Operations for myoma of uterus
All possible operations in case of myoma of uterus are performed on, using laparoscopic access. Among them there are the following:
- Conservative myomectomy. It is an organ-preserving operation- nodes are removed, the organ is preserved.
- Supravaginal amputation of uterus- it is an amputation of changed uterus without its neck.
- Hysterectomy - it is a removal of the whole of the organ alongside with the neck.
While treating myoma of uterus, a lot of factors influence upon the choice of operation. They are as follows: age, the desire to have kids, condition of the uterine neck and endometrium, etc. If during the examination accompanying diseases of ovaries or fallopian tubes are found out, it is necessary to perform on the surgical correction of pathology.
That is why it is necessary to forward to my e-mail puchkovkv@mail.ru
puchkovkv@mail.ru 
) the full description of USI of organs of small pelvis, to mention your age and the main complaints. Then I will be able to give you more exact answer about your situation.
An original, having no analogues, bloodless laparoscopic technique of organ-preserving myomectomy.
Uterus preserving as an organ is important not only for those who want pregnancy, but for those females who desire to preserve the menstrual function. When performing on operation for myoma of uterus, I always choose organ-preserving tactics of treatment and try to preserve uterus.
Advantages of laparoscopic myomectomy are evident: decreasing of interference (instead of incision of anterior abdominal wall-3 punctures-5-10 mm), cosmetic effect, reducing of the risk of adhesion development, fast recovery. And laparoscopic operations usually are performed on, as a rule, for patients with superficial location of nodes, having the size 2-4 cm. And what to do with patients with big - sized myomas or if they are localized in those areas, where it is difficult to get there? To perform laparotomy? No, there is the way out!
Operations in case of big-sized myomas or if they are located in ‘difficult” areas
In case, if it is a ‘difficult” node, for example, located in the area of uterine isthmus, along its posterior wall, or if the size is big (within the range 6-12 cm), they suggest laparotomy. It is related to the possible bleeding during exposure of nodes out of uterus, if it is laparoscopy. This kind of complication sometimes promotes development of complications, bleeding, in particular, blood transfusion is required. And surgeons convert to laparotomy. That is why laparoscopic myomectomy, if nodes are big, can have complication-severe bleeding, as compared to laparotomy, and in this situation conversion to laparotomy takes place. If the situation is complex in case of laparoscopy, a surgeon places less reliable suture on the uterine wall as compared to laparotomy.
I have been actively searching the way out. As a result of 15 years of work a technique has been elaborated, giving a possibility to solve successfully all problems, described above, to perform on operations for big and complex myomas without blood loss, with safe stitching of uterine wall, and absence of adhesion in the area of small pelvis. It is very important to preserve ability of a patient for fertilization, pregnancy and delivery. This technique is called bloodless organ-preserving laparoscopic myomectomy with transient occlusion of uterine arteries.
The essence of the technique is as follows:
Patent. Method for laparoscopic
myomectomy
At first I perform on laparoscopy, and then, after exposure of uterine vessels, using soft vascular atraumatic forceps, I transiently stop blood flow in the vessels. Then I remove the nodes of myoma. The surgical site in these conditions is absolutely dry. I can clearly see the border of the node and healthy tissue, all the layers of the uterus, it means, there is no risk to loose yourself in the uterine cavity. During exposure of a node I use contemporary ultrasonic scissors that minimally traumatize the surrounding healthy tissue of uterine wall and improve the healing process in the area of interference. Then I stitch the uterine walls by synthetic resorbable thread, approximating layer by layer all the muscular layers. Good visualization of the surgical site gives a possibility to do it easily and safe.
In complex cases I use V-lock stitching system (Covidien, Switzerland), that is made of monofilament resorbable polydioxanone thread that is oriented in space with some set angle in one direction. It gives a possibility to thread to slide in one direction, and not to be shifted in another one. In this system there is no need to bind knots. Using of this system gives a possibility more carefully to approximate wound edges of the uterus (healing is faster) and formation of the scar is 3-4 times faster. At the next stage I use contemporary anticommissural gel that several times decreases the risk of adhesion development in the area of small pelvis, preserving fertility and possibility of the further delivery.
At the final stage I remove soft forceps from arteries and completely restore blood flow in uterus.
The advantage of a new bloodless technique is the following:
- Operation is performed on without blood loss, it gives a possibility to exposure the node with minimum trauma for surrounding tissues and without the risk of opening uterine cavity;
- this method gives a possibility to stitch uterus safely, it is necessary for the further pregnancy and delivery.
This method is especially important for the following patients:
- who want pregnancy;
- with the so-called “difficult” nodes on the uterus (if a node is near the isthmus,
- or along the posterior wall of uterus, centripetal nodes, big-sized nodes-more than 6cm);
- with multiple nodes;
- with anemia.
In case, if a small node (up to 2 cm) is located in submucous layer (it is not accessible during laparoscopy), it is necessary to remove a node hysterescopically (under the guidance of endovideoscope via the uterine cavity). In case of combination of subserous, intramuscular and submucous myomas, it is possible to remove simultaneously the last kind laparascopically and hysteresectoscopically. In this case sometimes it is required to administer hormones after operation.
During operations I use contemporary ultrasonic surgical scissors and device of dosed electrothermal ligating of tissues “LigaSure” (USA), that gives a possibility to mobilize organs fast and without blood loss, and no foreign bodies are left in the abdominal cavity (thread, clips). After operation I use anticommissural barriers to reduce the risk of adhesion development in the area of small pelvis.
I have the experience of performing on more than 3,500 miniinvasive operations for myoma of uterus, more than 50 scientific publications about this disease. Annually they hold up to 40 master-classes in Russia and abroad under the guidance of Professor Puchkov K.V.
I have the experience of more than 3,000 miniinvasive operations for myoma of uterus, and the results are in monographs ”Laparoscopic Operations in Gynecology” and in ”Simultaneous Operations in surgery and in Gynecology”, and more than 70 scientific publications in different professional scientific publishing houses in Russia and abroad.
Annually me and my team hold about 40 master-classes and seminars , related to the contemporary aspects of highly technological laparoscopic surgery in Russia, in CIS countries and in Western Europe. My seminars in laparoscopic treatment of myoma of uterus and other diseases are attended by doctors –specialists from big scientific centres, republican, regional hospitals, by those who study at the faculty of postgraduate education.
The restorative period after operation for removal of uterus.
After laparoscopic operation on the abdomen skin 3 incisions are left, having the length 5-10 mm. Since the first day after operation patients get up from their beds and take food. And they are discharged from hospital in 3-4 days.
After laparoscopic myomectomy (organ-preserving operation), as a rule, they administer light hormonal therapy-duration is 6 months- for optimization of reparative processes in uterus. Dynamic control of a gynecologist is required- examination and USI in 1, 3, 6 months. Pregnancy is possible in 6-8 months. It is desirable to do hysteroscopy whether there is obstruction of fallopian tubes or not and to learn about the condition of uterine cavity. Depending on the size of scars on uterus, delivery can be natural or due to cesarean section.
After radical operation for uterus a complete restoration depends on accompanying pathology (high BP, diabetes mellitus, obesity), and severity of anemia before the operation. Restoration is usually 12-21 days after operation.
Intimate relations are possible in a month after operation. If a patient thinks not to tell her husband about the volume of operation, he himself will not be able to determine the degree of anatomic changes in the body of his wife.
Removal of only body of uterus does not cause disharmony in intimate relations of spouses, does not decrease sexual satisfaction in females. The only testimony of uterus absence will be absence of menstruations and possibility to become pregnant. Uterus removal for myoma does not influence the time of climax coming or increasing symptoms of it, as uterus does not generate sexual hormones, but is an organ-target for them.
Answers about myoma of uterus to patients.
Why does myoma develop?
They think that there is congenital predisposition for developing uterine myomas as a result of injury of cells by unknown maternal factor at the stage of embryo. Realization of growth of myomatous nodes takes place on the background of disturbance of balance of endocrine system, inflammatory diseases of genital organs and traumas. In detail general questions of arising, development, treatment of myomas of uterus are met at the corresponding page of our site.
How long a patient with myoma of uterus can be controlled by a doctor?
As the latest investigations show, myomatous node influence the whole of uterus, it changes and increases the amount of hormones, getting into uterus, the amount of estradiol is increased, and amount of progesterone, getting into myometrium, is decreased. That is why in case, if observation period is long, uterus exists in the condition of disturbed hormonal status, that causes growth of all the muscular tissue of uterus and increase of its volume; gradual worsening of innervation of uterus, including vessels; worsening of blood flow of uterus, it is noticed at the level of microcirculation; increase of endometrium due to the increase of volume of uterine cavity, it promotes increase of blood loss during menses, and, to anemia. Taking into consideration all facts, innumerated above, the conclusion is as follows: operation should be performed on as early as possible. The less is myoma size, the more efficient and safer the operation will be -myomectomy. Especially young patients (up to 27) should do it on time, as there is an indication for them-myomectomy should be performed on immediately after finding out the tumour. All structures and functions of the muscular tissue of uterus will be restored within 8-10 weeks after myomectomy. Treatment by preparations-agonists ( bucereline, zoladex, etc) in young females does not cure myomas. When they stop taking them, myomatous nodes return to their previous sizes and sometimes even exceed them. That is why one can take those preparations only before operations to decrease the sizes of nodes, and to be careful with them.
Those patients, who have taken mentioned above preparations, should be operated on immediately after spontaneous beginning of menstruations after stopping taking them. It is related to the fact that agonists suppress constrictive activity of myometrium, and when menstruation is restored, hormonal background becomes like physiological parameters, and myometrium has ability to constrict.
How to get ready for operation?
In total, operation according to my technique requires to get ready to it, as any kind of laparoscopic operation. But this operation has its own peculiarities. If you are going to get surgical treatment with the method of organ-preserving myomectomy, I would like you to study attentively the chapter about preoperation preparation. The compulsory part is the prophilaxis of thrombosis and thromboembolism.
Is myoma related to oncology?
There was time, when scientists thought that fast growth of myoma was related to the theory about the risk of turning tumour nodes into malignant tumours. Now- adays it has been proved that uterine sarcoma in majority of cases develops in aged females ( aged 55-65), and the risk of development of sarcoma is 30 times lesser as compared to the risk of development of tumour in some other organ. According to the contemporary data, only one patient out of 3 thousand patients who has had myomectomy at fertile period, will be undergone operation for removal of malignant tumour. That is why we do not recommend to all patients with “fast growth” of myoma to remove uterus for the sake of prophilaxis. In this situation it is necessary to perform on organ-preserving operation-myomectomy.
If I have hyperplasia of endometrium, is it possible to remove myoma and to preserve uterus?
Previously patients with diseases of endometrium and myoma of uterus were recommended to remove uterus. Nowadays it is considered that only cancer of endometrium is a contraindication to preserve uterus. In order to exclude cancer of endometrium, all patients before myomectomy should have the condition of their endometrium investigated (either aspiration biopsy of endometrium or diagnostic abrasion ). According to some extensive investigation, cancer of endometrium has been found out only in 0.15% of females who is going to be undergone to myomectomy; none of patients of fertile period (up to 41) has had cancer. But hyperplasia (polyps of endometrium, cystous hyperplasia, etc) is not a contraindication for myomectomy. Nowadays only patients with relapsing atypical hyperplasia of endometrium should be considered as patients of high risk of development of adenocarcinoma of uterine body, for them myomectomy is not desirable. But even for this group of females, according to some investigations, abrasion of mucous membrane of uterus under the guidance of a hysteroscope with the further hormonal treatment promotes curing of diseases. That is why myomectomy for this group of patients is also possible, especially if the reason of operation is their infertility, and they are going to resort to additional reproductive technology-ECF (extracorporeal fertilization).
Is myoma related to pregnancy? Can I become pregnant?
Myomectomy is the basic element of treatment of patient who suffer because of myoma and infertility. Extremely long conservative treatment of infertility in females, having myoma, is less efficient, it is related to considerable waste of money and to the risk of loosing an organ due to the progressing symptoms of myoma of uterus. Patients should be operated within 3-6 months when it has become clear that myoma is the reason of infertility. The attempt to solve this problem with the help of ECF without preliminary myomectomy is not efficient, as even in case of successful implantation there is a high risk of natural abortion, and if the diameter of nodes of myoma is 5 cm or more, there are serious ploblems, related to the risk of loosing uterus ( necrosis of the node in the first trimester, the risk of loosing uterus because fetus becomes infected, delivery of premature infant, etc).
Myomectomy provides normalization of structure and function of uterus, microcirculation is restored, as well as function of ovaries. Ability to fertilization and carrying of a pregnancy is restored within 6 months in 35-45 % of patients with the primary infertility and in 55-60 % of patients with the secondary infertility. About 25-30 % of patients can become pregnant even after using contraceptives, the remaining 10-15 % of patients who can’t restore fertility, can resort to ECF.
Is the operation necessary, if myoma is not big, and I am not going to become pregnant in the nearest future?
Among the patients of the reproductive age, having myoma of uterus, that should be removed, there are a lot of females who at present are not going to have pregnancy, but would like to have it later. Among these patients there are those ones who have had pregnancy, but the result of it has been an abortion; they have one kid, but are not married now; and there are those patients, who have never been married, and they would like to postpone the time of operation. Many of them have been taking a conservative treatment for a long time, and have the increasing risk to loose their organ-uterus. According to some investigation they have found out that among patients, younger than 35, having myoma for more than 5 years, only the fifth of them has been operated for myoma (21%), for the rest of the patients they have removed uterus. The saddest thing is that only every tenth patient was operated for myoma when it had been found out at the age earlier than 27! From all mentioned above things it is clear that for the sake of prophilaxis myoma should be removed even if symptoms are not obvious; it helps to preserve reproductive function for young patients.
I am 45. Is it possible to perform on operation for myoma and to preserve uterus?
For some patients at the age of 40-50 preserving of menstruational function and uterus is an important indicator of life quality. We think that if it is a patient ‘s desire to preserve her uterus as menstruating organ, and it is possible to preserve it, as there are no indications to remove uterus, we should consider her desire as indication to myomectomy. According to the latest investigations, the risk of relapse of myoma after myomectomy in this age group is low (4-6 %); if relapse develops, it is on average in 3-8 years after operation, these nodes grow slowly and without symptoms. Thus, this group of patients can quietly proceed to climax; without moral discomfort that they have no the “important” organ.
Why should I choose myomectomy?
At present for treatment of myoma of uterus organ-preserving methods become wide-spread and they have advantages. Definitely, preserving of uterus as an organ is important not only for those patients who want to preserve fertility, but also for those ones who want to preserve menses. They consider EUA (embolization of uterine arteries) and FUS-ablation (focused ultrasonic ablation) of myoma of uterus to be non-surgical organ-preserving methods. EUA is more efficient, in case if nodes are small (up to 4 cm, located subserously).
Indication to FUS-ablation is presence of myomatous nodes that can absorb ultrasonic energy properly, when the size of nodes is within the range 3-6 cm, the number of them is not more than 3, if nodes are accessible for focused ultrasound (localization is along the anterior wall of uterus, the depth is not more than 12 cm from the skin surface and not closer to sacral bone than 4 cm).
One should bear in mind that EUA and FUS-ablation of myoma of uterus are not indicated to patients who is going to preserve reproductive function, as it still has not been proved whether it influences negatively or not on fertility, pregnancy, its course, delivery.
EUA should not be done for those patients who is going to become pregnant, who has multiple nodes, “difficult” nodes ( located near isthmus, along the posterior wall of uterus, centripetal nodes, nodes that are more than 8 cm); for patients with anemia due to uterine bleeding we suggest that they should be undergone myomectomy with the preliminary occlusion of uterine vessels.
When we are performing on myomectomy, at first we apply soft atraumatic forceps onto the vessels nourishing uterus, transiently stopping blood flow in uterine vessels, then we remove nodes. The surgical site in this case is “dry”, a surgeon clearly can see the boundary of the angle and healthy tissue, and all the layers of uterine wall are clearly seen, too, i.e. there is no risk to open uterine cavity by chance.
We expose the node, using the contemporary ultrasonic scissors, they minimally traumatize surrounding healthy tissue of uterine wall and improve processes of healing in the area of interference. The peculiarity of our operations is virtuos handling of surgical laparoscopic suture, using the contemporary synthetic thread, giving a possibility to place a reliable suture on uterus; a good visualization promotes it. After stitching walls of uterus we compulsory use contemporary anticommissural barriers that considerably reduce the risk of adhesion development; it is necessary for fertility and delivery. After the end of the basic stage of operation soft forceps are removed from the arteries, blood flow in uterus is restored. Transient stop of blood flow in vessels, nourishing uterus, is not harmful for uterus, there is no negative influence for it.
And as a conclusion, we should mention the main advantages of our technique of myomectomy:
Operation is performed on without blood loss; it gives a possibility to expose the node with minimum trauma for surrounding tissues without the risk of opening the cavity of uterus; safely to stitch uterine wound that is possible in condition of good visualization-it is required for further pregnancy and delivery.
If in addition to myoma I have some more diseases, is it possible to treat them all during one and the same operation?
It is possible to perform several operations, sometimes using 3-4 or even 5 surgeons, but general anesthesia will be given by one person, and you are admitted to hospital once. These kinds of operations are called simultaneous. In many patients myoma is combined with some other diseases, not of gynecological kind, they also require surgical treatment: nodular changes in the thyroid gland, hiatal hernia, nodes in mammary glands, umbilical hernia, inguinal hernia, varicous disease of veins of lower extremities, etc. The techniques of miniinvasive surgery, that I use, give a possibility to perform 2-3 operations simultaneously during one anesthesia by the team of surgeons. In detail the problem of simultaneous operations for myoma of uterus is explained in a special chapter of our site. Simultaneous operations will help to reduce overloading of the body, will decrease the time of staying in hospital, will make the restoration of the body faster as compared to performing on several operations with the interval of 5-6 weeks.
How do you use pain-killers for a patient in case of myomectomy?
It is a frequent question! In total, operation is performed on only using general anesthesia. We administer additional getting ready of a patient to the procedure (premedication) that is done in the ward, we should exclude any kinds of psychological stress in patients who are expecting their operation.
What will happen after operation?
Laparoscopic myomectomy, that is performed on according to the original technique of our clinic, is overcome easily by our patients, because the trauma of the anterior abdominal wall and blood loss are minimal. A patient spends 2-3 days in the hospital after operation, gets antibacterial, antiinflammatory treatment, intravenous solutions, the preparations that reduce uterus. The medical staff takes control over the temperature of a patient and amount of genital discharge. When a patient is leaving hospital, she gets recommendations in detail; how to behave at home, how to take tablets. The postoperation period is controlled by operating doctors over the telephone and during consultations, where USI specialist is also invited to take control of scar of the uterus.
Bloody discharge from genitals can take place for 7-14 days; as a rule, they are intensive only during the first 1-2 days, then they become poor. Temperature of the body can increase during 5-7 days, the first 2 days-up to 38 degrees, then -37.5-37.3 degrees. A patient is allowed to take a shower when stitches are removed (5-7 days after operation), before that time it is recommended not to make gauze wet.
Next day after operation we allow to take broth, sour milk, yohurt, in 2 days- soup, chicken cutlet (not fried, but cooked using steam), cottage cheese; when stool appears it is recommended gradually to include more kinds of food according to the physiological parameters.
USI is done in 5-7 days after operation, the next USI is administered by an operating surgeon individually, approximately in 1, 3 and 6 months after operation. If a patient has become pregnant, it is necessary to take control of the condition of the uterine scar. It is recommended for patients not to have intimate relations within a month after operation. In 3 weeks patients are allowed to attend the swimming pool, in 1.5-2 months-to return to usual active life.
Is it necessary to take some preparations after myomectomy? When can I make plans for pregnancy?
As a rule, patients are administered oral contraceptives for 4-6 months in order to give time for the body to restore completely-reparative processes in the area of postoperation scar of the uterus, normalization of hormonal statute and prophilaxis of exacerbation of inflammatory processes in the area of small pelvis.
Pregnancy is allowed in 6-8 months if USI data tells us that everything is OK with the uterine scar.
There are indications for cesarean section for the following patients after myomectomy:
- scar on uterus after removal of node, located on the posterior wall of uterus;
scar on uterus after removal of atypical nodes ( in the neck of uterus, between
leaves of broad ligament of uterus);
scar on the uterus after removal of several nodes of big sizes.
After operation we have possibilities in our clinic for management of a patient until her fertilization and pregnancy term 12 weeks. Before operation a patient has a possibility to have the total investigation to determine the best tactics of treatment for her and choosing the method of operation.
Where do they perform on operations for myomectomy?
I perform on many operations (1,100-1,200 operations annually), among them demonstrative operations and master-classes in several clinics of Russia, in CIS countries and in Western Europe. The primary consultation is in Moscow in Swiss University Clinic. You can get acquainted with the main clinics in Moscow and Switzerland
I have performed on most of all organ-preserving operations (myomectomies) (2500 patients) in Russia during the last 10 years. Many operated patients have become mothers and enjoy happiness. To read references of my patients, written when they have left hospital or in several years after that you can do at the next page of the site: References of ex-patients with myomas of uterus. At this page you can find e-mails of those patients who have agreed to reply the questions of other women who are interested in my operations. If you have the desire to communicate with them, you are welcome to use those e-mails.
