Gynecologic Myomectomy 

Updated: Jun 11, 2018
Author: Sarah Hagood Milton, MD; Chief Editor: Michel E Rivlin, MD 

Overview

Background

Uterine leiomyomas are among the most common problems encountered by the obstetrician/gynecologist. They are a frequent cause of pelvic pain and abnormal uterine bleeding and are thought to be involved in infertility. Uterine leiomyomas are the most frequent indication for hysterectomy in the United States. Many patients with symptomatic leiomyomas desire to retain the option of future childbearing or simply want to preserve their uterus. For these women, myomectomy, the removal of the myomas with reconstruction and preservation of the uterus, is an important option.

History of the Procedure

Successful abdominal myomectomy was reported as early as 1845 by brothers Washington and John Atlee in the American Journal of Medical Science. Washington, the older brother, eventually published his experience with 14 abdominal myomectomies, winning the annual essay award of the American Medical Association despite the death of 5 of the patients.[1]

The operation was slow to gain widespread use. In 1875, W.H. Byford gave the Chairman's address to the American Medical Association Section on Obstetrics and Gynecology and said abdominal myomectomy was "so dangerous and difficult as not to be thought of except in desperate conditions."[1]

At the turn of the 20th century, abdominal myomectomy was associated with a mortality rate of 40%, compared with 6-7% for abdominal hysterectomy. Victor Bonney is credited for advocating and popularizing the procedure in the 1920s.[2]

Problem

Uterine leiomyomata, or fibroids as they are more frequently known, affect more than 20% of reproductive-aged women[3] . Patients can have a single myoma or numerous myomas. They are benign muscular growths in the wall of the uterus (figure1). The majority of myomas are small, do not cause symptoms, and are noted as incidental findings during routine pelvic examinations or pelvic imaging studies. When they enlarge, they can cause a mass effect, resulting in pelvic pressure or pain or a distortion of the uterine wall or endometrial cavity, which leads to abnormal uterine bleeding. More infrequently, myomas can prolapse through the cervix or may be confused for an ovarian mass. They can also cause problems in pregnancy depending upon their location and, in some patients, myomas are thought to be linked to infertility.

Small uterine myomas visualized at laparoscopy. Small uterine myomas visualized at laparoscopy.

Epidemiology

Frequency

Uterine leiomyomata occur in 20-40% of reproductive-aged women.[3] Results from some ultrasonographic studies indicate the presence of at least one small myoma in 51% of pre-menopausal women. Of these women, 10-35% of Caucasian women and 30-50% of African American women have fibroids of clinical significance.[4] Myomas grow in response to estrogen stimulation and regress after menopause. Thus, they are most frequently found in women in their fifth decade of life and are quite rare in those younger than 20 years. In 2001, Schwartz reviewed the epidemiology of leiomyomas. The risk is 2-3 times higher in African American women than in white women, increases with age, decreases with having a live-born child, may increase with body mass index, and may decrease with cigarette smoking. Riskmayalso increase with diets high in red meat and ham and it may decrease with diets high in intake of green vegetables.[5]

Although most myomas are asymptomatic, there are many women who have significant symptoms from myomas, and myomas are the most frequent indication for hysterectomy in the United States. This indication constituted 38.1% of all hysterectomies (1.36 million) from 1994-1999.[6] Figures for myomectomy are older, but, in 1984, 18,000 myomectomies were performed, compared with 112,000 hysterectomies, suggesting approximately 1 myomectomy per 6 hysterectomies among women aged 15-44 years.[7] The symptoms of fibroids, along with both surgical and medical treatments, result in enormous costs for affected women and society. A study designed to estimate the annual cost of various methods of treatment of uterine fibroids showed that the mean cost for a myomectomy in the United States was $6,707 compared to $6,331 for abdominal hysterectomy, $7,108 for laparoscopicallyassistedvaginal hysterectomy, $6,809 for supracervical hysterectomy. Length of hospitalization was similar between totalabdominalhysterectomy(mean 2.9 days), supracervical hysterectomy (mean 2.7 days) and Myomectomy 2.6 days).[8]

Etiology

Leiomyomas are smooth muscle tumors that form in the uterine wall. The development and growth of uterine fibroids are influenced by multiple factors including autocrine and paracrine growth factors, genetic abnormalities, race, and environmental estrogen exposure related to age of menarche, obesity, and parity.[9]

The precise etiology is not known, although many cytogenetic and genetic studies have been performed. Approximately 40-50% of myomas have karyotypic abnormalities, particularly involving chromosomes 6, 7, 12, and 14. Within a myoma, all cells are identical and a monoclonal origin has been confirmed[10] Other changes associated with the presence of myomas include increased expression of estrogen, progesterone, and insulin-like growth factor 1 and 2 receptors and abnormalities in the myometrium adjacent to the myoma.[11]

Pathophysiology

Although myomas are common, relatively few actually cause symptoms. Whether symptoms are present depends largely on a combination of size, number, and location of the myomas. In general, myoma growth is a result of the stimulation of estrogen, which is present until menopause. Over time, previously asymptomatic myomas may grow and become symptomatic. Conversely, many myomas begin to shrink as menopause removes the estrogen stimulation and many myoma-related symptoms resolve spontaneously shortly after menopause.

Myomas are generally categorized by location. Intramural myomas are entirely or mostly contained within the myometrium (Figure2). Subserosal myomas project outward from the uterus (Figure 3). Submucosal myomas project into the endometrial cavity (figure 4). Pedunculated myomas are attached to the uterine wall by stalks and can be directed into either the peritoneal or the uterine cavity (figure 5).

Intramural myoma. Intramural myoma.
Small uterine myomas visualized at laparoscopy. Small uterine myomas visualized at laparoscopy.
Submucosal myoma visualized at hysteroscopy. Submucosal myoma visualized at hysteroscopy.
Pedunculated myoma. Pedunculated myoma.

Pelvic pressure and pain symptoms are usually the result of mass effect. This can occur either from a single large myoma or from a combination of multiple smaller myomas. A fibroid uterus can grow to be quite large, at times reaching the size of a term gravid uterus. Interestingly, perhaps due to the slow growth and accommodation by the patient, some extremely large uteri are well tolerated by patients and do not require intervention. Some large myomas that impinge on the ureters can cause hydronephrosis and, very rarely, ureteral obstruction.

Bleeding abnormalities related to myomas are usually the result of distortion of the endometrial cavity. Unlike pain, which is usually caused by large or multiple myomas, some patients have significant bleeding from a single, small, strategically placed myoma. A submucosal myoma can prolapse through the cervix and may cause no symptoms or may cause significant bleeding or pain.

Acute pain resulting from myomas is uncommon and usually stems from one of two possibilities. Pedunculated myomas can undergo torsion, causing the same severe pain as torsion of the ovary. Large myomas can outgrow their blood supply, leading to infarction and necrosis (degenerating myoma), which can be extremely painful. Lastly, prolapse of a myoma can be acutely painful.

Although general agreement is lacking on the mechanism, myomas are also thought to be related to infertility, fetal malpresentations, and preterm labor. Possible mechanisms for infertility include distortion of the endometrial cavity and abnormal endometrial surface, thereby affecting both sperm transport and embryo implantation.

Very rarely, myomas can be associated with erythrocytosis. This triad of myomatous uterus, erythrocytosis, and maintenance of normal hematologic values despite menorrhagia is called myomatous erythrocytosis syndrome.[10] A number of etiologies have been hypothesized, but alterations in erythropoietin levels seem likely.

Presentation

Most leiomyomata are small and do not cause symptoms. Many are found as incidental findings after an obstetric or gynecologic ultrasonographic examination (Figure 6) or after a routine pelvic examination.

Myoma identified on vaginal ultrasound. Myoma identified on vaginal ultrasound.

However, myomas can cause a number of symptoms. They can cause menstrual irregularities, particularly menorrhagia. This bleeding usually begins gradually and progressively worsens as the responsible myoma enlarges. A regular menstrual pattern should be still discernible despite the development of heavier or prolonged bleeding. If no regular pattern is noted, an alternative etiology such as chronic anovulation is more likely.

Some patients present with progressive pelvic pressure, pelvic pain, or low back pain. The differential diagnoses for such symptoms is diverse; however, if they are noted in someone with a medium- or large-sized uterus (>14-15 weeks' size), the myomas are more likely to be contributing. Some fibroid uteri can grow out of the pelvis and into the abdomen, where they can be palpated by the patient. This can be disturbing, even if the patient is having mild or no symptoms. Some are visible, distorting the abdominal wall and, at times, making the patient appear pregnant.

Most myomas grow slowly, and some remain relatively unchanged over prolonged periods. In the past, rapid growth was considered worrisome for leiomyosarcoma. In 1994, Parker et al showed that sarcoma was quite rare, even in rapidly growing uteri (0.27%). This risk was similar to the risk of leiomyosarcoma in myomas that were stable in size (0.21%).[12] However, most of the patients were premenopausal. Rapid growth in postmenopausal women should be treated with greater caution.

The diagnosis of a degenerating myoma should be considered in a patient with known fibroids and an acute onset of severe pelvic pain. The patient can also develop fever and an elevated white blood cell count that can be confused with infection. Upon examination, tenderness is usually quite specific and localized to the exact region of the degenerating myoma.

Infertility evaluations usually include an investigation for myomas, specifically submucosal myomas. Ultrasonography, hysterosalpingography (HSG), sonohysterography, or hysteroscopy are used frequently because submucosal myomas may not be detectable during pelvic examination.

Although less common, myomas can be found incidentally on speculum examination when they prolapse through the cervical os. Prolapsing myomas can also present with acute pain caused by “delivery” of the myoma through the cervix. Pedunculated myomas can also be mistaken for adnexal masses on routine pelvic examination.

Indications

The decision to perform surgery for uterine leiomyomata is complex and varies from patient to patient based on their medical comorbidities, surgical history, clinical scenario and patient preference. In general, consideration for a hysterectomy is given in patient with:

  • Excessive uterine bleeding

    • Profuse bleeding causing lifestyle derangements that is refractory to medical management

    • Uterine bleeding that results in anemia

  • Pelvic discomfort caused by myomata

    • Acute and severe

    • Chronic lower abdominal pain or low back or pelvic pressure with evidence of sizeable leiomyoma on imaging studies

  • Leiomyomata that are palpable abdominally

Indications for myomectomy are similar and this procedure is considered when patient either has a desire for future fertility or feels strongly about retaining their uterus. Whether discussing hysterectomy or myomectomy, these criteria are directed at relieving symptoms or improving quality of life by decreasing the patient's concerns. No indications exist for removing asymptomatic fibroids

A definite risk exists for myoma recurrence after myomectomy and, with it, the need for a repeat surgical procedure in the future. If the patient no longer desires to retain her fertility or her uterus, hysterectomy is the usual procedure of choice. Interestingly, a number of women who have completed childbearing still request myomectomy for management of symptomatic myoma. This decision is usually motivated by patient preference and a desire to retain organs. Because the short-term risks of myomectomy compare favorably with hysterectomy[11] and despite the risk of recurrence, a myomectomy is not unreasonable for appropriately counseled patients.

Although controversial, myomectomies are also performed for patients with infertility in the presence of uterine fibroids. Several studies suggest that patients with fibroids who are undergoing assisted reproductive technology procedures may have lower success rates compared with patients without fibroids.[13, 14] On the other hand, a Cochrane review on surgical management of fibroids in infertile patients did not find any statistically significant difference in clinical pregnancy rate, miscarriage rate or live birth rate between patients with uterine fibroids who had myomectomies and those who were managed conservatively. The authors caution that this data must be interpreted carefully because of the small nature of the existing studies and the significant need for additional data on the topic.[12] Further, there is no randomized data regardingtheimpact of hysteroscopic myomectomy of fertility outcomes butseveral case series report favorable pregnancy rates.[15, 16] Current recommendations include consideration of myomectomy in infertile women after extensive evaluation eliminating other causes of infertility.

Relevant Anatomy

Leiomyomata are usually confined to the myometrium but can occur in the lower uterine segment or cervix or can project out into the broad ligament. These myomas are frequently the most difficult to remove and are problematic during both hysterectomy and myomectomy.

Within the uterus, the myomas can be at any level within the uterine wall. Intramural myomas are entirely or mostly contained within the myometrium(Figure7). Subserosal myomas project outward from the uterus (Figure 8). Submucosal myomas project into the endometrial cavity (figure 9). Pedunculated myomas are attached to the uterine wall by stalks and can be directed into either the peritoneal or the uterine cavity (figure 10).

Intramural myoma. Intramural myoma.
Small uterine myomas visualized at laparoscopy. Small uterine myomas visualized at laparoscopy.
Submucosal myoma visualized at hysteroscopy. Submucosal myoma visualized at hysteroscopy.
Pedunculated myoma. Pedunculated myoma.

Contraindications

Myomectomy has a number of important contraindications. Myomectomy is not reasonable in the management of symptomatic leiomyomata in patients who no longer desire fertility or uterine preservation. It should not be performed if the possibility of endometrial cancer or uterine sarcoma have not been excluded. Generally, it should be avoided if the patient is pregnant. With the possible exception of otherwise unexplained infertility, it should not be performed in asymptomatic patients. No evidence supports prophylactic myomectomy of asymptomatic myomas for decreasing the risk of any adverse outcome later in life.

A relative contraindication to myomectomy is the strong possibility that a functional uterus could not be reconstructed after excision of the myomas. For myomectomy to be considered successful, reconstructing the uterus must be possible. Leiomyomata located in the region of the uterine vessels or broad ligament are sometimes difficult to remove without performing a hysterectomy. If the patient has numerous small myomas, removing them and reconstructing the uterus in such a way as to support a future pregnancy may be impossible. Excision of very large leiomyomata that constitute the entire anterior or posterior wall of the uterus may leave defects so large that closure is prohibited.

 

Workup

Laboratory Studies

See the list below:

  • Pregnancy test: No patient should have a myomectomy until the possibility of pregnancy is excluded.

  • A preoperative hemoglobin level should be obtained.

Imaging Studies

See the list below:

  • Ultrasonography: Uterine leiomyoma can usually be detected on pelvic examination. If any doubt remains or if the uterine enlargement must be confirmed or differentiated from a pelvic mass, ultrasonography is very useful. Leiomyomas can also be detected with CT scanning or MRI, but, in general, these tests are more expensive and do not help visualize the uterus as well as ultrasonography does.

  • HSG or sonohysterography: In the evaluation of the endometrial cavity, if a strong possibility exists that myomas are present within the endometrial cavity, an HSG or sonohysterography can aid in localization. This allows the preoperative detection of myomas that may be more amenable to hysteroscopic resection and may thereby preclude the need to enter the endometrial cavity during an abdominal procedure.

  • MRI: Myomectomy is possible only for myomas; therefore, one must reasonably believe that the uterine enlargement is from leiomyoma and not from adenomyosis. The presence of myomas can usually be confirmed based on ultrasonography or physical examination findings by the characteristic irregularities of a uterus with multiple fibroids. If any doubt remains, MRI has been found useful in differentiating leiomyoma from adenomyosis.[17, 18]

Diagnostic Procedures

See the list below:

  • Endometrial biopsy: Myomectomy is not an acceptable option if the patient has an endometrial malignancy. An endometrial biopsy should be performed prior to performing myomectomy in any patient older than 35 years who has a history of irregular bleeding.

 

Treatment

Medical Therapy

Management of symptomatic uterine fibroids includes a number of nonsurgical approaches. Of note, treatment is usually strictly for patient comfort, and withholding treatment is reasonable in patients with no symptoms or with mild, well-tolerated symptoms. While medical treatment does not currently allow a permanent cure for fibroids, therapy with nonsteroidal anti-inflammatory drugs, oral contraceptive pills, progesterone modulators, progestins and estrogens, and gonadotropin-releasing hormone (GnRH) analogs is often attempted.[19] In a 2007 Cochrane review evaluating the effectiveness of SERMs in treating fibroids, evidence was insufficient to show any improvement in fibroid size or clinical symptoms.[20]

In general, surgery is reserved for patients in whom medical management has failed. Despite the lack of good randomized evidence for the use of nonsteroidal anti-inflammatory drugs and oral contraceptive pills, these seem to be appropriate first-line options for properly selected women without contraindications. Many women with fibroids, particularly those who have fibroids that are compounding dysfunctional bleeding, can be treated successfully with a combination of nonsteroidal anti-inflammatory drugs, birth control pills, or cyclic progestins. A short course is reasonable for patients with fibroids before committing to surgery because some patients can be treated successfully with medical management. Most studies of medical management are short, from three months to one year, and long-term success remains uncertain. Patients who are treated with medical management are usually examined more frequently than once a year.

Surgical Therapy

A number of surgical therapies are available for the management of myomas, including hysterectomy, abdominal myomectomy, laparoscopic myomectomy, and hysteroscopic myomectomy. Myomas are most commonly treated with hysterectomy. The following sections focus on uterine conserving surgery for leiomyomas. The traditional procedure is abdominal myomectomy, although laparoscopic myomectomy is an acceptable option for experienced laparoscopic surgeons.

Uterine artery embolization (UAE) is often considered an alternative to hysterectomy or myomectomy in patients with symptomatic uterine leiomyoma. In this procedure, angiographic catheters are introduced in the groin and passed to the uterine artery under fluoroscopic guidance. Microspheres are then injected, which lodge in the blood supply to the myomas and cause them to infarct. UAE is contraindicated in patients to desire future fertility and is often considered for patients who have a poor surgical risk profile. Quality of life parameters are similar in patients who underwent surgery versus UAE at 5 years however almost one-third of patients treated with UAE required re-intervention secondary to symptom recurrence.[21] In the absence of desired fertility and significant perioperative risks, patients should be counselled regarding UAE outcomes and informed that UAE is a viable alternative to surgery.

Myomectomy can be performed laparoscopically under certain conditions. Development of this procedure was driven by the desire to create a minimally invasive approach that would obviate a major abdominal laparotomy. Numerous published series document the feasibility of laparoscopic myomectomy.[22, 23, 24, 25] Further, a review of randomized studies and clinical series concluded that laparoscopic myomectomy is feasible in well-selected individuals and, with meticulous closure of the myometrium, is safe in women considering pregnancy in the future.[26] A randomized control trial revealed similar cumulative pregnancy and live birth rates in women with unexplained infertility following laparoscopic versus abdominal myomectomy.[27] Based on the existing literature andincreasing patient interest in minimally invasive surgery, laparoscopic myomectomy is gradually becoming a more acceptable treatment for myomas.

The risk of intraperitoneal dissemination of malignant tissue led to a 2014 FDA black box warning against the use of laparoscopic power morcellation to remove uterine fibroid tumors.[28]

A retrospective cohort study by Stentz et al reported an 11% absolute increase in the use of abdominal myomectomy post-FDA warning. The study also reported that although abdominal myomectomy consistently had higher morbidity rates when directly compared to laparoscopic myomectomy, there were not significant changes in morbidity post-FDA warning.[29]

Hysteroscopic myomectomy can also be used selectively for myomas impinging on the endometrial cavity that are thought to contribute to abnormal bleeding or infertility. Over the last 30 years, hysteroscopic resection of fibroids has become the standard for conservative treatment for submucosal fibroids. With the recent improvements in smaller scopes, continuous flow monitoring systems, and operative resecting tools the procedure has become safer and less invasive and, in many cases, can be performed with minimal anesthesia and cervical dilation. Proper patient selection and correct surgical technique are essential for optimizing operative success and reducing risk of complications.[30]

Preoperative Details

Abdominal myomectomy

The use of GnRH analogues has been studied extensively in patients undergoing abdominal myomectomy and is the subject of a Cochrane review.[31] The systematic review noted increased preoperative hemoglobin levels (weighted mean difference, 1.3 g) and decreased uterine size (weighted mean difference in volume, 159 mL) with pre-operative administration of a GnRH analogue. Intraoperatively, they noted a lower incidence of vertical incisions (odds ratio 0.11; 95% confidence interval, 0.02-0.75). They did not find any difference in duration of surgery or incidence of transfusion. They noted decreased estimated blood loss (67 mL), but only in the trials that had a no pretreatment arm as opposed to a placebo arm. They noted no difference in terms of quality of life or postoperative complications.[31] In summary, GnRH agonists may improve the likelihood of completing the procedure through a more cosmetic incision, but they do notappear to routinely improve other relevant clinical outcomes.

Reported in 1997, Deligdisch et al performed a histologic study of the cleavage planes between the myoma and the myometrium in hysterectomy specimens in patients treated with GnRH analogues and a group of untreated controls. They noted that loss of the histologic cleavage plane occurred in 91% of patients pretreated with GnRH analogues and in 50% of controls leading to the conclusion that successful surgical removal may be limited after use of GnRH analogues.[32]

A small, placebo-controlled, randomized trial suggests that administering misoprostol at 400 mcg intravaginally 1 hour before surgery significantly increases postoperative hemoglobin levels (9.7 g/dL vs 8.9 g/dL) and decreases estimated blood loss (472 mL vs 621 mL), operating time (48.5 min vs 58 min), and need for transfusion (15.3% vs 33.3%).[33]

Preoperative bowel preparation is not necessary for patients undergoing a myomectomy unless unusual adhesions are expected. Although data on pre-operative antibiotic prophylaxis is limited, because this procedure is usually performed on patients who want to retain their fertility and because the consequences of infection on tubal function are severe, many providers administer prophylactic antibiotics empirically. A vaginal preparation is also a sensible precaution because 1-2% of these procedures, by necessity, are converted into abdominal hysterectomies.

Laparoscopic myomectomy

A number of authors have attempted to define who is a candidate for a laparoscopic myomectomy. The size, number, and location of the fibroids as well as the experience of the surgeon all must be factors in the decision to proceed with the laparoscopic approach.

In 1991, Nezhat et al reported on the laparoscopic removal of myomas as large as 15 cm in diameter.[34] Other authors are more conservative. In 1996, Dubuisson and Chapron suggested not removing any myoma larger than 8 cm and not performing laparoscopic myomectomy if more than 2 myomas are present.[35] In 1994, Parker and Rodi suggested limiting the procedure to patients with uteri smaller than 14 weeks' size, fibroids smaller than 8 cm, at least 50% of the myoma being subserosal, and myomas located in noncritical locations.[36] In 2003, Sinha et al reported on 51 laparoscopic myomectomies for large myomas ranging in size from 9-21 cm with a mean myoma weight of 700 g and concluded that the laparoscopic approach was a safe alternative to laparotomy.[37] In light of the variation in these opinions, surgeon experience is a critical factor in decision to proceed with laparoscopic myomectomy.

Newer laparoscopic approaches to myomectomy include single port laparoscopic myomectomy and robotic myomectomy. While randomized data is lacking on single port laparoscopic myomectomy, retrospective data suggest it may be associated with shorter operative time and decreased post-operative pain.[38] Robotic myomectomy has become increasingly common in the last decade. A retrospective study comparing conventional laparoscopic myomectomy to robotic myomectomy showed decreased blood loss and increased incidence of a double layer closure in the robotic group and showed no difference in length of hospital stay or operative time.[39] Additional randomized studies on both technologies are necessary to further elucidate their long-term role in the treatment of uterine leiomyomata.

GnRH analog use can slightly decrease operating time and blood loss during lap[40] aroscopic myomectomy. Zullo et al noted that preoperative use of leuprolide acetate decreased estimated blood loss from 172 mL to 132 mL and operating time from 113 minutes to 99 minutes. On the other hand, longer operative times, 112 minutes versus 157 minutes, with preoperative GnRH analog use found by Campo and Garcia, were attributed to difficulty in detecting the myoma cleavage plane.[41]

All patients undergoing laparoscopic myomectomy should also give consent for laparotomy because conversion to a laparotomy intraoperatively may be necessary in as many as 8% of procedures.[25]

Hysteroscopic myoma resection

Patient selection for hysteroscopic myomectomy is essential to achieve resolution of bleeding symptoms, enhance fertility, and reduce surgical risks. Preoperative imaging with MRI, 3-dimensional ultrasonography or saline-infused sonohysterogram can provide a map of the uterine myomas and identify the intramural component of the fibroids. The European Society of Hysteroscopy designed a classification system for submucosal fibroids based primarily on this concept.

  • Type 0 fibroids are pedunculated with no intramural component.

  • Type I fibroids are sessile submucosal fibroids with less than 50% intramural component.

  • Type II fibroids have a greater than 50% myometrial invasion.[42]

When complete resection of the fibroid is accomplished, recurrence of bleeding is unlikely regardless of the type of fibroid resected. Incomplete resection of the fibroid is more likely in type II fibroids than in type I fibroids because of the more extensive intramural component in type II myomas. The patient with type II fibroids should be counseled on the risk of failure and the procedure should be performed by experienced hysteroscopic surgeons.

Preoperative treatment with danazol or a GnRH agonist has been shown to reduce surgical time, bleeding, and absorbed distension media.[43, 44] Some authors have recommended pretreatment with a GnRH analogue for submucosal fibroids greater than 3 cm in diameter.[45] Other studies have found no benefit and have even suggested a longer operating time possibly due to difficulty with cervical dilation in the pretreated group.[46] Whether the cost and side effects of pretreatment are outweighed by any potential benefit remains unclear.

The most common complications with hysteroscopic myomectomy are uterine perforation, cannulation of a false cervical canal, and excessive absorption of distension media.[47, 48] . Hemorrhage and infection are rare and antibiotic prophylaxis is not recommended routinely.[49, 50] Preoperative cervical ripening with a prostaglandin analogue has been demonstrated to facilitate cervical dilation. Misoprostol 200 mcg applied vaginally 8-12 hours prior to surgery is well tolerated and can decrease surgical time and reduce the risk of surgical complications.[51]

Intraoperative Details

Abdominal myomectomy

Patients undergoing abdominal myomectomy require anesthesia adequate for a laparotomy, usually general endotracheal anesthesia. An incision is chosen that allows maximal exposure. Many myomectomies can be performed through a Pfannenstiel incision, but vertical incisions can be used when necessary. In some cases, better exposure could be the difference between the ability to stop hemorrhage and preserve the uterus and the need to proceed with hysterectomy to control bleeding. Several excellent atlases are available for full details of surgery.[52, 53]

One important issue with myomectomy is controlling blood loss from the raw myoma beds after they have been excised. Several techniques have been studied. A randomized trial comparing vasopressin and saline injected into the serosa prior to the uterine incision showed that vasopressin is extremely effective for decreasing blood loss. In this study, 50% of patients receiving saline required transfusion, while none of those in the vasopressin group required transfusion (13% vs 5% decrease in hematocrit values).[54]

Many providers place tourniquets to control bleeding.[55] This is usually performed by making a window in the broad ligament at the level of the internal cervical os bilaterally and passing a Foley catheter or red rubber catheter through the windows and around the cervix and then tightening it with a clamp to constrict the uterine vessels. In combination with this, vascular clamps are generally placed on the utero-ovarian ligaments.

Two randomized trials compared vasopressin and tourniquet use. In 1996, Fletcher et al showed that vasopressin was associated with less blood loss than patients in whom a tourniquet was used.[56] Ginsberg et al noted no statistically significant difference between use of vasopressin versus a tourniquet, although their study was much smaller.[57] Study results clearly suggest that vasopressin (usually 20 U in 50-100 mL normal saline) should be injected routinely prior to making the incision in the wall of the uterus. Whether additional use of a tourniquet further decreases blood loss remains unclear. A Cochrane review evaluating techniques to decrease intraoperative blood loss in both abdominal and laparoscopic approaches found that misoprostol, vasopressin, bupivacaine plus epinephrine, and pericervical tourniquet all lead to significantreduction in blood loss.[58]

After dilute vasopressin has been injected, an incision is made through the wall of the uterus into the myoma. Once the plane between the myometrium and myoma has been defined, it is dissected bluntly and sharply until the entire fibroid is removed. As many fibroids as possible are removed through a single incision. Once the fibroids have been removed, the defect is closed in layers with delayed absorbable suture.

Proper placement of the incision is frequently overlooked but is important. Reported in 1993, Tulandi et al studied 26 women with uteri larger than 6-8 weeks' size. Abdominal myomectomies were performed, followed by a second-look laparoscopy 6 weeks later. Patients with incisions in the posterior wall of the uterus had a much higher likelihood of significant adhesions as measured by percentage with adhesions or American Fertility Society (AFS) adhesion score compared with patients with incisions in the fundus or anterior wall of the uterus.[59] Use of the adhesion barrier Interceed is associated with decreased incidence of adhesion formation in gynecologic surgery but this does not translate to increased pregnancy rates.[60]

Laparoscopic myomectomy

Unfortunately, a number of important unresolved technical issues remain regarding laparoscopic myomectomy. One difficulty is in the removal of the fibroids, which has been performed using morcellation[61] , minilaparotomy[62] , or colpotomy. Alternatives to these are to destroy the fibroids in place with cryotherapy[63] , bipolar cautery[64] , or laser[65] . No trials have compared these techniques to determine which is the safest or most effective.

Articles by Peacock[66] and Parker[67] reviewed techniques for laparoscopic myomectomy. Intraoperative port placement depends on uterine size, and size and location of the fibroids. Often, 2 ports are used on the patients left or right side for fibroid enucleation and suturing, including a port 2 cm medial to the iliac crest, as well as a 5 mm port lateral to the umbilicus. For retraction and exposure purposes, another port is placed on the opposite side of these ports. An umbilical port site is made for the laparoscope; however, an upper quadrant port may be necessary for a large uterus.

After vasopressin injection into the myoma, a transverse incision over the fibroid with the Harmonic scalpel or other cautery is extended down to the avascular myoma plane. A tenaculum is then used to grasp the myoma to create countertraction. The cleavage plane between fibroid and uterus is identified, and the myoma is dissected out of the uterus. One to three layers of delayed absorbable sutures are used to repair the myometrium and serosal defect. Morcellation of the myoma is followed by irrigation and placement of adhesion barrier.

Closing the uterine defect left by the destruction or removal of the fibroid is a critical technical issue. This is much more difficult than during an open procedure. As reported in 1991 and 1996, Nezhat et al performed laparoscopic myomectomy and then performed a second-look laparoscopy on 28 women 6 weeks later. They had removed 37 myomas from these women and closed the defects with laparoscopically placed sutures. At the second look, indentations were visible at all of the sites where the myomas had been excised. In addition, 6 uterine fistulas were visible on postoperative HSG findings.[34, 68]

As mentioned previously, robotic surgery has become increasingly popular in gynecologic procedures involving cancer staging, hysterectomies, and myomectomies. Advantages to the da Vinci including 3-dimensional imaging and enhanced dexterity may help surpass the obstacles encountered while enucleating the fibroid, and repairing the uterine defect in laparoscopic myomectomy. Pundir et al preformed a systematic review and meta-analysis in 2013 evaluating robotic assisted laparoscopic myomectomy versus abdominal myomectomy versus laparoscopic myomectomy. In the study arm comparing robotic- assisted myomectomy to abdominal myomectomy, robotic-myomectomy resulted in lower blood loss, decreased incidence of transfusion, and shorter hospital stay, however, operative time and cost were higher in the robotic group. In the study arm comparing robotic assisted myomectomy to laparoscopic myomectomy, there was an increased risk of blood transfusion and increased cost with the robotic approach.[69]

Robotic myomectomy. A 32-year-old woman was found to have a large fibroid during pregnancy. Postpartum, the fibroid caused pelvic pain and dyspareunia. Pelvic ultrasonography revealed a 10-cm fundal transmural fibroid. Part 1. Video courtesy of Tarek Bardawil, MD.
Robotic myomectomy. A 32-year-old woman was found to have a large fibroid during pregnancy. Postpartum, the fibroid caused pelvic pain and dyspareunia. Pelvic ultrasonography revealed a 10-cm fundal transmural fibroid. Part 2. Video courtesy of Tarek Bardawil, MD.

Laparoscopic versus Abdominal Myomectomy

Three prospective randomized trials comparing abdominal and laparoscopic myomectomy are as follows:

  • In 2000, Seracchioli et al compared 65 women undergoing abdominal myomectomy with 66 women who underwent a laparoscopic procedure. They excluded patients with more than 3 myomas greater than 5 cm or uterine size extending above the umbilicus. They found significantly less febrile morbidity, lower transfusion rates, and shorter hospitalization stays in the group of women treated laparoscopically.[70]

  • In 2001, Rossetti et al reported on 81 women randomized to laparotomy or laparoscopy for treatment of myomas greater than 3 cm, with no more than 7 myomas per patient. At 40-month follow-up, the recurrence rates were similar between the 2 groups.[71]

  • Alessandri and colleagues randomly assigned 148 women to either laparoscopy or minilaparotomy for fibroid removal. Laparotomy resulted in shorter operative times and lower postoperative hemoglobin, while hospital stay and pain were less in the laparoscopic group. No recurrences were detected in either group after 6 months.[72]

A recent retrospective study evaluated perinatal outcomes after laparoscopic versus abdominal myomectomy. This study found no significant differences in preterm birth, low APGAR scores, post-partum hemorrhage, emergency delivery, placental abnormalities, non-reassuring fetal surveillance or intrauterine fetal death between groups.[73]

Hysteroscopic resection of myomas

A thorough discussion of hysteroscopy can be found in Medscape Reference's Hysteroscopy article. Patients undergoing diagnostic hysteroscopy should also give consent for resection of myomas projecting into the endometrial cavity. Myoma resection is usually performed with a loop electrode by shaving the visible portion of the myoma into small pieces (see the image shown below).[74, 75, 76] Sometimes, myomas deeply embedded in the myometrium cannot be completely excised.

Submucosal myoma being resected hysteroscopically Submucosal myoma being resected hysteroscopically with a loop resectoscope.

Various sizes of operating hysteroscopes are now available, but they all include a telescope with a fiberoptic light source and camera. The angle of the telescope is either 0° or an acute angle of 12-30°. The straight visual 0° scope might be helpful with fundal myomas but an angled perspective is more commonly used for fibroid resection. The telescope inserts through an external sheath and internal sheath for continuous outflow and inflow of distension media.

The working element of the operating hysteroscope is the resecting loop that is available in many sizes and angles. The electrosurgical energy connected to the loop can be monopolar or bipolar. With the monopolar loops, using nonionic distension media such as glycine 5% or sorbitol 1.5% is necessary. With bipolar loops, both electrodes are within the cavity and normal saline can be used for distending solution. For hysteroscopic myomectomy, various laser types and mechanical loops without electrical energy have also been described.

There are multiple methods of using the electrosurgical loop to optimize fibroid resection. To maintain good visualization, fragments of resected fibroid need to be removed during the procedure. The surgeon may transfer fragments out of the field of resection or retrieve them from the cavity by grasping the tissue with the resecting loop. An intrauterine morcellator also exists that may improve surgical time by aspirating fibroid fragments through the hysteroscope.[77]  The risk of intraperitoneal dissemination of malignant tissue led to a 2014 FDA black box warning against the use of laparoscopic power morcellation to remove uterine fibroid tumors.[28]  When applying the monopolar loop, currents as high as 75-150 W are required for smooth tissue cutting.[78] Current should only be applied while the loop is being retracted into the hysteroscope or while the entire resectoscope is being pulled away from the fundus. A combination of the 2 movements is used by the surgeon to safely and effectively slice through the tissue.

Resection of type 0 fibroids can be accomplished in one step by most hysteroscopic surgeons since the border of the fibroid with the endometrium is easily identified.[79] Type I and type II fibroids require more surgical expertise as resection of the fibroid extends into the myometrial space.

In many circumstances, resection of large fibroids with significant intramural component is a 2-step approach since there is often further intracavitary expulsion of the fibroid after the initial surgery. The second procedure can be performed 3-6 weeks later when the residual fibroid has migrated into the submucosal space.[80]

Hysteroscopic myomectomy. A 24-year-old woman with menorrhagia and severe anemia in whom hormonal treatment failed. Sonohysterography showed multiple submucosal fibroids. She underwent hysteroscopic myomectomy after administration of Depo-Lupron. Part 1. Video courtesy of Tarek Bardawil, MD.
Hysteroscopic myomectomy. A 24-year-old woman with menorrhagia and severe anemia in whom hormonal treatment failed. Sonohysterography showed multiple submucosal fibroids. She underwent hysteroscopic myomectomy after administration of Depo-Lupron. Part 2. Video courtesy of Tarek Bardawil, MD.

Postoperative Details

After abdominal myomectomy, patients are treated as any other patients who have had a laparotomy. Patients should attempt ambulation early, and the diet should be advanced at the surgeon's discretion. The patients tend to be young and healthy; therefore, recovery is usually fairly rapid. Postoperative vaginal bleeding is common. Fever is also common, particularly in the first 48 hours, but does not appear to be due to infection.[81] Although, there is little data to elucidate the optimal time from surgery to conception; a prudent plan is to allow patients to heal for at least several months prior to any attempts.

Follow-up

Patients who have had myomectomies should be monitored for recurrence of myomas. Patients are typically seen for a routine postoperative examination 2-6 weeks postoperatively. A pelvic examination at 3 months, 6 months, and 1 year to assess for myoma recurrence seems reasonable, although no studies have been performed to support this protocol. If no recurrence is observed in 1 year, annual examinations are likely adequate.

Complications

Abdominal myomectomy

Abdominal myomectomy is associated with both short- and long-term problems. Short-term complications include all of the usual complications of gynecologic laparotomy, including bleeding, infection, visceral damage, and thromboembolism. Intraoperative blood loss is variable depending on the size and location of uterine fibroids.

In 1996, Iverson et al reviewed the relative morbidity of abdominal myomectomy compared with abdominal hysterectomy in patients at Tufts Medical Center. Patients who underwent myomectomy had an average blood loss of 464 mL and a risk of transfusion of approximately 28%. However, nearly three quarters of these transfused units were autologous blood replacement, and many of these patients likely would not have received blood if only random donor blood had been available. Approximately 13% of patients had temperatures of at least 38.5°C (101.3°F) 48 hours postoperatively and were started on antibiotics for presumed infection. When compared with hysterectomy, operative times were nearly identical. The blood loss, traditionally thought to be more than with hysterectomy, was actually significantly lower.[11]

No intraoperative visceral injuries occurred in patients who underwent myomectomy, although a number occurred in patients who underwent hysterectomy. In 1993, LaMorte et al noted similar complication rates in an uncontrolled series of patients at Yale[82] , and, in 2000, Sawin and coworkers noted similar results when hysterectomy and myomectomy were compared.[83]

Patients undergoing myomectomy have an unusually high incidence of fever occurring in the first 48 hours postoperatively, a phenomenon that appears to be unique to this procedure. This was also studied by Iverson et al in 1999.[81] They noted a baseline risk of approximately 33% for fever of at least 38.5°C (101.3°F) within the first 48 hours. When compared with hysterectomy and using multivariate analysis to control for age, parity, estimated blood loss, and type of physician performing the surgery, they noticed a 3.9-fold increased risk. This "myomectomy fever" may be due to the release of unknown pyrogenic factors during the myoma dissection or from hematomas forming in defects left by the removed myomas.

The most significant short-term risk is the potential need to convert a myomectomy to a hysterectomy intraoperatively. This occurs largely for two reasons. First, reconstructing the uterus may not always be possible because of the many defects left by the removal of multiple small fibroids or a single large fibroid. Second, a hysterectomy may be necessary intraoperatively to control bleeding. In the Tufts series reported by Iverson et al in 1996, conversion to hysterectomy intraoperatively became necessary in 2 of 103 myomectomies.[11] In the Yale series reported by LaMorte et al in 1993, 1 of 128 required a hysterectomy.[82] All patients undergoing myomectomies should be apprised of this possibility as part of the consent process.

Only one study separately examined complications in patients who underwent a second myomectomy. In 2002, Frederick et al reported on a study of 58 women who underwent repeat abdominal myomectomy, and they noted 33% febrile morbidity and 700 mL median blood loss. Of these women, 12% were transfused and 1 required hysterectomy.[84]

Overall, data evaluating abdominal myomectomy and subsequent uterine rupture is lacking. However, 2 case reports revealed postabdominal myomectomy uterine rupture at 20 weeks' and 12 weeks' gestational age[85, 86] , and 1 study reported 3 uterine ruptures in 24 patients with prior myomectomies involving uterine cavity entry[87] .

Laparoscopic myomectomy

Laparoscopic myomectomy has all of the usual risks of laparoscopy, predominantly those related to trocar placement. This includes injury to bladder, bowel, ureter, and blood vessels, and the need to convert to a laparotomy. Rates of conversion vary from very low to 8-10%, largely depending on the complexity of the case.

Suboptimal defect closures are of great concern for uterine rupture in future labor. A number of case reports have been published that describe uterine rupture after laparoscopic myomectomy.[88, 89, 90] Two retrospective analyses evaluating uterine rupture after laparoscopic myomectomy showed no cases of uterine rupture.[91, 92] . Another retrospective study showed a rupture rate of 3.7% (2/54 patients)[93] . The largest published series of laparoscopic myomectomy reported 1 uterine rupture per 213 patients.[25]

Hysteroscopic myoma resection

Complications of hysteroscopic myoma resection include hemorrhage, uterine perforation, damage to the cervix, and excessive absorption of the distention media into the vascular system, which can cause metabolic disturbances.[94]

One of the most serious potential complications with hysteroscopic myomectomy is excessive absorption of distension media, which can cause pulmonary edema, hyponatremia, cerebral edema, and even death.[95] This is especially true when using nonconducting distension solution with monopolar cautery. A surgeon should also be cautious with saline during resections with bipolar cautery since large volumes of fluid can lead to overload complications. A fluid management system that can accurately calculate the amount of absorbed fluid by measuring the inflow and outflow of distension fluid should be used. Intrauterine synechiae can also occur after hysteroscopic myoma resection.[96]

Outcome and Prognosis

Although myomectomy is a relatively frequently performed procedure, data on long term outcomes and prognosis are still relatively sparse. This is primarily due to a lack of clear data on the recurrence rate of myomas after myomectomy and on the impact of surgical removal of fibroids on fertility.

Abdominal myomectomy

In 1998, Vercellini et al extensively reviewed abdominal myomectomy as a fertility-enhancing procedure.[97] They noted that although numerous papers report on fertility outcomes after myomectomy, they all share the same serious flaws. In particular, not a single study included controls or used randomization. Only a few of the studies used life-table analysis. All used differing definitions of infertility and included heterogeneous uses of other infertility treatments. Nonetheless, the studies were fairly consistent, with approximately two thirds of patients with myomas and otherwise unexplained infertility conceiving after myomectomy.

Similar results were noted in both prospective and retrospective studies. However, results were inconsistent when subgroups were analyzed. Myomectomy continues to be offered routinely to patients with uterine fibroids and infertility, but until controlled studies with expectantly managed controls are performed, the benefit of this procedure for patients remains unclear.

The risk of myoma recurrence is similarly poorly studied. Patients undergoing myomectomy should be counseled that they are at risk for fibroid recurrence and the potential for additional surgery in the future. Most studies on this topic are limited because they include heterogeneous study groups composed of a mixture of symptomatic patients who are treated for fibroids and asymptomatic patients who are treated for infertility. Follow-up in all of these studies is poor, with many patients lost to follow-up and most with short follow-up periods. Because fibroids may recur slowly over a long period, studies with short follow-up times do not yield the necessary information.

In addition, the studies use different definitions of recurrence, some limited only to symptomatic recurrence and some including patients with asymptomatic fibroids detected after ultrasonographic or pelvic examination. Most do not use life-table analysis.

Many women are likely to experience recurrence of myomas after myomectomy. In 1995, Fedele et al reported on the use of ultrasonography to help diagnose recurrences and noted a cumulative recurrence rate of 51% over 5 years.[98] However, asymptomatic recurrence is not generally a relevant outcome. Limiting to studies that look at patients who require reintervention after myomectomy and appreciating that most of these studies have short (< 5-y) follow-up, recurrence rates of 8-27% are noted (see Table 1). Most of the higher rates are noted in older studies, when hysterectomy was performed for much more liberal indications and was performed much more frequently. Looking at these studies, the medium-term risk for the need for repeat surgery after myomectomy is 5-10%.

Table 1. Summary of Studies Reporting Need for Future Surgery for Myomas After Myomectomy (Open Table in a new window)

Study

Year

Follow-up, mo

Reoperation Rate

Finn and Muller[99]

1950

24-120+

13%

Brown et al[100]

1956

>72

17%

Malone[101]

1969

>60

27%

Berkeley et al[102]

1983

17

8%

Garcia and Tureck[103]

1984

>10

6%

Rosenfeld[104]

1986

>12

4%

Smith and Uhlir[105]

1990

NR

5%

Verkauf[106]

1992

42

6%

Gehlbach et al[107]

1993

>12

12%

Acien and Querada[108]

1996

4-144

8%

Stewart et al[109]

2002

84 ± 35

35%

Hanafi[110]

2005

2-136

17%

Several studies established particular risk factors for reoperation. In 1969, Malone noted that removal of multiple myomas was a strong risk factor for reoperation.[101] Future repeat surgery was required in 26% of patients with multiple myomas, compared with 11% of patients with single myomas. Also, pregnancy after myomectomy appears to be protective. In 1991, Candiani et al noted that over 10 years following myomectomy, 15% of patients achieving pregnancy and 30% of patients not achieving pregnancy required repeat surgery.[111]

In 2002, Stewart et al noted a decreased risk of repeat surgery if the uterus was greater than 12 weeks' size at the time of the initial surgery (hazard ratio, 0.1; 95% confidence interval, 0.01-0.4) and an increased risk with weight gain of more than 30 pounds since age 18 years.[109] In 2005, a retrospective analysis of 132 patients after myomectomy via laparotomy revealed a 62% 5-year recurrence rate and a 17% rate of reoperation for myomas. Lower recurrence rates were seen in patients with uterine size < 10 weeks, patients with a single myoma, and those who had a subsequent childbirth.[110]

Another long-term complication that must be considered is the risk of uterine rupture during pregnancy. Fortunately, this is quite rare and is most likely to occur in labor. Although data are limited to support it, the usual recommendation is to offer cesarean delivery to patients who had myomectomies in which large defects in the active segment of the uterus were created by removal of the fibroids. Some recommend cesarean delivery any time the endometrial cavity is entered during the procedure, but what seems more likely is that the total extent of the defect, not entry into the endometrium, is the factor that presents the risk to the patient. Recommendations must be individualized for each patient. These recommendations are best made by the physician performing the myomectomy and should be clearly documented in the chart and conveyed to the patient so that the recommendations are clear in the event of future pregnancy.

Laparoscopic myomectomy

Regarding fertility, successful reproductive outcomes are possible after both laparoscopic and abdominal myomectomy. A retrospective study by Seracchioli et al in 2006 reported a 54% pregnancy rate and a 67% delivery rate postlaparoscopic myomectomy.[112] Cumulative pregnancy rates and live birth rates in a randomized controlled trial comparing laparoscopic myomectomy and abdominal myomectomy noted no difference between these 2 groups. However, the per cycle live birth rate and pregnancy rate were higher in patients who underwent laparoscopic fibroid removal.[27] In a 2008 Cochrane review that included only one randomized controlled trial, pregnancy rates were similar in infertile patients who underwent myomectomy via laparotomy compared to laparoscopic myomectomy.[105] Althoughthe data is more limited, studies have shown favorable reproductive outcomes after robotic-assisted laparoscopic myomectomy.[113, 114]

A few studies have reported on the risk of recurrence after laparoscopic myomectomy. One study observed 114 women for a mean of 37 months and defined recurrence as the return of any myoma. The cumulative recurrence risk was 10.6% at 1 year, 31.7% at 3 years, and 51.4% at 5 years. Of the patients, 14% required repeat surgery.[68]

Another group observed 192 women after laparoscopic myomectomy and found, based on symptoms and ultrasonographic findings, a cumulative recurrence risk of 16.7% at 5 years. Approximately 4% of the patients required further surgery.[115] Interestingly, another study noted that the preoperative use of GnRH agonist increased the risk of myoma recurrence after laparoscopic myomectomy.[71]

Compared with abdominal myomectomy, patients having undergone laparoscopic myomectomy have less pain, shorter hospitalization[67, 116] , and fewer postoperative adhesions, but longer operative time.[116] Overall, no difference is apparent in postoperative complications or fibroid recurrence between the 2 groups.[66]

Hysteroscopic myoma resection

Many studies have assessed fertility rates after hysteroscopic myomectomy and have noted pregnancy rates similar to those after abdominal myomectomy, approximately 60% (see Table 2). Again, no studies include expectantly managed control groups.

Table 2. Pregnancy Rates in Patients Undergoing Hysteroscopic Myomectomy (Open Table in a new window)

Author

Year

Study Size

Pregnancy Rate

 

 

 

 

Goldenberg et al[117]

1995

15

47%

Vercellini et al[118]

1999

40

37%

Fernandez et al[119]

2001

59

27%

Bernard et al[120]

2000

31

35%

Shokeir[121]

2005

29

72%

Litta[122]

2013

104

86%

Reoperation after hysteroscopic myomectomy has also been studied. Similarly, these studies are limited by short follow-up periods. In 1999, Vercellini et al studied 108 women who had hysteroscopic resection of submucous, pedunculated, sessile, or intramural leiomyomas. After a mean follow-up of 41 months, 27 patients had myoma recurrence based on ultrasonographic findings, with a 3-year cumulative recurrence rate of 34%. Twenty women had recurrent menorrhagia, with a 3-year rate of 30%.[118]

In 1999, Emanuel et al reported on 285 women who had submucous myomas treated with hysteroscopic myoma resection without endometrial ablation. Several patients required multiple procedures. Patients were monitored for a median of 46 months. Forty-one patients (14.5%) required repeat surgery. Patients who required repeat surgery were more likely to have larger uteri and higher numbers of submucous myomas. Hysterectomy was required in 20 of the 41 patients who required repeat surgery. Most (90.3%) patients with normal-sized uteri and 2 or fewer myomas did not require future surgery at 5 years.[123]

In a second series from Britain, also reported in 1999, Hart et al studied 122 women for a mean of 2.3 years. Of these women, 21% required repeat surgery by 4 years and 0% thereafter. Their regression analysis suggested that outcome was better in older women in whom the uterus was smaller than or equal to 6 weeks' gestational size or the fibroid was smaller than or equal to 3 cm and mainly intracavitary.[124] In 1994, Donnez et al studied the recurrence of menorrhagia based on the site of the myoma. They noted that women who had multiple submucosal myomas were much more likely to have recurrent symptomatic menorrhagia than women who had only 1-2 myomas. Having the largest diameter inside the uterine cavity and the largest portion of the uterine wall were less accurate predictors.[125]

Although many reports exist regarding fertility after hysteroscopic myomectomy, currently no good randomized controlled trials have evaluated this outcome.[126]

Vaginal removal of a prolapsed myoma

Management of a prolapsed vaginal myoma can also be problematic. A single study noted that removal of prolapsed myomas represented 2.5% of all procedures for myomas. Approximately 93.5% of these procedures were successful with transvaginal removal, and 6.5% of patients needed a total abdominal hysterectomy. Of the failures, only 1 had very serious complications. After the initial vaginal myomectomy, 34 patients were monitored for a median of 5.5 years. In these patients, 79% had no further symptoms from their fibroids. Of those remaining, 21% developed other symptoms, of whom 6% required a hysterectomy, 6% had a single repeat prolapsed myoma, and 3% (1 patient) had multiple repeat procedures.[127]

Future and Controversies

Many questions remain regarding the natural course of untreated fibroids, the efficacy of medical management, and the unanswered questions regarding surgery as discussed previously.

Current controversies include the role of minimally invasive procedures. In particular, laparoscopic myomectomy has many theoretical advantages, including lower cost and avoidance of prolonged hospitalizations. However, whether the repair of the defect is as effective as that performed with abdominal myomectomy remains unclear, and the procedure may be associated with an increased risk of uterine rupture during pregnancy.

Medical therapy is also being explored. At present, data for medical management are very scant. The role of GnRH analogs also requires further clarification. The advantages in terms of making the fibroids smaller must be balanced against the high cost and the subsequent inability to locate fibroids that were previously reduced by treatment.