Myomectomy

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Myomectomy is a surgical procedure to remove fibroids. 

The goal during myomectomy is to remove the fibroids that cause symptoms and to reconstruct the uterus. Unlike a hysterectomy, which removes the entire womb, a myomectomy removes only the fibroids and leaves the uterus.

Women who undergo myomectomy report an improvement in heavy periods, urinary frequency and pelvic pressure/pain.

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Why it is done

 

A myomectomy is recommended for fibroids that are troublesome or interfere with your normal activities. If you need surgery, reasons to choose a myomectomy instead of a hysterectomy for uterine fibroids include:

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• Family is not complete.

• The uterine fibroids might be causing subfertility.

• You want to keep your womb.

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Safety - Complications

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A myomectomy has a low complication rate. Still, the procedure poses a unique set of challenges. Risks of myomectomy include:

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• Excessive blood loss. Many women with uterine leiomyomas already have low blood counts (anemia) due to heavy menstrual bleeding, so they're at a higher risk of problems due to blood loss. 

  During myomectomy, we take extra steps to avoid excessive bleeding. These may include blocking flow from the uterine arteries by using tourniquets and clamps and injecting medications around fibroids to cause blood vessels to clamp down. However, most steps don't reduce the risk of needing a transfusion.

  In general, studies suggest that there is less blood loss with hysterectomy than myomectomy for similarly sized uteruses.

• Scar tissue. Incisions into the uterus to remove fibroids can lead to adhesions — bands of scar tissue that may develop after surgery. we aim to perform, the myoimectomies as laparoscopic procedures Laparoscopic myomectomy may result in fewer adhesions than abdominal myomectomy (laparotomy).

• Pregnancy or childbirth complications. A myomectomy can increase certain risks during delivery if you become pregnant. If your surgeon had to make a deep incision in your uterine wall, the doctor who manages your subsequent pregnancy may recommend cesarean delivery (C-section) to avoid rupture of the uterus during labor, a very rare complication of pregnancy. Fibroids themselves are also associated with pregnancy complications.

• Rare chance of hysterectomy. If bleeding is uncontrollable or other abnormalities are found in addition to fibroids.

• Rare chance of spreading a cancerous tumor. Rarely, a cancerous tumor can be mistaken for a fibroid. Taking out the tumor, especially if it's broken into little pieces (morcellation),  can lead to spread of the cancer. The risk of this happening increases after menopause and as women age.

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How is a myomectomy carried out

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Preparation

 

Prior to a myomectomy, you may require:

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• Iron supplements and vitamins. If you have anaemia from heavy periods, you will require iron supplements and vitamins to build up the blood count before surgery.

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• Medications to shrink the fibroids. A special type of drug, called GnRH agonists, can shrink the fibroids and womb enough to allow  a minimally invasive approach — such as a smaller, horizontal incision rather than a vertical incision, or a laparoscopic procedure instead of an open one. This drug causes menopausal symptoms, such as hot flashes, night sweats and vaginal dryness. However, these end after you stop taking the medication. Treatment generally occurs over three to six months before surgery.

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The procedure

 

Whether you stay in the hospital for just part of the day or overnight depends on the type of procedure you have. Abdominal myomectomy (laparotomy) usually requires a hospital stay of one to two days. In most cases, laparoscopic myomectomy is done with only one overnight stay. Hysteroscopic myomectomy is often done with no overnight hospital stay.

You will need someone to accompany you on the day of the surgery. Make sure you have someone lined up to help with transportation and to be supportive.

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The different types of myomectomy

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Depending on the size, number and location of your fibroids, one of the following three surgical approaches to myomectomy may be chosen.

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Abdominal myomectomy

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In abdominal myomectomy (laparotomy), your surgeon makes an open abdominal incision to access your uterus and remove fibroids. Your surgeon will generally prefer to make a low, horizontal ("bikini line") incision, if possible. Vertical incisions are needed for larger uteruses.

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Laparoscopic myomectomy

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In laparoscopic myomectomy, the fibroids are removed through small abdominal incisions.  Compared with women who have a laparotomy, women who undergo laparoscopy have less blood loss, shorter hospital stay, faster recovery, lower complication rates and lower risk adhesion formation after surgery. ​

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Sometimes, the fibroid is cut into pieces (morcellation) and removed through a small incision in the abdominal wall. Other times the fibroid is removed through a bigger incision in your abdomen so that it can be removed without being cut into pieces. Rarely, the fibroid may be removed through an incision in your vagina (colpotomy).

 

 

Hysteroscopic myomectomy

 

This approach is used to remove the fibroids that lie under the lining of the womb.  A hysteroscopic myomectomy generally follows this process:

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• A clear liquid is inserted into the womb through the cervix, to expand the uterine cavity and a lighted tube with a camera at its end (hysteroscope) is used to examine the uterine walls.

• Through the hysteroscope either a wire loop or a morcellator are used to cut the fibroid into pieces.

• Using the resectoscope or the hysteroscopic morcellator, the pieces of the fibroid are removed from the womb until the fibroid is completely removed. Sometimes large fibroids can't be fully removed in one surgery, and a second surgery is needed.

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After the procedure

 

At discharge from the hospital, you will be prescribed oral pain relief, and given post-operative care instructions.  You can expect some vaginal spotting or staining for a few days up to six weeks, depending on the type of procedure you have had.

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Results

 

Outcomes from a myomectomy include:

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• Symptomatic relief. Most women experience relief of bothersome signs and symptoms, such as excessive menstrual bleeding and pelvic pain and pressure.

• Fertility improvement. Women who undergo laparoscopic myomectomy, with or without robotic assistance, have good pregnancy outcomes within about a year of surgery. After a myomectomy, suggested waiting time is three to six months before attempting conception to give time to your womb time to heal.

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Fibroids that are not detected during surgery or could not be completely removed, could eventually grow again and cause symptoms. New fibroids, may also develop. Women with one fibroid have a lower risk of developing new fibroids, than women who had multiple fibroids. Women who become pregnant after surgery also have a lower risk of developing new fibroids than women who do not become pregnant.

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Some women with new or recurring fibroids may choose a hysterectomy if they have completed their family.