Uterine myomectomy

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Uterine myomectomy
Myomenukleation.jpg
A laparoscopic myomectomy: The uterus has been incised and the myoma is held and about to be shelled out.
Other namesFibroidectomy
ICD-9-CM 68.29

Myomectomy, sometimes also called fibroidectomy, refers to the surgical removal of uterine leiomyomas, also known as fibroids. In contrast to a hysterectomy, the uterus remains preserved and the woman retains her reproductive potential. It still may impact hormonal regulation and the menstrual cycle. [1]

Contents

Indications

The presence of a fibroid does not mean that it needs to be removed. Removal is necessary when the fibroid causes pain or pressure, abnormal bleeding, or interferes with reproduction. The fibroids needed to be removed are typically large in size, or growing at certain locations such as bulging into the endometrial cavity causing significant cavity distortion.

Treatment options for uterine fibroids include observation or medical therapy, such a GnRH agonist, hysterectomy, uterine artery embolization, and high-intensity focused ultrasound ablation.

Procedure

A myomectomy can be performed in a number of ways, depending on the location, size and number of lesions and the experience and preference of the surgeon. Either a general or a spinal anesthesia is administered.

Laparotomy

Traditionally a myomectomy is performed via a laparotomy with a full abdominal incision, either vertically or horizontally. Once the peritoneal cavity is opened, the uterus is incised, and the lesion(s) removed. The open approach is often preferred for larger lesions. One or more incisions may be set into the uterine muscle and are repaired once the fibroid has been removed. Recovery after surgery takes six to eight weeks.

Laparoscopy

Using the laparoscopic approach the uterus is visualized and its fibroids located and removed. Studies have suggested that laparoscopic myomectomy leads to lower morbidity rates and faster recovery than does laparotomic myomectomy. [2] As with hysteroscopic myomectomy, laparoscopic myomectomy is not generally used on very large fibroids. A study of laparoscopic myomectomies conducted between January 1990 and October 1998 examined 106 cases of laparoscopic myomectomy, in which the fibroids were intramural or subserous and ranged in size from 3 to 10 cm. [3]

Hysteroscopy

A fibroid that is located in a submucous position (that is, protruding into the endometrial cavity) may be accessible to hysteroscopic removal. This may apply primarily to smaller lesions as pointed out by a large study that collected results from 235 patients with submucous myomas who were treated with hysteroscopic myomectomies; in none of these cases was the fibroid greater than 5 cm. [4] However, larger lesions have also been treated by hysteroscopy. [5] Recovery after hysteroscopic surgery is but a few days.

Complications and risks

Complications of the surgery include the possibility of significant blood loss leading to a blood transfusion, the risk of adhesion or scar formation around the uterus or within its cavity, and the possible need later to deliver via cesarean section. [6]

It may not be possible to remove all lesions, nor will the operation prevent new lesions from growing. Development of new fibroids will be seen in 42–55% of patients undergoing a myomectomy. [7]

It is well known that myomectomy surgery is associated with a higher risk of uterine rupture in later pregnancy. [8] Thus, women who have had myomectomy (with the exception of small submucosal myoma removal via hysteroscopy, or largely pedunculated myoma removal) should get Cesarean delivery to avoid the risk of uterine rupture that is commonly fatal to the fetus.

To reduce bleeding during myomectomy, the use of misoprostol in the vagina and the injection of vasopressin into the uterine muscle are both effective. [9] There is less evidence supporting the usefulness chemical dissection (such as with mesna), vaginal insertion of dinoprostone, a gelatin–thrombin matrix, tranexamic acid, infusion of vitamin C, infiltration of a mixture of bupivacaine and epinephrine into the uterine muscles, or the use of a fibrin sealant patch. [9]

Myomectomy during pregnancy

Leiomyomata tend to grow during pregnancy but only the large ones causing endometrial cavity distortion could interfere with the growing pregnancy directly. [10] Generally, surgeons tend to stay away from operative interventions during the pregnancy because of the risk of haemorrhage and the concern that the pregnancy may be interrupted. Also, after a pregnancy, myomas tend to shrink naturally. However, in selected cases myomectomy may become necessary during pregnancy, or also at the time of a caesarean section to gain access to the baby. [11]

Related Research Articles

Dilationand curettage (D&C) refers to the dilation (widening/opening) of the cervix and surgical removal of part of the lining of the uterus and/or contents of the uterus by scraping and scooping (curettage). It is a gynecologic procedure used for diagnostic and therapeutic purposes, and is the most commonly used method for first-trimester miscarriage or abortion.

<span class="mw-page-title-main">Tubal ligation</span> Surgical clipping,removal or blocking of the fallopian tubes

Tubal ligation is a surgical procedure for female sterilization in which the fallopian tubes are permanently blocked, clipped or removed. This prevents the fertilization of eggs by sperm and thus the implantation of a fertilized egg. Tubal ligation is considered a permanent method of sterilization and birth control.

<span class="mw-page-title-main">Hysterectomy</span> Surgical removal of the uterus

Hysterectomy is the partial or total surgical removal of the uterus. It may also involve removal of the cervix, ovaries (oophorectomy), fallopian tubes (salpingectomy), and other surrounding structures. Partial hysterectomies allow for hormone regulation while total hysterectomies do not.

Heavy menstrual bleeding (HMB), previously known as menorrhagia or hypermenorrhea, is a menstrual period with excessively heavy flow. It is a type of abnormal uterine bleeding (AUB).

<span class="mw-page-title-main">Asherman's syndrome</span> Medical condition

Asherman's syndrome (AS) is an acquired uterine condition that occurs when scar tissue (adhesions) forms inside the uterus and/or the cervix. It is characterized by variable scarring inside the uterine cavity, where in many cases the front and back walls of the uterus stick to one another. AS can be the cause of menstrual disturbances, infertility, and placental abnormalities. Although the first case of intrauterine adhesion was published in 1894 by Heinrich Fritsch, it was only after 54 years that a full description of Asherman syndrome was carried out by Joseph Asherman. A number of other terms have been used to describe the condition and related conditions including: uterine/cervical atresia, traumatic uterine atrophy, sclerotic endometrium, and endometrial sclerosis.

<span class="mw-page-title-main">Adenomyosis</span> Extension of endometrial tissue into the myometrium

Adenomyosis is a medical condition characterized by the growth of cells that proliferate on the inside of the uterus (endometrium) atypically located among the cells of the uterine wall (myometrium), as a result, thickening of the uterus occurs. As well as being misplaced in patients with this condition, endometrial tissue is completely functional. The tissue thickens, sheds and bleeds during every menstrual cycle.

<span class="mw-page-title-main">Vaginal bleeding</span> Medical condition

Vaginal bleeding is any expulsion of blood from the vagina. This bleeding may originate from the uterus, vaginal wall, or cervix. Generally, it is either part of a normal menstrual cycle or is caused by hormonal or other problems of the reproductive system, such as abnormal uterine bleeding.

<span class="mw-page-title-main">Hysteroscopy</span> Medical procedure

Hysteroscopy is the inspection of the uterine cavity by endoscopy with access through the cervix. It allows for the diagnosis of intrauterine pathology and serves as a method for surgical intervention.

<span class="mw-page-title-main">Gynecologic ultrasonography</span>

Gynecologic ultrasonography or gynecologic sonography refers to the application of medical ultrasonography to the female pelvic organs as well as the bladder, the adnexa, and the recto-uterine pouch. The procedure may lead to other medically relevant findings in the pelvis.This technique is useful to detect myomas or mullerian malformations.

<span class="mw-page-title-main">Endometrial polyp</span> Medical condition

An endometrial polyp or uterine polyp is a mass in the inner lining of the uterus. They may have a large flat base (sessile) or be attached to the uterus by an elongated pedicle (pedunculated). Pedunculated polyps are more common than sessile ones. They range in size from a few millimeters to several centimeters. If pedunculated, they can protrude through the cervix into the vagina. Small blood vessels may be present, particularly in large polyps.

<span class="mw-page-title-main">Uterine fibroid</span> Medical condition with benign tumors of uterus

Uterine fibroids, also known as uterine leiomyomas or fibroids, are benign smooth muscle tumors of the uterus. Most women with fibroids have no symptoms while others may have painful or heavy periods. If large enough, they may push on the bladder, causing a frequent need to urinate. They may also cause pain during penetrative sex or lower back pain. A woman can have one uterine fibroid or many. Occasionally, fibroids may make it difficult to become pregnant, although this is uncommon.

<span class="mw-page-title-main">Endometrial ablation</span>

Endometrial ablation is a surgical procedure that is used to remove (ablate) or destroy the endometrial lining of the uterus. The goal of the procedure is to decrease the amount of blood loss during menstrual periods. Endometrial ablation is most often employed in people with excessive menstrual bleeding, who do not wish to undergo a hysterectomy, following unsuccessful medical therapy.

<span class="mw-page-title-main">Placenta accreta spectrum</span> Medical condition

Placenta accreta occurs when all or part of the placenta attaches abnormally to the myometrium. Three grades of abnormal placental attachment are defined according to the depth of attachment and invasion into the muscular layers of the uterus:

  1. Accreta – chorionic villi attached to the myometrium, rather than being restricted within the decidua basalis.
  2. Increta – chorionic villi invaded into the myometrium.
  3. Percreta – chorionic villi invaded through the perimetrium.
<span class="mw-page-title-main">Arcuate uterus</span> Medical condition

The arcuate uterus is a form of a uterine anomaly or variation where the uterine cavity displays a concave contour towards the fundus. Normally the uterine cavity is straight or convex towards the fundus on anterior-posterior imaging, but in the arcuate uterus the myometrium of the fundus dips into the cavity and may form a small septation. The distinction between an arcuate uterus and a septate uterus is not standardized.

A uterine septum is a form of a congenital malformation where the uterine cavity is partitioned by a longitudinal septum; the outside of the uterus has a normal typical shape. The wedge-like partition may involve only the superior part of the cavity resulting in an incomplete septum or a subseptate uterus, or less frequently the total length of the cavity and the cervix resulting in a double cervix. The septation may also continue caudally into the vagina resulting in a "double vagina".

Reproductive surgery is surgery in the field of reproductive medicine. It can be used for contraception, e.g. in vasectomy, wherein the vasa deferentia of a male are severed, but is also used plentifully in assisted reproductive technology. Reproductive surgery is generally divided into three categories: surgery for infertility, in vitro fertilization, and fertility preservation.

<span class="mw-page-title-main">Interstitial pregnancy</span> Medical condition

An interstitial pregnancy is a uterine but ectopic pregnancy; the pregnancy is located outside the uterine cavity in that part of the fallopian tube that penetrates the muscular layer of the uterus. The term cornual pregnancy is sometimes used as a synonym, but remains ambiguous as it is also applied to indicate the presence of a pregnancy located within the cavity in one of the two upper "horns" of a bicornuate uterus. Interstitial pregnancies have a higher mortality than ectopics in general.

A morcellator is a surgical instrument used for division and removal of large masses of tissues during laparoscopic surgery. In laparoscopic hysterectomy the uterus is cut up in strips, or morcellated, into smaller pieces inside the patient's abdominal cavity in order to extract from the abdomen. It can consist of a hollow cylinder that penetrates the abdominal wall, ending with sharp edges or cutting jaws, through which a grasper can be inserted to pull the mass into the cylinder to cut out an extractable piece.

<span class="mw-page-title-main">FIGO classification of uterine bleeding</span>

The International Federation of Gynecology and Obstetrics is an international organization that links about 125 international professional societies of Obstetricians and Gynecologists. In 2011 FIGO recognized two systems designed to aid research, education, and clinical care of women with abnormal uterine bleeding (AUB) in the reproductive years. This page is a summary of the systems and their use in contemporary gynecology.

Robert S. Neuwirth was an American physician, inventor, and real estate developer. Neuwirth devoted his career to crafting and refining noninvasive practices promoting women's health. He was one of the first doctors to employ endoscopy in gynecological practice, in which a small optical instrument called an endoscope is used to examine areas tucked deep into the body. He is known as the first doctor to introduce laparoscopy to the United States, in 1968.

References

  1. ↑ "About - Mayo Clinic". www.mayoclinic.org. Retrieved 2018-11-06.
  2. ↑ Agdi M, Tulandi T (August 2008). "Endoscopic management of uterine fibroids". Best Practice & Research. Clinical Obstetrics & Gynaecology. 22 (4): 707–16. doi:10.1016/j.bpobgyn.2008.01.011. PMID   18325839.
  3. ↑ Soriano D, Dessolle L, Poncelet C, Benifla JL, Madelenat P, Darai E (June 2003). "Pregnancy outcome after laparoscopic and laparoconverted myomectomy". European Journal of Obstetrics, Gynecology, and Reproductive Biology. 108 (2): 194–8. doi:10.1016/S0301-2115(02)00436-0. PMID   12781410.
  4. ↑ Polena V, Mergui JL, Perrot N, Poncelet C, Barranger E, Uzan S (February 2007). "Long-term results of hysteroscopic myomectomy in 235 patients". European Journal of Obstetrics, Gynecology, and Reproductive Biology. 130 (2): 232–7. doi:10.1016/j.ejogrb.2006.01.014. PMID   16530319.
  5. ↑ Camanni M, Bonino L, Delpiano EM, Ferrero B, Migliaretti G, Deltetto F (2010). "Hysteroscopic management of large symptomatic submucous uterine myomas". Journal of Minimally Invasive Gynecology. 17 (1): 59–65. doi:10.1016/j.jmig.2009.10.013. PMID   20129334.
  6. ↑ "Page Not Found". www.asrm.org.{{cite web}}: Cite uses generic title (help)
  7. ↑ Fedele L, Parazzini F, Luchini L, Mezzopane R, Tozzi L, Villa L (July 1995). "Recurrence of fibroids after myomectomy: a transvaginal ultrasonographic study". Human Reproduction. 10 (7): 1795–6. doi:10.1093/oxfordjournals.humrep.a136176. PMID   8582982.
  8. ↑ Kelly BA, Bright P, Mackenzie IZ (January 2008). "Does the surgical approach used for myomectomy influence the morbidity in subsequent pregnancy?". Journal of Obstetrics and Gynaecology. 28 (1): 77–81. doi:10.1080/01443610701811738. PMID   18259905. S2CID   10493000.
  9. 1 2 Kongnyuy, Eugene J; Wiysonge, Charles Shey; Kongnyuy, Eugene J (2014). "Interventions to reduce haemorrhage during myomectomy for fibroids". Reviews. 8 (8): CD005355. doi:10.1002/14651858.CD005355.pub5. PMC   9017065 . PMID   25125317. S2CID   205178527.
  10. ↑ Lee, Hee Joong; Norwitz, Errol R; Shaw, Julia (2010). "Contemporary Management of Fibroids in Pregnancy". Reviews in Obstetrics and Gynecology. 3 (1): 20–27. ISSN   1941-2797. PMC   2876319 . PMID   20508779.
  11. ↑ Bhatla N, Dash BB, Kriplani A, Agarwal N (February 2009). "Myomectomy during pregnancy: a feasible option". The Journal of Obstetrics and Gynaecology Research. 35 (1): 173–5. doi:10.1111/j.1447-0756.2008.00873.x. PMID   19215567. S2CID   205509012.
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