MINISTRY OF EDUCATION AND SCIENCE OF THE RUSSIAN FEDERATION

Far Eastern Federal University

School of Biomedicine

MYOMA OF THE UTERUS

MODERN METHODS OF
TREATMENT

Krasnopeeva Iuliia Vladimirovna P.H.D.,

Chief of gynecology department
 LECTURE CONTENT:
What is uterine fibroids;
Classification of uterine fibroids;
Clinical manifestations;
Diagnosis of uterine fibroids;
Treatment;
Factors affecting the choice of
treatment for uterine fibroids;
Types of surgical treatment of uterine
fibroids;
Complications.
Uterine fibroids - benign, monoclonal, good delimited, encapsulated tumor
originating from smooth muscle cells of the body or cervix is one of most common
benign tumors female genital area, which occurs in 2-40% of women reproductive
age.

Uterine fibroids, being progesterone-dependent pathological process, develops,

as a rule, with ovulatory menstrual cycle.

Uterine fibroids are most common in women in the reproductive period. The disease
is not observed in girls until menarche. In postmenopausal women, the growth of
uterine fibroids usually stops and its reverse development occurs.

Uterine fibroids are associated with genetic predisposition (family forms), hormonal
influences, the presence of receptors in the nodes to estrogen and progesterone and
growth factors. Large stress and immunodeficiency can trigger the growth of fibroids.
 Myoma occurs in almost every second woman on the
planet (up to 77%)! after 35 years old and accounts for
80% of operations in gynecology.

The flip side of In other words: Of the 15 girls in the

statistics class, the most ordinary school, 11
will be diagnosed with myoma.

And 8 out of 11 in the future have the

probability of organ-bearing surgery.
CLASSIFICATION OF UTERINE SIZE CLASSIFICATION OF UTERINE
FIBROIDS DEPENDING ON FIBROIDS (ESHRE):
NUMBER OF NODES: SMALL FIBROIDS: UP TO 5 CM;
•SINGLE; LARGE FIBROIDS: MORE THAN 5 CM;
•MULTIPLE GIANT FIBROIDS: MORE THAN 8 CM.

Clinical and anatomical classification (localization in various parts of the uterus and
tumor growth in relation to muscle layer of the uterus)
1. Submucous (0-2 type);
2. Intramural (3-4 type);
3. Subserous (5-7 type);
4. Intraligmentary (8 type);
5. Cervical (8 type);
6. Parasitic (implanted pieces of myomatous nodes left in the abdominal cavity after
surgical removal of fibroids earlier) (8 type).
 Clinical manifestations:

1.Menstrual disorders - uterine bleeding, leading to anemia (submucous

and interstitial fibroids).
2.Pain syndrome (atypical fibroids between the leaves of the broad
ligament, submucous fibroids during menstruation, subserous
fibroids on the leg, impaired blood supply to any node).
3.Infertility (often submucous and interstitial fibroids or large myomatous
nodes).
4.Miscarriage (often submucous and interstitial fibroids or large
myomatous nodes).
5.Violation of the function of neighboring organs - the bladder
dysuria), the rectum - (constipation) (often subserous fibroids or multiple
uterine fibroids of large sizes).
 MENSTRUAL DISORDERS CAUSED BY FIBROIDS.

Menorrhagia – cyclic bleeding in menstrual days.

Metrorrhagia – irregular heavy bleeding at frequent
intervals.
Hypermenorrhea – heavy flow (> 80 mL).
Polymenorrhea - longer flow (> 7 days).
Promenomenorrhea - periods too close together (< 21
days).
Intermenstrual bleeding – bleeding between otherwise-
normal menses.
Midcycle bleeding – bleeding at time of expected ovulation.
Premenstrual spotting – light bleeding preceding regular
menses.
 DIAGNOSIS OF UTERINE FIBROIDS

Abdominal examination:
the abdomen can be enlarged, sometimes significantly, up to the size of a full-
term pregnancy;
shapes, dense, often painless formations can be palpated through the anterior
abdominal wall

Pelvic exam bimanually:

enlarged, densely elastic congruence of the uterus, tuberous, mobile or
restrictedly mobile, painless or slightly sensitive.

BLOOD TESTS ARE NOT CHANGED OR ANEMIA OF 1-3 DEGREES.

 * The main method is Ultrasound scan
ROUNDED FORMATION, HOMOGENEOUS ISOECHOIC STRUCTURE,
WITH CLEAR EVEN CONTOURS, WITH BLOOD FLOW LOCI ALONG THE
PERIPHERY.

REQUIREMENTS FOR THE PROTOCOL OF

ULTRASOUND OF UTERINE FIBROIDS:

•Topic nodes - wall (front, back, side);

•Level in relation to the internal pharynx
•Depth of penetration into a muscle or cavity
•The presence of adenomyosis, suspected endometriotic
node.
•The size
•Amount
•Node blood supply
•Figure how the node is located
 *MRI - when necessary

•Atypical myomatous nodes (type 8) -

interconnected, cervical-isthmus, incomprehensible.
•Sarcoma Suspicion
•If organ-preserving surgery is planned - Multiple
uterine fibroids (to determine the localization of
each node)

REQUIREMENTS
FOR THE MRI PROTOCOL FOR UTERINE MYOMA
- A DETAILED DESCRIPTION OF EACH NODE AND ITS
STRUCTURE
 TREATMENT
CONSERVATIVE
(DRUG TREATMENT)
SURGERY

Arget drug treatment - relief or elimination symptoms associated with

uterine myoma, regression of fibroids or preoperative treatment

The appointment of drugs is not recommended for asymptomatic course of

fibroids, except of tumors large sizes

Recommended as a non-hormonal drug 1st lines for

abnormal uterine bleeding apply antifibrinolytics, in particular
tranexamic acid
 Gonadotropin-releasing hormone agonists (GnRH agonist):

GnRH agonist suppresses the secretion of gonadotropins with subsequent suppression of ovarian
function and the onset of drug menopause.

Preoperative treatment of patients with uterine myoma and anemia (hemoglobin <80 g/l)
To reduce the size of fibroids and facilitate the surgical procedure (if it is impossible to perform
laparoscopically or transvaginally).

The duration of preoperative treatment is limited to 3 months.

Injectable formulations:
Diferelin 3.75 mg (Triptorelin), Buserelin 3.75 mg (Buserelin)
The drug should be administered in the first 5 days of the menstrual cycle. Further
administration should be carried out every 4 weeks at a dose of 3.75 mg.

If the drug is in a dose of 11.25 mg, then the administration regimen is once every three months.
 ULIPRISTAL ACETATE

In the guidelines of uterine fibroids in 2015, the use of ulipristal acetate (a

selective progesterone receptor modulator) was recommended for the
treatment of uterine bleeding and preoperative treatment of uterine leiomyoma

Scheme: 3 months. continuously, 2 months a break, a repeated course for 3

months. in women of reproductive age over 18 years old.

Ulipristal acetate reduced the size of the myomatous node without

causing side hypoestrogenic effects and reduced bleeding.

AT THE MOMENT, THE USE OF THE DRUG IS STOPPED FOR THE PURPOSE OF
FURTHER STUDY IN CONNECTION WITH SIDE EFFECTS FROM THE LIVER
 PROGESTOGENS USE:

To reduce the volume of abnormal uterine bleeding and increase hemoglobin levels,
For the prevention of endometrial hyperplastic processes associated with uterine myoma

PROGESTOGENS DO NOT AFFECT THE STABILIZATION OR DECREASE IN THE GROWTH OF

MYOMATOUS NODES

Preparations:
Levonorgestrel containing an IUD (Mirena)
Duphaston, Utrozhestan, Orgametril, etc.
Progestins as part of combined hormonal contraceptives (Klayra, Janine, Jes, etc.)

IT IS NOT RECOMMENDED TO USE PROGESTOGEN THERAPY WITH THE PRESENCE OF

SUBMUCOUS UTERINE FIBROIDS
 INDICATIONS
FOR SURGICAL TREATMENT
SYMPTOMIC MYOMA
Menstrual disorders (uterine bleeding).
Anemization of the patient.
Pain syndrome.
Impaired function of neighboring organs (dysuria, constipation, etc.).
Infertility and miscarriage.

SIZE OF MYOMA AND DYNAMICS OF GROWTH

The size of the uterus is more than 12 weeks pregnancy.
Rapid tumor growth (more than 4 weeks per year).
The growth of a node in menopause.

LOCALIZATION OF NODES
Submucous and centripetal growth of nodes.
The subserosal pedunculeted node .
Atypical location of the node (cervical, isthmus, intraligamentary).
 TYPES OF SURGICAL TREATMENT OF UTERINE FIBROIDS

ORGAN REMOVAL SURGERY: ORGAN PRESERVING SURGERY:

1. Increased fibroids in menopause

1. Young age
2. Suspected atypical process in the
2. Unrealized reproductive function
myomatous node
3. Patient's desire to save the uterus
3. Precancerous diseases of the cervix
4. Endometrial hyperplastic process
(recurrent, with atypia)
5. Multinodal uterine fibroids (myomatosis)
in a patient with realized reproductive
function
6. The impossibility of organ-preserving
surgery
7. The patient does not want organ-
preserving surgery
 ORGAN REMOVAL SURGERY:
TOTAL HYSTERECTOMY
(EXTIRPATION UTERUS)
Any processes of the uterus and
cervix with atypia and a high
development of the oncological
process in the future
The growth of myomatous nodes
in menopause
Cervical Disease
Technical features of surgery
when there is no way to save the
cervix
Patient's desire to remove the
cervix
SUBTOTAL HYSTERECTOMY (SUPRACERVICAL
AMPUTATION OF THE UTERUS)
The patient wants to keep the
cervix
The cervix is healthy (normal
colposcopy, normal Pap test)
There is no suspicion of
endometrial oncology (histological
examination of the endometrium
without atypia)
No suspicion of sarcoma of the
myomatous node
There is no endometriosis of the
uterus and cervix of the 2-3 stage.
 ORGAN PRESERVING SURGERY:
MRGFUS
(FOCUSED ULTRASOUND (FUS) -
MYOMECTOMY UTERINE ARTERY EMBOLIZATION
ABLATION)
Multiple fibroids with intramural
Pregnancy planning Method is under study
and submucous growth of
Single or a few Intramural fibroids
nodes (myomatosis),
myomatous nodes Patient's desire to save
accompanied by menorrhagia
Patient's desire to save the uterus
Patient's desire to save the
the uterus Contraindications for
uterus
surgical treatment or
Contraindications for surgical
anesthesia
treatment or anesthesia
There is no suspicion of
There is no suspicion of
oncology process
oncology process
Pregnancy is not planned in the
future.
 Factors affecting the
choice of treatment for
uterine fibroids:
•The presence of symptoms
•Fibroid size
•Patient age
•Reproductive plans
•Node localization
•Number of nodes
•The presence of concomitant
pathology
•Patient's desire
 THE PRESENCE OF SYMPTOMS
UTERINE FIBROIDS OF A SMALL SIZE, NOT LEADING TO THE ONSET OF SYMPTOMS,
IS NOT AN INDICATION FOR SURGERY.

PERHAPS CONSERVATIVE TREATMENT: SURGICAL TREATMENT IS

INDICATED FOR:

MENSTRUAL DISORDERS. PAIN SYNDROME.

INFERTILITY.
MISCARRIAGE
VIOLATION OF THE FUNCTION
OF NEIGHBORING ORGANS.
Fibroid size
Clinically insignificant node: Clinically significant node:
Pre-autonomous period” of growth Autonomous period" of growth
Does not have expansive growth Expansive growth
A conservative treatment is possible in More radical tactics
order to stabilize the growth of the node, Hormonal drugs can cause node
by using hormonal drugs (oral growth.
contraceptives, Mirena)

Fibroid
Fibroid
more than 2-3 cm
up to 2 cm
 FIBROID SIZE
IF THE NODE IS SMALL AND ASYMPTOMATIC UP TO 3.5 CM, THEN THE ONLY INDICATION FOR
SURGERY IS DEFORMATION OF THE UTERINE CAVITY.
IF THE ASYMPTOMATIC INTERSTITIAL OR SUBSEROUS NODE IS 3.5 TO 5.0 CM, THEN THE ONLY
INDICATION IS THE REPRODUCTIVE PLANS.
NODES MORE THAN 8 CM - AN INDICATION FOR SURGICAL TREATMENT

Small fibroids: less then 5 cm

Large fibroids: more than 5 cm;

Giant fibroids: more than 8 cm

Patient age TIME BEFORE MENOPAUSE
IS THE DEFINING VALUE

PREMENOPAUSE
REPRODUCTIVE
FIBROID SIZE AGE

5 cm 5 cm

КCONSERVATIVE THERAPY SURGERY

*THE CLOSER MENOPAUSE IS A CONSERVATIVE TACTIC.

 CANCER ALERTNESS IN WOMEN WITH UTERINE FIBROIDS
ENTERING MENOPAUSE:

MENOPAUSE OCCURS 1-3 YEARS LATER

Risk factors in menopause in patients with uterine myoma:

•Lack of regression of fibroids for 1-2 years of persistent menopause
•Genital tract spotting after one year of persistent menopause
•An increase in M-ECHO to 5-8 mm or more + recurrent HPE
•Pathology of the ovaries
•Chronic anemia of unknown etiology
•The combination in adenomyosis 2-3 tbsp.

NB: Nodal growth after a postmenopausal regression

period is an indication for radical surgical treatment
Reproductive plans?

*UTERINE FIBROIDS WITH INFERTILITY AND MISCARRIAGE IS

INDICATION FOR SURGICAL TREATMENT.

SURGICAL TREATMENT SHOULD BE:

• MAX CAREFUL
• aimed at creating a wealthy uterine scar

BEFORE THE ART PROTOCOL, ALL SUBMUCOUS FIBROIDS OF ANY SIZE

AND INTRAMURAL MYOMATOUS NODES MORE THAN 4.0 CM MUST BE
REMOVED.
CLINICAL GUIDELINES FOR ART AND IIS 2018
INDICATIONS FOR SURGERY, DEPENDING
ON THE LOCATION OF THE FIBROID:

SUBMUCOUS

INTRALIGMENTAL LOCALIZATION
SUBSEROUS ON A THIN FOUNDATION
 Number of fibroids:

Single uterine fibroids (simple

fibroleomyomyoma)

•Low risk of relapse - 27%

•The risk of reoperation - 11%
•Organ Preserving Operations
•Laparoscopic access
HYPERPLASIA
MUSCLE
CELL
 Number of fibroids =
features of surgical
treatment

Multiple uterine fibroids

(proliferating angioleiomyoma,
myomatosis)

After organ-preserving surgery: High risk

of recurrence myoma - 59%
The risk of reoperation - 26%
Laparotomy access with myomectomy
Radical interventions
Uterine Artery Embolization
 SUMMAR - THE CHOICE OF SURGICAL APPROACH FOR MYOMECTOMY

Intrauterine approach: Hysteroresectoscopy

(submucous myoma up to 5.0 cm)

Abdominal access:
Myomectomy laparoscopy (a small number of nodes, sizes up to 10.0 cm –
interstitial myoma or subserous fibroid up to 20.0 cm ) *
Clinical recommendations 2015, Adamyan L.V., Serov V.N.
Myomectomy laparotomy (a large number of nodes of large sizes more than
10 cm)
Hysterectomy (Multiple uterine fibroids in combination with pathology of the
cervix and endometrium, completed reproductive plans)

Uterine artery embolization (multiple uterine fibroids, completed

reproductive plans, mainly interstitial and submucous nodes,
metrorrhagia, desire to save the uterus)
 During this period, uterine blood supply is
Features of surgical reduced, there is no swelling of tissues
associated with a progestin effect, the uterine
interventions on the tone is increased, which makes it easy to
reproductive organs determine the boundaries of the myomatous
(myomectomy, node, and minimize physiological blood loss
during surgery.
hysterectomy)

Performing surgery in the 1st phase of the

menstrual cycle:
optimal period from 5 to 9 day
 PATIENT POSITION ON THE OPERATING TABLE DEPENDING ON ACCESS TO THE
GYNECOLOGY

GYNECOLOGICAL LAPAROTOMY POSITION POSITION FOR GYNECOLOGICAL LAPAROSCOPY, HYSTEROSCOPY

(HYSTERORESECTOSCOPY) AND VAGINAL SURGERY

TRENDELENBURG POSITION FOR

PELVIC SURGERY FOWLER POSITION FOR REVISION OF THE UPPER ABDOMINAL
CAVITY, FOR OMENTUM RESECTION
 HYSTERECTOMY

The frequency of hysterectomy for all the incidence in our clinic

(MC FEFU 2017-2020)

APPROACH:

1. LAPAROSCOPY – 90% (MAINLY WITH FIBROIDS AND OTHER DISEASES

REQUIRING REMOVAL OF THE UTERUS)
2. LAPAROTOMY – 9% (MAINLY WITH GIANT TUMORS OR OVARIAN CANCER)
3. VAGINAL – 1% (MOSTLY WITH PROLAPSE)
SUBTOTAL HYSTERECTOMY
TOTAL HYSTERECTOMY (EXTIRPATION UTERUS)
(SUPRACERVICALAMPUTATION OF THE UTERUS)

TYPE OF
HYSTERECTOMY FOR
FIBROIDS:
VAGINAL HYSTERECTOMY IS
SUITABLE FOR:
contraindications for endotracheal anesthesia
contraindications to abdominal access (severe pathology of
internal organs)
complete or partial prolapse of the uterus and vagina

Conditions for the possibility of a surgical procedure:

vaginal capacity and uterine mobility
lack of adhesion of the pelvis
small size of the uterus
lack of need for simultaneous operations on the uterine
appendages or organs of the abdominal cavity

SUBTOTAL HYSTERECTOMY IS NOT POSSIBLE

ONLY TOTAL HYSTERECTOMY IS POSSIBLE
 HYSTERECTOMY (SUBTOTAL\TOTAL) INDICATION AND
CONDITIONS FOR THE POSSIBILITY OF A SURGICAL PROCEDURE:

Laparoscopy approach:
Recommended in all cases when there are no conditions for a vaginal
approach
No contraindications for pneumoperetoneum
Technical ability (may be limited by the size of the uterus and the skills of
the surgeon)

Laparotomy approach:
Only a small number of patients with extremely large tumors
are needed (more than 24 weeks and 1,500 g)
With contraindications for the position of trendelenburg or
pneumopereteneum.
 TYPE OF INCISION FOR LAPAROTOMY Location of trocars
LOWER MIDDLE LAPAROTOMY
during laparoscopy
PFANNENSTIEL LAPAROTOMY
Navel
McBurney Point
McBourney's counterpoint
2-3 transverse fingers above the
pubic bone
 STAGES
OF TOTAL AND SUBTOTAL HYSTERECTOMY:

LAPAROTOMY: TISSUE ARE LAPAROSCOPY: TISSUE IS COAGULATED USING

CLAMPED, DIVIDED, AND BIPOLAR COAGULATION OR ULTRASOUND ENERGY
SUTURELIGATED WITH 0 VICRYL AND DISSECTED WITH SCISSORS, ULTRASOUND
OR ANOTHER TYPE OF A THREAD OR MONOPOLAR ENERGY

THE INTERSECTION OF THE ROUND LIGAMENT AND THE ANTERIOR LEAF OF THE BROAD
LIGAMENT TO THE VESICOUTERINE PLATE
THE INTERSECTION OF THE FALLOPIAN TUBE AND THE OVARIAN'S LIGAMENT (WHILE
MAINTAINING ADNEX) OR THE INFUNDIBULOPELVIC LIGAMENT WITH MESOSALPINX (WITH
ADNEXECTOMY)
INTERSECTION OF THE POSTERIOR LEAF OF THE BROAD LIGAMENT
ISOLATION OF THE VASCULAR BUNDLE AND ITS INTERSECTION
THE SAME STEPS ON THE OTHER HAND
 THE INTERSECTION OF THE ROUND LIGAMENT AND THE ANTERIOR LEAF OF THE BROAD
LIGAMENT TO THE VESICOUTERINE PLATE LEFT-HAND SIDE

LEFT-HAND SIDE
LEFT-HAND SIDE
THE INTERSECTION OF THE INFUNDIBULOPELVIC THE INTERSECTION OF THE FALLOPIAN TUBE
LIGAMENT WITH MESOSALPINX (WITH AND THE OVARIAN'S LIGAMENT (WHILE
ADNEXECTOMY) MAINTAINING ADNEX)

LEFT-HAND SIDE
 ISOLATION OF THE VASCULAR BUNDLE AND ITS INTERSECTION

LEFT-HAND SIDE
PERSECUTION OF THE SACRO-UTERINE LIGAMENT ZONE

IN ORDER TO PREVENT
PROLAPSE, IT IS BETTER
TO MAINTAIN THE ARCH
OF THE SACRO-UTERINE
LIGAMENTS
 SUBTOTAL HYSTERECTOMY
CUTTING OFF THE UTERINE BODY
FROM THE CERVIX AT THE LEVEL OF
THE INTERNAL PHARYNX
SUBTOTAL HYSTERECTOMY
SUTURING THE CERVIX STUMP AND
UTERUS LIGAMENTOUS FIXATION
 LAPAROSCOPY WITH TOTAL HYSTERECTOMY REQUIRES A UTERINE MANIPULATOR TO
MAXIMIZE THE TENSION OF THE UTERUS IN THE CRANIAL DIRECTION (PREVENTION OF
URINARY TRACT INJURY)
COLPOTOMY VAGINA AFTER TOTAL HYSTERECTOMY

VAGINAL CLOSURE
UTERUS LIGAMENTOUS FIXATION (MCCALL
CULDOPLASTY)
 Myomectomy is a surgery that is accompanied by
large blood loss.
HARVESTING
AND REINFUSION OF AUTOLOGOUS BLOOD

Autologous blood is harvested 7-14 days before surgery

Surgery begins with hemodilution (Ionosteril, Sterofundin)
Autologous blood reinfusion is performed during surgery at a time when the risk of bleeding
is minimized (vascular ligation, wound closure)
PROS:

Stimulation of erythropoiesis
During reinfusion, a decrease in bleeding wounds
The absence of anemia in the postoperative period (HB after surgery is
higher than before surgery)
Strengthening repair processes in the postoperative period
 THE MAIN RISK AFTER
MYOMECTOMY IS SCAR FAILURE
AFTER MYOMECTOMY AND
MYOMA
UTERINE RUPTURE DURING
PREGNANCY OR CHILDBIRTH. MAY
RESULT IN DEATH FROM THE
FETUS AND FROM THE MOTHER!

THE MAIN OBJECTIVE OF THE

OPERATION IS THE FORMATION OF
A WEALTHY SCAR ON THE UTERUS.
 MYOMECTOMY

APPROACH:

Laparoscopy
Laparotomy (huge and multiple fibroids)
Vaginal

MYOMECTOMY THROUGH COLPOTOMY VAGINAL APPROACH SUITABLE FOR :

Conditions for the possibility of a surgical procedure:

single subserous and intramural fibroids located on the back wall of the uterus
fibroids, located in the vaginal part of the cervix
vaginal capacity and uterine mobility
lack of adhesion of the pelvis
small size of fibroids
lack of need for simultaneous operations on the appendages or organs of the abdominal cavity
 LAPAROTOMY
VS
LAPAROSCOPY

CONS OF LAPAROSCOPY
Blind entry
Long-term surgery / anesthesia
No tactile sensitivity
Limited field of view
The inability to extract large
macropreparations from the abdominal
cavity
Energy Dependence
 THE MAIN INDICATIONS FOR LAPAROTOMY

The main indication: a large deep myomatous fibroid (more than 20.0 cm -
conditional limit); * Clinical recommendations 2015, Adamyan L.V., Serov V.N.
Smaller fibroid + endometrioid infiltration or endometrioid node with damage to
the area around the uterine cavity)
Multiple uterine fibroids, when the duration and complexity of laparoscopic surgery
is much higher than open access
All other cases (atypical, submucous uterine fibroids) are justified by the surgical
skills of the operating doctor and the possibility of applying a quality suture to the
uterus
Contraindications for applying pneumoperitoneum
LAPAROTOMY
 MYOMECTOMY
ENERGIES USED FOR INCISION AND COAGULATION

The use of ultrasonic energy -

for dissection of the muscle and
Use of monopolar The use of bipolar energy
removal of the node with minimal
energy only in cutting mode, do not only to
coagulation effect of small vessels.
(minimal thermal damage to tissues, -
coagulate (large lateral damage) stop bleeding from large
lateral damage from 1 to 3 mm) vessels, after peeling the
node, the bed is not
coagulated, quick wound
closure is necessary
 Ultrasonic
instruments

How it works:
Electrical energy is supplied to the piezoelectric
ceramic disk, which is “excited” and
begins to vibrate. Max vibration frequency - 55 500 /
sec. Due to this rapid webration (mechanical
energy) tissue friction occurs, thermal energy is
generated (up to 150 ° C) - a tissue incision,
simultaneously with the coagulation effect. There is
no large lateral damage as when using the electric
energy of a monopolar and bipolar.
Earth is the neutral electrode and
the sky is monopolar.
LATERAL TISSUE DAMAGE USING MONOPOLAR ENERGY

CUTTING

CURRENT QUICKLY HEATS CELLS

ABOVE 100 ° C
FLUID BOILS
CELL PRESSURE INCREASES
THE CELL IS TORN

COAGULATION

CURRENT HEATS CELLS

WATER FROM THE CELL
EVAPORATES
CELL SHRINKS
ALBUMIN COLLAPSE
 1 2 3

THE FIBROID IS CAPTURED BY BULLET FORCEPS,

TISSUE DISSECTION AND FIBROID REMOVAL WITH AN
ULTRASONIC SCALPEL ARE PERFORMED

2 3
 Opening cavity uterus
MAY OCCUR WHEN:

•IF SUBMUCOUS MYOMA, IMMERSED IN THE CAVITY BY MORE

THAN 1/3 OF THE DIAMETER
•WITH ENDOMETRIOTIC NODES AND FIBROIDS WITH ENDOMETRIOID
INFILTRATION.
The principles of suturing
the wound of the uterus
after removal of the
fibroid PRINCIPLES:

•SUTURING THE UTERUS WITH

ABSORBABLE SUTURE ONLY
•LAYERED SEAM WITH BOTTOM GRIP
•DOUBLE OR MULTI-LAYERED NODAL OR
CONTINUOUS SEAM
•GOOD MATCHING OF THE EDGES OF THE
UTERINE WOUND
 Using V-loc Thread

The absorbable monofilament material V-Loc allows the thread to be pulled in only one
direction.

After tightening, the thread does not relax.

This design of the thread allows you to close the wound 50% faster than regular suture
material.

Unidirectional spikes on the thread evenly distribute the tension in the tissue throughout the
thread, which ensures uniform blood supply to the wound and its successful healing.

Full resorption - 90 or 180 days (two types of thread).

Laparoscopic suturing of the uterine wound
SCHMIDEN FURRIER SURGICAL STITCH
THREAD - V-LOC 180 GOES INSIDE OUT - INSIDE OUT
 MORCELLATION -
THE PROCEDURE OF GRINDING TISSUE DIRECTLY INSIDE THE
HUMAN BODY IN ORDER TO EXTRACT FIBROIDS OR THE UTERUS
FROM THE ABDOMINAL CAVITY DURING LAPAROSCOPIC
OPERATIONS

ELECTROMECHANICAL
MORCELLATOR
 Complications
of marcellation: parasitic fibroids
(morcellomas))
Parasitic fibroids (morcelloma)
- a site of a remote myomatous node
or a whole “forgotten” node
that restores blood supply and is
implanted in surrounding tissues

WHAT IS IT?
The patient had a spleen injury 17 years ago.
These are multiple self-implanting spleens after rupture.
 Histological types of fibroids
Simple uterine leiomyoma (fibroleiomyoma) mitoses are absent, there is fibrous tissue, not much
muscle tissue and blood vessels;
Proliferating Leiomyoma (Angioliomyoma) there is a large number of muscle tissue and blood vessels,
fast-growing
Bizarre leiomyoma (cell tumor) - cell polymorphism
Myomatosis is a benign myoma, spreading by the hematogenous route and growing in the lumen of
the vessel and giving metastases to many organs (brain, heart, intestines,
lungs, etc.);
There are cellular polymorphism and pathological mitoses in the sarcoma, even with a
single pathological mitosis in the field of view IHC is shown

MYOMETRIUM MYOMA MYOMA SARCOMA

 SIMPLE MYOMA
Peripheral type of blood supply from the
Color Doppler uterine vessels
flow mapping: Blood flow speed (Vmax) = 0.12-0.25 cm³
Resistance Index (RI) = 0.58-0.69

PROLIFERATING FIBROIDS
Active diffuse and / or central blood flow,
neovascular
Blood flow speed (Vmax) = 0.18-0.30 cm³
Resistance Index (RI) = 0.5-0.56

SARCOMA
Pronounced chaotic vascularization, both
inside and out, of neovascular
Blood flow speed (Vmax) ≥ 0.4 - 0.8 cm³
Resistance Index (RI) ≤ 0.4
The risks of
•Forgetting (leave) fibroids in the abdominal cavity
developing parasitic
•Rough morcellation, leaving part of the chips in the
fibroids: abdominal cavity
•Proliferating fibroids, bizarre fibroids and myomatosis
have a greater risk of morcellomas than simple

THE FREQUENCY OF PARASITIC FIBROIDS

FROM 0.12 TO 0.9%.

Risk factors:
young age
hormone therapy

Options on fibroid morcellation: a

literature review hans Brölmann et all, 2015
Morcellation in a bag ‘le sac’
HYSTERORESECTOSCOPY INDICATIONS - SUBMUCOUS UTERINE FIBROIDS UP TO 5 CM

After the expansion of the cervical canal to No. 10 with

Geghar dilators, a hysteroresectoscope is inserted into
the uterine cavity. Through the channel of the
hysteroscope, sterile fluid is supplied to expand the
uterine cavity and to create a special electrically
conductive or non-neutral environment.
If a bipolar resectoscope is used (current flows from
the loop to the passive electrode, which is located on
the loop itself), an 0.9% isotonic sodium chloride
solution is used.
If a monopolar resectoscope is used (current flows
from the loop to the passive electrode located on the
patient’s thigh), a solution of 5% glucose is used.
A loop electrode is used, which with the help of electric
energy cut the fibroid on chips.
 THE MAIN CLINICAL MANIFESTATIONS OF FIBROIDS WITH
SUBMUCOUS GROWTH

1. MENSTRUAL BLEEDING (OMC), LEADING TO ANEMIA

(SUBMUCOUS AND INTERSTITIAL FIBROIDS WITH
CENTRIPETAL GROWTH).
2. PAIN DURING MENSTRUATION, CRAMPING.
3. INFERTILITY.
4. MISCARRIAGE.

TYPE 0
TYPE 2
THE MAIN DIAGNOSTIC
METHOD:
ULTRASOUND SCAN
MRI IF NECESSARY
OFFICE HYSTEROSCOPY
IF NECESSARY
 HYSTERORESECTOSCOPY
PERFORMING SURGERY IN THE 1ST PHASE OF THE MENSTRUAL CYCLE:
OPTIMAL PERIOD FROM 5 TO 9 DAY

TYPE 0
INDICATIONS - SUBMUCOUS UTERINE FIBROIDS

CONDITIONS OF SURGICAL PROCEDURE

TYPE 0 - UP TO 5-6 CM IN DIAMETER
TYPE 2
TYPE 1 - UP TO 3-4 CM IN DIAMETER
TYPE 2 - UP TO 2-3 CM IN DIAMETER
 TURP OR TUR-SYNDROME (WATER INTOXICATION SYNDROME)

WHEN A LARGE VOLUME OF IRRIGATING SOLUTION IS ABSORBED, IATROGENIC WATER

INTOXICATION DEVELOPS - TUR-SYNDROME.

THE MOST COMMON CAUSES OF TUR SYNDROME:

FIBROID CAPSULE DAMAGE
VENOUS VASCULAR DAMAGE
HIGH PRESSURE FLUSHING FLUID
THE USE OF HYPOTONIC SOLUTIONS IN MONOPOLAR RESECTION
ABSORPTION OF A LARGE AMOUNT OF FLUID INTO THE BLOODSTREAM
BLOOD LOSS
LONG OPERATION TIME

PATHOGENESIS
ABSORPTION OF FLUID INTO THE BLOODSTREAM
HYPERVOLEMIA, CENTRAL VENOUS PRESSURE
HYPONATREMIA HEMODILUTION
HEMOLYSIS OF ERYTHROCYTES
PULMONARY EDEMA, CEREBRAL EDEMA, SHOCK, ACUTE RENAL FAILURE

CONFUSED CONSCIOUSNESS; EXCITATION; WEAKNESS THROUGHOUT THE BODY; DYSPNEA; VOMITING; CYANOTIC
SKIN; TACHY AND BRADYARRHYTHMIAS; HYPERTENSION, THEN HYPOTENSION; WHEEZING IN THE LUNGS;
INVOLUNTARY URINATION; ECG - WORSENING OF CORONARY BLOOD FLOW
 UTERINE ARTERY EMBOLIZATION

THE TERM "EMBOLIZATION" IN MEDICINE IS CALLED ARTIFICIAL BLOCKAGE OF BLOOD

VESSELS USING SPECIAL MICROSCOPIC PARTICLES - EMBOLI.

EMBOLI ARE MADE OF A SPECIAL MEDICAL POLYMER AND HAVE A STRICTLY DEFINED SIZE. THEY
SELECTIVELY CLOSE THE LUMEN OF ARTERIES THAT FEED ALL MYOMATOUS NODES IN THE UTERUS.
FIBROIDS STOP SUPPLYING BLOOD DECREASE IN SIZE AND STOP GROWING.
 UTERINE ARTERY EMBOLIZATION

The procedure is performed under local anesthesia.

Contrast is injected through the femoral or brachial artery through a catheter into the
arteries of the uterus. It stains the entire vascular network of the uterus.
Then a suspension of emboli is introduced. . Repeatedly control the blood flow by
contrast. If the contrast no longer stains the arteries, and this means that the blood
flow is stopped.
 THE MAIN INDICATIONS:

Multiple uterine fibroids with predominantly interstitial and submucous growth of nodes, if desired, to
preserve the uterus with reproductive function.

THE MAIN CONTRAINDICATIONS:

ABSOLUTE: THE PRESENCE OF ACUTE AND SUBACUTE INFLAMMATORY PROCESSES IN

THE BODY.
RELATIVE: WITH SUBSEROUS MYOMATOUS NODES ON A THIN BASE, THE SIZE OF THE
UTERUS IS MORE THAN 20 WEEKS. IN THESE CASES, UAE IS POSSIBLE AS A STAGE
BEFORE SURGICAL TREATMENT.
 UTERINE ARTERY EMBOLIZATION

IT IS CARRIED OUT BEFORE MENSTRUATION IN THE SECOND PHASE OF

THE MENSTRUAL CYCLE

PREOPERATIVE PREPARATION (METRONIDAZOLE) FOR

2 TO 4 DAYS. BEFORE SURGERY

POSTEMBOLIZATION SYNDROME: SEVERE PAIN, NAUSEA, VOMITING, DYSURIA, TENESMUS, FEVER,

INFLAMMATORY CHANGES IN THE BLOOD, WEAKNESS, ASTHENIA.

THERE IS NO DIRECT RELATIONSHIP BETWEEN THE SEVERITY OF POSTEMBOLIZATION

SYNDROME AND UTERINE SIZE.

IN THE POSTOPERATIVE PERIOD:

ADEQUATE PAIN RELIEF
ANTIBIOTIC THERAPY
EXTRACT FROM THE HOSPITAL FOR 3-7 DAYS
 UTERINE ARTERY EMBOLIZATION
THE DYNAMICS OF TRANSFORMATION OF THE MYOMATOUS
FIBROIDS AFTER UAE
THE “DRY” TYPE TRANSFORMATIONS:
INTERSTITIAL NODES ARE REDUCED IN SIZE.
CENTRIPITAL NODES (TYPE 2–3) CAN MIGRATE INTO THE UTERINE CAVITY.
SUBMUCOUS FIBROIDS (TYPE 2-1) - MAY EXPULSION FROM THE UTERINE CAVITY
DURING THE YEAR

THE “WET” TYPE TRANSFORMATIONS OR PARTIAL MYOLYSIS IS CHARACTERISTIC OF SUBMUCOUS NODES

OF TYPE 0, WHICH “LEAK” FROM THE UTERINE CAVITY IN THE FORM OF WHITISH FILMS MORE OFTEN
DURING THE FIRST MONTH AFTER SURGERY.

THE MIGRATION OF
SUBMUCOUS MYOMAS
 COMPLICATIONS OF UTERINE ARTERY EMBOLIZATION

Fever, suppuration, and septic conditions

Severe ischemic damage to the uterus
Termination of ovarian function - the onset of menopause (there is an anastamosis
between the uterine and ovarian artery)
Thromboembolic complications (Pulmonary embolism, gluteal artery embolism, etc.)
COMPARISON OF TREATMENT METHODS FOR UTERINE FIBROIDS
 MRGFUS (FOCUSED ULTRASOUND (FUS) -ABLATION)

Magnetic Resonanceguided Focused Ultrasound Surgery - remote tissue destruction by MR-controlled focused ultrasound).
Focused ultrasonic energy destroys the fibroid without damaging the surrounding tissue. Inside the fibroid, a temperature of
55-85 * C is obtained until dry necrosis is formed.

ADVANTAGES
THE METHOD IS EFFECTIVE IN THE TREATMENT OF
NON-INVASIVE,
TYPICAL UTERINE FIBROIDS AND IS INEFFECTIVE IN
DOES NOT HAVE A CLINICALLY SIGNIFICANT OVERALL "CELLULAR" FIBROIDS AND NODES WITH
ACTION ON THE BODY, DESTRUCTIVE CHANGES.
CARRIED OUT ON AN OUTPATIENT BASIS,
NO PERIOD REHABILITATION AND TEMPORARY DISABILITY

ABSOLUTE CONTRAINDICATIONS:
THE PRESENCE OF CONTRAINDICATIONS FOR ORGAN-SAVING
TREATMENT, ACUTE INFLAMMATORY PROCESS OF THE
GENITALS, PREGNANCY.
 REGULATIONS

ORDER OF THE MINISTRY OF HEALTH OF THE RUSSIAN FEDERATION OF NOVEMBER 1, 2012 NO.
572N "ON THE APPROVAL OF MEDICAL CARE IN THE PROFILE" OBSTETRICS AND GYNECOLOGY (EXCEPT
FOR THE USE OF ASSISTED REPRODUCTIVE TECHNOLOGIES) ""

CLINICAL RECOMMENDATIONS, 2015. UTERINE FIBROIDS: DIAGNOSIS, TREATMENT,

REHABILITATION

SCAT PROGRAM
(ANTIMICROBIAL THERAPY CONTROL STRATEGY)
WHEN PROVIDING STATIONARY
MEDICAL CARE
RUSSIAN CLINICAL GUIDELINES, 2018

CLINICAL GUIDELINES FOR ART AND IIS 2018