Myomectomy

Fibroids, also called myomas or leiomyomas, are firm, non-cancerous growths of the smooth muscle of the uterus. They range from a few millimetres to more than ten centimetres and are described by position: submucosal fibroids bulge into the cavity where a pregnancy implants, intramural fibroids sit within the muscular wall, and subserosal fibroids grow on the outer surface, sometimes on a stalk. Myomectomy removes the fibroids and repairs the uterine wall, leaving the uterus able to carry a pregnancy. The approach follows the type of fibroid. Hysteroscopic myomectomy shaves away submucosal fibroids from inside, through the cervix, with no cuts on the abdomen. Laparoscopic and robot-assisted myomectomy remove intramural and subserosal fibroids through small abdominal cuts, with careful stitching of the wall in layers. Open myomectomy, through a lower abdominal cut, is used for very large or numerous fibroids.

Myomectomy is considered when fibroids cause symptoms and a woman wants to keep her uterus. Typical symptoms are heavy or prolonged periods, which can cause anaemia; pelvic pain or pressure; a swollen abdomen; frequent urination or constipation from pressure on the bladder or bowel; and pain during sex. Fibroids that distort the cavity of the uterus can make it harder to conceive and raise the risk of miscarriage, and removing them may improve fertility, which is why hysteroscopic myomectomy is often advised before IVF. The benefit of removing fibroids that do not touch the cavity is less certain and is weighed case by case. Alternatives include hormone medicines, which can control bleeding or shrink fibroids for a time, uterine artery embolisation by an interventional radiologist, and focused ultrasound or radiofrequency ablation in selected cases. Small fibroids without symptoms usually need only monitoring, and women who have completed their family may be offered a hysterectomy.

Hysteroscopic myomectomy is done under general or spinal anaesthesia, or deep sedation. A thin telescope passes through the vagina and cervix, the cavity is filled with fluid, and the fibroid is shaved away with an electric loop or a mechanical cutting device. It usually takes 30 minutes to an hour, and a large submucosal fibroid may need two sessions. Laparoscopic myomectomy is done under general anaesthesia through three or four small cuts. The surgeon injects medicine into the uterine wall to reduce bleeding, opens the wall over each fibroid, frees it, and then closes the wall in layers with stitches, a step that matters for future pregnancy. The fibroid tissue is removed through a small cut, ideally inside a protective bag. Robot-assisted surgery follows the same steps with instruments controlled from a console, and open myomectomy uses a lower abdominal cut. Keyhole and open operations take about 1.5 to 4 hours.

Candidates are women with symptomatic fibroids who want to keep their uterus and are fit for surgery. The team maps the fibroids with a pelvic ultrasound and often an MRI, because their number, size and position decide the approach and whether keyhole surgery is realistic. Blood tests check for anaemia, which is common and may be corrected with iron, or with hormone treatment that stops periods for a few months and can also shrink fibroids before surgery. Rapidly growing fibroids, unusual scan findings or bleeding after menopause need further assessment first, because a rare cancer called leiomyosarcoma can look like a fibroid. If you are planning a pregnancy, discuss timing and the likely birth plan in advance. Blood thinners are adjusted on medical advice and you fast for about six hours. International patients can usually send scans, ideally an MRI, for a remote review of the plan before travel.

After hysteroscopic myomectomy most women go home the same day, have cramping and light bleeding for a few days, and return to normal activities within a week. After laparoscopic or robotic surgery the stay is usually 1 to 2 nights, with tiredness and abdominal soreness for a couple of weeks and a return to desk work after about 2 to 4 weeks. After open surgery, plan on 2 to 4 nights in hospital and about 4 to 6 weeks before normal activities. Heavy lifting and intense exercise wait about 4 to 6 weeks after keyhole or open surgery. For travel, a stay of a few days is usually enough after a hysteroscopic procedure, while about 1 to 2 weeks after keyhole surgery, or 2 to 3 weeks after open surgery, allows a wound check and a discussion of the pathology report. Your discharge letter should describe where the fibroids were and how deep the repair went, for any future pregnancy care.

Myomectomy is generally safe, but it can involve more bleeding than a hysterectomy, because the uterus keeps its blood supply. A blood transfusion is occasionally needed, and very rarely, if bleeding cannot be controlled, the surgeon has to remove the uterus; you should be told about this possibility beforehand. Other risks include infection, injury to nearby organs and adhesions, scar tissue that can affect fertility, especially after open surgery. After hysteroscopic surgery, scar tissue inside the cavity or fluid absorption are possible. If a fibroid unexpectedly proves to be a sarcoma, cutting it up can spread it, which is why careful assessment before surgery matters. Fibroids can return: new ones may grow, and some women need further treatment over the years. In a pregnancy after a myomectomy that went deep into the wall, there is a small risk of the scar opening, so many specialists advise a caesarean birth. For most women, bleeding and pressure symptoms improve clearly.