In cases of fibroids in which a woman wishes to preserve her fertility, a myomectomy may be the best procedure. However, it is not that simple. Cutting into the uterine tissue in order to remove these masses can be a difficult process, which requires meticulous planning and attention to detail. Here 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 to use strictly for laparoscopic surgeons, ensuring almost scarless incisions. We have also developed our bloodless myomectomy procedure, with 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.
What is a myomectomy?
A myomectomy, derived from the words myoma (fibroid) and ectomy (to remove), is simply 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 the preferred procedure as it preserves the uterus as opposed to a hysterectomy.
What are fibroids and where do they grow in the uterus?
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, on a stalk and more. The following classifications of fibroids are made, based off of where they are located:
Intramural fibroids: fibroids located in the thick wall of the uterus (myometrium).
Subserosal fibroids: fibroids located outside the wall of the uterus.
Submucosal fibroids: fibroids located beneath the lining of the uterus (endometrium).
Intracavity fibroids: fibroids located within the uterine cavity.
Cervical fibroids: fibroids located in the cervix, the neck of the uterus.
Pedunculated fibroids: fibroids located on a stalk that grows into the uterus or outside the uterine wall
To read more about fibroids and how they are classified, Click Here.
How common is it for a myomectomy to be performed in the US?
According to US News Health, about 34,000 myomectomies are performed on women in the U.S. each year . However. even more commonly, 200,000 hysterectomies are performed each year in order to treat fibroids. This makes up about ⅓ of hysterectomy cases within the country.
At first glance, it may be alarming to see that hysterectomies are over 5 times more common than myomectomies in the treatment of fibroids. The reasoning for this is that 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. Thus 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, as once the uterus is taken out she can no longer bear children.
When is a myomectomy recommended?
This begs the question: If a myomectomy takes longer to heal and is more invasive than a hysterectomy, then when is it recommended?
Preserve fertility: The primary reason a myomectomy is performed is to preserve a patient's fertility. By removing fibroids that are preventing the uterus from carrying a child, a patient is able to preserve their uterus for pregnancy. Submucosal and intramural fibroids are perhaps some of the most common forms of fibroids that are removed when it comes to overcoming infertility. Intramural fibroids often make it very difficult to for a patient to conceive a child, while submucosal fibroids not only make conception challenging but can also increase a patient’s chances of miscarriage. Therefore by performing a myomectomy, these fibroids can be removed while preserving the uterus in order to increase one’s chances of fertility.
Singular fibroids: A myomectomy is more commonly advised in cases of singular fibroids. Whenever a fibroid is removed from the uterine muscle, it requires meticulous uterine repair and healing time. However, a single fibroid requires less repair and healing time as compared to if multiple fibroids are removed.This is why in cases of multiple fibroids a hysterectomy can be an option.
Easily removable location: While most fibroids are located within the muscle of the uterus, there are a few times when the benign mass is on a stalk, termed pedunculated. In these cases, it is much easier to remove the fibroid via a myomectomy procedure, while at the same time requiring minimal uterine repair.
A pedunculated fibroid on a stalk is much more easy to remove compared to a submucosal fibroid buried within the muscular wall of the uterus.
Remember, 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.
A singular fibroid removed following a myomectomy procedure.
Different classifications of myomectomy?
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.
Hysteroscopic myomectomy: A hysteroscopic myomectomy uses a narrow telescope-like instrument (hysteroscope) that is inserted into the vagina and passed through the cervix to visualize the uterine cavity. Using just this technique, some experienced surgeons can remove small, superficial fibroids vaginally.
Laparoscopically-assisted myomectomy: This technique is the same as a hysteroscopic myomectomy, however, a laparoscope is also inserted into the abdomen to ensure the fibroid or the surgery does not extend into the uterine wall. Therefore, fibroids that already extend into the uterine wall or are exposed outside the uterine cavity, will require laparoscopy.
Robotic-assisted laparoscopic myomectomy: While the same concept as a laparoscopically assisted myomectomy, this procedure uses robotics as some feel it allows capabilities that are advantageous to surgery. However, it is important to note that the skill of your surgeon is much more important as to whether or not robotics is used. Remember, just by having a robot does not make up for the expertise of a highly skilled surgeon.
Open abdominal myomectomy: Also referred to as a laparotomy, this procedure makes one large horizontal (“bikini line”) or vertical incision into the abdomen. This gives the surgeon direct access to the uterus but requires the largest incision to be made in comparison to other myomectomy techniques, thus requiring a longer time to heal and more scarring. Some surgeons may feel this is technique is needed when fibroids are abnormally large.
Why is hormone therapy used after a myomectomy surgery?
To lower one’s risk for fibroid regeneration and other more harmful diseases following a myomectomy or hysterectomy procedure, patients are often prescribed hormonal replacement therapy. These hormone therapies can vary depending on the type of procedure that was conducted.
Combination Therapy for Myomectomy: Following a myomectomy, a woman will retain her uterus, which has been repaired to preserve uterine function. In these cases, it has been proven through research studies that a combination hormone therapy is key in reducing the risk of uterine cancer. This is because if the uterus is retained and the patient is prescribed just an estrogen-only therapy, then they are at grave risk for abnormal growth in the endometrium. However, by giving a combination hormone therapy, the effects of estrogen-induced uterine tissue growth is controlled by the hormone progesterone, thus reducing the risk of uterine cancer.
Monotherapy for Hysterectomy: If a woman’s uterus is removed then it is highly advised for the patient to take a low-dose estrogen-only therapy. This can help reduce menopause symptoms, while at the same time reducing a patient’s risk of blood clots or stroke.
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 upon a treatment that is right for their particular case.
Symptoms to be of concerned of that could warrant a myomectomy?
Because a myomectomy is a procedure to remove fibroids, the symptoms that can warrant the procedure are linked to fibroids. Therefore the following symptoms should all be considered when a patient is concerned about having fibroids:
Heavy and prolonged menstrual bleeding (menorrhagia), which can include clots
Feeling of pressure in the pelvis, which can cause abdominal pain, back pain and bladder and/or bowel dysfunction
Dyspareunia (pain during intercourse). This is common in cervical fibroids
Deep thigh aches with varicose veins
No symptoms at all, which is reported in 75% of women diagnosed. Differences in symptoms may be due to varying size and location of the fibromas themselves
What diagnostic tests must be done before a myomectomy is conducted?
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.
Labs: Lab work before a myomectomy procedure is needed in order to obtain a patient’s complete blood count (CBC). This is highly important as a myomectomy involves cutting into and then reconstructing and restoring the uterus. While the best surgeons will ensure minimal blood loss, this type of procedure will nevertheless lead to some blood loss in comparison to a hysterectomy. Therefore it is crucial to check a patient’s blood count before conducting a myomectomy.
Endovaginal ultrasound: Imaging tests are often highly useful in providing a presumptive diagnosis, especially when it comes to fibroids. An endovaginal and abdominal sonogram can be used to determine the size, number and location of fibroids within the uterus. This will give your surgeon an understanding whether or not a hysteroscopic versus laparoscopic myomectomy procedure is needed.
MRI: Magnetic resonance imaging produces a much more detailed picture of the body in comparison to an ultrasound. It can distinguish leiomyomas from other intramural lesions. However usually an ultrasound will suffice, which is beneficial for the patient as it can be done in an office setting and is far less expensive.
Frequently Asked Questions
How can a myomectomy be a treatment for infertility cases?
A myomectomy is primarily performed in order to preserve the uterus so that it can bear a child during pregnancy. Another reason why a myomectomy can increase a woman’s fertility is that the fibroids removed can also be preventing the patient from getting pregnant in the first place, leading to issues in conceiving the child itself. This can occur through fibroids blocking the path of a sperm cell such as through the cervix, uterus or fallopian tubes. Finally, the type of fibroid that develops can actually play 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 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.
What to expect on the day of your myomectomy?
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. For the patient, this truly is the most important part of your process during your preoperative course. Remember, asking the right questions will bring the right answers. Based on your symptoms and preoperative diagnostic tests such as a 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 more than expected number of fibroids, larger fibroids, more blood loss, etc. For these reasons it is important to be well informed and ready for your surgery, and here are a few ways in which you can do so:
Sleep: As said above, it is important to be well informed and ask any questions you may have leading up to your surgery. For this reason, it is important to get enough sleep the day before your surgery. Being well rested will not only make you alert and ready prior to your surgery, but it should also make the healing process following right after the surgery much more bearable. Remember, being well rested can never hurt.
Bowel prep: The night prior to your surgery, it is highly advised to have a light meal. It is common for a surgeon to have their patients conduct bowel preparation, which entails making sure to mechanically empty the bowels the night before surgery as well as not ingesting any food or drink starting at midnight the day of your surgery.
Blood bank: This is one aspect very unique to a myomectomy procedure, especially in the case of intramural fibroids. Because the uterus will be cut into and reconstructed, bleeding will inevitable, despite the efforts of your surgeon to reduce the amount of blood spilled. Therefore it is advised to have a blood bank as a backup in case there is an excessive amount of blood loss in surgery. While this is very rare, it is a highly valid discussion to have with your surgeon in order to gain an understanding of how much blood loss they are expecting in your particular case.
Report daily meds: When you check into the operating room and before the surgery itself, you will be introduced to the entire surgical team, which includes your surgeon, anesthesiologist and the rest of the team. It is important to tell them all the daily medications that you may be on, such as beta blockers, aspirin, coumadin, blood thinners, antidepressants, etc.
Depending on the type of myomectomy, how will this affect the day of surgery?
What to expect the following days after your myomectomy?
As noted above, the type of myomectomy surgery you undergo will affect your recovery time and any symptoms felt after. For example, following a hysteroscopic myomectomy there will be some degree of spotting or a short period, whereas, after a laparoscopic myomectomy, 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 tendency of drug dependency when this type of medication is prescribed. 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:
Diet: We advise light meals, such as soup for the first day following your surgery. Patients should stay away from both high protein products (meat, eggs, etc) and dairy (milk, cheese, etc) until they begin passing gas and bowel movements naturally. Once this occurs, patients can generally go back to their normal diets.
Ambulate: Following any surgery, it is crucial to get up and walk as early as possible. Patients that are able to do this later in the day, following their surgery, often find that they have a much easier time recovering and resuming their normal day to day activities.
Showering: Patients are only allowed to shower after 24 hours following their surgery. This is to ensure that their wounds are given the proper time to heal naturally and lowest chance of becoming undone.
Return: If patients experienced continue surgical complication symptoms, such as continuously passing gas, painful bowel movements, etc. then they are advised to return to the hospital in which they were operated on. It is highly recommended that patients go there versus a general emergency room, as only the team that operated on you, will have the best understanding of your case. You do not want other physicians misdiagnosing your case, or worse, rushing into another surgery that could be unnecessary.
What are the risks of myomectomy surgery?
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:
Excessive blood loss: Perhaps the biggest risk to be mindful of before a myomectomy is conducted, is the potential for blood loss. This is especially relevant in cases of intramural fibroids, in which the fibroid is buried within the muscular layer of the uterus. Thus during a myomectomy, this tissue will need to be cut into and will in turn bleed. It is normal for some bleeding to occur in such procedures, but it also raises the possible risk for excessive bleeding. Therefore it is wise to ask your surgeon how they will ensure that this blood loss will be minimal.
Pregnancy complications: During pregnancy, the uterus must be able to stretch and expand as the fetus grows. For these reasons, a doctor may recommend a c-section for a patient who has had a myomectomy, due to the fear of rupturing of the uterus and the undoing of the reconstructive work that was done following the removal of fibroids. This, however, is a highly rare complication. Fibroids themselves can also be associated with pregnancy complications.
Left-behind scar tissue: Adhesion development is always a cause for concern whenever there is surgical removal of tissue. These bands of scar tissue can develop in a number of places from the inside uterus to the outside, which brings the possible chance of blocking the fallopian tubes and thus leading to pregnancy complications. Development within the uterus is much rarer, but it can cause such symptoms as light menstrual periods and difficulties with fertility.
What surgical techniques do we use to remove fibroids?
We have spent over two decades meticulously perfecting our myomectomy technique, which is catered specifically to your case, depending on the type of fibroid that needs to be removed. Below are the ways in which we removed fibroids, depending on their specific classification:
Intracavitary and submucosal fibroids (hysteroscopic myomectomy): These fibroids which are located within the uterine cavity and below the surface of the uterine lining can both be removed hysteroscopically. While most surgeons removed these fibroids laparoscopically, we have gained the experience and expertise to perform this technique through the vagina and out of the cervix, which is termed a hysteroscopic myomectomy. By removing these fibroids vaginally, we eliminate the need to make large incisions in the abdomen, ensuring the patient has minimal scarring. We can perform this technique whether there is just a single fibroid or multiple ones.
Intramural and subserosal fibroids (laparoscopic myomectomy): Unlike intracavity and submucosal fibroids, these masses must be removed with the assistance of laparoscopy. We have great experience in handling large fibroids, having removed fibroids causing the uterus to enlarge to a size equivalent to that of a 22-week pregnancy. Even for laparoscopic myomectomies, we have catered our technique to optimally fit each classification of fibroids.
Pedunculated subserosal fibroids (bead string and culdotomy technique): When fibroids grow on these stalks, it makes it much easier for us to remove them without causing any harm to the uterus. This procedure is done with a loop electrode or single trocar stitch. While it is most common to remove these fibroids through incisions in the abdomen, which surgeons call a "mini-laparotomy," our preferred method has no large incisions abdominally. By making a small culdotomy incision (vaginal incision), we are able to remove the fibroid vaginally through a natural orifice. This is done by using what we call the beading technique, in which we line fibroids in a bead string, cut it at the base of the stalk, put it in a surgical bag and then pull it out with an instrument, shaped like a fish hook. Using this method, fibroids that are up to 8-9cm can be removed without any large incisions to the abdomen.
Intramural fibroids (bloodless myomectomy): Because these fibroids are buried in the muscular layer of the uterus, they are perhaps the most challenging fibroids to remove. They thus require a truly specialized myomectomy procedure (involve a cut on the uterus), as these fibroids can grow to be the size of a football at times. Our unique method of removing these fibroids is through what we call a "bloodless myomectomy." Using this procedure, we are able to remove the intramural fibroid, while ensuring minimal blood loss and uterine repair and preservation.This technique requires three steps:
Step 1 "Tourniquet Technique": In this step, the blood supply is temporarily cut off from the fibroid, just like a nurse wraps a rubber band around your arm when you have blood drawn. This blocks the arterial blood flow to the uterus, ensuring minimal blood spillage during the procedure. Injecting diluted Pitressin (8-Arginine vasopressin) intramuscularly also prevents uterine bleeding. This combination of the tourniquet technique plus diluted Pitressin allows for minimal bleeding as we cut through the muscle of the uterus in order to remove the fibroid buried within it. The “tourniquet technique” uses a tourniquet, a device that stops blood flow, to ensure there is minimal blood spillage during a myomectomy procedure.
Step 2 Enucleation: The second step of the bloodless myomectomy procedure is enucleation of the fibroid. This is the removal of the fibroid, without cutting into the mass or dissecting it in order to ensure no smaller pieces get left in the body. The fibroid is instead removed in its entirety and then collected in what is called an “endo-bag.”
Step 3 Uterine Repair: Finally once the fibroid has been removed, suturing and reconstruction of the uterus is needed in order to preserve uterine function.
Reconstructing the uterus is required in any procedure that cuts into the uterus, such as intramural fibroids. By seamlessly suturing the uterine wall, we are to conserve uterine function.
Why do we not use morcellation in fibroid removal?
Morcellation is a common technique that surgeons use to remove fibroids. It uses a round knife in order to cut the fibroid piece by piece, which is then all removed separately. This method is known to cause the spillage of blood and other contents, such as leftover fibroid pieces. In fact, recent research studies have shown that when fragments of the myoma are left behind following morcellation, they can seed and grow, termed parasitic myomas [Paul, P. G., 2006] This is why we have taken great care to master and improve our bloodless myomectomy technique. On top of this, we also use copious irrigation and an underwater examination following any myomectomy procedure, in order to check if there is any oozing from the bed of the tissue from where the fibroid was removed. Using all these measures, we are able to ensure our patients that this issue of blood spillage and leftover fibrous content is not a cause for their concern.
Why do we not use robotics in our myomectomy procedures?
While we are trained in the use of robotic surgery, we generally stray away from robotic procedures, especially when it comes to a myomectomy. As noted before, 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 worked tirelessly to make our bloodless myomectomy technique do 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 wherein 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, on top of going through all options that are choices in your particular case. Here at the Seckin Endometriosis Center, we pride ourselves on keeping our patients informed so that they can decide if such procedures as a myomectomy, us the 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.