Fibroid Treatment in Istanbul: How Uterine Fibroids Can Be Removed Selectively – While the Uterus Is Preserved

Note: Fibroids are usually benign and rarely an emergency. With very heavy bleeding accompanied by anemia, however, the assessment should not be delayed.

Does the uterus really have to be removed with fibroids?

With fibroids, removal of the uterus is only rarely mandatory, because in most cases it is enough to remove the fibroids themselves. The hysterectomy is regarded as the last step and mainly comes into question when family planning is complete and a definitive solution is wanted. As long as organ preservation is medically reasonable, it comes first.

When a hysterectomy makes sense at all

Removal of the uterus can make sense when other methods are exhausted or a definitive solution is consciously wanted. It is a legitimate option, but not an automatic consequence of the diagnosis of fibroids. This decision should be discussed without time pressure and with all alternatives.

Source: clinical guideline on indication and methodology of hysterectomy for benign conditions (AWMF)

Which treatment method suits which fibroid?

The suitable method depends mainly on where the fibroid lies and how large it is. Fibroids at the uterine lining are treated differently from fibroids in the uterine wall or very large findings. This classification is the most important decision point before any treatment, because it determines the approach and recovery.

Submucosal fibroids – through the vagina

Fibroids that protrude into the uterine cavity can usually be removed via a hysteroscopy. A thin instrument is inserted through the vagina, so no incision is needed. This procedure is often performed on an outpatient basis, and many women can go home the same day.

Fibroids in the uterine wall – laparoscopic

If the fibroids lie in the wall of the uterus, the removal is usually performed via a laparoscopy with several small ports. This minimally invasive technique spares the tissue and allows faster recovery in suitable cases. The uterus is then carefully sutured again after the removal.

Very large or numerous fibroids – open, but uterus-preserving

With very large or numerous fibroids, an open approach through an abdominal incision is often the safer choice. Here too the uterus is preserved — the larger incision serves only for overview and safety. The method thus follows the findings and not the wish for the smallest possible scars.

When do fibroids actually need treatment?

Not every fibroid needs treatment, because what is decisive are the symptoms and not the finding alone. Fibroids are very common — an estimated around 70 % of women develop at least one fibroid by the age of 50, many of them without any symptoms. Treatment becomes sensible mainly when heavy bleeding, pressure or pain symptoms, anemia or a wish to conceive are involved.

Symptom-free fibroids can often be monitored at first, since they frequently shrink after menopause. The frequency rises with age and is about a third in women between 40 and 60; in women of African descent, fibroids occur about three times as often. Whether and when to treat should be guided by the degree of suffering.

What examinations are needed before surgery?

Before any fibroid treatment there is a precise assessment that determines the method and scope of the procedure. Important is a clear picture of the number, location and size of the fibroids, for which, besides ultrasound, MRI is especially suitable. This imaging also helps to plan the treatment safely and to better assess the rare possibility of a malignant finding.

While ultrasound allows a first assessment of location and size, MRI provides a precise map of all fibroids. A blood count additionally shows whether the bleeding has already led to anemia.

How does a uterus-preserving fibroid operation (myomectomy) work?

In a myomectomy, the fibroid is removed from the uterine wall and the uterus is then closed again. The procedure is performed under general anesthesia and, depending on the findings, often takes about one to two hours. The goal is to eliminate the symptoms and preserve the function of the uterus.

Before surgery: imaging and planning

First, the location, size and number of the fibroids are determined based on the imaging. On this basis, the approach is decided and the likely course is discussed. So it is clear before the procedure which method fits best.

During surgery: remove the fibroid, reconstruct the uterus

During surgery, the fibroid is carefully detached from the surrounding muscle tissue and removed. To keep blood loss low, vessel-sparing techniques are used depending on the case. The uterine wall is then sutured layer by layer so that it remains stable.

Is fibroid embolization an alternative to surgery?

Fibroid embolization is a non-surgical alternative in which the blood supply to the fibroids is selectively interrupted. Heavy bleeding improves in about 80 to 90 % of women, pressure symptoms less often, in about 30 to 60 %. However, it is not suitable for every patient, especially not with an existing wish to conceive.

With a wish to conceive, most professional societies advise against embolization, since the chances of pregnancy fall and miscarriages occurred in studies in about 20 of 100 pregnancies. In this case, fibroid removal is usually the more suitable choice. After embolization, there are also complications in about 3 % and a permanently absent period in about 4 %.

Source: gesundheitsinformation.de of the IQWiG (Institute for Quality and Efficiency in Health Care)

How safe is the keyhole method – and what does the discussion about morcellation mean?

Laparoscopy is an established and safe method for fibroids, but one point deserves honest explanation: morcellation. So that a larger fibroid can be retrieved through the small ports, the tissue must be fragmented in the abdomen, and in doing so cells can theoretically be scattered. This is mainly relevant when, in very rare cases, a malignant tumor hides behind a presumed fibroid.

Why tissue is fragmented during laparoscopy

With the minimally invasive method, fragmenting is often technically necessary in order to avoid a large abdominal incision. The risk of an undetected malignant finding is low — less than 0.5 % of "fast-growing" fibroids are actually a sarcoma, and uterine sarcomas make up only around 1 % of malignant tumors in the female genital area overall. Nevertheless, this possibility can never be ruled out with full certainty before surgery.

How we lower the risk with the closed retrieval bag

We address this risk by carrying out the fragmentation wherever possible in a closed retrieval bag. The tissue is retrieved in a sealed bag, so that no cells reach the abdomen freely. Before every procedure we explain this question to you openly, rather than passing over it.

Source: safety information of the FDA (U.S. Food and Drug Administration) on laparoscopic morcellation

Do fibroids come back after surgery?

New fibroids can in principle form again after an organ-preserving treatment, since the predisposition for them remains in the uterus. With all uterus-preserving methods, a repeat treatment is needed within about 5 years in around 15 % of women. We address this openly, because a "never again" with a hormone-dependent finding would not be medically serious.

As long as a woman has not passed menopause, new fibroids can in principle arise. This does not speak against organ preservation, but for honest explanation and a planned follow-up. After menopause, by contrast, new fibroids only rarely form.

Fibroids and the wish to have children: does surgery improve the chance of pregnancy?

With a wish to conceive, a fibroid removal can improve the conditions for a pregnancy, especially when fibroids deform the uterine cavity. Surgery can lower the risk of miscarriages and pregnancy complications, which is why with a wish to conceive myomectomy is preferable to embolization. At the same time, honesty includes that after a removal in the uterine wall, a delivery by cesarean section is often recommended.

After a myomectomy, a waiting time of often about three to six months is usually recommended so that the uterine wall can heal stably. This planning is done individually, since it depends on the location and depth of the removed fibroid. This way, organ preservation can be combined with the safest possible course of pregnancy.

Source: guideline of the DGGG (German Society for Gynecology and Obstetrics)

How does recovery after a fibroid operation proceed?

Recovery depends strongly on the chosen method and is usually quicker after a laparoscopy than after an abdominal incision. How quickly you are fit again depends on the size and number of the removed fibroids. A rough orientation frame often looks like this:

• Operation duration: usually about 1 to 2 hours
• Hospital stay: after laparoscopy often short, after an abdominal incision about 2 to 3 days
• Return to light activities: often within about 2 weeks
• Full recovery after open surgery: often 4 to 6 weeks
• Pregnancy: usually possible after a few months

Our treatment approach: how we select the right method for you

Our starting point is always your individual finding and not a preferred technique. Associate Professor Dr. Cengiz Andan and our team assess the location, size and number of the fibroids as well as your wish to have children, before we decide on the method together with you. We see the hysterectomy as a last resort and not as a first step.

Findings, size and location as the basis

We begin by reviewing all available documents and, if needed, adding an MRI. On this basis, we classify the fibroids and determine the suitable approach. Only then do we talk about the course and recovery.

Uterus preservation takes priority where it is medically reasonable

We try to preserve the uterus whenever this is safely possible. Where organ preservation reaches its limits, we say so openly and explain the reasons. This keeps the decision understandable and aligned with your findings.

Home country or Istanbul – how does fibroid treatment differ?

The difference lies not in the quality, but mainly in waiting time, continuity and cost. The surgical techniques and the underlying international guidelines are the same, so the medical standard remains comparable. The price difference arises from the exchange rate as well as lower operating and staff costs and thus reduces the price, not the standard.

What happens if symptoms arise after returning home?

Serious complications are rare with experienced execution, and for any such case we remain reachable for you. If symptoms arise after the return, we coordinate with your gynecologist in your home country and provide all surgical and findings documents. The histological examination of the removed tissue and further aftercare can also be supported remotely.

How does the path from abroad work – from the inquiry to aftercare?

The process is set up so that the most important steps are clarified before your arrival. You send in your findings, ideally with an MRI, these are reviewed and the possible treatment path is discussed, before you come to Istanbul. After the procedure, you receive an understandable surgical and findings report that you can present to your doctor at home.

Before the journey, imaging and prior findings are reviewed and open points named, so that you arrive with a clear plan. After surgery, the documents are compiled and the next steps explained. Aftercare can be organized partly on site, partly remotely.