Wen-Qi Han

1Shandong University of Traditional Chinese Medicine, Jinan 250300, China.

Abstract Hysteromyoma is a gynecological multiple benign tumor disease, but it will still affect women's physical and mental health and may become malignant tumors.Therefore, it is necessary to treat it as soon as possible.Due to the lack of safe and effective medicine treatment with low recurrence rate, surgery is still the main treatment.Surgical treatment has a long history.This article introduces the history of surgical treatment of hysteromyoma.The earliest and most widely implemented is Laparoscopic myomectomy, which began in the 1920s.With the development of science and technology, Laparoscopic myomectomy, Hysteroscopic myomectomy and Transvaginal myomectomy in the late twentieth century gradually made the treatment of hysteromyoma minimally invasive.In recent years, laparoscopic uterine vascular occlusion combined with hysteromyomectomy, uterine artery embolization and high-intensity focused ultrasound have gradually appeared, and the treatment methods of hysteromyoma are becoming more and more perfect.

Keywords: hysteromyoma; uterus preservation; development history; laparotomy; minimally invasive surgery

Background

For the uterine fibroids patients with a need to retain reproductive, the better treatment is uterine myomectomy.In addition to retain reproductive function, the more important thing is myomectomy operation can preserve the anatomical integeity of the pelvis, maintain normal physiological function of the uterus and the hypothalamus-pituitary-ovarian-has little effect on uterine shaft [1].With the development of medicine, there are more and more surgical methods of myomectomy.Clinically, there are three commonly used methods: Laparoscopic myomectomy, laparoseopie myomeetomy and Transvaginal myomectomy.For the rest, there are high-intensity focused ultrasound and other ways.(Figure 1)

Figure 1 Development history of hysteromyoma surgery with uterus preservation

Laparoscopic myomectomy

Laparoscopic myomectomy is the earliest non-hysterectomy method for the treatment of uterine fibroids, which began in the 1920s.In the 1980s, the technology has been relatively perfect, and the success rate of surgery is relatively high.

Indication

Laparoscopic myomectomy’s indication is widely available and suitable for patients with uterine fibroids who need to retain reproductive function.It is not limited by the size, location and number of myomas.Therefore, it is more suitable for patients with multiple myomas and recurrent myomas whose uterine volume is larger than 12 weeks of pregnancy with myomas close to mucosal location [2].

Advantage

The biggest advantage of laparotomy is that it can open the surgical field of vision and facilitate observation and elimination.At the same time, doctors can put their hands into the abdomen and find small fibroids that have not been detected before surgery through touch, so as to carry out more thorough elimination and effectively reduce the recurrence rate after surgery.

Disadvantage

It has the disadvantage of long operation time and many postoperative complications.It also can't meet the demand of the patients with beauty.Although the elimination is more thorough, but still cannot avoid the risk of recurrence.Studies show that the the recurrence rate is about 20%, and the recurrence rate could rise with the passage of time [3], Whether the patient has a postoperative recurrence is closely related to the age, number and size of fibroids at the operation, and there is no obvious correlation with the preoperative and postoperative pregnancy history, clinical symptoms, and the growth site of fibroids [4].

Post-operation recovery

Laparoscopic myomectomy has a large abdominal incision, more intraoperative bleeding, great interference to the abdominal environment, postoperative pelvic adhesion and intestinal adhesion, wound pain is more serious.Therefore, the time of the patients required for postoperative ground movement, gastrointestinal tract exhaust and total length of hospital stay are relatively long [5].It is recommended to avoid pregnancy within two years.In general, subserous myomectomy has almost no damage to the uterine membrane, and the postoperative pregnancy rate is high [6].

Hysteroscopic myomectomy

In the 1970s, Neuwrith first proposed the technology of hysteroscopy in the treatment of hysteromyoma.Submucous myoma is 10% of the incidence rate of myoma.Currently, hysteroscopic myomectomy has become the best treatment for submucous myoma.

Indications

(1) uterus ≤ 11 weeks, uterine depth ≤ 13 cm; (2) The patient's coagulation was normal; (3) Myoma diameter ＜ 5 cm; (4) Submucosal myoma, tumor pedicle ≤ 6cm; (5) No canceration of uterus.

Advantages

(1) The operation does not require an open abdomen, it has small wound and will recover fastly; (2) No uterine incision, less harm to the uterus, and effectively reduce the probability of cesarean section during postoperative pregnancy; (3) The prognosis of surgery can be comparable to that of traditional open surgery [14].

Disadvantages

(1) The operation field of uterine cavity is narrow and the conduction of electric energy is difficult to estimate.If the operation is improper, uterine perforation may occur, resulting in the operation from minimally invasive to giant trauma; (2) The surface of larger myoma is usually rich in nutrient vessels.During resection, it is easy to cause excessive bleeding, blur the visual field, hinder the operation, prolong the operation time, and patients are prone to hyponatremia, even life-threatening; (3) The operation combines light, electricity and machinery, which is technically difficult.

Laparoseopie myomeetomy

Laparoseopie myomeetomy was first reported in the 1979, but the technical difficulties limited its development and use until the early 1990s.There have been reports on its successful application [7].With the update of laparoscopic technology and the progress of methods such as reducing blood loss during surgery, as well as its small wound, laparoscopic myomectomy has been increasingly recognized and loved by patients, and its clinical application has become increasingly widespread.

Indication

Single or multiple hysteromyomas of subserular or broad ligament of uterus.The maximum diameter of hysteromyoma is 8–10cm, and pedicled hysteromyoma is the most suitable; (2) Single or multiple intramural hysteromyomas with a diameter of 4–10cm; (3) The number of multiple myomas should not be more than 4; (4) Possible possibilities of uterine fibroids have been excluded before surgery.

Post-operation recovery

Because the field of vision of laparoscopic surgery is not as large as that of Laparoscopic myomectomy, and the small myoma located between muscles cannot be touched by hand, it is easy to occur that the small myoma is not completely removed during surgery, resulting in a higher recurrence rate of postoperative myoma than that of Laparoscopic myomectomy, patients relapse after an average of two years [8].Studies have shown that the cumulative recurrence rate of 5 years after laparoscopic myomectomy is 11% for single myoma and 74% for multiple myoma [9].Magnetic resonance imaging is significantly better than ultrasound in detecting the number, size and location of hysteromyoma before operation [10].Magnetic resonance imaging method is significantly better than ultrasound method for the number, size and position of uterine fibroids before surgery.In order to be more accurately precipitated before surgery and minimize postoperative recurrence, especially for the multi-hair uterine fibroids, recommended pelvic magnetic resonance imaging.

Advantage

(1) Each of the pregnancy period after surgery is significantly higher than that of the open surgery group [11]; (2) Postoperative adhesion is low and the degree of adhesion is small; (3) The surgical wound is small, the physical damage to the patient is small, and the patients recover quickly.

Disadvantage

(1) LM has a small wound and cannot fully expose the surgical site.It is difficult to stop bleeding during operation.The effect of electrocoagulation is not ideal.In order to reduce hemostasis, pituitrin needs to be injected before operation; (2) Small myomas cannot be touched during operation, and they still need to be examined before operation to further determine the number, size and location of myomas; (3) Laparoscopic surgery has limited conditions, which is only applicable to patients with a small number and small volume of uterine fibroids.If the patient's uterine fibroids are difficult to remove, she need to be converted to open surgery [12].

Laparoscopic assisted myomectomy

Laparoscopic assisted myomectomy is a kind of difficult operation between laparoscopy and laparotomy.During the operation, the myoma was exposed and removed by laparoscopy, and then the uterine incision was sutured through a small incision on the abdominal wall.LAM is especially suitable for the removal of large anterior uterine fibroids or deep intramural fibroids [13].

Laparoscopic uterine vascular occlusion combined with myomectomy

With the development of medical technology, more strict requirements are put forward for the minimally invasive surgical treatment of patients with hysteromyoma in clinic.It is not only necessary to reduce the surgical trauma, but also try not to destroy the integrity of the patient's uterus and affect the secretion of sex hormones.The conventional laparoscopic subuterine myomectomy cannot meet this requirement.However, if only uterine vascular occlusion is used, for large uterine leiomyoma, because the tumor is still in the uterus and blood loss occurs, the patient may have pelvic pain caused by tumor ischemic necrosis.Therefore, it is proposed to use uterine vascular occlusion in laparoscopic myomectomy.

Indications

(1) Submucosal myoma, subserous myoma and intramural myoma were diagnosed by B-ultrasound; (2) The number of myomas ＜ 4; (3) The diameter of myoma is not more than 12 cm.

Advantages

(1) this method effectively solves the limitation of difficult hemostasis under laparoscopy, with less blood loss and fast recovery; (2) Less intraoperative bleeding is conducive to ensure the clarity of the operation field and facilitate the operator to distinguish the focal anatomy of hysteromyoma; (3) The surgical trauma is small.After myoma lesion removal, single-layer continuous suture is carried out to reduce scar [20] and reduce the damage to the uterus; (4) It has little effect on patients’ endocrine [21].

Postoperative recovery

(1) Laparoscopic uterine vascular occlusion combined with myomectomy can reduce the recurrence rate of myoma and the incidence of complications, improve the pregnancy rate, and have less damage to the body's immune function [22]; (2) Although this method will prolong the operation time, it will not affect the postoperative exhaust time, but will shorten the hospital stay of patients; (3) Uterine vascular occlusion will cause necrosis of some small hysteromyomas due to ischemia, limit the lesions of small hysteromyomas and reduce the risk of recurrence.

Uterine artery embolization

In 1991, in order to reduce intraoperative bleeding, uterine artery embolization was first introduced into the treatment of hysteromyoma as an auxiliary means before hysteromyoma surgery.In 1993, rvail in France began to study the therapeutic effect of uterine artery embolization on hysteromyoma; In 1994, in order to reduce the surgical risk of high-risk patients, uterine artery embolization was first used in the treatment of hysteromyoma as an auxiliary means of hysteromyoma surgical treatment.This method was used to block the blood supply of hysteromyoma before operation, reduce intraoperative bleeding, make the operation easy and reduce blood transfusion.In 1995, Ravina et al.First reported the success of uterine artery embolization in the treatment of uterine fibroids.Because uterine artery embolization can effectively treat the symptoms of menorrhagia and uterine mass caused by hysteromyoma, and has achieved the same effect as surgical resection, it was recognized as an alternative treatment for the first time.By the end of 1998, 1500 to 2000 cases of this operation had been carried out all over the world, and the technology was gradually mature.

Indications

(1) Premenopausal patients aged 27–58 years; (2) Normal bleeding and coagulation function; (3) Protein ＞ 58 G/L; (4) Myoma 10 mm–100 mm; Submucosal, intermuscular or subserosal myomas with the number of myomas ≥ 1.Uterine artery embolization can also be performed for uterine leiomyomas with a diameter greater than 12 cm and pedicled submucosal leiomyomas, but special treatment needs to be given after operation [23].

Advantages

(1) Small surgical wound, conducive to recovery and less postoperative adverse reactions; (2) The operation is simple, the technical requirements are low, and it is easy to implement; (3) Some studies have shown that [24], this method has a good therapeutic effect.After one year of treatment, the volume of hysteromyoma is significantly reduced, the ovarian function is not affected, and the symptoms caused by hysteromyoma are significantly improved; (4) Even if arterial embolization fails, it does not affect the progress of other treatment methods; (5) Arterial embolization can also be used as an auxiliary treatment for myomectomy.By reducing the size of myoma, it can reduce the difficulty and time of operation, reduce the amount of intraoperative bleeding and accelerate the rehabilitation of patients.

Disadvantages

(1) the complications of uterine artery embolism include pain, infection and hematoma, fever, irregular vaginal bleeding, etc; (2) The uterine artery is tortuous and slender, and it is impossible to completely avoid it even with the aid of microcatheter during embolization.In the process of arterial embolization, the embolic particles may enter the ovarian artery through the anastomotic branch of the uterine artery and the ovarian artery, and the ovarian artery may be embolized by mistake, and a very few patients may have ovarian failure [25]; (3) If the operation is improper, the bladder branch and urinary catheter branch of uterine artery may not be avoided during embolization, resulting in the injury of some embolic agents flowing into the above branches.The incidence of this situation is about 0.5% [26].(4) It may be accompanied by rare complications such as femoral nerve injury, uterine ischemic infarction, bilateral iliac artery embolism, large and small labia necrosis, uterine wall injury, bladder uterine fistula and so on [26].

Transvaginal myomectomy

The first domestic report of Transvaginal myomectomy was published in 1993 [15], and the application has gradually increased since then.When the myoma’s size is too large or the myomas are abundant, there are disadvantages of small myoma residue and difficult hemostasis of suture in the residual cavity in the subabdominal myomectomy.The vaginal myomectomy can not only solve the above problems, but also retain the advantages of minimally invasive, which has been widely recognized in clinic.

Indications

(1) Good uterine activity without pelvic adhesion; (2) The uterine volume is less than 14 gestational weeks; (3) B-ultrasound and gynecological examination showed that it was subserosal hysteromyoma or intramural hysteromyoma; (4) The diameter of myoma was less than 12 cm; (5) The number of myomas exceeded 10; (6) The tumor growth site is special, such as the cervix, in the broad ligament, near the ureter, bladder or uterine blood vessels [16].

Advantages

(1) It has less trauma, less interference to abdominal cavity and no scar on abdominal wall; (2) The average recovery time after abdominal surgery was 41.2 days, while that after vaginal surgery was 29.3 days, which was shortened by about 12 days; (3) And less inflammation and short use of antibiotics; (4) The degree and incidence of postoperative heat absorption are low [17]; (5) Compared with laparoscopic myomectomy, it has wider indications and has the advantages of short operation time, less intraoperative bleeding and less impact on hormone secretion [18].It can also touch the uterus, which has the advantages of the above-mentioned laparotomy, making the elimination more thorough.

Disadvantages

(1) It is unable to explore the situation in the pelvic cavity in an all-round way, which is easily affected by pelvic adhesion, uterine mobility, etc.(2) It may be converted to open surgery because the tumor body is too high to be removed [17].The feasibility of operation should be evaluated before operation for large uterine bottom myoma.Careful consideration should be given to patients with uterine myoadenoma.For patients who do not meet the indications of transvaginal surgery, transabdominal surgery is the best choice at present.

Laparoscopic auxiliary vine uterine fibroids.

Since the first report of laparoscopic assisted vaginal myomectomy in 1989, it has good curative effect, less trauma, obvious advantages, and its recognition had gradually improved.This method combines the advantages of LM and TVM, which can not only reduce the amount of intraoperative bleeding and shorten the postoperative hospital stay, but also the postoperative disease rate (2.5%) and recurrence rate (7.5%) are significantly lower than 10% and 15% in the vaginal operation group [19].The specific advantages are as follows: (1) With the assistance of laparoscopy, it can comprehensively evaluate the situation in the pelvic cavity, and make the operation more precise, so as to reduce the injury to the ureter, bladder and rectum.At the same time, it can find and deal with the pelvic adhesion in time, so as to enhance the safety of the operation; (2) During the operation, the uterus can be turned out from the vagina and the uterine body can be touched directly by hand, which is conducive to the discovery of small intramural fibroids, which can be removed completely and reduce the postoperative recurrence rate; (3) Transvaginal direct vision is conducive to suture and hemostasis without leaving dead space, which can reduce the amount of intraoperative bleeding and reduce the postoperative infection rate; (4) The abdominal cavity can be thoroughly cleaned with the aid of laparoscopy to reduce the incidence of pelvic infection.

High intensity focused ultrasound ablation of hysteromyoma

High intensity focused ultrasound (HIFU) ablation is a minimally invasive technique rising in recent years, which has been more and more used in the treatment of hysteromyoma.It is mainly by concentrating the ultrasonic energy in the treatment area to rapidly increase the local temperature to 60–100 ℃, so as to destroy the diseased tissue in the leiomyoma, but the surrounding normal tissue will not be damaged.Different from general surgery, this method depends more on imaging evaluation.

Indications

(1) Diagnosed as single hysteromyoma; (2) The focus was located in the anterior wall of the uterus and was an intramural myoma; (3) No contraindications of contrast-enhanced ultrasonography; (4) The patient's motion is small and the image is clear during angiography; (5) The operation range of preoperative simulated positioning focus can completely cover the focus, and the acoustic channel has no bone and intestinal obstruction.

Advantages

(1) It has less blood loss, operation time, postoperative out of bed time and hospital stay [27], which has significant advantages in reducing patients' physical burden and accelerating postoperative recovery; (2) The pregnancy rate was 65.0% and the normal delivery rate was 56.6%, which was higher than that of patients undergoing laparoscopic myomectomy; (3) The trauma to the uterus is small and there will be no adhesion; (4) It can significantly improve menstrual disorders, infertility and other symptoms caused by hysteromyoma.

Disadvantages

(1) Studies have shown that [27] after laparoscopic myomectomy, there is no recurrence of myoma, the probability of disappearance of clinical symptoms and reduction of myoma volume by more than 80% is 78.3%, the probability of recurrence rate is low, most of clinical symptoms disappear, and the probability of myoma volume reduction by 50%–80% is 100%, while the data of high-intensity focused ultrasound myoma ablation are 41.7% and 83.3% respectively, It shows that focused ultrasound ablation of hysteromyoma is less effective.

Summary

The treatment of uterine fibroids has been developed for nearly a century.With the improvement of women's cognition of the uterus and their aesthetic requirements, hysterectomy is gradually replaced by the operation of retaining the uterus, and low-invasive and non-invasive surgery has become the trend of the treatment of hysteromyoma.Over the past century, from the initial open approach in the 1920s, to the minimally invasive approach developed in the 1970s, and then to the non-invasive approach in the 1990s, the treatment methods of hysteromyoma have flourished with the progress of science and technology and the improvement of medical level, and some surgical methods have gradually matured.On the premise of meeting the surgical conditions, there are more and more surgical methods for patients to choose, and the treatment effect is gradually improving.The development history of treating hysteromyoma will gradually plump with the passage of time.The only constant is to choose the most appropriate treatment method according to the situation of patients, so that medical technology can better serve people.

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