Fibroid Treatments Demystified, Part IV: Myomectomy
Myomectomy, a widely practiced method of removing subserosal or intramural uterine fibroids, is an alternative to hysterectomy for fibroid patients seeking uterine preservation.
How Myomectomy Works
In myomectomy, a surgeon removes one or more fibroids by cutting them out of the uterine wall. While incisions are made in its tissue, the uterus itself ultimately stays in place. Depending on the type and location of the fibroids, myomectomy may be performed laparoscopically (accessing the uterine cavity through abdominal incisions) or hysteroscopically (accessing the uterine cavity by way of the vagina).
The method used for performing myomectomy dictates the recovery and hospitalization time. Post-operative hospital stays currently range from 0-2 days, and recovery time ranges from 4-6 weeks.
Myomectomy patients typically see an enduring reduction in symptoms: in a recently published study, the research team of Pitter et al. reported that 62.9% of the myomectomy patients in their study population were free of symptoms at three years post-procedure.
Once a fibroid is completely removed, it will not grow back. That is not to say, however, that new fibroids won’t develop, potentially triggering the return of symptoms. A study by Yoo et. al assessed the probability of fibroid recurrence in laparoscopic myomectomy patients over an 8-year follow-up period. The researchers observed that the cumulative probability increased steadily from 11.7% at 1 year post-procedure to 84.4% at the 8 year mark. Factors influencing fibroid recurrence were found to be patient age, number of fibroids, pre-operative uterine size, and childbirth following the procedure. Another team of researchers, Obed et al., added family history of fibroids and multiple symptoms as to that list of factors, and concluded from their own study that “there is a high recurrence of uterine fibroids following myomectomy”.
Risks associated with myomectomy include post-surgical adhesions and both intra- and post-operative bleeding. Dubuisson et al. observed adhesions, or scars produced as incisions in the uterine tissue heal, in 35.6% of patients during “second-look” laparoscopy; this result that has been corroborated by additional studies. Cases of uterine rupture during pregnancy following a laparoscopic myomectomy have also been reported.
Since a myomectomy does not involve removal of the uterus, it is possible to preserve the patient’s fertility. Research largely suggests that myomectomy is an appropriate procedure for fibroid patients who desire pregnancy. That said, certain complications associated with myomectomy, such as adhesions, can, themselves, impair fertility – a fact that should be taken into account when considering the fertility-sparing aspects of the procedure.
One technique for removing larger fibroids through small ports in laparoscopic myomectomy, called power morcellation, has recently been the subject of major controversy. In power morcellation, a tool called a morcellator is used to dissect large fibroids, so that the dead tissue may be more easily extracted without expanding the abdominal incisions. In April 2014, the Federal Drug Administration (FDA) released a safety communication notice discouraging use of power morcellation, citing concerns that the technique could spread cancerous cells within the abdominal cavity if it came in contact with cancerous tissue. While uterine fibroids (also called leiomyomas) are almost always benign, the rare fibroid (about 1 in 1,000) that is malignant may not be detected as such in advance of surgery. Several manufacturers of the power morcellator have since pulled the device from the market, and power morcellation is now rarely used in laparoscopic myomectomies.
Pitter, M.C. et al. “Fertility and Symptom Relief following Robot-Assisted Laparoscopic Myomectomy”, Obstetrics & Gynecology, Apr 19, 2015. ePub. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4417601/. Retrieved July 2, 2015
Yoo, E. et al. “Predictors of leiomyoma recurrence after laparoscopic myomectomy.” Journal of Minimally Invasive Gynecology, Nov-Dec 2007; Vol. 14(6):690-7
Obed et al. “Uterine fibroids: risk of recurrence after myomectomy in a Nigerian population.” Archives of Gynecology and Obstetrics, Feb 2011; Vol. 283(2):311-5
Dubuisson J.B., et al. “Second look after laparascopic myomectomy”, Human Reproduction. 1998; Vol. 13:2102–6
“FDA discourages use of laparoscopic power morcellation for removal of uterus or uterine fibroids”, FDA News Release, Apr 17,2014. Web: http://www.fda.gov/newsEvents/Newsroom/PressAnnouncements/ucm393689.htm. Retrieved July 2, 2015.