FIBROID%20UTERUS%20FINAL%20PPT copy.pptx

Fibroid uterus

1. FIBROID UTERUS BY - DR SHUBHAVANI B R GUIDED BY - DR AMITHA KAMAT

2. CONTENTS Introduction Incidence Etiology Risk factors Pathology Classification Secondary changes Clinical spectrum Investigations Management

3. INTRODUCTION Fibroids (Myoma, Leiomyoma, Fibromyoma) These are the most common benign, monoclonal tumors of smooth muscle cells of the uterus. Fibroids can be single or multiple. It is composed of smooth muscle and fibrous connective tissue.

4. INCIDENCE It is seen in 20-25% of women in reproductive age group. It is responsible for 27% of gynecological admissions. More common in African and Carribean women. The prevalence is highest between 35 – 45yrs age. 50% of the fibroids are asymptomatic.

5. ETIOLOGY Genetic factors Hormonal factors

6. GENETIC FACTORS Individual leiomyoma is monoclonal; it arises from somatic mutation of progenitor myocyte. 50% of the leiomyomas have chromosomal abnormalities, most common being - Translocation between the long arms of chromosomes 12 to 14. - Deletion of the long arm of chromosome Y. These chromosomal abnormalities alter genes that results in elevation in the cytokines like EGF,IGF, TGF, and Angiogenic growth factors. These growth factors are responsible for the growth of leiomyoma.

7. HORMONAL CAUSES Estrogen is the major hormone influencing the growth of the fibroids, hence the growth of the fibroid is seen only in the reproductive age group. Increased exposure to estrogen like early menarche, nulliparity, late menopause, Hormone replacement therapies are all the major risk factors. Myocytes in leiomyoma have higher number of estrogen receptors than the adjacent normal myometrium. Higher levels of cytochrome P450 aromatase enzyme levels are seen in leiomyomas.

8. Progesterone acts as mitogen and causes myocyte cellular proliferation, extracellular matrix accumulation and cellular hypertrophy. It is evidenced by increasing size of leiomyomas during pregnancy and shrinkage of the tumor with antiprogesterones like mifepristone.

9. RISK FACTORS Increasing age Nulliparity Ethnicity Obesity Meat and high fat diet PCOD Hormone replacement therapy Family history

10. PROTECTIVE FACTORS Multiparity Smoking Exercise OCP use Menopause

11. GROSS APPEARANCE – These are round to oval shaped, single or multiple, well circumscribed, firm and pearly white tumours with cut sections showing smooth whorled appearance and trabeculations. PATHOLOGY OF LEIOMYOMA

12. Microscopically interlacing smooth muscle bundles with swirled pattern and variable amount of fibrous tissues are seen.

13. TYPES OF FIBROIDS Intramural or interstitial(75%) Subserous (10%) Submucous(5%) Cervical (anterior, posterior, central, lateral) (1-2%) Broad ligament fibroid

14. CLASSIFICATION

15. INTRAMURAL/INTERSTITIAL FIBROID 75% of the fibroids are intramural. Initially the fibroids are intramural in origin, they gradually grow inwards or outwards to become submucous or subserosal fibroids. These fibroids grow steadily with formation of a false capsule by compressing the surrounding myometrium.

16. SUBSEROSAL FIBROID These fibroids are partially or completely covered by peritoneum. They can be sessile or pedunculated with a pedicle. Large pedunculated fibroids can undergo torsion, and if the pedicle is torn the fibroid gets the blood supply from the omental or mesenteric adhesions – Wandering or parasitic fibroid.

17. SUBMUCOUS FIBROID These fibroids lie just beneath the endometrium. They can be sessile or pedunculated. They produce maximum symptoms like menorrhagia and dysmenorrhea compared to other types of fibroids. Infertility due to fibroids is maximally seen in this type as they distort the uterine cavity. Pedunculated fibroids can come out through the cervix appearing as endometrial or endocervical polyp.

18. CERVICAL FIBROID These can be anterior – arising from the anterior lip of cervix and grows anteriorly undermining the bladder producing urinary symptoms. Posterior – growing from the posterior part of cervix and compressing the rectum against sacrum. Lateral – the myoma grows from lateral cervix and burrows out in the broad ligament forming pseudobroad ligament fibroid. They compress ureters and cause hydronephrosis.

19. Continued… Central – here the tumor is either interstitial or submucous in origin and it expands equally in all directions, giving the appearance of ‘ the lantern on the dome of St Paul’s cathedral’.

20. Broad ligament fibroid It is the most common tumor of broad ligament. True broad ligament fibroid arises within the broad ligament and displaces ureters medially. Pseudo broad ligament fibroids arises from the lateral cervix and displace the ureters laterally.

21. SECONDARY CHANGES IN FIBROIDS Degenerations Necrosis Infection Vascular changes Sarcomatous changes (<0.1%) Atrophy

22. Other complications Torsion. Axial rotation of the uterus. Uterine inversion. Capsular rupture. Pseudo Meig’s syndrome.

23. DEGENERATIONS Vascular supply of the leiomyomas is by the peripheral vessels in the loose areolar tissue beneath the false capsule hence the center of the tumor is least vascular and undergoes degenerations. Types – 1 Hyaline degeneration 2 Cystic degeneration 3 Fatty degeneration 4 Calcific degeneration 5 Red degeneration

24. HYALINE DEGENERATION It is the most common type of degeneration (65%). The least vascular central part is the common site. Cut surface shows irregular homogenous area with loss of whorled appearance. Microscopically, hyaline changes of both muscle and fibrous tissues seen with loss of cellular details.

25. CYSTIC DEGENERATION It is commonly seen in interstitial fibroids after menopause. It is formed by liquefaction of the areas with hyaline changes, with cystic spaces lined by irregular ragged edges. These can often be confused with ovarian cyst radiologically.

26. FATTY DEGENERATION It is seen after menopause. Fat globules are deposited in the myocytes .

27. CALCIFIC DEGENERATION It is due to precipitation of calcium carbonate or phosphates within the tumor following fatty degeneration. The whole tumor gets converted into calcified mass hence it is called womb stone.

28. RED DEGENERATION It is seen in the second half of pregnancy due to vascular thrombosis. Seen in large fibroids. Grossly the tumor is dark in colour with cut surface showing raw beefy cystic spaces and it has typical fishy odour due to fatty acids. Clinically it mimics UTI, APH, strangulated hernia and ovarian torsion It is also called necrobiosis.

29. Continued ….. It can be diagnosed by USG and MRI. Ultrasound imaging shows mass with heterogenous echogenicity located adjacent and connected to the gravid uterus by a bridge of hypoechoic tissue.

30. CLINICAL SPECTRUM OF FIBROID Incidental finding : 50% are asymptomatic. Gynecological problems : AUB, dysmenorrhea, non cyclic pain, Vaginal discharge. Reproductive problems : Infertility Obstetrics problems : Early pregnancy loss, recurrent pregnancy loss, preterm labour, PPROM, IUGR, pain, red generation, malpresentations, dysfunctional labour, LSCS and PPH. Pressure symptoms : Urinary tract obstruction, bowel symptoms. Generalised problems : Anaemia, poor health, mass per abdomen. Rare problems : Ascites, polycythemia, benign metastasizing uterine fibroids with RCC. Malignant change : Sarcomatous change.

31. Menstrual disturbances Menorrhagia i.e. an increased blood loss at normally spaced intervals is the typical symptom of leiomyomas. It is gradual in onset and progressive. The cycles are not altered unless the tumors are so large as to disturb the blood supply and function of ovary. It is commonly manifested in the age group of 35-45yrs. Intermenstrual bleeding and continuous irregular bleeding is seen only when there is ulceration of submucous fibroid or polypoidal change or sarcomatous change.

32. Factors causing menorrhagia are Increased surface area of the endometrium. Increased vascularity of the uterus. Associated hyperestrogenism and endometrial hyperplasia. Compression of veins by tumors with consequent dilatation and engorgement of venous plexus in endometrium and myometrium. Interference with normal uterine contractions due to interposition of fibroid. Imbalance of thromboxane A2 (TXA2) and prostacyclin (PGI2) with relative deficiency of thromboxane A2.

33. Dysmenorrhea It can be spasmodic : In submucous fibroid stimulating expulsive uterine contraction. Congestive : due to pelvic venous congestion.

34. Pressure symptoms Bladder : Weight of the tumor causes bladder irritability and in increased diurnal frequency, Urinary retention is seen in cervical fibroid or an impacted corporeal fibroid. Alimentary tract : Dyspepsia, rarely constipation is seen from the pressure over rectum. Veins and lymphatics : Edema and varicosities of veins of lower limbs seen in large fibroids. Nerves : Large myomas impinging on sacral plexus and obturator nerves can cause lower back pain. A broad ligament fibroid can produce ureteric compression, hydro ureteric changes, hydronephrotic changes, infection and pyelitis.

35. Infertility Distortion or elongation of uterine cavity and prevention of rhythmic uterine contraction during intercourse – difficult sperm ascent and transport. Congestion and dilatation of endometrial venous plexuses – defective implantation. Atrophy and ulceration of endometrium over the submucous fibroids – defective nidation. Cornual block and associated salpingitis due to position of the fibroid. Elongation of the tube over a big fibroid. Associated anovulation and hyper estrogenic state.

36. Clinical signs Pallor Mass per abdomen – when tumor > 12weeks size it is felt as firm in consistency, well defined margins except the lower pole, surface can be nodular or uniformly enlarged, horizontal mobility is seen and restricted vertical mobility. The mass is dull on percussion. On BME – Uterus and mass can be felt as single mass, movements of the cervix is transmitted to the mass and vice versa. Subserous pedunculated fibroids and broad ligament fibroids feel as different mass with grove sign.

37. Differential diagnosis Adenomyosis Pregnancy Endometrial polyp Myohyperplasia Pyometra Hematometra Malignancy like choriocarcinoma and sarcoma Ovarian tumor Tubo ovarian mass Endometriosis

38. INVESTIGATIONS Ultrasound : Diagnosis can be confirmed with transabdominal or transvaginal ultrasound. It is reliable for evaluation with the uterine volume less than or equal to 375cc. TVS has high resolutions and can accurately assess the myoma location, dimensions, number and any adnexal pathology. Transabdominal ultrasound is required for the larger myomas to delineate the exact dimensions. On ultrasound the uterine contour is enlarged and distorted.

39. Continued… Myometrium is normally homogenously hypoechoic and serosal surface is smooth and regular. Distortion in any of these two suggests myometrial lesions. Depending the amount of smooth muscles and connective tissues, fibroids can be hypoechoic or hyperechoic. A fibroid usually appear as well defined hypoechoic lesion with peripheral vascular rim. The echogenicity of the fibroid increases with its fibrous tissue and vascularity. In degenerations, fibroids show heterogenous echogenicity. Calcific degenerations can be detected In ultrasound. Cystic degenerations appear as anaechoic areas.

40. Colour doppler On colour doppler typically peripheral vascularity is seen in fibroids, resistance of the vessels is same as that of adjacent myometrium. Resistance is higher in submucosal and deep intramural fibroids than subserosal fibroids. Degenerated fibroids have low resistance.

41. Diffuse leiomyomatosis

42. Saline infusion sonography 17F SIS catheter is inserted through the cervical os, 10-20ml of normal saline is infused slowly. The uterine imaging is done with vaginal ultrasound. This procedure is done within first 10days of cycle. Submucosal fibroids and polyps can be detected.

43. Hysteroscopy It is useful to locate the exact site of small submucosal fibroids in cases of unexplained infertility and RPL. Diagnostic hysteroscopy doesn’t require anaesthesia or cervical dilatation. A fibreoptic telescope is used for visualization after distending the uterine cavity with CO2 or normal saline or glycine. It is performed in the post menstruation period and the chances of conception disturbance is absent .

44. HSG – in infertility patients due to submucosal fibroids, filling defect can be seen. Diagnostic laparoscopy – Broad ligament fibroids, subserosal fibroids, associated endometriosis, and tubal pathology can be diagnosed under direct visualisation.

45. MRI – It is more accurate than ultrasound and it differentiates between leiomyoma, leiomyosarcoma and adenomyosis. It gives better resolution and more accurate assessment of size, number, and position of myomas, as it is useful in selecting the treatment options like myomectomy, hysterectomy or uterine artery embolization. It also detects change in vascularity and size of the fibroids after giving GnRH agonists pre operatively.

46. Intravenous urography – It is done only when there is suspected ureteric compression by large cervical fibroids, broad ligament fibroids and large subserosal fibroids. Dilatation and curettage or endometrial biopsy – It is done when there is fibroid uterus with postmenopausal bleeding or thickened endometrium, to rule out associated malignancy before surgical treatment.

47. MANAGEMENT It can be divided into 4 approaches : 1 Expectant management 2 medical management 3 Non surgical management 4 Surgical management

48. Leiomyoma diagnosed in uterus, cervix or broad ligament Asymptomatic uterus upto 12 weeks. Definite diagnosis. Asymptomatic uterus >/= 14weeks, diagnosis uncertain, pedunculated. Symptomatic myoma. Surgery Expectant management and follow up every 6 months No increase in size or symptoms Increase in size or symptomatic Follow up continued Surgical treatment Medical management Improvement Continued with follow up Surgical management Young patients with infertility and RPL Pt not keen for hysterectomy, no infertility Uterine artery embolization Large myoma Family completed Cervical fibroid MRgfUS Vaginal hysterectomy For size <14 weeks. TLH for size 14 -16 weeks TAH Myomectomy Open myomectomy (Large, cervical, broad ligament) Laparoscopic myomectomy Hysteroscopic myomectomy (Submucosal myomas)

49. Expectant management Asymptomatic patients. Size of the uterus with myoma less than 12weeks. Diagnosis of the fibroid is certain. It is suitable for women nearing menopause. Clinical and ultrasound follow up is done at every 6 months interval. Subserosal or submucosal sessile fibroids not at risk of torsion.

50. Medical management It is considered in symptomatic patients with AUB, infertility, anaemia and poor health. Most common symptom being AUB, patients present with moderate to severe anaemia. It is important for the correction of anaemia with blood transfusion or parenteral iron therapy. With stoppage of the therapy, the tumor will gradually regain it’s size. Various hormonal and non hormonal drugs are used during the correction of anaemia to minimize further blood loss. It is also done pre operatively for 3-6 months in large fibroids requiring surgical intervention to reduce the size and vascularity of the tumor.

51. Continued… It is given in patients with infertility due to small cornual fibroid for temporary regression of tumor. It can be given in symptomatic perimenopausal women and women with high risk factors for surgery. Preoperative medical management of large fibroids > 14weeks size regress the tumor size thereby facilitating vaginal hysterectomy. Two step approach in resecting large submucosal myomas can be avoided by pre operative medical management. It also reduces operative blood loss during myomectomy or hysterectomy.

52. Drugs used in medical management Antiprogesterone – Mifepristone (RU486) Selective progesterone receptor modulators GnRH agonists GnRH antagonists Gonadotropin antagonists Aromatase enzyme inhibitors LNG – IUS Combined oral contraceptive pills

53. Mifepristone ( RU 486) It is a partial agonist and competitive antagonist of both A and B type of progesterone receptors. It has bioavailability of 25% in oral route with t ½ of 20-36hrs. A daily dose of 5-10mg is recommended in treatment of leiomyoma. It reduces the size of fibroids by 50% and improves menorrhagia significantly. It can be given for 3-6 months and the long term therapy is avoided due to the risk of endometrial hyperplasia.

54. Ulipristal acetate It is selective progesterone receptor modulator without the effect of endometrial hyperplasia. The efficacy of ulipristal is equal to GnRH analogues in reducing the size and vascularity of the tumor. It is given in a dose of 5mg per orally OD for 3 months. It can be given upto 4 cycles with a gap of 3 months after each cycle. Reduction in menorrhagia by 90% and tumor size by 53% is seen. It is suitable for young nulliparous females and perimenopausal women. Disadvantages are high cost and risk of fulminant hepatitis when given for longer duration.

55. GnRH analogues GnRH agonists Lueprolide, Goserelin, Buserelin, Nafarelin and Triptorelin. These are the most commonly used drugs in the treatment of leiomyoma. They act by downregulation of gonadotropin receptors in pituitary causing decrease in gonadotropins and suppression of estrogen and progesterone levels. They also cause pain relief and amenorrhea. They reduce the size of tumor by 60%. Suitable for treatment of perimenopausal women.

56. Disadvantages High cost Loss of libido. Vaginal dryness. Emotional liability. Osteopenia and osteoporosis. Menopausal symptoms like hot flushes; can be treated with conjugated estrogen 0.3-0.625mg + MPA 10mg from D16 to 25.

57. They have high affinity for GnRH receptors and resistance to enzymatic hydrolysis. They initially cause flare effect for 1-2 weeks followed by sustained downregulation. After 2 weeks, estrogen levels falls <20pg/ml. Recovery occurs after 2 months of stopping the treatment along with increase in the size of leiomyoma.

58. Inj. Leuprolide acetate 3.75mg IM or SC every month for 3-6 months. It can also be given as 11.25mg every 3 months. Inj. Goserelin 3.6mg depot subcutaneously over anterior abdominal wall every month for 3-6 months or 10.8mg every 3 months. Inj. Triptorelin 3.75mg IM every month or 11.25mg IM every 3 months for 3-6 months. Nafarelin 300mcg BD nasal spray for 3-6 months.

59. GnRH antagonists Cetrorelix, Ganirelix, Elagolix and Relugolix. They competitively inhibit GnRH. Onset of action is rapid with no initial stimulatory action. Tab. Elagolix 300mg BD for 24 months can be given with add back therapy of 1mg estradiol and 0.5mg norethindrone acetate. Adverse effects are similar to that of GnRH agonists.

60. LNG IUS It can be used in smaller myomas <12weeks size with HMB. It improves blood loss and reduces the size of myoma. Also acts as effective contraception. It is not suitable for large submucosal myomas distorting the uterine cavity. High expulsion rate when inserted in submucosal leiomyomas.

61. Aromatase inhibitors Letrozole and anastrozole causes hypoestrogenic state thereby reducing the tumor size. They are associated with significant menopausal symptoms. Not yet approved for the treatment of leiomyomas.

62. OCPs : This are used to make cycles anovulatory and reduce menstrual blood loss. Prostaglandin synthetase inhibitors : Mefenamic acid 250-5oomg TID improves menorrhagia by 20-50%. Antifibrinolytic agents : Tranexamic acid 1gm 2-4 times/day reduces menstrual blood loss by 50%. It is contraindicated in patients at risk of thromboembolic phenomenon. Other drugs for symptomatic relief

63. NON SURGICAL MANAGEMENT Uterine artery embolization Magnetic resonance guided focused ultrasound. Radiofrequency volumetric thermal ablation. Myolyisis with Nd – YAG laser or cryotherapy. Laparoscopic B/L uterine artery ligation.

64. Uterine artery embolization This procedure is done under IV sedation by interventional radiologist. It improves menorrhagia in 80% women, dysmenorrhea in 77% and reduction in size of the fibroid by 33%. Pre operatively Pap smear and Cervical swab cultures should be done. CBC, RFT, coagulation profile are mandatory. Active PID, pregnancy and malignancy are absolute contraindications for the procedure. Not recommended In women desiring fertility.

65. Procedure Under IV sedation, angiographic catheter is put percutaneously in one femoral artery. Under fluoroscopic guidance the catheter is advanced till both the uterine arteries. PVC particles or trisacryl gelatine microspheres are delivered to the uterine arteries to produce ischemia and necrosis of myoma.

66. Uterine artery embolization

67. Postoperative complications Post embolization syndrome Persistent fever Infection Pain Groin hematoma Vaginal discharge Mesenteric artery occlusion Reduced fertility Pedunculated subserous fibroids can become infected and cause peritonitis.

68. Magnetic resonance guided focused ultrasound Procedure – Under MRI guidance with patient in prone position high intensity ultrasound energy is focussed on the myoma -> coagulative necrosis. Advantages – Non invasive, Rapid recovery. Disadvantages – Expensive Contraindications – Pregnancy, previous abdominal surgery, large myomas >10cm, Pelvic infection and infertility.

69. Surgical management Myomectomy - 1) Vaginal myomectomy 2) Hysteroscopic myomectomy 3) Laparoscopic myomectomy 4) Open myomectomy Hysterectomy – 1) Vaginal hysterectomy 2) Laparoscopic hysterectomy 3) Total abdominal hysterectomy

70. Pre operative investigations Complete blood count Blood grouping and Rh typing Bleeding and clotting time Serology for HIV and HBsAg Urine examination with culture and sensitivity FBS and PPBS RFT, LFT and serum electrolytes Chest x ray ECG UPT

71. Myomectomy It is an uterus preserving surgery where only the myoma is excised, leaving behind potentially functioning uterus. It was first demonstrated by Victor Bonney in 1913 in a nulliparous woman.

72. It can be vaginal, abdominal, hysteroscopic or laparoscopic depending the location and size of the myoma. It is suitable for women desiring fertility and women who refuse for hysterectomy. Blood loss during myomectomy is unpredictable and uncontrollable bleeding is an indication for converting into hysterectomy. The consent for the same should be taken pre operatively. All other causes of infertility should be ruled out before performing myomectomy including husband’s semen analysis. Asymptomatic women with moderate to severe hydroureteronephrosis is an indication for myomectomy.

73. No attempt should be made for myomectomy in asymptomatic subserosal myomas, intramural and cervical myomas during caesarean section. Painful leiomyomas during pregnancy are managed conservatively. Subserosal myoma with torsion is an indication for laparotomy and myomectomy. Before performing myomectomy endometrial cancer should be ruled out by endometrial biopsy in perimenopausal women with AUB.

74. Preoperatively patient’s general condition should be improved and anaemia correction should be done either by blood transfusion or parenteral iron therapy. Cochrane review shows significant improvement in preop Hb levels and reduction in intra operative blood loss with use of pre operative GnRH analogues for 3-6 months. Use of intra myometrial vasopressin also reduces operative blood loss.

75. Open myomectomy / Conventional myomectomy It is indicated if there are > 3 myomas with size > 10-12cms. 3-4 units of blood is arranged preoperatively. Patient should be explained about 50% recurrence rate in 5 years of surgery. Consent for possible hysterectomy should be taken. It is performed in proliferative phase of the cycle to reduce blood loss.

76. Procedure Pfannenstiel incision is preferred. For the myoma size is > 16weeks, broad ligament myoma, associated adhesions midline vertical incision is given. Location of the myoma identified, diluted vasopressin (20IU in 200ml saline) is injected to the myoma and to its base.

77. Bladder peritoneum is incised and reflected downwards.

78. For larger myomas simple rubber catheter can be used as torniquet by making small holes in broad ligament and passing the torniquet around the cervix and the lower uterus thereby occluding uterine artery.

79. Continued… Alternatively Bonney’s myomectomy clamp can be applied along with ring forceps to the infundibulopelvic ligament. The clamp is applied from the pubic end of the abdominal wound with the angle between the blades and the shanks opening downwards to grip the round ligaments. Clamps or torniquets used should be released temporarily to avoid accumulation of histamine metabolites.

80. continued… Uterine incision is given over the anterior uterine wall over the myoma. The capsule of the myoma is cut and the myoma is enucleated with myoma screw.

81. Multiple myomas can be removed through single uterine incision, if the myomas are far from each other multiple incisions can be given. Submucous myomas also removed by opening the endometrial cavity. Bleeding points in the myoma bed can be ligated or cauterised. Incision on the endometrial lining is closed with 2-0 or 3-0 vicryl.

82. Bonney’s hood operation It is done in large posterior wall myomas. Incision is made over the posterior wall. The myoma enucleated. Some redundant hood trimmed. The remaining hood is brought anteriorly and stitched to the anterior uterine wall.

83. After enucleation the dead space is obliterated by mattress suturing using 1 or 1-0 vicryl in 2-3 layers. The serosa is closed by baseball suturing with 1-0 vicryl. Adhesion barriers like interceed, seprafilm is used to cover the myomectomy wound. Round ligaments are plicated to prevent retroversion of the uterus.

84. Complications Intraoperative – 1) Primary haemorrhage. 2) Bladder injury. 3) Ureteric injury in broad ligament myoma excision. 4) Bowel injury (sigmoid colon and rectum). Post operative – 1) Reactionary haemorrhage. 2) Infection. 3) Need for relaparotomy. Late sequelae – 1) Adhesion formation b/w uterus and rectosigmoid. 2) Peritubal adhesions causing infertility. 3) Recurrence.

85. Laparoscopic myomectomy It is done in cases with myoma size </= 5cm and it being Intramural or subserosal. Advantages : Minimally invasive procedure. Lesser operative blood loss. Reduced post operative pain. Lesser hospital stay. Cosmetic advantage.

86. Vaginal myomectomy It is done only in fibroid polyps which are easily accessible and protruding into the vagina. Pedicle is clamped, cut and ligated with vicryl suture. If the pedicle is inaccessible vagina and cervix is cut, bladder separated before clamping the pedicle .

87. Hysteroscopic myomectomy It is an incisionless day care procedure with faster recovery. 85-90% long term efficiency for improvement in HMB. Improved fertility. Indications – 1) Symptomatic type 0 and type 1 myomas. 2) Infertility due to cornual submucous myomas. 3) Pedunculated myoma.

88. Procedure Patient is placed in lithotomy position after giving subarachnoid block. Preoperative 400mcg vaginal misoprostol is kept. Cervix is dilated with Hegar dilators. Operative hysteroscope is inserted and uterus is distended with glycine or normal saline to maintain the intra uterine pressure of 75-100mmHg. Whole of the uterine cavity is inspected for other pathologies like adhesion, septum and presence of both the ostia. Target myoma is identified, the cutting loop is passed beyond the fibroid, with the cutting being activated only when the loop is moving towards the operating surgeon.

89. Continued… Fibroid is resected down to the level of adjacent myometrium. In type 1 myomas, while performing the resection more of the myoma projects into the uterine cavity, allowing for it’s further resection. Type 2 myomas can be resected in 2 settings after the interval of 6 weeks to 3 months. Fragments of the myoma are removed from the cavity with grasping forceps. Any bleeding area is coagulated with roller ball coagulation. Foley’s catheter inflator balloon can also be used for control of bleeding.

90. Complications of the procedure Uterine perforation - first sign being rapid loss of fluid and vision. Fluid overload – a fluid deficit of 750ml is a warning sign and fluid deficit of 1ltr is indication for termination of the procedure. Haemorrhage. Infection.

91. Hysterectomy Indications : 1. Large symptomatic fibroids 2. Family is completed 3. Failure of conservative methods 4. Broad ligament fibroids 5. Cervical fibroids 6. Associated extensive endometriosis

92. Vaginal hysterectomy It is the preferred route if uterus < 14weeks size. Myoma can be enucleated before hysterectomy. Not suitable in the presence of pelvic adhesions.

93. Laparoscopic hysterectomy It can be done with the uterine size upto 16weeks. Minimally invasive. Early recovery. Not suitable for cervical and broad ligament fibroids.

94. Total abdominal hysterectomy Suitable for large myomas with size > 16weeks. Highest success and satisfaction rate. Better handling of ureters, bladder and rectum under direct visualisation. Broad ligament and cervical fibroids can be removed.

95. THANK YOU