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Myomectomy
Definition : Myomectomy is the removal of fibroids (non-cancerous 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 by laparoscopy or hysteroscopy.
Purpose
A myomectomy can remove uterine fibroids that are causing such symptoms as abnormal bleeding or pain. 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.
Demographics
Uterine fibroids are more common among African- American women than among women of other ethnicities. Fibroids affect 20–40% of all women over the age of 35, and 50% of African-American women. A 2001 study by the National Institute of Environmental Health Sciences found that the incidence of fibroids among African-American women in their late 40s was as high as 80%, while approximately 70% of white women of that age were diagnosed as having fibroids. Women who are obese, are older, or started menstruating at an early age are also at an increased risk of developing uterine fibroids. Another study published in 2003 indicated that women with less education were more likely to have a hysterectomy performed to treat fibroids, instead of a less-invasive procedure such as myomectomy.
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 removed, 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. The surgeon then sutures the abdominal wall and muscle layers above it with absorbable stitches, and closes the skin with clips or non-absorbable 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 4–5 in (10–13 cm) 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.
Diagnosis / 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 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 usually recover completely within 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
• weakening of the uterine wall to the degree that future deliveries need to be performed via cesarean section
• adverse reactions to anesthesia
• internal scarring (and possible infertility)
• reappearance of new fibroids
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 (autologous blood donation).
Normal results
Removal of uterine fibroids will usually improve any side effects that the patient may have been suffering from, including abnormal bleeding and pain. Under normal circumstances, a woman who has had a myomectomy will be able to become pregnant, although she may have to deliver via cesarean section if the uterine wall has been weakened.
Morbidity and mortality rates
Depending on the surgical approach, the rate of complications for myomectomy is about the same as those for hysterectomy (anywhere between 3% and 9%). The rate of fibroid reoccurrence is approximately 15%. Adhesions (bands of scar tissue between organs that can form after surgery or trauma) occur in 15–53% of women postoperatively.
Alternatives
Hysterectomy (partial or full removal of the uterus) is a common alternative to myomectomy. The most frequent reason for hysterectomy in the United States is to remove fibroid tumors, accounting for 30% of all hysterectomies. A subtotal (or partial) hysterectomy is the preferable procedure because it removes the least amount of tissue (i.e., the opening to the cervix is left in place). Fibroid embolization is a relatively new, less-invasive procedure in which blood vessels that feed the fibroids are blocked, causing the growths to shrink. The blood vessels are accessed via a catheter inserted into the femoral artery (in the upper thigh) and injected with tiny particles that block the flow of blood. The fibroids subsequently decrease in size and the patient’s symptoms improve.
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