Abdominal Hysterectomy as a Surgical Approach in Large Fibroids

Uterine fibroids, also known as leiomyomas, are usually benign masses that are most commonly found in women of reproductive age. Fibroids are usually asymptomatic and tend to be incidental findings on ultrasound. When clinically relevant, however, patients report symptoms such as menorrhagia, pelvic pain, and bulk-related symptoms. Treatment of symptomatic fibroids may be pharmaceutical with gonadotropin-releasing hormone agonists, radiological using MRI-guided focused ultrasound surgery (or magnetic resonance-guided focused ultrasound), or minimally-invasive uterine artery embolization, but the treatment is largely surgical. There are many different surgical approaches that can be utilized, including myomectomy or hysterectomy. Treatment of choice depends on multiple factors, including the severity of symptoms, size of fibroids, and patient’s desire to preserve fertility. However, out of all of the different surgical techniques available, hysterectomy is the only definitive treatment for these patients. Here, an abdominal hysterectomy was performed on a 45-year-old patient with symptomatic uterine fibroids. 

Leiomyoma; hysterectomy; menorrhagia; pelvic pain; infertility.

Leiomyomas, also known as fibroids, are the most common benign tumors in women of reproductive age. According to Boosz et al., fibroids can be seen in up to 80–90% of females.¹ Due to its high prevalence, it also poses a large economic burden; estimated health care costs for management of fibroids are as high as two billion dollars annually in the United States.²

These tumors originate from the myometrium of the uterus, and thus its growth is affected by female hormones, estrogen and progesterone. As a result, increased age until menopause is one of the risk factors for fibroid development.³ Other risk factors, such are African American race, early menarche, nulliparity, obesity, and family history of fibroids.³ Fibroids are treated when symptomatic in patients. Treatment of symptomatic fibroids may be pharmaceutical with gonadotropin-releasing hormone agonists, radiological using MRI-guided focused ultrasound surgery (or magnetic resonance-guided focused ultrasound), or minimally-invasive uterine artery embolization, but the treatment is largely surgical, to include myomectomy or hysterectomy. Hysterectomy is the most effective treatment.² Symptomatic fibroids account for up to 39% of all hysterectomies performed in the United States annually.³ In this case, an abdominal hysterectomy was performed on a 45-year-old female who presented with symptomatic leiomyomas.

Symptoms in patients with fibroids are diverse, depending on the size and location of these masses. Common presenting symptoms include metrorrhagia, menorrhagia, or a combination of the two. Additional symptoms to assess include dyspareunia, pelvic pain or pressure, constipation, urinary frequency, infertility, recurrent miscarriages, and signs and symptoms related to anemia. Patients may also be completely asymptomatic, with an incidental finding of fibroids on imaging.³

Symptoms can range from asymptomatic to significant complications such as infertility. The pathogenesis of fibroids involves local anatomical changes in the uterus that cause a disruption in endometrial function, such as increased contractility and impairment of uterine blood supply.² These functional changes manifest clinically as heavy menstrual bleeding and pelvic pain, which are the most common symptoms that patients present with.¹ When these masses grow large enough, these patients can also present with bulk-related symptoms, such as pelvic pressure, bowel dysfunction, urinary frequency and urgency or retention, low back pain, constipation, and protuberant abdomen. Sometimes, fibroids can be palpated during a routine pelvic exam. However, these masses can also be detected with imaging, which is used instead to make an official diagnosis.The physical examination starts with an abdominal examination that should include inspection of the abdomen to assess any visible distension or asymmetry, and gentle palpation to detect an enlarged or irregularly shaped uterus. Pelvic examination includes external examination of the genitalia, a speculum exam, and a bimanual exam to assess the size, shape, and consistency of the uterus, and to detect any vaginal or cervical pathology. The presence of an irregular, firm mass is indicative of fibroids. In certain cases, a rectovaginal examination may be performed to better assess the posterior aspect of the uterus.³

Transvaginal ultrasound is the gold standard for diagnosing leiomyomas.³ Fibroids detected on ultrasound are typically incidental findings due to their asymptomatic nature. As a result, it is not recommended for physicians to screen for fibroids in asymptomatic patients.¹ Hysteroscopy is another diagnostic tool that can be particularly helpful in differentiating intracavitary myomas from polyps.² Regardless, detection of fibroids with imaging coupled with patient symptoms and physical exam findings are sufficient to confirm a diagnosis of fibroids. 

Currently, the FIGO (Fédération Internationale de Gynécologie et d’Obstétrique) classification includes a total of nine types of fibroids - types 0 through 8:

1. Submucosal
   • 0 - Pedunculated intracavitary fibroid (i.e., submucosal fibroid without intramural extension).
   • 1- Submucosal fibroid with intramural extension < 50%.
   • 2 - Submucosal fibroid with intramural extension > 50%.
2. Intramural
   • 3 - Intramural fibroid in contact with the endometrium but not extending into the uterine cavity or serous surface.
   • 4 - Intramural fibroid without contact with the endome-trium and without extension into the uterine cavity or serous surface.
3. Subserosal
   • 5 -  Subserosal fibroid with intramural extension > 50% and < 50% subserosal.
   • 6 - Subserosal fibroid with intramural extension < 50% and > 50% subserosal.
   • 7 - Subserosal pedunculated fibroid.
4. Other - 8 - Other types of fibroids (e.g., cervical, broad ligament, and parasitic fibroids).
5. Hybrid type - 2–5 -  Hybrid classification used when a fibroid extends from the endometrial cavity to the serosa, composed of two numbers, separated by a hyphen, the first characterizing the relationship between the fibroid and the endometrium and the second characterizing its relationship with the serosa.¹³

The MUSA (Morphological Uterus Sonographic Assessment) criteria are used to standardize the ultrasound evaluation of uterine fibroids.

• "Measurement of length, anteroposterior diameter, transverse diameter, and volume of the uterus.
• The serosal contour is regular or lobulated.
• Myometrial walls are symmetrical or asymmetrical.
• The myometrium is homogeneous or heterogeneous.
• Myometrial lesions:
  • Margins: well-defined or ill-defined.
  • Number of lesions and their location: anterior, posterior, fundal, right/left lateral, or global.
  • Type: according to the FIGO classification.
  • Size: using three perpendicular diameters.
  • Outer lesion-free margin: Distance from the serosal surface.
  • Inner lesion-free margin.
  • Distance from the endometrial surface.
  • Echogenicity: Hypoechoic, isoechoic, or hyperechoic.¹³

Fibroids that are left untreated not only lead to a worsening of symptoms but also cause significant complications such as iron deficiency anemia and infertility. The pathophysiology of infertility secondary to fibroids involves hormonal changes that may impair gamete transport and/or reduce blastocyst implantation.² Female patients who present with infertility should therefore be evaluated for fibroids and have them removed. Multiple studies have shown that women with uterine fibroids have an increased risk of complications such as cesarean delivery, breech presentation, preterm premature rupture of membranes (PPROM), delivery before 37 weeks gestation, and postpartum hemorrhage secondary to uterine atony.³ Therefore, it is recommended that pregnant patients who have fibroids be monitored closely to prevent these complications.

Fortunately, these benign masses have a very small risk of developing into malignant tumors. Prevention of malignancy alone is therefore not an indication for hysterectomy.

Management of fibroids is largely surgical, with hysterectomy serving as the only definitive treatment for this condition.² However, indications for surgical intervention depend on a variety of different factors such as the severity of symptoms as well as the desire to maintain fertility. Therefore, patients must be consulted on their desire to preserve fertility before determining the treatment of choice. 

Other therapeutic techniques include uterine artery embolization (UAE), a minimally-invasive procedure for patients that involves injecting occluding agents into the uterine arteries to limit blood supply to the fibroids.³ Additionally, procedures such as MR-guided focused ultrasound and myomectomy are alternative treatment options that are particularly indicated for patients who are planning to conceive in the future.³

Drug therapies are occasionally used as a pretreatment to surgical intervention. Due to the pathogenesis of fibroid development, medications such as gonadotropin-releasing hormone (GnRH) analogs and selective progesterone receptor modulators (SPRMs) that antagonize the effects of estrogen and progesterone, respectively, can be given to help shrink these masses before surgical intervention.²

The goal of treatment is to remove fibroids when indicated in order to relieve symptoms and other complications that may impact the patient’s quality of life.

Patients should always be asked whether or not they would like to preserve their fertility before determining the treatment of choice. For patients who would like to preserve their fertility, MR-guided focused ultrasound or myomectomy is the best option. Otherwise, interventions such as hysterectomy and UAE are the preferred treatment options.

In this case, a successful abdominal hysterectomy with preservation of the ovaries was performed on a 45-year-old patient who presented with symptomatic leiomyomas. Hysterectomy is the second most commonly performed surgery in the world following cesarean section.⁴ It is the most effective treatment for symptomatic fibroids and can be performed via different approaches: laparoscopic, vaginal, abdominal or robotic approach.²

Choice of surgical technique depends on several factors such as the size and location of fibroids, size and shape of the vagina and uterus, accessibility of the uterus, extent of ectopic disease, need for concomitant procedures, surgeon training and experience, average surgical volume, available hospital technology, devices, and support, whether the case is emergency or elective and patient preference.⁸

In this case the choice of abdominal approach has been made based on the size of the fibroids and due to the narrow vagina.

Vaginal hysterectomy is associated with positive outcomes such as shorter operative time, decreased blood loss, shorter hospitalization, reduced postoperative pain, and earlier return to normal activity.^3-4 Alternatively, laparoscopic hysterectomy is becoming a more popular technique and is also associated with positive outcomes similar to vaginal hysterectomy. In fact, rates of laparoscopic hysterectomies performed have increased over the last twenty years, increasing from 0.3% in 1990 to 11.8% in 2003.⁵ It should be noted that laparoscopic removal of the uterus is sometimes performed with morcellation. As a result, laparoscopic hysterectomy should be performed only in patients without suspected or known uterine cancer in order to prevent the dissemination of potentially malignant tissue.

Laparoscopic hysterectomy lengthens duration of surgery, requires specific equipment. Analysis of hysterectomy rates worldwide shows that abdominal hysterectomy is performed most frequently.⁹ However, these approaches are not indicated when patients present with larger fibroids, due to their increased risk of complications. Laparoscopic extraction of the uterus can be especially challenging, as trocar insertion is more difficult and can directly injure the uterus and/or intraabdominal organs, causing excessive bleeding and thus prolonged operative time. According to Hwang et al., uterine fibroids that are greater than 13 cm are contraindicated in both vaginal and laparoscopic hysterectomy, and abdominal hysterectomy, which was performed in this video, is instead the treatment of choice.⁴

Indications for abdominal hysterectomy include enlarged or bulky uteri, a history of abdominal surgery, narrow vagina and pubic arch, undescended immobile uterus, supracervical hysterectomy, or the presence of extrauterine disease (eg. adnexal pathology, severe endometriosis, adhesions) or gynecological malignancies. These conditions often make a minimally-invasive approach technically challenging.^7,9 Besides this technique is easier to perform and learn compared to laparoscopic surgery. However abdominal hysterectomy has a morbidity and mortality rate three times higher than that of laparoscopic hysterectomy. The disadvantages of abdominal hysterectomy include higher rates of postoperative infections, incisional hernias, thromboembolic complications, and intraoperative blood loss.⁹

The midline longitudinal incision is the gold standard for pelvic surgery to facilitate the procedure and avoid injury to vital structures, even in the modern era of laparoscopic surgery. The abdominal wall is incised longitudinally from the pubis toward the umbilicus, followed by the fascia and the peritoneum. A transverse incision is preferred only if the uterus is not too large.¹⁰

UAE is an alternative procedure that has several indications: multiple fibroids, very large fibroids, restricted operability, a history of multiple operative procedures in the abdomen, and the patient’s desire to preserve her uterus.³ UAE is associated with several positive patient outcomes, such as reduced blood loss, shorter procedural times, and shorter hospital stays.¹ On the other hand, UAE has also been associated with a higher risk of reintervention and unwanted effects such as complete amenorrhea, abdominal pain from ischemic necrosis of fibroids, and risk of infection.² In a study conducted by van der Kooij et al., reintervention or secondary hysterectomy rates were as high as 26–34% during a 5-year follow-up period.⁶ Furthermore, UAE is may be associated with subclinical deterioration of ovarian function. As a result, this procedure is not recommended for patients who would like to preserve their fertility. Other contraindications include pregnancy, active uterine or adnexal infections, IV contrast allergy, and renal insufficiency.³

MR-guided focused ultrasound is another treatment option for those who want to maintain their fertility. MRI is used to help visualize and target the mass before ultrasound energy is utilized to induce coagulation tissue necrosis.² This procedure is generally well tolerated; however, patients are at risk for developing complications such as skin burns, pain, nausea, and allergic reactions.¹ Another drawback to performing this procedure is its relatively high rate of recurrence. In a five-year follow-up study, the reoperative rate for patients who underwent this procedure was as high as 59%.³ This procedure is also contraindicated in pregnant patients or those who have pre-existing contraindications to MRI.

Myomectomy is another option for patients who wish to conceive in the future. Hysteroscopic myomectomy, in particular, is a standard minimally invasive procedure for submucosal myomas smaller than 2 cm and can be done in an outpatient setting.² Alternatively, laparoscopic myomectomy can also be indicated for smaller fibroids and is associated with shorter recovery and reduced postoperative morbidity compared to abdominal myomectomy. However, several studies have reported no differences in outcomes between the two approaches.² There are several contraindications for laparoscopic myomectomy, such as intramural myomas greater than 10–12 cm and multiple myomas (>4) in different sites of the uterus that would require multiple incisions.² However, as with UAE and MR-guided focused ultrasound, studies have shown that recurrence of symptomatic fibroids post-myomectomy can occur in up to 10% of patients within the next decade.³

In some circumstances, drug hormonal therapy such as GnRH analogs, selective estrogen receptor modulators (SERMs), aromatase inhibitors, and SPRMs is used in patients in addition to surgical intervention. In a study published by Boosz et al. medications such as GnRH analogs have been shown to lead to a volume reduction in fibroids; however, they also come with a plethora of side effects including dizziness, hot flushes, and loss of bone mineral density, which preclude them from being used long-term.¹ Additionally, when these medications are stopped in patients due to their adverse effect profiles, studies have shown that fibroids will grow back to their original size.¹ Other medications, antagonizing estrogen effects, such as aromatase inhibitors and SERMs come with similar side effects due to hypoestrogenism.³ On the other hand, SPRMs, notably ulipristal acetate, have a much better side effect profile and also have a sustained effect in reduced fibroid size after discontinuation.² As a result, these drugs are typically favored over GnRH analogs. 

However, there is little evidence that shows that pretreatment with these drug therapies improves resectability or reduces operative time.¹ Furthermore, it is still too early to determine whether or not these drugs can be used as monotherapy over surgical intervention. As a result, further research is needed to determine the role that these therapies play, if at all, in the treatment of fibroids.

Standard equipment.

Nothing to disclose.

The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.