About the Hysteroscopic Resection of Uterine Fibroids

 

Uterine Fibroids pic

Uterine Fibroids
Image: drreislerobgyn.com

Based in Plano, TX, Keith Reisler, MD, has almost 30 years of experience as an ob-gyn and is regularly recognized as one of the best doctors in America. In addition to offering comprehensive ob-gyn services, Dr. Keith Reisler has specialized training in minimally invasive procedures, such as the hysteroscopic resection of uterine fibroids.

Hysteroscopic resection is most often used for fibroids located under the inner wall of the uterus that have grown into its inner cavity. The procedure is performed via the patient’s birth canal and involves no external cuts. Many patients are able to go home the same day, with little to no pain from the procedure.

Unlike laparoscopic procedures, which often require several incisions and may keep patients in the hospital overnight or longer, hysteroscopic procedures are performed with a small camera that has a surgical loop attached to its end. In addition to a quick recovery time, hysteroscopic resection maintains the integrity and function of the patient’s uterus so she can still become pregnant and have a normal pregnancy. However, the procedure is not without side effects, and light bleeding for up to four to six weeks is normal.

Hysterectomy Methods

Hysterectomy Image: mayoclinic.org

Hysterectomy
Image: mayoclinic.org

Keith Reisler, MD, of Plano, TX, has been in private practice for over 24 years. Dr. Keith Reisler completed his OBGYN residency at highly regarded, Southwestern Medical School/Parkland Hospital. Among the issues that women are confronted with are whether to have a hysterectomy, and which approach to use.

Hysterectomy involves the surgical removal of the womb or uterus. There are many reasons why it is performed, the most common being the presences of uterine fibroids. These are benign growths which can cause medical complications.

The various hysterectomy methods include abdominal, vaginal, laparoscopic, and robotic-assisted. Abdominal hysterectomy is the more traditional approach and requires a 6-to-12-inch incision in the abdominal wall. Vaginal hysterectomy involves the removal of the uterus through the vagina. Laparoscopic hysterectomy involves three to four small incisions in the abdominal wall and is considered non-evasive. The robotic-assisted procedure is relatively new, and its effectiveness vis-a-vis other methods is still under study. It is currently the most expensive approach.

There are many factors to consider in which method to use, including technical, medical, financial, and even the availability of medical equipment. One major consideration, of course, is that the surgeon performing the operation be highly skilled in the method used.

Hysteroscopic Resection for Uterine Fibroids and Polyps

Dr Keith Reisler pic

Dr Keith Reisler
Image: drreislerobgyn.com

Over the course of his career, obstetrician and gynecologist (OBGYN) Keith Reisler, MD, Plano, Tx, has treated numerous uterine fibroids and polyps. Dr. Keith Reisler draws on an in-depth knowledge of minimally invasive techniques to offer hysteroscopic resection as a treatment option for these conditions. Due to Dr Reisler’s expertise with various removal techniques, he is able to perform many these procedures as a day surgery procedure without an incision. Many doctors without this level of training might perform these procedures with an abdominal incision as an inpatient procedure and with a much longer recovery.

Hysteroscopic resection, also known as hysteroscopic myomectomy and hyesteroscopic poypectomy, uses a specially designed surgical scope to remove uterine fibroids and polyps. To perform the procedure, the surgeon introduces a salt or sugar solution that expands the uterus and allows for better visualization of the area. Insertion of the hysteroscope enables the surgeon to view any fibroids or polyps, and to strategize removal using a looped wire. This procedure is done without making any incisions and just by dilating the cervix.

Most patients who undergo hysteroscopic resection can return home the day of the procedure. Postoperative pain is generally minimal and manageable using basic oral analgesics. Risk of infection is low, as the procedure does not involve an abdominal incision, and most patients experience no detrimental effects in terms of fertility. In fact, the procedure’s history features high pregnancy rates among those patients whose fibroids have interfered with conception.

The Pap Smear Exam

Dr Keith Reisler pic

Dr Keith Reisler
Image: drreislerobgyn.com

For more than 20 years, Keith Reisler, MD, has provided women in the Plano, Texas, area with comprehensive gynecologic and obstetric care. As an OBGYN, Dr. Keith Reisler performs minimally invasive procedures and administers preventative care for women of all ages.

A procedure that many women receive from their OBGYN is a Pap smear exam. The purpose of a Pap smear is to determine whether or not precancerous cells are present in a woman’s cervix. The tests consists of a doctor or nurse taking a sample of cells from the cervix, transferring them to a glass slide, and then sending the slide off for laboratory testing. The results can usually be processed within a week.

One in 10 Pap smear tests reveals abnormalities, but less than one percent of these cases are cancerous. If any abnormalities exist, the OBGYN who performed the exam may recommend further testing.

Some women choose to have a yearly Pap smear as part of their overall female wellness checkup. However, many physicians believe it is acceptable to have a Pap smear every three years for women between the ages of 18 and 70.

Exercise During Pregnancy

In December of 2015, The American Congress of Obstetrics and Gynecologists published there latest guidelines regarding exercise in pregnancy contained in Committee Opinion Number 650.  What follows is a summary of some of these guidelines.

Here are their recommendations:

-Physical activity in pregnancy has minimal risks and has been shown to benefit most women, although some modifications to exercise routines may be necessary because of normal anatomic and physiologic changes and fetal requirements.

-A thorough clinical evaluation should be conducted before recommending an exercise program to ensure that a patient does not have a medical reason to avoid exercise

-Women with uncomplicated pregnancies should be encouraged to engage in aerobic and strength-conditioning exercises before, during and after pregnancy

-Obstetrician-gnecologists and other obstetric care providers should carefully evaluate women  with medical or obstetric complications before making recommendations on physical activity participation during pregnancy.  Although frequently prescribed, bed rest is only rarely indicated and, in most cases, allowing ambulation should be considered.

-Regular physical activity during pregnancy improves or maintains physical fitness, helps with weight management, reduces the risk of gestational diabetes in obese women, and enhances psychologic well-being.

Additional research is needed to study the effects of exercise on pregnancy-specific outcomes, and to clarify the most effective behavioral counseling methods and the optimal intensity and frequency of exercise.  Similar work is needed to create an improved evidence base concerning the effects of occupational physical activity on maternal-fetal health.

Observation studies have shown benefits of exercise in pregnancy such as decreased gestational diabetes, decreased cesarean section and operative vaginal deliveries, and decreased postpartum recovery time.  However it is important to state that evidence from large randomized trials regarding benefits of exercise in pregnancy is limited.  However the risks from exercise seem minimal compared to the possible benefits.

The following are contraindications to Aerobic Exercise During Pregnancy:

  • Hemodynamically significant heart disease
  • Restrictive lung disease
  • Incompetent cervix or cerclage
  • Multiple gestation at risk of premature labor
  • Persistent second or third trimester bleeding
  • Placenta previa after 26 weeks of gestation
  • Premature labor during the current pregnancy
  • Ruptured membranes
  • Preeclampsia or pregnancy-induced hypertension
  • Severe anemia

The Following are relative contraindications to Aerobic Exercise during pregnancy and should be discussed with your doctor:

  • Anemia
  • Unevaluated maternal cardiac arrhythmia
  • Chronic Bronchitis
  • Poorly controlled type 1 diabetes
  • Extreme morbid obesity
  • Extreme underweight (BMI less than 12)
  • History of extremely sedentary lifestyle
  • Intrauterine growth restriction in current pregnancy
  • Poorly controlled hypertension
  • Orthopedic limitations
  • Poorly controlled seizure disorder
  • Poorly controlled hyperthyroidism
  • Heavy smoker

 

The following are examples of safe and unsafe Physical activities in Pregnancy

The following are safe to initiate or continue in an uncomplicated pregnancy after consultation with your Obstetrician:

  • Walking
  • Swimming
  • Stationary cycling
  • Low-impact aerobics
  • Yoga, modified (Positions that result in decreased venous return and hypotension should be avoided as much as possible.)
  • Pilates, modified
  • Running or jogging (In consultation with your obstetrician, running or jogging , racquet  sports, and strength training may be safe for pregnant women who participated in these activities regularly before pregnancy.  I do not recommend initiating these during pregnancy)
  • Strength training

The following activities should be avoided:

  • Contact sports (eg, ice hockey, boxing, soccer, and basketball)
  • Activities with a high risk of falling(eg. downhill snow skiing,water skiing, surfing, off-road cycling, gymnastics, and horseback riding)
  • Scuba diving
  • Sky diving
  • “Hot yoga” or “hot Pilates”

 

The following are warning signs to discontinue exercise during pregnancy:

  • Vaginal Bleeding
  • Regular painful contractions
  • Amniotic fluid leakage
  • Dyspnea before exertion
  • Dizziness
  • headache
  • Chestpain
  • Muscle weakness affecting balance
  • Calf pain or swelling

 

The exercise program should gradually work up to an eventual goal of moderate-intensity exercise for at least 20 to 30 min/day on most or all days.  For a moderate intensity program the best way to monitor the level of the work out may be through patient perceived level of exertion or difficulty.  On the Borg scale below a rating of “somewhat hard” 13 to 14 may be most appropriate.  Another wasy to monitor the level of exertion is the “talk test”.  As long as a woman carry on a conversation during pregnancy then she is probably not overexerting herself.  A high intensity or prolonged exercise of 45 minutes can lead to hyperglycemia and should be avoided.  Adequate caloric intake before pregnancy is important as is adequate hydration before and during exercise.  Avoid lying on your back for prolonged periods of time.  Exercise should be performed in a controlled temperature environment to help prevent dehydration and other effects of the elements.   Pregnant women with back pain would be best served to engage in water exercises as an alternative.

Borg scale of Preceived exertion:

  • 6
  • 7     Very, very light
  • 8
  • 9     Very light
  • 10
  • 11    Fairly Light
  • 12
  • 13    Somewhat Hard
  • 14
  • 15    Hard
  • 16
  • 17    Very Hard
  • 18
  • 19    Very, very hard
  • 20

 

Bottom Line:  Exercise in moderation seems good for the uncomplicated pregnancy for many reasons.  Discuss this with your doctor to individualize your own program

 

Keith Reisler, MD, Plano, Tx – author

 

 

Robotic and Laparoscopic Surgery in Gynecology

For patients who are considering hysterectomy, uterine myomectomy, treatment of ovarian cysts, or other gynecologic surgeries, the following is some information and recommendations that you may find useful. The Amercian College of Obstetricians and Gynecologists and the Society of Gynecologic Surgeons has issued a Committee Opinion Number 628-March 2015 entitled “Robotic Surgery in Gynecology”. This bulletin has also been endorsed by the American Urogynecologic Society. This opinion emphasizes that for the most part there is no proven benefit of Robotic surgery over traditional laparoscopic surgery

Here are some excerpts from the committee opinion:

Summary of Current Evidence

“The rapid adoption of robotic technology for gynecologic surgery is not supported by high-quality patient outcomes, safety, or cost data.” ” Four randomized controlled trials compared robot-assisted surgery for benign gynecologic disease with laparoscopy, and none showed any benefit form using the robotic approach.” “Adoption of new surgical techniques should be driven by what is best for the patient, as determined by evidence-based medicine rather than external pressures.”

Benign Hysterectomy

“Overall, the current literature shows conflicting evidence and is of poor quality. Based on Randomized controlled trials and two large cohort studies, robot-assisted hysterectomy appears to have similar morbidity profiles to laparoscopic procedures but results in significantly higher costs. Further comparative studies that assess long-term outcomes and patient safety and identify subgroups of patients who would benefit from a robotic approach are warranted. Reporting of adverse events is currently voluntary and unstandardized, and the true rate of complications is not known”

Myomectomy

“Despite the purported benefits of robot assistance, data are limited to observational studies of varying quality and power. Although shown to have significantly shorter postoperative recovery times than abdominal myomectomy, robot-assisted laparoscopic myomectomies have longer operative times and significantly higher costs than abdominal and laparoscopic approaches.” “Furthermore, the current literature is insufficient to comment on post procedure conception rates or pregnancy outcomes. Comparative effectiveness studies are needed to better evaluate outcomes, safety, and cost of robot-assisted myomectomy”

Other Gynecologic Procedures

“Patients scheduled for gynecologic procedures of short duration and low complexity are unlikely to benefit from robotic-assisted surgery. The College and SGS suggest that there is no advantage, and that there are possible disadvantages, to performing the following procedures with robotic assistance compared with other minimally invasive approaches: Tubal ligation, Simple ovarian cystectomy, Surgical management of ectopic pregnancy, Prophylactic bilateral salpingo-oophorectomy”

On March 14, 2013 a “Statement on Robotic Surgery” was published by the President of the American College of Obstetrics and Gynecology. Here are some excerpts:

“Many women today are hearing about the claimed advantages of robotic surgery for hysterectomy, thanks to widespread marketing and advertising. Robotic surgery is not the only or the best minimally invasive approach for hysterectomy. Nor is it the most cost-efficient. It is important to separate the marketing hype from the reality when considering the best surgical approach for hysterectomies.”

“Vaginal hysterectomy, performed through a small opening at the top of the vagina without any abdominal incisions, is the least invasive and least expensive option. Based on its well-documented advantages and low complication rates, this is the procedure of choice whenever technically feasible. When this approach is not possible, laparoscopic hysterectomy is the second least invasive and costly option for patients.”

“Robotic hysterectomy generally provides women with a shorter hospitalization, less discomfort, and faster return to full recovery compared with traditional total abdominal hysterectomy(TAH) which requires a large incision. However, both vaginal and laparoscopic approaches also require fewer days of hospitalization and a far shorter recovery than TAH. These two established methods also have proven track records for outstanding patient outcomes and cost efficiencies.”

Bottom Line:

When a hysterectomy is indicated my personal preference as a Board Certified ObGyn physician is to perform vaginal hysterectomy or laparoscopic hysterectomy when possible. These are time proven methods with low complications and less costly than Robotics. There are certain specific complicated cases that I feel may benefit from a Robotic approach. In these situations I refer my patient to a surgeon whom I know is an expert in the field of Robotics and has a practice concentrated in this area, since there is a steep learning curve in Robotics. My approach has always been to recommend the procedure that I feel is best for the patient, and to have this performed by the physician that I feel is most competent to perform the procedure. We are always glad to perform second opinions regarding best surgical approaches for each individual patient.

Keith Reisler – author

Board Certified in Obstetrics and Gynecology