Myomectomy, sometimes also fibroidectomy, refers to the surgical removal of uterine leiomyomas, also known as fibroids. In contrast to a hysterectomy the uterus remains preserved and the woman retains her reproductive potential.
The presence of a fibroid does not mean that it needs to be removed. Removal is necessary when the fibroid causes pain or pressure, abnormal bleeding, or interferes with reproduction. The fibroids needed to be removed are typically large in size, or growing at certain locations such as bulging into the endometrial cavity causing significant cavity distortion. Patients have many options in the management of uterine fibroids, including: observation, medical therapy (such a GnRH agonists), hysterectomy, uterine artery embolization, and high-intensity focused ultrasound ablation. Despite these many options, the surgical approach of selected fibroid removal remains an important choice for those women who want or need to preserve the uterus.
A myomectomy can be performed in a number of ways, depending on the location and number of lesions and the experience and preference of the surgeon. Either a general or a spinal anesthesia is administered.
Traditionally a myomectomy is performed via a laparotomy with a full abdominal incision, either vertically or horizontally. Once the peritoneal cavity is opened, the uterus is incised, and the lesion(s) removed. The open approach is often preferred for larger lesions. One or more incisions may be set into the uterine muscle and are repaired once the fibroid has been removed. Recovery after surgery takes six to eight weeks.
A fibroid that is located in a submucous position (that is, protruding into the endometrial cavity) may be accessible to hysteroscopic removal. This may apply primarily to smaller lesions as pointed out by a large study that collected results from 235 patients suffering from submucous myomas who were treated with hysteroscopic myomectomies; in none of these cases was the fibroid greater than 5 cm. However, larger lesions have also been treated by hysteroscopy.
Recovery after hysteroscopic surgery is but a few days.
Complications of the surgery include the possibility of significant blood loss leading to a blood transfusion, the risk of adhesion or scar formation around the uterus or within its cavity, and the possible need later to deliver via cesarean section. It may not be possible to remove all lesions, nor will the operation prevent new lesions from growing. Development of new fibroids will be seen in 42-55% of patients undergoing a myomectomy. It is well known that myomectomy surgery is associated with a higher risk of uterine rupture in later pregnancy Thus, women who have had myomectomy (with the exception of small submucosal myoma removal via hysteroscopy, or largely pedunculated myoma removal) should get Cesarean delivery to avoid the risk of uterine rupture that is commonly fatal to the fetus. To reduce bleeding during myomectomy, the use of misoprostol in the vagina and the injection of vasopressin into the uterine muscle are both effectiveThere is less evidence supporting the usefulness chemical dissection (such as with mesna), vaginal insertion of dinoprostone, a gelatin-thrombin matrix, tranexamic acid, infusion of vitamin C, infiltration of a mixture of bupivacaine and epinephrine into the uterine muscles, or the use of a fibrin sealant patch.
The length of time you may spend in the hospital varies.
Recovery time depends on the method used for the myomectomy:
Fibroids return after surgery in 10 to 50 out of 100 women, depending on the original fibroid problem. Fibroids that were larger and more numerous are most likely to recur. Talk to your doctor about whether your type of fibroid is likely to grow back.
Risks may include the following: