Myomectomy is a surgical procedure used to treat uterine fibroids (myomas), a condition that affects anywhere from 5 to 50 percent of women globally, depending on the country. In the U.S. about 40 percent of women develop fibroids by age 50. Fibroids can cause vaginal bleeding, discomfort during sexual intercourse, pelvic pain or pressure, and fertility problems. Myomectomy is a common procedure, one that is performed roughly 65,000 times a year in the United States alone.
What are Uterine Fibroids?
Uterine fibroids, also known as leiomyomata (a single fibroid is called a leiomyoma), are benign solid tumors (growths) that arise usually in the muscle layer of the uterus. They are almost always benign, although there is a very rare malignant version known as a leiomyosarcoma (more on this below). They generally appear during a woman’s later childbearing years, and can cause such problems as:
- Pelvic pain, back pain, pelvic pressure
- Heavy or irregular vaginal bleeding
- Pressure on the affected woman’s bladder, causing frequent urination
- Uncomfortable or painful sexual intercourse
- Anemia from heavy menstrual blood loss
- Difficulty conceiving, increased risk of miscarriage
- Increased risk of pregnancy complications such as premature birth
- Abdominal enlargement like in early pregnancy
While an estimated 40 percent of women have uterine fibroids at some point in their lives, most of these women are never aware of them because in the majority of cases, they do not cause any symptoms. When they do cause symptoms, however, those symptoms can be significant. Fibroids can also interfere with a woman’s plans to have children by preventing embryo implantation, or in rare cases, by blocking the fallopian tubes or the cervix. Thankfully, myomectomy makes it possible to treat these fibroids without resorting to hysterectomy (removal of the uterus).
Different Types of Myomectomy
There are several different types of myomectomy:
Abdominal myomectomy (also known as open myomectomy) requires that a four-inch (or larger) incision be made in the lower abdomen. This incision is usually made horizontally at the bikini line, roughly the spot where pubic hair begins to grow. Because this incision is horizontal, it usually results in less visible scarring than a vertical incision and an easier recovery.
The drawback to this procedure is that it provides the surgeon with limited access to your pelvic cavity, and therefore may not be feasible if an especially large fibroid needs to be removed. In some cases, an abdominal myomectomy may be performed with a vertical incision, which runs from just below the navel to just above the pubic bone. This is typically done if the uterus is very enlarged (larger than it would be at a 24-week pregnancy, which is quite rare).
Laparoscopic myomectomy is a less invasive procedure that involves the use of a laparoscope, a long, flexible tube equipped with a camera and a light. Several small incisions are made in the abdomen, rather than a single, large incision. The laparoscope is inserted into one of these incisions displaying the entire field of view on multiple video monitors positioned in the O.R. The surgeon inserts other instruments into other incisions to perform the operation.
With laparoscopic surgery, the patient has less pain and scarring, loses less blood, and has a quicker recovery than with an abdominal procedure. If you need myomectomy surgery, your candidacy for this type of procedure will be determined by the size of your uterus and by the size and number of fibroids that need to be removed.
Much controversy has taken place recently regarding this laparoscopic approach. Typically, after the fibroid is detached from the uterus, it is too large to be removed from the body through the small openings created. For years, surgeons (usually gynecologists) used to use a device called a morcellator to chop up or grind the fibroids into smaller pieces, allowing for their removal. However, rare cases of undiagnosed cancer (see leiyomyosarcoma above) have been treated this way, which then allowed those cancer cells to spread. Because of this, tissue morcellation is now rarely done, and this will continue to be the case until new methods are developed to prevent any possible spread of cells.
Hysteroscopic myomectomy is used to treat submucosal fibroids, which are located either in the muscle beneath the endometrium (the inner membrane lining of the uterine cavity), or entirely inside the uterine cavity (these are called intracavitary myomas). These are the types of fibroids most likely to distort the shape of a woman’s uterus, prevent embryo implantation, or increase the chances for miscarriage.
The surgeon inserts a narrow device called a hysteroscope into the woman’s vagina and through the cervix opening (which usually needs to be dilated a bit). A sterile saline solution is injected into the uterine cavity in order to expand it so that the operation can be performed more easily.
A special cutting device called a resectoscope can be passed through the hysteroscope, and this device cuts through tissue using electricity. The fibroid is worked on until it is even with the surface of the uterine wall and no longer projecting; or sometimes the entire fibroid can be removed. Any excess tissue is then flushed from the uterine cavity with the same saline solution that was used to expand the uterus.
Newer devices have been designed based on the principle of the morcellator mentioned above (hysteroscopic morcellation). These use a tiny mechanical grinding tip and continuous suction to literally chop the fibroid into little pieces, which are immediately sucked away. With this method, there is no concern for the spread of cancer cells as there is when using a similar device abdominally.
Hysteroscopic myomectomy leaves no visible scars, but unfortunately it is only useful for treating submucosal and intracavitary fibroids.
Open myomectomy generally takes about two hours, and the patient remains in the hospital for two to three days. Discomfort following surgery generally lasts about ten days, but full recovery and return to work might take six weeks or more. When there are multiple fibroids, this approach can often provide the best repair, especially if pregnancy is a goal in the future.
Laparoscopic myomectomy is usually an outpatient procedure, or perhaps a one-night stay if a lot of work was done. Pain lasts maybe a week, and return to work is usually possible within two to four weeks.
Hysteroscopic myomectomy is an outpatient procedure and there is minimal pain post-op, but there may be bleeding on and off for weeks. One week off work is normally sufficient for recovery.
Risks Associated with Myomectomy
As with any surgical procedure, there are some risks associated with myomectomy. These include:
- Bleeding/excessive loss of blood
- Possible damage to other nearby organs such as bladder or bowel
- Possible damage to the uterus such as perforation
- Weakening of the uterine wall (For this reason, women who may be planning future pregnancies are usually encouraged to have an abdominal myomectomy.)
- Recurrence of fibroids
Scar tissue adhesions are another concern. As with any uterine surgery, there is a chance that bands of scar tissue may form after myomectomy. These formations can adhere to the uterus and cause menstrual difficulties or fertility problems in the future, a condition known as Asherman’s syndrome.
A myomectomy can also complicate childbirth in future pregnancies. If a deep incision is made, the uterus can rupture at the site of the incision during labor, even years later. If you have had a myomectomy, the physician in charge of your childbirth will probably recommend a C-section delivery.