Myomectomy: a Guide to Fibroid Removal Surgery

What is a myomectomy?

A myomectomy is a surgical procedure that removes only uterine fibroids while preserving the uterus and can be performed in various ways depending on the size, number, and location of the fibroids. 

Myomectomy procedures can be classified based on the surgical approach used, including:

1. Hysteroscopic myomectomy

2. Abdominal myomectomy (laparotomy)

3. Laparoscopic myomectomy

4. Robotic-assisted myomectomy

Generally, a myomectomy alleviates symptoms associated with fibroids, such as heavy menstrual bleeding, pelvic pressure or pain, and anaemia caused by excessive blood loss. Additionally, a myomectomy can enhance fertility if the fibroids are large or located within or beneath the uterine lining.

However, before undergoing a fibroid removal surgery, it is important to be aware of potential risks, such as:

• Blood loss

• Scar tissue. (Incisions in the uterus to remove fibroids can create adhesions, potentially leading to infertility)

• Pregnancy or childbirth complications (due to weakened uterine walls)

• Allergic reactions to anaesthesia.

What is a hysteroscopic myomectomy?

This procedure involves removing fibroids using specialised instruments inserted through the vagina and cervix into the uterus. This is the least invasive type of myomectomy and you may go home after several hours of observation without hospitalisation. Some benefits include: 

• Outpatient procedure

• Minimal recovery time

• Minimal need for opioids or prolonged pain medication

• Minimal postoperative restrictions (Along with the ability to quickly return to work, sports and intercourse)

• Reduced surgical complications

• Reduced fever-related complications

• Minimal or no myometrium scarring (A scarred myometrium may require the patient to have a caesarean delivery for future childbirth)

However, this procedure is suitable only for women with submucosal fibroids that are not deeply embedded within the uterus.

When should I consider undergoing a hysteroscopic myomectomy?

Consider a hysteroscopic myomectomy if you have symptoms from uterine fibroids. This is a good option if the fibroids can be treated without needing open surgery or laparoscopy, and if no other fibroids or conditions require treatment.

What happens during a hysteroscopic myomectomy?

During the procedure, a speculum is placed in the vagina, and a long, slender "telescope" (hysteroscope) is inserted through the cervix into the uterine cavity. A clear fluid, typically a sterile saline solution, is introduced into the uterus to expand the uterine cavity and examine the uterine walls. 

The surgeon then uses instruments, such as a wire loop resectoscope or a hysteroscopic morcellator,  to shave and remove pieces of the submucosal fibroids.

Things to expect post-myomectomy

After finishing the procedure, you may experience some of the following symptoms:

1. Vaginal bleeding and discharge 

Some bleeding and discharge are to be expected.

2. Restrictions on sexual activity and tampon use

Do not engage in sexual activity or use tampons until you are fully healed.

3. Avoiding heavy lifting

Refrain from heavy lifting until you have fully recovered.

4. Rest

Follow your doctor’s instructions regarding adequate rest.

5. When to contact your doctor

Inform your doctor immediately if you experience heavy bleeding, fever, or any signs of infection.

6. Conception

Wait 3-6 months before attempting to conceive to allow your uterus adequate time to heal completely.

The information provided is intended for general guidance only and should not be considered medical advice. For personalised recommendations and tailored advice, please consult a gynaecologist at Thomson Women's Clinics.

FAQ

How long does a hysteroscopic myomectomy take?

The procedure usually takes around 30-60 minutes.

When can I go home after the hysteroscopic myomectomy?

Hospitalisation is usually not required. This procedure is usually done as an outpatient. After the procedure, you will be able to go home after several hours of observation in the recovery room. 

What should I expect after the hysteroscopic myomectomy?

After the procedure, your doctor will prescribe oral pain medication prior to discharge.

You may experience cramping and light bleeding/vaginal spotting or staining for a few days after the procedure. 

How long does it take to recover from hysteroscopic myomectomy?

Recovery time after a hysteroscopic myomectomy is typically short, often requiring only 1-3 days of rest at home. You may not need to take additional time off work if the procedure is scheduled just before a weekend. 

Will there be any visible scarring after a hysteroscopic myomectomy?

No, you won't see any scars after the procedure since it does not involve any incisions on your skin.

What are the possible complications of hysteroscopic myomectomy?

1. Laceration of the cervix 

• This can happen during dilation due to the positioning of the forceps and dilators. Revising the laceration site, with tamponade and/or suturing, typically yields excellent results.

2. Uterine perforation 

• This can occur during cervical dilation or surgery. 

• Uterine perforation should be suspected when there is a rapid negative fluid balance and the uterine cavity cannot be visualised.

3. Uterine bleeding

• This can occur due to the superficial vessels of the myomas or from the myometrial bed.

4. Fluid overload

• Maintaining a strict fluid balance is crucial to prevent complications. It is important to exercise caution if a negative balance of 1000 mL is reached and to avoid a negative balance of 2000 mL, as these could lead to serious health issues.

5. Infection

• Signs of infection include fever, pelvic pain, and abnormal vaginal discharge.

• Prompt recognition and treatment with antibiotics are essential to manage the infection and prevent further complications.

6. Air embolism (rare)

• Late complications may include adhesions and placenta accreta, particularly in areas where large resections were performed.

7. Unplanned hysterectomy (very rare)

What are the reasons someone shouldn't have a hysteroscopic myomectomy? 

Hysteroscopic myomectomy should not be performed on patients who are unsuitable for hysteroscopic surgery, such as those with:

• Active pelvic infection

• Pyometra

• Intrauterine pregnancy

• Known cervical or uterine cancer