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.
What is a myomectomy?
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 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, and on a stalk. The following classifications of fibroids are made according to their location:
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 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.
Why is a hysterectomy more common than a myomectomy?
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.
When is a myomectomy recommended?
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. By performing a myomectomy, these fibroids can be removed while preserving the uterus in order to increase a patient'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 than 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 rare cases where the benign mass is on a stalk (pedunculated). In these cases, it is much easier to remove the fibroid via a myomectomy procedure, requiring minimal uterine repair.
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.
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 similar in concept to a laparoscopically assisted myomectomy, this procedure uses robotics. However, it is important to note that the skill of your surgeon is much more important than whether robotics are used.
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 believe this 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 patient retains her uterus, which has been repaired to preserve uterine function. In these cases, it has been proven through research that a combination hormone therapy is key in reducing the risk of uterine cancer. If the uterus is retained and the patient is prescribed just an estrogen-only therapy, they are at grave risk for an 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 patient’s uterus is removed then it is highly advised that the patient 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 on a treatment that is right for their particular case.
Symptoms 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. The following symptoms should be considered when a patient is concerned about 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
Urinary incontinence or leakage
Difficulty emptying bladder
Deficiency of blood cells (anemia)
Dyspareunia (pain during intercourse), which 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 of whether a hysteroscopic or 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, an ultrasound alone will usually suffice, and it can be performed in an office setting and is far less expensive.
Frequently Asked Questions
How can a myomectomy treat infertility cases?
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 the 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.
What can I expect on the day of my 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. Asking the right questions will provide 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 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:
Sleep: 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 prior to your surgery, but it should also make the healing process following surgery much more bearable.
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 mechanically emptying 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 very unique to a myomectomy procedure, especially in the case of intramural fibroids. Because your surgeon will cut into and reconstruct the uterus, bleeding will be inevitable, despite your surgeon's efforts 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 pre-surgery, you will be introduced to the entire surgical team, which includes your surgeon and anesthesiologist, among others. It is important to inform them of the daily medications you may be on, such as beta blockers, aspirin, coumadin, blood thinners, antidepressants, etc.
How will each type of myomectomy affect my day of surgery?
What can I expect the days following my myomectomy?
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 a 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:
Diet: We advise light meals, such as soup or juices, 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 who are able to walk as soon as possible, ideally the same day of their surgery, often find they have a much easier time recovering and resuming their normal activities.
Showering: Patients are only allowed to shower 24 hours after their surgery. This is to ensure that their incisions are given the proper time to heal naturally and the lowest chance of becoming undone.
Return: If patients experience surgical complication symptoms, such as continuously passing gas, painful bowel movements, etc., then they are advised to return to the hospital. It is highly recommended that patients go to the same hospital where they had sugery 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 aware of before a myomectomy is conducted is the potential for blood loss. This is especially relevant in cases of intramural fibroids, where the fibroid is buried within the muscular layer of the uterus. 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 of excessive bleeding. It is wise to ask your surgeon how they will ensure that this blood loss is 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 risk of rupturing of the uterus and undoing the reconstructive work completed after fibroid removal. This 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. Scar tissue outside the uterus can block the fallopian tubes and lead to pregnancy complications. Scar tissue within the uterus is much more rare, but it can cause symptoms such 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 and depends on the type of fibroid that needs to be removed. Our methods to remove fibroids, depending on their specific classification, include:
Intracavitary and submucosal fibroids (hysteroscopic myomectomy): These fibroids, located within the uterine cavity and below the surface of the uterine lining, can be removed hysteroscopically. While most surgeons remove 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 and ensure that the patient has minimal scarring. We can perform this technique regardless of whether the patient has a single fibroid or multiple fibroids.
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, they are easy to remove 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 them at the base of the stalk, put them in a surgical bag, and then pull the bag 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 require a truly specialized myomectomy procedure which involves a cut on the uterus, as these fibroids can grow to be the size of a football. 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, similar to the way a nurse may wrap 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 a bloodless myomectomy procedure is the enucleation of the fibroid. This is the removal of the fibroid where the mass is neither cut nor dissected in order to ensure that no smaller pieces are 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: Once the fibroid has been removed, it is necessary to suture and reconstruct the uterus in order to preserve uterine function.
Why do we not use morcellation in fibroid removal?
Morcellation is a common technique that surgeons use to remove fibroids. A round knife is used to cut the fibroid piece by piece, which are 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 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.
Why do we not use robotics in our myomectomy procedures?
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 the right choice for their particular case.
Our office is located on 872 Fifth Avenue New York, NY 10065. You may call us at (646) 960-3080 or have your case reviewed by clicking here.
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.
Dr.Seckin is so much more than a surgeon. His passion for helping endometriosis sufferers and determination to improve the quality of life in all of his patients is undeniable. I remember when my gynecologist first told me I needed a laparoscopy. Her exact words were "I can do the surgery, but if you were MY daughter- I'd send you to…
I was there for hysterectomy but then I found out that I also had endometriosis.My both surgeries went excellent and I feel great!.I am so thankful to Dr.Seckin and all his team for making my journey smooth!
I am a physician who suffered from deep infiltrative endometriosis. I needed laparoscopic surgery, so I went to see my former gynaecologist and he performed the procedure (a surgery which he supposedly does hundreds of times a year) last November. I had severe pain again when I had my period in January and was advised to go on taking a…
After years of excessively painful periods, a serious loss of quality of life, and a series of uninformed and uninterested doctors, Dr. Seckin and Dr. Goldstein turned my life around. I was told I woke up from my surgery almost a year ago with a smile on my face, and I haven't stopped since. Before I heard of Dr. Seckin,…
Dr Seckin and his team gave me back my life! Tomorrow will be 1 month since my surgery and I feel great. Dr. Seckin, Dr Liu, and Dr Goldstein are not only beyond words talented and amazing Doctors, but they are also genuinely wonderful and caring people. I cannot say enough great things about Holly, Asiye and Kim as well.…
Dr. Seckin and his staff spared me from years and years of heavy periods and unbearable endometriosis pain. After having surgery with him (my first) I can now function like a regular human. No more eating NSAIDs like candy and calling out sick from work. Thank you, Dr. Seckin!