What is Myomectomy Surgery?

A myomectomy is a surgery that removes uterine fibroids, also known as leiomyomas. The fibroids are removed and the uterus is either reconstructed or removed.¹ Fibroids are growths made of muscle cells and connective tissue, and they are mostly benign (non-cancerous). These can appear at any time in your life but usually occur during a person's childbearing years. Removing these fibroids alleviates symptoms i.e., pressure in the pelvis and heavy menstrual bleeds.¹ 

Reasons to have a myomectomy

Your daily life may be impacted by symptoms which come with fibroids. One option is a hysterectomy (removal of the uterus). However, you may consider a myomectomy instead if you don’t want to lose your uterus, or if the fibroids have been affecting your fertility.¹

Things to consider

There are some risks to having a myomectomy:

Preventing complications

To reduce risks of complications, you may be recommended to take preventative measures such as:

Taking hormonal medication

You may be given gonadotropin-releasing hormone agonists (GnRH) or other hormonal medication. This temporarily stops you from producing progesterone and oestrogen which in turn prevents menstruation, thus combating anaemia.^10,11 This also shrinks fibroids before surgery, so incisions can be smaller and bleeding may be decreased.¹² 

However, a caveat of GnRH is that it may cause menopause-like symptoms, although this will cease after stopping the medication.^11,13 Additionally, this medication may make the fibroids shrink to the point that they are harder to find and may be missed.¹⁴ Discussing this with your doctor is the best option before using this medication. Your doctor may consider alternate medications i.e., selective progesterone receptor modulators (SPRMs) which also shrink fibroids.¹⁵

Taking supplements

Your doctor may recommend vitamins and iron supplements to increase your red blood cell count if you suffer from anaemia due to heavy menstrual periods.

Getting ready for surgery 

Food, drink and medicines

In the hours before surgery you won't be able to eat or drink anything, and your doctor should give you instructions about when to start fasting. Make sure to bring all of the prescribed medications, vitamins, supplements and over-the-counter medicines that you may need to the hospital, and if any changes to your usual regime are required this will be explained. 

Prepare for your hospital stay and recovery

The hospital stay is a few days at the most depending on the type of myomectomy performed. Once home it may take up to six weeks before you feel completely recovered. 

Anaesthesia

The type of anaesthesia given depends on the type of surgery you have, and there are a few different types.

Monitored anaesthesia care (MAC) is one option. One benefit is that you are not required to have a tube down your throat and you will feel as if you are completely asleep and won’t remember the procedure. Hysteroscopic myomectomy is less invasive so this method of anaesthesia is usually used.

Another option is general anaesthetic. For this, a tube will be put down your throat but you will be completely asleep. This is used in laparoscopic myomectomy, often in abdominal myomectomy and occasionally in hysteroscopic myomectomy.

Less commonly local anaesthesia or spinal anaesthesia are used.^16,17

Different types of myomectomy

Your surgeon will choose a surgical approach based on the location and size of the fibroids, this approach may be:

Abdominal myomectomy (open myomectomy)

Your uterus will usually be accessed by making a low, horizontal incision across the abdomen, though sometimes a vertical incision is made. This is the best option for removing very big fibroids.

Hysteroscopic myomectomy

In a hysteroscopic myomectomy, fibroids will be removed from your uterus by inserting instruments up through your vagina and cervix. A surgeon may advise this method to treat submucosal fibroids (small fibroids that protrude into your uterus).¹⁸

Either a hysteroscopic morcellator (uses a manual blade) or wire loop resectoscope (uses electricity) is inserted into your uterus through your vagina and cervix to cut the fibroid.^18,19 Fibroids are shaven down using the hysteroscopic morcellator or the resectoscope, amongst other techniques. Sometimes a second surgery is required if large fibroids cannot be fully removed during the first surgery.¹⁹

Robotic and laparoscopic myomectomies

With robotic and laparoscopic myomectomies, your surgeon will create several little incisions in the abdomen and remove fibroids through these. 

With a laparoscopic myomectomy, there are reduced complication rates, a shorter stay in hospital, reduced recovery time, reduced blood loss, and less scar tissue than with a laparotomy.^3,20 However, hospitalisation time, postoperative complications and blood loss were on average the same for laparoscopic myomectomy and robotic myomectomy, though robotic procedures can take longer.²¹

With a laparoscopic myomectomy, a small incision is made near your navel by your surgeon. They then insert a camera on a tube (laparoscope) into your abdomen. Other small incisions will be made in your abdomen so that surgical instruments can access your fibroids to remove them.²²

A robotic myomectomy is performed similarly to a laparoscopic myomectomy, however, a separate console is used to control the movement of the surgical instruments.²¹ Robotic and Laparoscopic myomectomies are also available through one incision (single-port).²³ 

Fibroid removal techniques 

• A fibroid may be removed through a small incision after being cut into smaller chunks (morcellation)²⁴ 
• Sometimes a larger incision is made so fibroids can be removed without cutting them up
• A fibroid may also be removed via a colpotomy (incision in your vagina) though this is uncommon²⁵

After the surgery

Oral pain medication will be available after the surgery. Your doctor may also encourage you to take short walks to avoid blood clots after the procedure, though you may have to wait 6 weeks before returning to your regular activities.

Outcomes

Improved fertility:

Within a year after a laparoscopic myomectomy, people can experience good pregnancy outcomes. However, it's suggested that you wait 3-6 months before trying to get pregnant to allow for adequate healing time. 

Reduced symptoms:

Relief from symptoms like heavy menstrual periods, pelvic pressure, and pain are usually experienced post-surgery.

New or recurrent fibroids

Fibroids may not be detected or removed completely in surgery and may cause symptoms in the future.^1,19 New fibroids can also grow, though this is less likely if you only have one fibroid or if fibroid(s) are small rather than large.

Some alternative and supplementary treatments 

Other than a myomectomy, there are a range of alternative and supplementary treatments such as MRI-guided focused ultrasound surgery (MRgFUS) which uses Magnetic resonance imaging (MRI) to guide a heat source which is used to ablate (wear away) fibroids. Similarly, fibroids can be broken down by utilising radiofrequency energy to create heat and friction; this is called radiofrequency volumetric thermal ablation (RVTA). Finally, uterine artery embolisation (UAE) can be used to limit the blood supply to the uterus via an injection of tiny particles guided by a tube (catheter) into the uterine blood vessel(s).

Summary

• A myomectomy is a surgical procedure to remove fibroids
• It is suitable for people who want to become pregnant in the future
• Myomectomies improve symptoms such as heavy menstrual periods, pelvic pressure and fertility
• There are some risks including excessive blood loss and scar tissue formation
• Hormonal medications and supplements may be advised to reduce the chance of complications
• Recovery can take up to 6 weeks
• There are different types of myomectomy; the type you receive is dependent on the size and location of your fibroids
• Some fibroids may remain or new ones may appear
• There are also a variety of non-surgical options which may be appropriate for you