Medical Updates

Fibroid Embolization - A New Treatment Option

Fibroids are common, benign growths of the muscle wall of the uterus. About 30% of women will have fibroids during their lifetime, but 80% of those women have no symptoms and, therefore, need no treatment. For women with uterine fibroids that cause bothersome symptoms, a number of treatments options are available. While some doctors still recommend hysterectomy as a first option for women with bothersome uterine fibroids, we find that this is rarely necessary. Removal of just the fibroids, called myomectomy, can almost always be performed. Myomectomy may be performed through a bikini incision, or through the navel with the laparoscope. When the fibroid is within the uterine cavity, a telescope called a hysteroscope, can be placed through the cervix into the uterus. A special attachment to the telescope can then be used to shave the fibroid out of the cavity.  Both laparoscopic and hysteroscopic surgery are performed as outpatient surgery with quick recovery.

Recently, a technique developed in France, called uterine artery embolization, has been used to treat women with fibroids in the United States. This non-surgical technique utilizes a very small tube that is inserted into an artery in the groin and passed directly into the main vessels feeding the uterus and associated fibroids. Once this tube, or catheter, is in place, very small pellets of polyvinyl alcohol are pushed through the catheter and into the vessels, blocking off the blood flow to the uterus. It appears that fibroids need a greater amount of blood flow than normal uterine muscle.   After the embolization procedure leads to a loss of blood supply, the lack of oxygen to the fibroid cells causes them to die off.   The cells release biochemicals into the surrounding area that cause a fair amount of discomfort during the first few days after the procedure. Most women stay in the hospital overnight in order to receive pain medication.   However, the majority of women go home the next day and can expect reasonable recovery in 1-2 weeks.

Without a blood supply, the fibroids will begin to shrink. After a few months, most studies have shown about a 40% reduction in size of the fibroids. The best results have been found in women who have bleeding from the fibroids as their most bothersome symptom.  Almost all of these women are able to avoid hysterectomy.
This procedure is a relatively new application of an established technique. Therefore, while long-term results are expected to be good, we do not have definitive results as yet. Some fibroids do not respond well to this treatment, specifically fibroids that attach to the uterus with a stalk, called pedunculated fibroids. Often, the stalk will wither away, leaving the fibroid free to wander about in the abdomen or inside the uterine cavity.

One potential problem is that some of the pellets have been found to spread to the vessels feeding the ovary. As a result, about 5-10% of women will have the blood supply to the ovary decreased enough to lead to premature menopause. The procedure has not been commonly used in women who wish to get pregnant, again because we do not know the long-term effects. Few women who have had embolization and attempted pregnancy have been studied. Therefore, questions regarding the strength of the uterine wall after embolization and the ability of the uterus to withstand the forces of pregnancy and childbirth have not been adequately answered.

However, we feel this procedure does have a place in the treatment options we offer women with fibroids. Women who have completed their families and who have large fibroids that primarily cause bleeding may be excellent candidates for this procedure. Embolization is performed in the hospital by an interventional radiologist. If you are interested in this procedure, ask us about it. If embolization is appropriate for you, we can refer you to an expert in the field.

Laparoscopic Supracervical Hysterectomy

As always, we strive to stay on the cutting edge of developments in gynecology. While we pride ourselves in performing hysterectomies usually as a last resort to gynecologic problems, the operation is sometimes necessary and appropriate. Our practice has a superb reputation for gynecologic surgery in general, and laparoscopic surgery specifically. We have been performing operative laparoscopic surgery since 1987 and laparoscopic hysterectomies since 1993.

Recently, new instruments have been developed that allow a laparoscopic procedure to be performed that previously was difficult and tedious. This procedure, laparoscopic supracervical hysterectomy, differs from standard laparoscopic hysterectomy in that the cervix is retained in the woman's body, while the uterus (and tubes and ovaries, if necessary or desired) is detached and removed through small (one inch) incisions near the pubic hairline. The instrument that makes this surgery feasible is called an electronic morcellator. It is able to cut the uterus into small pieces so that the tissue can be removed through these small incisions.

There is much debate as to whether there is any benefit to not removing the cervix. The proponents of supracervical hysterectomy suggest that bladder and sexual function are better preserved with this operation because the nerves running to the bladder and cervix are not disturbed if the cervix is left in place. In addition, proponents feel that healing and recovery are faster because there are not any stitches in the vagina that need to heal.  However, studies have shown conflicting results, and it is not clear if these benefits truly exist.  Ater supracervical hysterectomy, it is important to continue to have Pap smears yearly. However, pap smears are still a good idea every few years even if the cervix has been removed, in that the test is able to find vaginal cancer.

We now have extensive experience performing laparoscopic supracervical hysterectomies and our own patient’s experience has been very favorable. We find that postoperative discomfort is less and healing is faster, and overall recovery is shorter than with total laparoscopic hysterectomy. There are indications and reasons for each procedure, and we discuss these with each patient who needs a hysterectomy before surgery.

A New Procedure For Incontinence - TVT
The tension-free vaginal tape procedure, or TVT, is a new procedure first developed in Sweden in 1995.  This procedure uses a synthetic tape to form a hammock under the urethra that bolsters it when you laugh, cough, exercise, or strain in any other way.

This procedure has been performed on over 150,000 women in Europe and 20,000 in the United States, and the initial results are excellent.  The success rate so far is 85%. Surgery takes about 30 minutes and may be performed with local or epidural anesthesia. Most women can leave the hospital within a few hours and can urinate without problems immediately after surgery.

The TVT procedure is performed through a small incision in the vagina directly below the urethra.  A loose hammock is made beneath the urethra, and the ends of the hammock are pulled up through two very small (1/2 inch) incisions made side by side in the skin just above the pubic bone.  The tape is carried up to the abdominal wall with an instrument.  Once the tape is placed properly below the urethra the incisions on the skin’s surface are closed.

Recovery is very rapid following TVT. The small incisions, the one in the vagina and the two above the pubic bone, only cause mild discomfort for a few days. Since the surgery can be performed under local or epidural anesthesia with mild sedation, there is none of the grogginess people sometimes feel after general anesthesia.  Our patients are usually walking around within a few hours and go home from the hospital shortly thereafter.

The advantages of this to women who leak are obvious.  We finally have a minimally invasive procedure that can be done on an outpatient basis with very good success and very little pain or hassle. We have been very impressed with the results in our own practice.  Our youngest patients have been in their 30's, our oldest are in their 90's.  Most women are back to normal activity in 1 week. However, it is necessary to limit lifting to 5lbs. or less for 8 weeks.  Patients typically return to work in 1 to 2 weeks.  If you think you could benefit from this procedure please make an appointment with either Drs. Rosenman or Parker.