Abdominal Myomectomy
Abdominal surgery, using general anesthetic, is usually required for a myomectomy. A horizontal bikini-line incision, 13 to 18 centimetres (five to eight inches) in length, is preferred but larger fibroids may require a vertical incision.
In a small fraction of myomectomies, it becomes too difficult to remove fibroids without removing the uterus or causing heavy bleeding. Hysterectomy may be required in about one percent of myomectomies. Your surgeon should discuss this possibility with you before surgery.
Blood transfusions are sometimes required during this procedure. The need for a transfusion increases with the size of the fibroid, and transfusion rates range from five to 25 percent.
Bleeding and abdominal pain are expected, and women typically stay in hospital for two to four days after the surgery. It may take six to eight weeks for a full recovery, depending on your lifestyle and activity level.
Between 20 and 40 percent of women have some complications after a myomectomy but these are usually mild, most commonly a post-operative fever. Serious complications, such as a puncture of the uterine wall or an infection, are uncommon. Abdominal myomectomy can leave scars on the uterus, which can cause abdominal pain. They can also make future surgery more complicated and can, in rare cases, reduce a woman's fertility.
Laparoscopic Myomectomy
Women with smaller fibroids on the outside of the uterus may have them removed by laparoscopic surgery, particularly if they are attached by a thin stalk of tissue (pedunculated). The laparoscope is inserted through small incisions in the abdomen, in and around the belly button. Guided by a fibreoptic camera, the surgeon removes the fibroid(s), using laser surgery or a more traditional incision. A laparoscopic myomectomy is usually day surgery and requires one to two weeks of recovery time.
Hysteroscopic Myomectomy
A hysteroscopic myomectomy uses a long, slender scope, called a hysteroscope, to remove the fibroid. This procedure is only appropriate for women who have fibroids on the inner wall of the uterus (submucosal fibroids). These fibroids are the type most likely to cause uterine bleeding.
A local or general anesthetic may be used. The uterus is filled with fluid and the hysteroscope is inserted through the cervix into the uterus. This device guides the physician to the fibroid, which is then removed in pieces with a wire loop. Sometimes a second procedure is needed to remove the entire fibroid.
The greatest advantage of hysteroscopic myomectomy is the quick recovery time. It is usually done as day surgery, and a woman can resume her normal activities in a few days. After surgery, most women experience some pain and bleeding, but the pain can generally be managed with oral pain medication.
If your pain is severe or your bleeding is heavy and bright red, you should contact your doctor and return to the hospital emergency room immediately. The risks of this procedure include bleeding and infection, but these complications are rare.
Assuming that it is done correctly and there are no complications, a hysteroscopic myomectomy should not interfere with a woman’s fertility. Pregnancy rates have been high among women who had this procedure to remove a fibroid that was causing fertility problems.
Endometrial Ablation
In some circumstances, hysteroscopic myomectomy is combined with another technique called endometrial ablation. During this procedure, the uterine lining (the endometrium) is destroyed, permanently stopping menstrual bleeding and preventing future pregnancy. This procedure is used when there is heavy bleeding and multiple fibroids. It is a more permanent solution for women who have completed childbearing. One study reported that after six years, only eight percent of women required followup treatment.
Endometrial ablation can be done using one of a variety of energy sources, including laser, microwave, electric current, heated fluid or freezing.
Gonadotropin-releasing hormone (GnRH) agonists are sometimes used for a few months before the procedure, to thin the endometrium and reduce the size of the fibroids. The side effects of this medication include symptoms similar to menopause, including hot flashes, mood swings, vaginal dryness, headaches, insomnia and weight gain. GnRH-a therapy can also weaken your bones.
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