like most of the procedures I have discussed on this blog. Laparoscopy and robotic assisted laparoscopy can be a great way to manage symptomatic fibroids. This allows all the benefits of laparoscopy and often patients will be able to go home the same day. This is one of the most challenging laparoscopic procedures and care must be taken to not damage the uterus too much and to use appropriate care and skill when stitching the uterine incisions after removing the fibroids.

Many fibroids are treated by hysterectomy. In patients with symptomatic fibroids who are done having children, this probably a more logical option. Hysterectomy is less risky than myomectomy and has lower complications and blood loss. Again, most hysterectomies can be completed without a large incision on the abdomen. This can be done with laparoscopy or robotics or at times with a small 3-5 cm incision on the low belly when fibroids are very, very large.

GNRH Agonists such as Lupron can be used to shrink the fibroids prior to surgery. In my experience this makes a laparoscopic or robotic approach more difficult. GNRH agonists cause fibroids to shrink but also makes them mushy and hard to grasp during laparoscopy.

A less common approach is to isolate the uterine arteries laparoscopically and tie them off. The uterus itself continues to get blood supply from extra flow through their connection with the ovaries, but the decrease in blood supply to the fibroids causes fibroid cells to die and the fibroid to shrink down.

Why Use Laparoscopy for Complex Surgery

I am frequently asked about why a surgeon would use laparoscopy for complex pelvic and abdominal surgery when it could be performed through a laparotomy or open incision in less time. It is true that in most cases, a hysterectomy for a very large 16-22 week size uterus can be completed in less time open than laparoscopically. Also complex cases such as large, non-cancerous ovarian cysts, severe endometriosis, and large or multiple fibroids can be completed through either open surgery or laparoscopy.

It is usually true that surgery for a large uterus, fibroids, or large ovarian cysts takes less time with an open incision (this is not always the case). Surgery for adhesions or severe endometriosis is difficult and long no matter the surgical approach.

When I am asked why I would take 2-3 hours to perform a hysterectomy laparoscopically or with robotic assistance instead of performing a laparotomy for a uterus the size of a 16-24 week pregnancy, my answer is clear, "My patients and I like the trade off!"

With the assistance of laparoscopy either to complete the entire operation or to convert from a large vertical incision to a small 3-5 cm mini-laparotomy incision, patients trade time spent in the operating room for a quicker recovery. Rarely do surgeries for even the most complex pathology take longer than three hours to perform laparoscopically. Most open surgeries for the same conditions average 1.5-2 hours. Frequently a laparoscopic surgery can be completed in that amount of time. When it is longer, a laparoscopic approach may add up to an additional 1.5 hours depending on what is done.

In the case of hysterectomy for a very large uterus, the uterus must be cut into small pieces to remove it in a minimally invasive fashion. This aspect of surgery often is longer than the actual hysterectomy itself.

In the beginning of my private practice, I often wondered if the extra time was worth it after a difficult, long surgery. I got my answer the next morning while rounding on the patients. They were doing well with minimal pain medicine requirement. They were walking and ready to go home within 24 hours of the completion of the surgery. This was reiterated when I saw them at their postoperative visits. They were already back to work and feeling normal again.

Laparoscopy can also make a big difference in patients who have some complicating medical conditions. Patients with obesity can benefit by a lower risk of wound infections. Diabetics are frequently out of the hospital before their regimen is interrupted. Patients with a history of blood clots in their legs or lungs are up walking the same day of surgery.

Yes, there are increased risks and cost with longer operative times under anesthesia. In my five years of practice after fellowship, I have not seen an anesthesia related complication. The higher operative cost is more than offset by the decrease in hospital stay by 2-3 days. The cost benefit to the patient is further increased by allowing them to return to work faster after release from the hospital.

A recent patient summed it up best when she wrote, "I am grateful that I was made to switch doctors at the last moment. My inconvenience turned out to be a huge blessing!!! To think that I went from being told I would need an abdominal hysterectomy to what you were able to accomplish is amazing. Thank you for being concerned about my healing and taking the time with the longer procedure. Your success was my gain."

Minimally Invasive Centers of Excellence

The Council on Gynecologic Endoscopy sponsored by the AAGL allows application and designation of hospital centers to be come centers of excellency in regards to minimally invasive surgery. This council recognizes hospitals and centers who are committed to promoting and providing minimally invasive options to patients.

Although there are currently no designated centers in Utah, I am working with and encouraging the local Ogden hospitals to move in this direction. I hope they will continue to encourage the local physicians to expand their practices and skills to involve minimally invasive procedures in gynecology, general surgery and other specialties. From a gynecologic aspect and my practice, it is enticing. By expanding other specialties such and general surgery and urology into laparoscopic and robotic options, it opens the door to expanded endometriosis treatments. A specialized team will be able to offer complete surgical management of invasive endometriosis involving the female organs, bowel, bladder and ureters.

An expanded awareness in the general public and medical community will continue to promote the benefits of less invasive surgical options.

Access to Less Invasive Surgery

A few posts ago I discussed the excitement about having a robotic surgical system come to the Ogden area. The most exciting part of this is the increasing availability of minimally invasive options to patients in our area. The robotic system does not offer much to a surgeon already trained in advanced laparoscopic techniques but it does increase the number of doctors who can perform advanced laparoscopic procedures.

For some reason, Utah seems to be lagging behind much of the US in its knowledge and acceptance of laparoscopic surgical options for women. Many patients are unaware that there is an option for surgery that does not require them to stay multiple nights in the hospital and take 4-6 weeks off work. Although 90% of patients surveyed said they expected their doctors to discuss less invasive options. Patients should be aware of all surgical and non-surgical options and discuss them in detail, even if their doctor does not offer that option.

Currently in Utah, 60-65% of hysterectomies are performed with a large abdominal incision. Over the last 4.5 years I have been able to decrease my open surgery rate for hysterectomy to less than 4%. Half of that 4% was due to patient choice. How I wish that more physicians would embrace these options and have a significant impact on their patient's lives.

With the advent of robotic surgery availability in Ogden, the number of surgeons performing laparoscopic hysterectomy has more than doubled. Unfortunately, after proven safety and efficacy in multiple studies, there is still resistance to implementation of robotic surgery programs at one local hospital. As these challenges continue, there are numerous women who are forced to accept open surgery as the only option provided by their doctors.

Many people believe that laparoscopic and robotic surgery is more expensive than "open" surgery. This is certainly true for costs of the actual surgery. What they fail to realize is that a less invasive surgery decreases cost outside the operating room. There are fewer costs attributed to lab work, room and board, complications, infections and nursing. There is also a significant financial advantage to patients as they return home sooner and are back to work in 3 days to 2 weeks as opposed to 4-6 weeks.

Taking into account the cost of the entire hospital stay, laparoscopic surgery is less expensive than open surgery and robotic surgery is less than, but almost equivalent to, open surgery.

Certainly I am biased in my discussion of surgical options, but the bias is proven by experience. I have had many grateful patients who have benefited from laparoscopic options. When I sit down and discuss options for a surgical need, all options are discussed including vaginal surgery, abdominal or open surgery, and laparoscopic surgery. In over four years I have had only 2 patients that have chosen to have an open procedure. Patients are grateful to have an option that will not "lay them up" for 6 weeks when vaginal surgery is not an option.

Change is difficult at times, but I am hopeful that those who are passionate about minimally invasive surgery will continue to share their knowledge and experience with others. As this happens, patients will truly be able to make an educated choice that is the best for their life and needs.

Laparoscopic Sacrocolpopexy (Vaginal Prolapse Surgery)

After becoming more proficient over that last few years and with the availability of the Davinci Robotic System, I have now added laparoscopic sacrocolpopexy to the procedures I can offer to patients. Sacrocolpopexy is considered the "gold standard" surgery for severe vaginal prolapse. It is a surgery that uses a synthetic mesh to help the body develop a strong support of the upper vagina to repair prolapse. From inside the abdomen, the mesh is sewn to the front and back of the vaginal wall. A tail of mesh is then sewn to a ligament along the front part of the sacrum.

Again this is a surgery that has been done for years by the "open" technique. For many years now it has been performed laparoscopically and with robotic assistance. The same benefits from laparoscopy apply in this situation also. These include similar operative times, much shorter hospital stay, quicker recovery and faster return to work when desired.

Some complications may occur with this procedure whether it is performed laparoscopically or open. These include bleeding, bowel or bladder injury and occasionally mesh rejection or infection. Thankfully these complications are rare.

The advances in laparoscopic surgery are very exciting to me. Every week I see the benefit it has in women's lives as they are faced with a difficult decision for surgery. They are thrilled and grateful to know that there is an option that does not require weeks off of work and days away from home.

Benefits of Robotic and Minimally Invasive Surgery

Press Release About Lack of Information for Minimally Invasive Procedures

This is a link to a press release by the President of the American Association of Gynecologic Laparoscopy. It has some data to suggest that patients are not made aware of minimally invasive options to treat common gynecologic disorders. http://www.prnewswire.com/mnr/aagl/33994/

Robotic Surgery

There has been much talk in Utah recently about the new DaVinci Robot for performing laparoscopic or minimally invasive surgery. It offers many advantages including a minimally invasive approach to surgery, less blood loss, fewer infections, better surgical visualization, and increased dexterity of performing complex laparoscopic procedures, not to mention a more ergonomic and comfortable operating experience for the surgeon.

There are a few hospitals in Salt Lake City which have these laparoscopic robots. They are allowing physicians in the Salt Lake area the ability to offer their patients advanced laparoscopic procedures instead of surgery performed through larger, traditional incisions.

I have trialed one of these robots at a conference, and it is truly a neat device. It allows a simplicity in performing advanced dissection techniques, and laparoscopic suturing. Access to a laparoscopic robot would provide many more surgeons the opportunity to learn advanced procedures without the time and effort of a fellowship or extended training.

Although there is an increase in cost to performing robot assisted surgery, the overall cost is still lower than a traditional "open" surgery.

To surgeons who are already trained and skilled in advanced laparoscopic surgery, the robot does not at this time offer too many advantages except in difficult cases. Gynecologic surgeries performed by laparoscopy include surgery for: hysterectomy, extensive endometriosis, uterine fibroids, adhesion, pelvic prolapse and bladder drop surgery.

Robot assisted laparoscopy is an upcoming addition to women's surgery. There are thousands of "robotic" surgeries performed each year. For years, traditional laparoscopic surgeons have been struggling to find a route to decreasing the number of open surgeries performed. Robotic surgery will dramatically increase the number of physicians able to perform minimally invasive surgery. Hopefully we will finally see a change in the type of surgery done for the majority of women that will allow them to get back home, go back to work, and get back to life quicker with less pain.