Myomectomy

A myomectomy is an operation performed to remove benign tumours called fibroids from the muscular wall of the uterus. Fibroids often cause pain and excessive menstrual bleeding. They can also interfere with your ability to become pregnant. They may degenerate or become infected, and therefore your doctor may feel they should be surgically removed. A hysterectomy may be suggested if you are over childbearing age.

Uterine fibroids

Fibroids are categorised by their locations, which include:

• Intramural - in the uterine wall. Intramural fibroids are the most common variety.
• Submucosal - in the uterine lining (endometrium). This type tends to cause excessive menstrual bleeding and period pain.
• Subserosal - on the exterior wall of the uterus. They sometimes appear like long stalks.

Medical issues to consider

Your doctor may order an ultrasound scan to try to pinpoint the fibroids prior to surgery. Some blood tests may be ordered to see if you are anaemic (symptoms can include excessive tiredness, breathlessness on exertion, pale skin and poor resistance to infection). A urine test will tell if you have an infection in your urinary system. The anaesthetist visits you prior to your operation to see if you are suitable to have a general anaesthetic. (If you are not suitable, you may have the operation performed under a spinal or epidural anaesthetic.) For a general anaesthetic, you are usually given a pre-medication injection to dry up your internal secretions and make you feel drowsy. Some surgeons request you have an enema and a portion of your pubic hair shaved prior to surgery.

Operation procedure

In most cases, the surgeon performs a dilatation and curettage (D&C) to check for irregularities in the inner surface of the uterus. The kind of myomectomy performed depends on the type, size, number and location of the fibroids, but can include:

• Abdominal myomectomy - the uterus is accessed via one large incision through the abdomen. Usually, a horizontal cut just on the bikini line is performed; in some cases, the incision may need to be made vertically in the midline of your abdomen. The uterus is cut, sometimes with a laser (which closes off blood vessels and reduces bleeding). The fibroids are then removed and the uterus, abdominal wall and skin are closed with sutures. This type of myomectomy is preferred for multiple or deeply rooted fibroids. The drawback of abdominal myomectomy is that it takes longer to recover.
• Laparoscopic myomectomy - subserosal fibroids can often be removed via laparoscopic (‘keyhole’) myomectomy. The surgeon makes a number of small incisions, which allow different instruments access to the uterus. Among these instruments is the laparoscope, which contains fibre-optic camera heads or surgical heads (or both). The fibroids are removed, and the small wounds sutured (sewn) closed. Recovery time for the patient is comparatively fast.
• Hysteroscopic myomectomy - the fibroids are removed via the dilated cervix, so no abdominal incisions are needed. The instrument is called a resectoscope, which is a hysteroscope fitted with a wire loop. The instrument is inserted through the cervix, and the wire loop slung over the fibroid. Electrical energy passes through the loop, which cuts the fibroid loose. The fibroid can then be removed through the vagina.

Immediately after the operation

After the operation, you can expect:

• Your temperature, pulse, respiration and blood pressure is observed and noted.
• Any vaginal discharge is noted.
• An intravenous fluid line may still be running into your arm to replace fluids in your body. Antibiotics may be included to combat infection.
• You may have some tubes at the wound site to drain off excess fluid if necessary.
• If you need pain relief, tell your nurse.
• You may have a catheter to drain off urine for the next day or so.
• You are given a normal diet, once your doctor feels it is safe to do so. Tell your nurses as soon as you pass wind or a bowel motion, as this shows that your digestive system is getting back to normal.
• Perform your breathing, coughing and leg exercises hourly when you are awake.
• You are assisted out of bed and taken for a walk the day following surgery.
• You may be in hospital for five to seven days following surgery.

Possible complications

Possible complications of myomectomy include:

• Haemorrhage
• Injury to the uterus
• Damage to the nearby organs of the urinary system
• Formation of scar tissue (adhesions) within the uterus
• Infection
• Blood clots
• Eventual re-growth of fibroids.

Taking care of yourself at home

Be guided by your doctor, but general suggestions include:

• Try to rest as much as possible for two weeks.
• Avoid standing for more than a few minutes at a time.
• Continue to take your medications, and follow strictly the instructions on taking your antibiotics.
• After two weeks, aim to walk for about 10 minutes every day, unless advised otherwise by your doctor.
• Depending on the type of surgery, you can return to work within two to six weeks (abdominal myomectomy takes the longest recovery time).
• If you have any excessive vaginal bleeding, or signs of infection at your wound site (such as redness, increasing pain, swelling, or an increased or offensive discharge from your wound), see your doctor immediately.

Long term outlook

You will still have your uterus and all reproductive organs following myomectomy. Once healed, there should be no effects on your sexual activity, and you should still be able to conceive. Depending on the depth of the scar in your uterus, you may require an elective caesarean section at 38 weeks to safely give birth. If you are seeking myomectomy as a remedy to excessive menstrual bleeding, it is important to know that the operation is unsuccessful in around 20 per cent of cases - your heavy menstrual flow may be due to factors other than fibroids. See your doctor for further information and advice.

Other forms of treatment

Other possible forms of treatment for fibroids may include:

• Monitoring - if the fibroids are asymptomatic, a ‘wait and see’ approach is often adopted.
• Drugs - such as hormones, used in combination, to shrink the fibroids prior to surgery.
• Hysterectomy - the surgical removal of some or all of the uterus. Pregnancy is no longer possible after a hysterectomy.

Where to get help

• Your doctor
• Gynaecologist.

Things to remember

• A myomectomy is an operation performed to remove benign tumours called fibroids from the muscular wall of the uterus.
• The kind of myomectomy performed depends on the type, size, number and location of the fibroids.
• You will still have your uterus and all reproductive organs following myomectomy.