Myomectomy Surgery for Uterine Fibroids

My gynecologist is recommending myomectomy. Can you tell me more about this alternative to hysterectomy?

Myomectomy is a surgical procedure in which fibroids are removed individually, and it can be performed in one of several ways. The least invasive options are the vaginal procedures, which involve the use of specialized instruments: a hysteroscope, a resectoscope, or a laparoscope. Minimally invasive laparoscopic surgery, which involves a small keyhole incision, is another approach. Another option is an open abdominal surgery, or laparotomy.

The aim of a myomectomy is to remove individual fibroids as a way to preserve the uterus. Any of the surgeries can be tedious, depending on the number of fibroids that are present and where they are found in the uterus. You may also want to note that fibroids have been known to return in some women who have had myomectomies.

If you are planning to undergo one of the vaginal procedures, you will probably want to seek out an endoscopic surgeon who has performed many of the procedures. About 40,000 myomectomies are performed annually in the United States compared with 200,000 hysterectomies for uterine fibroids. Many women who choose myomectomy do so because they hope to become pregnant in the future. The National Uterine Fibroids Foundation (NUFF) suggests the procedure may also be helpful for women nearing menopause who, because of a decline in cycling ovarian hormones, probably wouldn’t experience a fibroid resurgence.

Hysteroscope
A diagnostic procedure that uses a telescopic instrument to inspect the uterus.

Abdominal surgery
A surgical procedure performed through an incision similar to that of a cesarean section.

If you are planning to undergo one of the vaginal procedures, you will probably want to seek out an endoscopic surgeon who has performed many of the procedures.

Carolyn’s comment:

After learning about all of my options for treatment, I chose to have a myomectomy because I still wanted to have the possibility of becoming pregnant, and this procedure would ensure that the uterus was still viable for that. My surgery was very successful and without complication, although the size of the fibroid was a surprise; it was described as being like a football!

Kimberlee’s comment:

My first surgery was a myomectomy, and I was terrified. I knew it was a major surgery, and I was concerned about how difficult the recovery would be. On my preop appointment, my doctor as a rule went over the entire procedure with me layer by layer. It was difficult to hear at the time, but in hindsight it was very reassuring. I was in the hospital for 3 days after the surgery and sitting up in a chair the day following my procedure. I was of course uncomfortable at first, but with taking short walks and sitting in chairs, the recovery went very fast.

What are the potential risks of the myomectomy surgery?

Abdominal myomectomy is a major surgery, whether it is done by laparotomy or laparoscopically. The potential risks are as follows:

• Pain
• Bleeding—The amount of blood lost during the surgery may require a transfusion.
• Development of blood clots—Clots usually occur in the lower extremities.
• Potential injury to internal organs, such as the bladder, intestines, and uterus.
• Infection
• Recurrence of fibroids—Studies suggest a recurrence rate of 26% within 5 years. The recurrence rate is greater when the surgery is done laparoscopically.
• Development of partial small bowel obstruction— This condition may occur from a few days to a few weeks after surgery.

Deborah’s comment:

My second myomectomy occurred on December 12, 2000, at age 38. Fertility was still of paramount importance to me and after conducting much research on the uterine embolization procedure, which was considered experimental at the time, I opted to have another myomectomy. Approximately 7 fibroids were removed (the largest being 6 cm) and my bladder was no longer under stress. I was doing well until my wellness office visit with Dr. Greig in Fall 2001, in which he told me the pelvic ultrasound report indicated that I had innumerable myomas. I was devastated to hear that news. I could not believe the fibroids grew back so quickly after surgery.

What is a hysteroscopic-assisted myomectomy?

Hysteroscopic myomectomy has been shown to be effective in controlling the very heavy abnormal bleeding caused by submucosal fibroids. Hysteroscopic-assisted myomectomy involves the aid of a slender, lighted tube like instrument. The device is inserted through the vagina, so no incision is made in this procedure. It can be performed in an outpatient surgery center. Miniature instruments are used as part of the operation to remove fibroids (and/or uterine polyps when they are present). If you are to undergo operative hysteroscopic myomectomy, this method is used in the removal of submucosal fibroids.

What is a laparoscopic myomectomy?

The laparoscope is an instrument used in minimally invasive surgery. The technique is as follows.

A small quarter-inch incision is made just below the navel, and a special needle is gently inserted through this incision. This needle is attached to a special machine that is used to gradually pump air into the abdomen, resulting in the abdominal wall being pushed away from the internal organs (intestines, uterus, and liver).

Next, the laparoscope, which is a long pencil-like metal instrument, is inserted into the abdomen through the same incision. The laparoscope has a light at its far end, and a small video camera can be attached to its upper end. Once it is in place, live pictures are projected to television monitors stationed in the operating room.

The surgeon then makes additional small incisions near the pubic hair line; additional small surgical instruments are inserted through these incisions. The surgeon can proceed with the operation by looking directly at the television monitor.

Myomectomies or hysterectomies can be safely per- formed using this technique, depending on the size of the fibroids or uterus.

What is a resectoscope?

The resectoscope is actually a hysteroscope equipped with a special wire loop capable of emitting high electrical energy. This device is used to cut or resect growth such as submucosal fibroids.

The resectoscope is inserted through the vagina into the cervix, with a picture of the operative field being projected on a television screen. This procedure can also be used to remove uterine (endometrial) polyps. Like the conventional hysteroscopic procedure, a resectoscopic myomectomy can be performed in an outpatient surgery center.

Endometrial polyps
Small benign growths that pro- trude into the uterus.

Does having a myomectomy mean I will need a cesarean section when I become pregnant?

The general rule is that a cesarean section is advisable if you have had significant surgical invasion of the wall of the uterus during a myomectomy. Most studies however tend to show a very low incidence of uterine rupture in pregnant women who have had prior myomectomy. It must be emphasized that rupture of the uterus can cause very serious complications for both the mother and the baby.

Kimberlee’s comment:

My doctor delivered my son via a cesarean section. He wanted to deliver via cesarean to ensure there would be no complications from the previous surgery. I gave birth in 1998, and for the next 5 years I had no symptoms of fibroids.