Myomectomy

Definition

Myomectomy is the removal of fibroids (noncancerous tumors) from the wall of the uterus. Myomectomy is the preferred treatment for symptomatic fibroids in women who want to keep their uterus. Larger fibroids must be removed with an abdominal incision, but small fibroids can be taken out using laparoscopy or hysteroscopy.

Purpose

A myomectomy can remove uterine fibroids that are causing symptoms. It is an alternative to surgical removal of the whole uterus (hysterectomy). The procedure can relieve fibroid-induced menstrual symptoms that have not responded to medication. Myomectomy also may be an effective treatment for infertility caused by the presence of fibroids.

Precautions

There is a risk that removal of the fibroids may lead to such severe bleeding that the uterus itself will have to be removed. Because of the risk of blood loss during a myomectomy, patients may want to consider banking their own blood before surgery.

Description

Usually, fibroids are buried in the outer wall of the uterus and abdominal surgery is required. If they are on the inner wall of the uterus, uterine fibroids can be removed using hysteroscopy. If they are on a stalk (pedunculated) on the outer surface of the uterus, laparoscopy can be performed.

Removing fibroids through abdominal surgery is a more difficult and slightly more risky operation than a hysterectomy. This is because the uterus bleeds from the sites where the fibroids were, and it may be difficult or impossible to stop the bleeding. This surgery is usually performed under general anesthesia, although some patients may be given a spinal or epidural anesthesia.

The incision may be horizontal (the "bikini" incision) or a vertical incision from the navel downward. After separating the muscle layers underneath the skin, the surgeon makes an opening in the abdominal wall. Next, the surgeon makes an incision over each fibroid, grasping and pulling out each growth.

Every opening in the uterine wall is then stitched with sutures. The uterus must be meticulously repaired in order to eliminate potential sites of bleeding or infection. Then, the surgeon sutures the abdominal wall and muscle layers above it with absorbable stitches, and closes the skin with clips or nonabsorbable stitches.

When appropriate, a laparoscopic myomectomy may be performed. In this procedure, the surgeon removes fibroids with the help of a viewing tube (laparoscope) inserted into the pelvic cavity through an incision in the navel. The fibroids are removed through a tiny incision under the navel that is much smaller than the 4 or 5 inch opening required for a standard myomectomy.

If the fibroids are small and located on the inner surface of the uterus, they can be removed with a thin telescope-like device called a hysteroscope. The hysteroscope is inserted into the vagina through the cervix and into the uterus. This procedure does not require any abdominal incision, so hospitalization is shorter.

Preparation

Surgeons often recommend hormone treatment with a drug called leuprolide (Lupron) two to six months before surgery in order to shrink the fibroids. This makes the fibroids easier to remove. In addition, Lupron stops menstruation, so women who are anemic have an opportunity to build up their blood count. While the drug treatment may reduce the risk of excess blood loss during surgery, there is a small risk that temporarily-smaller fibroids might be missed during myomectomy, only to enlarge later after the surgery is completed.

Aftercare

Patients may need four to six weeks of recovery following a standard myomectomy before they can return to normal activities. Women who have had laparoscopic or hysteroscopic myomectomies, however, can leave the hospital the day after surgery and usually recovery completely within two to three days to one to three weeks.

Risks

The risks of a myomectomy performed by a skilled surgeon are about the same as hysterectomy (one of the most common and safest surgeries). Removing multiple fibroids is more difficult and slightly more risky.

Possible complications include:

• infection
• blood loss
• the wall of the uterus may be weakened if the removal of a large fibroid leaves a wound that extends the complete thickness of the wall. Special precautions may be needed in future pregnancies. For example, the delivery may need to be performed surgically (Caesarean section)
• adverse reactions to anesthesia
• internal scarring (and possible infertility)

Since fibroids tend to appear and grow as a woman ages (until menopause), it is possible that new fibroids will appear after myomectomy.

BOOKS

Carlson, Karen J., Stephanie A. Eisenstat, and Terra Ziporyn. The Harvard Guide to Women's Health. Cambridge, MA: Harvard University Press, 1996.

The Surgery Book: An Illustrated Guide to 73 of the Most Common Operations. Ed. Robert M. Younson, et al. New York: St. Martin's Press, 1993.

OTHER

Toaff, Michael E. "Myomectomy." Alternatives to Hysterectomy Page. <http://www.netreach.net/~hysterectomyedu/myomecto.htm>.

Carol A. Turkington

KEY TERMS

Epidural anesthesia—A method of pain relief for surgery in which local anesthetic is injected into the epidural space in the middle and lower back.