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Definition
Myomectomy is the surgical removal of myomas of the uterus (fibroids).
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Description
Uterine fibroids, technically called leiomyomata but also called fibromyomas or myomas, are benign growths in the uterus.
Fibroids are thought to arise from the growth and division of a single muscle cell that develops within the muscular wall of the uterus, the myometrium.
Fibroids may occur singly but are typically multiple in number. Although they start off within the wall of the uterus (intramural), they can grow toward the inside of the lining of the uterus (submucosal) or toward the surface (subserosal). If they grow away from the surface, they may develop a stalk, a pedunculated fibroid.
They can range in size from small, pea-size lumps to very large masses (eight to ten inches or larger in diameter), which distort the uterus, making it large, bulky, and irregular in contour.
The growth of fibroids is unpredictable. They may remain relatively stable, or they may increase in size rapidly.
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Causes and Risk Factors
It is not well known what causes fibroids, although there may be some familial tendency to develop them.
There does appear to be a link with the female hormone estrogen, as fibroids may increase in size during pregnancy, when estrogen levels are high, and decrease in size after menopause when estrogen levels are low.
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Symptoms
The majority of women with fibroids (up to 80 percent) have no symptoms.
If symptoms do occur, they may include a heavier menstrual flow or one of longer duration, increased menstrual cramping and backache, irregular or unpredictable bleeding, and lower-abdominal pressure, which is often described as an achy or heavy feeling, or which may be associated with the need to urinate more frequently.
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Procedure
The treatment of myomas includes total or subtotal abdominal, vaginal, or laparoscopic-assisted vaginal hysterectomy.
One of the earliest alternatives to hysterectomy (removal of the uterus) was myomectomy, the removal of fibroids from the uterus. A woman who chooses myomectomy may be given hormones a few months before surgery to shrink the tumors.
The advantage of myomectomy is that it preserves the ability to have children. If the fibroids are not too large, the incision may be made through a transverse (that is, bikini-line) incision.
A newer technique is called hysteroscopic surgery. Doctors guide a slender, camera-tipped tube through the cervix into the uterus, along with a laser to zap the fibroids or a wire loop to shave them from the uterine wall.
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Types of Myomectomy
There are at least three different ways of performing a myomectomy: hysteroscopically, abdominally, or laparoscopically.
Hysteroscopic Myomectomy removes fibroids with instruments inserted through the vagina and the cervix. It is ideal if the fibroids profile into the uterine cavity and are small (for instance, less than an inch across). The larger these fibroids are, the more difficult the operation can be.
If the fibroid is pedunculated (on a stalk), hysteroscopic myomectomy may be easy because the stalk is cut and the fibroid is removed. If it is hanging through the cervix, it may even be cut or twisted off without anesthesia. There are generally no nerve fibers in the stalk to send pain messages to the brain.
Abdominal Myomectomy consists of a lapararotomy, the general term for opening the abdomen through an incision. Fibroids deep in the muscle must be removed one by one, each being removed almost like the seed from an avocado.
Laparoscopic Myomectomy involves the removal of the fibroids using a laparoscope, with one or more small incisions in the abdomen.
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Disadvantages
On rare occasions, with very large tumors, there may be so much bleeding that emergency hysterectomy becomes inevitable. Serious infections during the first few days after surgery may also call for a hysterectomy.
Myomectomy cannot be guaranteed to provide a permanent cure. Even if the surgeon removes every single fibroid that can be seen, other tiny tumors, neither visible nor palpable, may be left behind and become evident after myomectomy.
Overall, about 15 to 20 percent of women undergoing myomectomy will need repeat surgery. Most of these will be for newly emerging fibroids, but a few operations may be necessary due to bowel obstruction caused by the adhesions (fibrous bands of tissue) that may be the result of previous myomectomy.
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Questions to Ask Your Doctor
Which method, a myomectomy or a hysterectomy, would be the better treatment?
What type of myomectomy would you recommend?
What kind of results can be expected with a myomectomy?
If the myomectomy is elected, will you be recommending a hormone treatment before surgery? If so, what type of side effects will there be?
How painful is a myomectomy?
How long will the hospital stay be?
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