子宮肌瘤 Myoma of the Uterus
General Considerations:
1. Incidence: around 30% of all reproductive females
2. Synonym: fibroid tumor, leimyoma.
3. Origin: smooth muscle of uterus.
4. Estrogen dependent.
5. Incidence of malignant transformation: 0.4%.
Clinical Features:
1. Abnormal uterine bleeding, excessive or prolonged menses
2. Pain: when there are degeneration change, myoma delivery, compression, torsion of pedunculated myoma.
3. Palpable mass
4. Asympomatic
5. Infertility, repeated abortion
Types of myoma:
1. Submucosal myoma
2. Pedunculated myoma (subsersal & submucosal)
3. Intramural myoma
4. Cervical myoma
5. Broad ligament myoma
Diagnosis:
1. Pelvic examination: size was described as gestation week
2. Gyn. sonography: transabdominal or transvaginal sonography
3. Computed tomography (CT scan)
4. MRI
5. Hysteroscopy: for submucosal myoma
Secondary Changes:
1. Hyaline degeneration
2. Cystic degeneration
3. Red degeneration
4. Fatty degeneration
5. Calcification degeneration
6. Necrotic degeneration
7. Septic degeneration
8. Malignant change: leiomyosarcoma
Pathology:
1. Leiomyoma
2. Degeneration changes
Treatments:
1. Expectant Tx:
a. Myoma < 6 cm often regress after menopause
2. Medical Tx:
a. Progestine and Antiprostaglandin : controll MC amount
b. GnRH-a, LHRH-a: reduce myoma size
c. Danazol: uncertain effect
3. Surgical Tx:
a. Myomectomy: recurrent rate of myoma is high (40%). used in p't not completing family or who don't want to receive hysterctomy.
b. Hysterectomy: ATH, LAVH.
4. Alternate Tx:
a. Uterine artery embolization (UAE) , after UAE uterine fibroidshrink at least 50% in volume on average and symptoms of refractory vaginal bleeding and chronic pelvic pain are controlled in approximately 85% of patients. (Reference)
b. Uterine artery ligation (electrocautization or clip ligation)
Indication of surgery：
1. Severe menorrhagia
2. Obvious symptom and sign of pain, compression
3. Rapid growing tumor
4. Possibility of malignant change
Pre-OP evaluation：
1. Pathology of Fr D&C + Cx Bx is required
2. Other evaluations are same as general Gyn. Pre-OP
Post-OP care：
1. Post-OP evaluation in the night of operation.
2. C.D., Flatus passage stimulation, CBC/DC et, al. are same as general Gyn laparotomy.
3. Pathology report on the third day postoperatively.
Special Conditions of Uterine Myoma：
1. Leiomyomatosis: polypoid extension of benign smooth muscle tumor into the pelvic vein.
2. Leiomyomatosis peritonealis disseminata: multiple myoma in the subperitoneal surface.
3. Benign metastasizing fibromyomas: a variant of low-grade leiomyosarcoma.
* 所有的myoma在手術中specimen切下來之後，一定要把所有myoma切開看看，若有necrosis部份必須送frozen section以免漏掉leiomyosarcoma。
* 若uterine myoma同時合併vaginal bleeding必須survey看有沒有凝血機能異常。
* 本院開ATH前一定要有半年內的Fr D&C + Cx Bx報告。
* Myomectomy後子宮縫合傷口最好用Interceed覆蓋以防腸粘黏。