Uterine myomectomy

Uterine myomectomy
Intervention
A laparoscopic myomectomy: The uterus has been incised and the myoma is held and about to be shelled out
ICD-9-CM	68.29

Myomectomy, sometimes also fibroidectomy, refers to the surgical removal of uterine leiomyomas, also known as fibroids. In contrast to a hysterectomy the uterus remains preserved and the woman retains her reproductive potential.

Indications

The presence of a fibroid does not mean that it needs to be removed. Removal is called for when the fibroid causes pain or pressure, abnormal bleeding, or interferes with reproduction.

Patients have many options in the management of uterine fibroids, including: observation, medical therapy (such a GNRH agonists), hysterectomy, uterine artery embolization, and high-intensity focused ultrasound ablation. Despite these many options, the surgical approach of selected fibroid removal remains an important choice for those women who want or need to preserve the uterus for reproduction.

Procedure

A myomectomy can be performed in a number of ways, depending on the location and number of lesions and the experience and preference of the surgeon.

Laparotomy

Traditionally a myomectomy is performed via a laparotomy with a full abdominal incision, either vertically or horizontally. Once the peritoneal cavity is opened, the uterus is incised, and the lesion(s) removed. The open approach is often preferred for larger lesions. One or more incisions may be set into the uterine muscle and are repaired once the fibroid has been removed. Recovery after surgery takes four to six weeks.

Laparoscopy

Using the laparoscopic approach the uterus is visualized and its fibroids located and removed. Morcellators are available to shred larger fibroids so that they can be removed through the small portholes of laparoscopy..^[1] Studies have suggested that laparoscopic myomectomy leads to lower morbidity rates and faster recovery than does laparotomic myomectomy.^[2] As with hysteroscopic myomectomy, laparoscopic myomectomy is not generally used on very large fibroids. A study of laparoscopic myomectomies conducted between January 1990 and October 1998 examined 106 cases of laparoscopic myomectomy, in which the fibroids were intramural or subserous and ranged in size from 3 to 10 cm.^[3]

Robotic surgery

Using the da Vinci Surgical System a limited numbers of myomectomies have been performed.It has not been proven that results are superior to laparoscopy.^[4]

Hysteroscopy

A fibroid that is located in a submucous position (that is, protruding into the endometrial cavity) may be accessible to hysteroscopic removal. This may apply primarily to smaller lesions as pointed out by a large study that collected results from 235 patients suffering from submucous myomas who were treated with hysteroscopic myomectomies; in none of these cases was the fibroid greater than 5 cm.^[5] However, also larger lesion have been treated by hysteroscopy.^[6] Recovery after hysteroscopic surgery is but a few days.

Complications and risks

Complications of the surgery include the possibility of significant blood loss leading to a blood transfusion, the risk of adhesion or scar formation around the uterus or within its cavity, and the possible need later to deliver via cesarean section.^[7]

It may not be possible to remove all lesions, nor will the operation prevent new lesions from growing. Development of new fibroids will be seen in 42-55% of patients undergoing a myomectomy.^[8]

There is some suggestion that myomectomy surgery is associated with a higher risk of uterine rupture in later pregnancy.^[9]

Myomectomy during pregnancy

Leiomyomata tend to grow during pregnancy but rarely interfere with the growing pregnancy directly. Generally, surgeons tend to stay away from operative interventions during the pregnancy because of the risk of haemorrhage and the concern that the pregnancy may be interrupted. Also, after a pregnancy, myomas tend to shrink naturally. However, in selected cases myomectomy may become necessary during pregnancy, or also at the time of a caesarean section to gain access to the baby.^[10]

References

1. ^ Walid MS, Heaton RL (2009). "Laparoscopic myomectomy: an intent-to-treat study". Arch Gynecol Obstet 281 (4): 645–9. doi:10.1007/s00404-009-1154-5. PMID 19536553. 
2. ^ Agdi, M. and Tulandi, T. “Endoscopic management of uterine fibroids.” Best Practice & Research Clinical Obstetrics & Gynecology, online publication 4 Mar 2008.
3. ^ Soriano, D. et al. "Pregnancy outcome after laparoscopic and laparoconverted myomectomy." European Journal of Obstetrics & Gynecology and Reproductive Biology 108 (2003): 194-198.
4. ^ Bedient CE, Magrina JF, Noble BN, Kho RM. (2009). "Comparison of robotic and laparoscopic myomectomy.". Am J Obstet Gynecol. 2009 Dec;201(6):566.e1-5. Epub 2009 Aug 15. 201 (6): 566.e1–5. doi:10.1016/j.ajog.2009.05.049. PMID 19683685. 
5. ^ Polena, V., et al. "Long-term results of hysteroscopic myomectomy in 235 patients." European Journal of Obstetrics & Gynecology and Reproductive Biology 130 (2007): 232-237.
6. ^ Camanni M, Bonino L, Delpiano EM, Ferrero B, Migliaretti G, Deltetto F. (2010). "Hysteroscopic management of large symptomatic submucous uterine myomas.". J Minim Invasive Gynecol. 2010 Jan-Feb;17(1):59-65. 17 (1): 59–65. doi:10.1016/j.jmig.2009.10.013. PMID 20129334. 
7. ^ American Society of Reproductive Medicine Patient Booklet: Uterine Fibroids, 2003
8. ^ Fedele L, Parazzini F, Luchini L, Mezzopane R, Tozzi L, Villa L (1995). "Recurrence of fibroids after myomectomy: a transvaginal ultrasonographic study". Hum Reprod 10 (7): 1795–6. PMID 8582982. 
9. ^ Kelly BA, Bright P, Mackenzie IZ. (2008). "Does the surgical approach used for myomectomy influence the morbidity in subsequent pregnancy?". J Obstet Gynaecol. 2008 Jan;28(1):77-81. 28 (1): 77–81. doi:10.1080/01443610701811738. PMID 18259905. 
10. ^ Bhatla N, Dash BB, Kriplani A, Agarwal N. (2009). "Myomectomy during pregnancy: a feasible option.". J Obstet Gynaecol Res. 2009 Feb;35(1):173-5. 35 (1): 173–5. doi:10.1111/j.1447-0756.2008.00873.x. PMID 19215567.