by Tamer Seckin, MD | Posted on May 20, 2020
If a woman has fibroids but wishes to preserve her fertility, a myomectomy may be the best procedure. Removing these masses can be a difficult process and requires meticulous planning and attention to detail. At the Seckin Endometriosis Center (SEC), we limit your concerns by utilizing several different techniques for removing fibroids, including hysteroscopic and laparoscopic removal. With over three decades of experience in fibroid surgery, we are confident in our standard techniques that have been established for use strictly by laparoscopic surgeons, ensuring almost scarless incisions. We have also developed our bloodless myomectomy procedure using a unique novel tourniquet technique in addition to standard putrescent for our more complex fibroid surgeries. This ensures minimal blood loss and stresses the vast importance of uterine suturing and reconstruction following the fibroid removal in order to preserve the uterus and maintain fertility. While most women are usually offered abdominal myomectomies (which require large incisions), our myomectomy techniques guarantee minimal invasion, a fast healing time, and nearly-scarless results.
A myomectomy, derived from the words myoma (fibroid) and ectomy (to remove), is defined as the removal of fibroids from the uterus. When a woman wishes to preserve the ability to bear children and suffers from fibroids, a myomectomy is a preferred procedure as it preserves the uterus as opposed to a hysterectomy.
Benign fibrous tumors that grow in the muscle layers of the uterus are termed fibroids. Fibroids can also be termed myomas or leiomyoma. It is important to note that it is a common misconception to believe that fibroids are cancerous. They are not. Fibroids, while considered tumors (swollen masses) are benign (non-cancerous) growths that develop in the uterine muscle. They can grow within the wall of the uterus (myometrium), outside the wall of the uterus, and on a stalk. The following classifications of fibroids are made according to their location:
According to US News Health, about 34,000 myomectomies are performed in the U.S. each year . However, 200,000 hysterectomies are performed each year in order to treat fibroids. About ⅓ of hysterectomy cases in the country are performed due to fibroids.
At first glance, it may be alarming to see that hysterectomies are over 5 times more common than myomectomies in the treatment of fibroids. A myomectomy is a more invasive procedure than a hysterectomy. While a myomectomy does preserve the uterus and its function, fibroids most often grow within the muscle of the uterus, and excising out the fibroid through a myomectomy procedure requires uterine repair and healing. It also can require larger incisions to be made, as the fibroid must be removed through the abdomen. A hysterectomy, on the other hand, removes the uterus in its entirety and can be performed more easily through smaller incisions. However, a hysterectomy, while less invasive, should only be performed in cases of fibroid treatment if the fibroids keep reoccurring and the patient is not looking to preserve her fertility. Once the uterus is taken out the patient can no longer bear children.
If a myomectomy takes longer to heal and is more invasive than a hysterectomy, then when is it recommended?
In cases where fertility is no longer an option and fibroids are recurring, a hysterectomy should be considered. Nevertheless, you should always discuss your plans and desired form of surgery with your doctor in order to ensure that you are both comfortable and fully understand the treatment to come.
Because a myomectomy is a procedure to remove fibroids, the symptoms that can warrant the procedure is linked to fibroids. The following symptoms should be considered when a patient is concerned about fibroids:
Before a patient can receive a myomectomy, several preoperative evaluations must be made in order to confirm a presumptive diagnosis of fibroids, as well as to ensure the patient is capable of going through a myomectomy procedure.
There are several different forms of myomectomy procedure, which vary in use based on the size and location of the fibroid itself. All of the following myomectomy procedures are performed in the operating room, under anesthesia.
To lower one’s risk for fibroid regeneration and other more harmful diseases following a myomectomy or hysterectomy procedure, patients are often prescribed hormone replacement therapy. These hormone therapies can vary depending on the type of procedure that was conducted.
It is crucial to note that not all patients have the same medical history and thus, hormone replacement therapy is not for everyone. Women should be highly informed by their surgeons of the risks and benefits of such precautionary measures so that they can agree on a treatment that is right for their particular case.
Myomectomies have a low rate of complication, especially in the hands of a skilled surgeon. However, like any procedure, there are risks to be mindful of, which include:
A myomectomy is primarily performed to preserve the uterus so it can bear a child during pregnancy. A myomectomy can also increase a woman’s fertility because they removed fibroids could have been preventing the patient from getting pregnant as fibroids can block the path of a sperm cell through the cervix, uterus, or fallopian tubes. Finally, the type of fibroid could have played a role in the severity of the patient’s infertility. For example, while intramural and cervical fibroids can make it difficult to conceive a child, submucosal fibroids have been linked to both complications of conceiving children and miscarriages. A myomectomy is thus a highly useful technique used in treating these cases of infertility, as it not only removes the fibroid(s) but also looks to repair and restore uterine function.
Understanding the procedure itself, including the type of myomectomy that will be performed, will help you familiarize yourself with what to expect the day of surgery. Make sure you understand what you consent to before signing. Asking the right questions will provide the right answers. Based on your symptoms and preoperative diagnostic tests such as hysteroscopy, sonohysterography, and more, your surgeon should be able to give you a presumptive estimate as to where your fibroid is located, and in turn, the technique that will be used to remove it. While a hysteroscopy and hysteroscopic myomectomy can be part of any myomectomy procedure, the location of your fibroids can lead to different techniques being performed on the day of your surgery. Nevertheless, you must also be aware that this is a presumptive diagnosis and thus every fibroid surgery, whether it is hysteroscopically or laparoscopically performed, may be complicated. This can mean a higher number of fibroids than expected, or larger fibroids, more blood loss, etc. For these reasons, it is important to be well informed and ready for your surgery. Below are a few ways you be as prepared as possible:
|Hysteroscopic myomectomy||Laparoscopically-assisted myomectomy (vaginal route)||Laparoscopically-assisted myomectomy (abdominal route)||Robotic myomectomy||Open myomectomy|
|Number of incisions||0 incisions||2-3 incisions||4 incisions||5 incisions (2.5cm)||1 large incision|
|Size of incisions||No incisions||1.5-2.5cm (abdominal) incisions||3 small (1cm) and 1 large (>5cm) incisions||3 small (7mm) and 2 large (2.5cm) incisions||5-20cm incisions|
|Length of procedure||<1 hr||1-3 hrs||1-3hrs||2-4 hours||Less than 3 hours (depends on a number of fibroids)|
|Hospital stay||Same day release||0-1 days||1-3 days||1-2 days||3 days|
|Recovery time||None||Less than a week||2-4 weeks||2-4 weeks||6-8 weeks|
As noted above, the type of myomectomy surgery you undergo will affect your recovery time and any following symptoms. For example, following a hysteroscopic myomectomy, there will be some degree of spotting or a short period. After laparoscopic myomectomy, on the other hand, there will be some discomfort and pain immediately following surgery, which should resolve over the next few hours. This pain can be controlled using non-steroid anti-inflammatory drugs (NSAID) and more powerful pain relievers such as Percocet or hydromorphone. However, we do not like to give narcotic oral medication more than one or two days following surgery due to the drug dependency that this medication causes. It can also slow down the GI tract, causing constipation and bladder dysfunction.
Below are other things to be mindful of following your myomectomy surgery:
We have spent over two decades meticulously perfecting our myomectomy technique, which is catered specifically to your case and depends on the type of fibroid that needs to be removed. Our methods to remove fibroids, depending on their specific classification, include:
Morcellation is a common technique that surgeons use to remove fibroids. A round knife is used to cut the fibroid piece by piece, which is then removed separately. This method is known to cause blood spillage and other contents, such as leftover fibroid pieces. In fact, recent research studies have shown that when fragments of the myoma are left behind the following morcellation, they can seed and grow (termed parasitic myomas) [Paul, P. G., 2006]. To avoid this, we have taken great care to master and improve our bloodless myomectomy technique. We also use copious irrigation and an underwater examination following any myomectomy procedure in order to check for any oozing from the bed of tissue where the fibroid was removed. With these measures, we are able to ensure our patients that blood spillage and leftover fibrous content is not a cause for concern.
While we are trained in the use of robotic surgery, we generally stay away from robotic procedures, especially with myomectomies. One of our major goals in any myomectomy procedure is to limit the amount of blood spillage. With over two decades of experience in removing fibroids, we have ensured that our bloodless myomectomy technique does exactly this. It is a procedure that requires meticulous execution in order to be performed properly. For these reasons, we prefer to have the procedure in our own hands as opposed to operating through robotics. Though robotics can have some benefits, it does not replace the skills developed by a surgeon who has decades of practice and experience.
A myomectomy is a highly personal surgery, especially in cases where the fibroids are located deep within the uterine muscle wall. For this reason, it is crucial to find a surgeon who will treat you with the personalized care and patience that you deserve. Your surgeon should feel comfortable answering any questions you may have, as well as detailing every option you have for treatment. At the Seckin Endometriosis Center, we pride ourselves on keeping our patients informed so they can decide if a myomectomy is a right choice for their particular case.
Tracee M was diagnosed with uterine fibroids in 2010. Five years later, she was referred to the Seckin Endometriosis Center, where she underwent a bloodless myomectomy procedure. Read about Tracee’s story here and how her symptoms have since been resolved.
You can read more stories of patients who received myomectomies, at varying stages, in our testimonial section.
Medically reviewed by Tamer Seckin, MD on May 20, 2020
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