What is Myomectomy?

Myomectomy is a surgical procedure that involves the removal of uterine fibroids — also known as leiomyomas. These common noncancerous growths are found in the uterus. Uterine fibroids usually develop during childbearing years, but they could happen at any age.

The surgeon's aim during myomectomy is to take out symptom-causing fibroids and reconstruct the uterus. Unlike a hysterectomy, which removes your complete uterus, a myomectomy removes only the fibroids and leaves your uterus.

Women who undergo myomectomy report improvement in fibroid symptoms, including reduced heavy menstrual bleeding and pelvic pressure.

Why it is done

Your doctor may recommend myomectomy for fibroids causing symptoms that are troublesome or interfere with your normal activities. If you require surgery, reasons to choose a myomectomy rather than a hysterectomy for uterine fibroids include:

• You plan to bear children
• Your doctor suspects uterine fibroids may be interfering with your fertility
• You want to keep your uterus

Risks

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

• Excessive blood loss - Many women with uterine leiomyomas already have low blood counts (anemia) because of heavy menstrual bleeding, so they are at a higher risk of problems because of blood loss. Your doctor might suggest ways to build up your blood count before surgery.
  
  During myomectomy, surgeons take additional steps to avoid excessive bleeding. These might 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 do not reduce the risk of needing a transfusion.
  
  Generally, 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 could lead to adhesions — bands of scar tissue that might develop after surgery. Laparoscopic myomectomy might result in fewer adhesions than abdominal myomectomy (laparotomy).
• Pregnancy or childbirth complications - A myomectomy could increase specific 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 might recommend cesarean delivery (C-section) to prevent rupture of the uterus during labor, a very uncommon complication of pregnancy. Fibroids themselves are also related to pregnancy complications.
• Rare chance of hysterectomy - Rarely, the surgeon should remove the uterus if the bleeding is uncontrollable or other abnormalities are found in addition to fibroids.
• Rare chance of spreading a cancerous tumor - Rarely, a cancerous tumor could be mistaken for a fibroid. Taking out the tumor, particularly if it is broken into little pieces (morcellation) to remove through a small incision, could lead to the spread of cancer. The risk of this occurring increases after menopause and as women age.
  
  In 2014, the Food and Drug Administration (FDA) warned against using a laparoscopic power morcellator for most women undergoing myomectomy. The American College of Obstetricians and Gynecologists (ACOG) recommends you speak with your surgeon about the risks and benefits of morcellation.

Strategies to prevent possible surgical complications

To minimize risks of myomectomy surgery, your doctor might recommend:

• Iron supplements and vitamins - If you have iron deficiency anemia from heavy menstrual periods, your doctor may recommend iron supplements and vitamins to allow you to build up your blood count before surgery.
• Hormonal treatment - Another strategy to correct anemia is hormonal treatment prior to surgery. Your doctor might prescribe a gonadotropin-releasing hormone (GnRH) agonist, birth control pills, or other hormonal medication to stop or decrease your menstrual flow. When given as therapy, a GnRH agonist blocks the production of estrogen and progesterone, stopping menstruation and enabling you to rebuild hemoglobin and iron stores.
• Therapy to shrink fibroids - Some hormonal therapies, like GnRH agonist therapy, could also shrink your fibroids and uterus enough to allow your surgeon to use a minimally invasive surgical approach — like a smaller, horizontal incision rather than a vertical incision, or a laparoscopic procedure instead of an open procedure.
  
  Some research suggests that intermittent GnRH agonist therapy, over time, could shrink fibroids and decrease bleeding enough that surgery is not needed.
  
  In most women, the GnRH agonist therapy causes symptoms of menopause, including hot flashes, night sweats, and vaginal dryness. However, these discomforts stop after you stop taking the medication. Treatment generally happens over several months before surgery.
  
  Evidence suggests that not all women should take GnRH agonist therapy prior to myomectomy. GnRH agonist therapy might soften and shrink fibroids so much that their detection becomes more difficult. The cost of the medication and the risk of side effects should be weighed against the benefits.
  
  Another family of drugs known as selective progesterone receptor modulators (SPRMs), like ulipristal (Ella), might also shrink fibroids and reduce bleeding. Outside the United States, ulipristal is approved for three months of therapy prior to a myomectomy.

How you prepare

Food and medications

You will need to fast — stop eating or drinking anything — in the hours before your surgery. Follow your doctor's recommendation for a certain number of hours.

If you are on medications, ask your doctor if you should change your regular medication routine in the days before surgery. Tell your doctor about any over-the-counter medications, vitamins, or other dietary supplements you are taking.

Depending on your procedure, you might receive one of the following types of anesthesia:

• General anesthesia - With general anesthesia, you will be completely asleep and a tube will be placed in your throat. General anesthesia is used for laparoscopic myomectomy and generally for abdominal myomectomy; it is sometimes also used for hysteroscopic myomectomy.
• Monitored anesthesia care (MAC) - With this type of anesthesia, you typically do not remember anything and feel as if you are fully asleep. You do not have a tube placed in your throat. MAC is often used for hysteroscopic myomectomy since it is a less invasive procedure and therefore needs less anesthesia.

Sometimes other types of anesthesia, like a spinal or local, might be used. Ask your doctor about the type of anesthesia you might receive.

Finally, discuss with your doctor about pain medication and how it will likely be given.

Other preparations

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

Your facility might require that you have someone accompany you on the day of surgery. Ensure you have someone lined up to help with transportation and to be supportive.

What you can expect

Depending on the size, number, and location of your fibroids, your surgeon might choose one of three surgical approaches to myomectomy.

Abdominal myomectomy

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

Laparoscopic or robotic myomectomy

In laparoscopic or robotic myomectomy, both minimally invasive procedures, your surgeon accesses and removes the fibroids through several small abdominal incisions.

Compared to women who have a laparotomy, women who undergo laparoscopy have less blood loss, shorter hospital stays and recovery, and lower rates of complications and adhesion formation after surgery. There is little comparison between laparoscopic and robotic myomectomy. Robotic surgery might take longer and be more costly, but otherwise few differences in outcomes are reported.

• Laparoscopic myomectomy - Your surgeon makes a tiny incision in or near your belly button. Then he or she inserts a laparoscope — a thin tube fitted with a camera — into your abdomen. Your surgeon performs the surgery with instruments inserted through other tiny incisions in your abdominal wall.
• Robotic myomectomy - Your surgeon inserts instruments through tiny incisions similar to those in a laparoscopic myomectomy, and then controls the movement of the instruments from a separate console. Some surgeons are now doing single-port (one incision) laparoscopic and robotic myomectomies.

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

Hysteroscopic myomectomy

To treat smaller fibroids that bulge significantly into your uterus (submucosal fibroids), your surgeon might suggest a hysteroscopic myomectomy. Your surgeon accesses and removes the fibroids using instruments inserted into your vagina and cervix into your uterus.

A hysteroscopic myomectomy usually follows this process:

• Your surgeon inserts a small, lighted instrument into your vagina and cervix and into your uterus. He or she will most frequently use either a wire loop resectoscope to cut (resect) tissue using electricity or a hysteroscopic morcellator to manually cut the fibroid with a blade.
• A clear liquid, generally a sterile salt solution, is inserted into your uterus to expand your uterine cavity and allow examination of the uterine walls.
• Your surgeon shaves pieces from the fibroid using the resectoscope or the hysteroscopic morcellator, taking out the pieces from the uterus until the fibroid is fully removed. Sometimes large fibroids cannot be completely removed in one surgery, and a second surgery is needed.

After the procedure

When you are discharged from the hospital, your doctor prescribes oral pain medication, tells you how to care for yourself, and discusses restrictions on your diet and activities. You could expect some vaginal spotting or staining for a few days up to six weeks, depending on the type of procedure you have had.

Results

Outcomes from myomectomy might include:

• Symptom relief - After myomectomy surgery, most women experience relief of bothersome signs and symptoms, like 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 one year of surgery. After a myomectomy, the suggested waiting time is three to six months prior to attempting conception to allow your uterus time to heal.

Fibroids that your doctor does not detect during surgery or fibroids that are not completely removed could ultimately grow and cause symptoms. New fibroids, which may or may not require treatment, could also develop. Women who had only one fibroid have a lower risk of developing new fibroids — usually termed the recurrence rate — than do women who had multiple fibroids. Women who become pregnant after surgery also have a lower risk of developing new fibroids compared to women who do not become pregnant.

Women who have new or recurring fibroids might have additional, non-surgical treatments available to them in the future. These include:

• Uterine artery embolization (UAE) - Microscopic particles are administered into one or both uterine arteries, limiting blood supply.
• Radiofrequency volumetric thermal ablation (RVTA) - Radiofrequency energy is used to wear away (ablate) fibroids using friction or heat — for example, guided by an ultrasound probe.
• MRI-guided focused ultrasound surgery (MRgFUS) - A heat source is used to ablate fibroids, guided by magnetic resonance imaging (MRI).

Some women with new or recurring fibroids might choose a hysterectomy if they have completed childbearing.

Hill Regional (HRH) Hospital is here to assist all your medical needs with specialists and surgeons trained and experienced in the most advanced treatments. Our highly qualified doctors, nurses, and administrators are dedicated to caring for you with compassion in our state-of-the-art facilities.

Call us on 254-580-8500 to book an appointment with our specialist doctors.