Myomectomy

Myomectomy

Key Points

  • Depending on the leiomyoma phenotype(s), myomectomy can be performed vaginally, hysteroscopically, or via an abdominal route, either laparoscopically or laparotomically.
  • Appropriate and accurate evaluation of the leiomyoma phenotypes with imaging techniques is necessary before determining the appropriate route of removal.
  • Hysteroscopic myomectomy is the preferred approach to FIGO Type 0, 1,  selected Type 2 and, with appropriate training, occasional Type 3 tumors. Tumors larger than 5 cm in mean diameter typically require an abdominal approach.
  • For Type 2-5, 3-5, and all 4, 5, 6, and Type 7 tumors, an abdominal approach is necessary, preferably laparoscopically.
  • Vaginal myomectomy is reserved for prolapsing submucous myomas (generally Type 0), and selected type 8 tumors that originate in the cervix.
  • It may not be necessary to remove all leiomyomas; just those thought to contribute to symptoms, including infertility, AUB, and pressure.



The process of myomectomy refers to removal of a fibroid, or fibroids, therefore sparing the uterus. Myomectomy is the procedure best investigated for the treatment of fertility, or when future fertility is desired, as many of the image guided procedures have not undergone the research needed to be confident that they provide at least equal fertility outcomes as well as safety in a subsquent pregnancy.

Determining the Route of Myomectomy

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For the patient, the ideal approach to myomectomy is generally the one  that best combines achievement of  the desired clinical outcome while incurring the least morbidity and surgical risk. Consequently, hysteroscopic myomectomy is generally the most desirable, the laparoscopic approach the next, while laparotomy is reserved for those unsuitable for either technique. Of course, hysteroscopic myomectomy can only be performed for FIGO Type 0, 1, 2 and probably 3, with 2-5, 3-5 and all the others requiring and abdominal technique. Making this decision requires detailed and accurate phenotyping of the target leiomyoma(s), a clear understanding of the goals of the patient, and a surgical team that is trained and equipped to perform the procedure in a fashion that optimizes effectiveness and minimizes risks.

Vaginal Myomectomy

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When a fibroid, usually a FIGO Type 0 passes partially or totally through the exocervix, they may be a candidate for vaginal myomectomy. Generally the myoma can be twisted off the stock a process that may require some degree of analgesia. Selected leiomyomas (Type 8) that are in the exocervix may be removed following an incision in the appropriate region of the cervix, the tumor dissected out, and the cervical stroma reapproximated with delayed absorbable suture.

Hysteroscopic Myomectomy

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Removal of leiomyomas under hysteroscopic direction requires that the tumor is FIGO Type 0 or 1, most Type 2 or selected Type 3 tumors provided they are of reasonable size, generally less than  5 cm mean diameter. For Types 2 and 3 tumors it is essential that accurate determination of the outer free margin be determined with appropriate imaging techniques. The principles of hysteroscopic myomectomy, provided adequate endometrial cavity imaging, include dissection of the tumor from the myometrium (excepting Type 0 tumors) and then either radiofrequnency or electromechanical morcellation for removal from the endometrial cavity. Most of these procedures can be performed using local anesthesia. Since the major adverse events relate to systemic overload from distention media, a fluid management protocol, stringently followed is necessary.

Laparoscopic Myomectomy

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First described by Kurt Semm in 1979 (1) and reported for both subserous and intramural fibroids in 1991 by Dubuisson et al (2), laparoscopic myomectomy (LM) is a minimally invasive surgical alternative to laparotomic/open abdominal myomectomy (AM). In the classic LM, small surgical incisions are made on the abdomen. The surgeon inserts a laparoscope, which is a thin lighted tube fitted with a video camera, via the incision to visualize the fibroids, which are removed using small surgical instruments also inserted through the incision. Robotic-assisted laparoscopic myomectomy (RLM) is similar to classic LM, except that the surgeon sits at a console away from the patient to control robotic surgical instruments used to remove the fibroids. 

Laparotomic Myomectomy

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When vaginal, hysteroscopic, or laparoscopic myomectomy are not possible, or feasible because of leiomyoma phenotype, including number, size, and comorbidities such as endometriosis or other adhesiogenic disorders, laparotomy may be necessary. In some instances, "minilaparotomy" combined with laparoscopic direction preserves many of the advantages of laparoscopy, including early (same day) discharge.

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