MYOMECTOMY

MYOMECTOMY OVERVIEW

Fibroids are benign ‘growths’ within the uterus/womb. They are also called uterine leiomyomas or myomas. Most fibroids do not cause problems and treatment is not required. However, occasionally they may be responsible for troublesome symptoms (see section on UTERINE FIBROIDS).

Myomectomy is the surgical removal of fibroids from the uterus, leaving the uterus in place.

• The decision to surgically remove fibroids is usually based on several factors such as patient symptoms and the desire to retain fertility. In many cases attempts at more conservative management options have been unsuccessful.

Uterine fibroids

Myomectomy can be performed using different approaches:

• abdominal (laparotomy/open myomectomy),
• laparoscopic (‘key-hole’),
• hysteroscopic (telescope inserted into the womb through the vagina).

Fibroid location, number and size are important considerations when determining which surgical approach to use. In addition, the surgeon’s skills and experience as well as patient preference will influence decision-making.

1) Abdominal (open) myomectomy was developed in the early 1900s as a conservative treatment for women with uterine fibroids i.e. for women who did not wish to have a hysterectomy.

• It is performed mostly for women with intramural or subserosal fibroids (see diagram). Submucosal fibroids may also be removed during abdominal myomectomy but usually these are managed using the hysteroscopic approach.
• An incision in the abdomen (laparotomy) is required for the abdominal approach. The length of the incision will depend on the size and location of the fibroid(s).
• Occasionally, pre-surgical treatment with a medication (injection) to shrink the fibroid(s) may be recommended.

With any major surgery requiring a laparotomy, there are risks and potential complications:

• Postoperative infection – approximately 10% of cases. These aren’t usually serious and most respond to a simple course of antibiotics.
• Blood clots in the veins of the legs and/or chest (‘venous thrombo-embolism’) – approximately 0.5-1% of cases. Early mobilisation helps to prevent blood clots. Some women with specific risk factors for blood clots may be advised to take blood-thinning injections postoperatively.
• Injuries to structures such as the bladder, bowel and ureters (tubes that connect the kidneys to the bladder – 0.1-2% of cases. Certain conditions, such as adhesions (scar tissue) where organs are adherent to each other, increase the risk of injury.
• Bleeding – all major surgery carries a risk of haemorrhage. Haemorrhage is more likely if the fibroids are large and multiple. A blood transfusion may be necessary in some cases but this is relatively uncommon.

2) Laparoscopic myomectomy is similar in many respects to a traditional abdominal/open myomectomy. The key difference is that minimally invasive (‘key-hole’) techniques are employed with all the benefits of laparoscopic surgery (see section on LAPAROSCOPY).

• Laparoscopic myomectomy requires advanced training in laparoscopic surgery.
• Once separated from the uterus, removal of the fibroid(s) from the abdominal/pelvic cavity can be challenging owing to the small skin incisions used in laparoscopic surgery.
  • Fibroid removal can be achieved using a ‘Power Morcellator’ (a surgical tool used to cut bigger chunks of tissue into smaller ones).
  • However, this device has come under scrutiny owing to the small risk of spreading an undiagnosed rare uterine cancer called a leiomyosarcoma – see link for further information: https://www.bsge.org.uk/news/bsge-statement-power-morcellation/

3) Hysteroscopic myomectomy (also known as Transcervical resection of fibroids or TCRF)

This approach utilises a minimally invasive technique called hysteroscopy (see section on HYSTEROSCOPY) to remove submucosal/intracavitary fibroids (see diagram).

• Fibroids should be less than 5cm in size.
• A device called a resectoscope is used to visualise and cut the fibroid into small strips to allow removal.
• It is the procedure of choice for suitably trained gynaecologists.
• Occasionally, pre-surgical treatment with a medication (injection) to shrink the fibroid(s) may be recommended.