Myomectomy is a surgical procedure that is performed to alleviate symptoms caused by uterine fibroids without removing the entire uterus. Fibroid symptoms can include heavy bleeding during menstruation with or without accompanying anemia, abdominal and/or pelvic pain and pressure, bloating, frequent need to urinate and waking up at night to urinate, pain during sex.
There are three major types of myomectomy: open, laparoscopic, and hysteroscopic. Below are the overviews of each and the associated risks as well as the comparison to a non-surgical alternative to myomectomy – the UFE procedure.
Open myomectomy is the most common type and also the most invasive type. During an open myomectomy for a uterus that is enlarged, but below the belly button, a horizontal incision is made about 4 inches long. This type of incision is often referred to as a “bikini cut”, and made in the lower abdomen to gain access to the uterus. This incision is similar to that done for women who undergo a cesarean section.
The recovery after this type of surgery is 6-8 weeks. For a uterus that is enlarged by fibroids and extends above the belly button, a vertical incision from the breast bone down the pubic hairline is often required. The typical recovery from this surgery is 8 weeks or longer. Sometimes a horizontal incision is made, and then during surgery, it is realized that there is not enough exposure of the uterus to operate on fibroids at the very top of the uterus. If this occurs an additional vertical incision is added – an upside-down T-shape. This recovery is also at least 8 weeks or more.
Laparoscopic myomectomy involves multiple, shorter incisions with the placement of long thin metal tubes into those incisions in the abdomen. The abdomen is distended with carbon dioxide gas CO2 and the uterus is operated on with instruments placed through the metal tubes.
There are two types of laparoscopic myomectomy surgery and the distinction lies with who is holding the surgical instruments. If the Gynecologic surgeon is holding the instruments, this is a traditional laparoscopic myomectomy. If robotic arms are holding the instruments it is referred to as a robotic myomectomy.
Robotic myomectomy is more expensive than traditional laparoscopic myomectomy and involves a steep learning curve and continual performance of procedures to remain proficient. The recovery for both types of laparoscopic myomectomy is 4-6 weeks.
Hysteroscopic myomectomy is the least invasive type of myomectomy and also the least common. Hysteroscopic myomectomy is a non-surgical procedure performed for the least common type of uterine fibroids: pedunculated submucosal fibroids. This type of fibroid lies entirely inside the cavity of the uterus. It can cause very heavy periods and infertility similar to having an IUD. If this fibroid is smaller than 3.5 cm (<1.5 inches) then it can be removed with this approach. Larger fibroids can be removed with the help of uterine fibroid embolization (UFE) performed 2-3 weeks prior to the hysteroscopic myomectomy. This combined approach is a special scenario that does not come up very often, as this type of fibroid is uncommon and not typically large.
Uterine Fibroid Embolization
Uterine fibroid embolization (UFE) is a stand-alone, non-surgical procedure to treat symptomatic uterine fibroids. Unlike the typical myomectomy surgical procedure, UFE treats all of the fibroids. Under x-ray guidance, a tiny catheter like a piece of spaghetti is directed into each uterine artery one at a time. Each uterine artery is like a tree with a large, main trunk and progressively smaller branches until you get out to the periphery. The fibroids, therefore, are the leaves of this tree. Tiny particles sized for these small peripheral fibroid branches are injected resulting in the blood flow being cut off to all of the fibroids. The main trunk and larger branches of the uterus remain open. Therefore, the uterus remains alive, but the fibroids do not.
The fibroids start to die off, soften, and shrink. As this process occurs, the woman’s symptoms begin to fade away. UFE takes 30-40 minutes to perform and these patients are discharged on the day of the procedure following a several-hour recovery. Therefore, with UFE there is no hospital, no general anesthesia, and no surgery. Therefore, UFE is safer, much less invasive, much less expensive, and has a much shorter recovery than myomectomy surgery for fibroids.
Myomectomy Vs. UFE: Recurrence Rate, Recovery, Pregnancy
Myomectomy has a high recurrence rate of 11% per year as typically there are a number of living fibroids in the uterus after the surgery is performed, i.e. the surgeon cannot remove them all. With UFE, the recurrence is very low as typically there are no living fibroids in the uterus after the UFE procedure.
Myomectomy patients will often spend 2-3 nights in the hospital and also have to sign a medical release attesting to the fact that sometimes women go in for myomectomy surgery but wake up instead with a hysterectomy due to intraoperative bleeding or other complication. These complications include uterine scarring, severe blood loss requiring transfusion, surgical incision infection, damage to nearby organs, damage to the urinary system, emergency hysterectomy. Other complications after the surgery include bowel blockage and pain caused by pelvic adhesions, and severe scarring that can create fertility issues.
After a myomectomy, patients who become pregnant will require a C-section for delivery because the structural integrity of the uterus has been compromised. The typical birth after a UFE procedure is full-term with a vaginal delivery.