SURGICAL OPTIONS IN FIBROID TREATMENT:

WHEN AND HOW?Andreas Thurkow

AMCAmsterdam University

Medical Centres Bergman Clinics

Amsterdam

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DISCLOSURES

• Shares: none relevant to this lecture

• ad hoc consultant for : Olympus, Hologic, Ethicon, Gideon Richter

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SURGICAL OPTIONS IN FIBROID TREATMENT:

WHEN AND HOW?Andreas Thurkow

AMCUniversity of Amsterdam

Bergman Clinics Amsterdam

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WHAT?

Surgical treatment of fibroids:

• Myomectomy: hysteroscopic, laparoscopic, open

• Hysterectomy

• RF ablation?

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WHEN?

• blood loss

• pain, volume symptoms

• impaired fertility

• (no symptoms > no surgery!)

•

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ALTERNATIVE OPTIONS

•

• Medical treatment

• Embolisation

• Hysterectomy

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Do Nothing

• all asymptomatic myomas!

• imminent menopause?

• innocent disease!

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Do Nothing

ALTERNATIVE OPTIONS

• Do Nothing

•

• Embolisation

• Hysterectomy

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Medical Treatment

• Progestins

Also as a Pretreatment:

• GnRH agonists -

• SPERMS: Esmya®

but: - softer - cleavage plane may change

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Medical Treatment

ALTERNATIVE OPTIONS

• Do nothing

• Medical treatment

•

• Hysterectomy

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Embolisation

Embolisation

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ALTERNATIVE OPTIONS

• Do nothing

• Medical treatment

• Embolisation

•

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Hysterectomy

• effective, high satisfaction rate

• complications < myomectomy (blood loss, adhaesions, infection, recurrence)

• not in case of wish to preserve uterus

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Hysterectomy

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• effective, high satisfaction rate

• complications < myomectomy (blood loss, adhaesions, infection, recurrence)

• not in case of wish to preserve uterus

Hysterectomy

HOW?

•

• LAPAROSCOPIC MYOMECTOMY

• OPEN MYOMECTOMY

HYSTEROSCOPIC MYOMECTOMY

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HYSTEROSCOPIC MYOMECTOMY

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submucous fibroid and HMB: preference for hysteroscopic treatment (Guidelines RCOG, NVOG, AAGL)

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History:

Dr Robert Neuwirth (1922-2013)

1st hysteroscopic myomectomy urologic resectoscope 1976 (monopolar, 32% dextrane 70)

HYSTEROSCOPIC MYOMECTOMY

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FIGO Classification of Fibroids

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HYSTEROSCOPIC MYOMECTOMY

FIGO Classification of Fibroids

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HYSTEROSCOPIC MYOMECTOMY

Ultrasound!

TCRM STUDY: SUBMUCOUS MYOMAS & HMB

interim analysis

N = 50

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BIPOLAR!

NaCl 0,9%:

• better safety profile (RCT Berg ’09)

• no increased gas embolism risk (RCT Dyrbye ’12)

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RESECTION TECHNIQUE

USUAL:

• superficial to deep

• over entire width of the fibroid

• somtimes only intracavitary part

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ALTERNATIVE TECHNIQUE:hemisection: central incision until pseudo capsulemore incisions if needed

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RESECTION TECHNIQUE

Casadio P et al. Fertil Steril. 2011

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CONTRACTIONS FACILITATE EXPULSION

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MINI RESECTOSCOPE

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Giampietro Gubbini

GUBBINI MINI-RESECTOSCOPE

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RESECTIONS SLAZ 1995 – 2005

• STUDY

• TCRM 1995-2005

• N = 1232

• Incomplete resection: 19% → 1.5%

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completeincomplete

RESECTIONS SLAZ 1995 – 2005

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hemisection

bipolar

% INCOMPLETE RESECTIONS SLAZ 1995 – 2005

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ALTERNATIVE OPTIONS FOR HYSTEROSCOPIC MYOMECTOMY

Bipolar ElectrodesMorcellation

• •

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• 5 F electrodes

• cutting / vaporising

• ambulatory treatment

Bipolar Electrodes

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Bipolar Electrodes3 cm type 0, fully ambulatory

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Bipolar Electrodes3 cm type 0, fully ambulatory

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successful, but: 45 min

ALTERNATIVE OPTIONS FOR HYSTEROSCOPIC MYOMECTOMY

Bipolar ElectrodesMorcellation

• •

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MorcellationHysteroscopic

Inventor & patient holder: Mark Hans Emanuel

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HYSTEROSCOPIC MORCELLATOR

• short learning curve (van Dongen e.a.)

• better acceptation by patients

• suitable for ambulatory therapy!

• for fibroids?

HYSTEROSCOPIC

SURGERY

Removeyourfibroidsorthoseinfriends&relatives

yourself!

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MORCELLATION VS RESECTION

(Shazly et al. JMIG 2016)www.thurkow.com

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MORCELLATION VS RESECTION

(Shazly et al. JMIG 2016)

Hamidouche ‘15: type 2 : 29% in Myosure, 41% in VersapointEmanuel ’05: incl. polyps, exclusion of type 2 fibroids

Vitale et al. 2017: RCT, equivalent for type 0 & 1, less voor type 2

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MORCELLATION VS RESECTION

higher costs in morcellation (disposables!)

but with conversion to ambulatory balance could still be favourable!

rapid technological development

MORCELLATION VS RESECTION

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HOW?

• HYSTEROSCOPIC MYOMECTOMY

• LAPAROSCOPIC MYOMECTOMY

• OPEN MYOMECTOMY

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OPEN MYOMECTOMY

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Only when laparoscopic approach is not possible:

• size (12 cm?)

• multiple fibroids (> 3?)

• lack of expertise

OPEN MYOMECTOMY

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• longer recovery time

• longer admission time in hospital

• more pain

• more adhaesions

• more blood loss

but:

• faster, tactile feedback, shorter learning curve

OPEN MYOMECTOMY

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Indication for fibroid removal (other than type 0-2): preference for laparoscopic treatment whenever possible (Guideline NVOG)

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HOW?

• HYSTEROSCOPIC MYOMECTOMY

•

• OPEN MYOMECTOMY

LAPAROSCOPIC MYOMECTOMY

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LAPAROSCOPIC MYOMECTOMY

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HISTORY

• Atlee 1840: 1st fibroid enucleation

• Bonney ’46

• Semm ’80: 1st laparoscopic myomectomy

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‘Since cure without deformity or loss of function must ever be surgery’s highest ideal, the general proposition that myomectomy is a greater surgical achievement than hysterectomy is incontestable’

• Victor Bonney (1946)

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HISTORY

• Atlee 1840: 1st fibroid enucleation

• Bonney ’46

• Semm ’80: 1st laparoscopic myomectomy

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HISTORY

• Atlee 1840: 1st fibroid enucleation

• Bonney ’46

• Semm ’80: 1st laparoscopic myomectomy

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FIGO Classification of Fibroids

LAPAROSCOPIC MYOMECTOMY

CONTRAINDICATIONS• adenomyosis

• suspicion malignancy

• no wish to preserve uterus

• fibroids > 8 (?) cm

• > 3 fibroids (each > 5 cm)

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COMPLICATIONS %

• blood loss 0 - 11

• fever, infection 0 - 5 ?

• adhaesion formation 25 - 50

• dehiscence in pregnancy 0,5

• adenomyosis 0 - 1

• mortality 0

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TECHNIQUE

• see video presentation tips & tricks!

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RESULTSsubfertility:

71 - 75% (vs. 40 - 66,7% with laparotomy)

bleeding, pain:

73 - 80%

recurrence risk:

> 20% (cumulative over 10 y: -scopy = -tomy)

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PREREQUISITES (PERSONNEL & TRAINING)

• advanced lap. surgery!

• experienced surgeon & team:

• knot tying!

• morcellation

• ergonomy

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• electrogenerator, needle or hook

• alternative: ultrasone energy

• laparoscopic tenaculum

• needle holders, suture material (barbed)

• morcellator (in bag)

• adhaesion prevention?

PREREQUISITES (INSTRUMENTATION)

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TAKE HOME MESSAGES

• Accurate Preoperative Imaging

• Hysteroscopic>Laparoscopic>Open

• Premed if needed, only for TCRM

• Expertise!

• Concentration of care (volume)

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TAKE HOME MESSAGES

THANK YOU!KIITOS!

TA(C)K(K)!

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