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|Uterine Fibroid Embolization|
|Female Reconstructive Surgery|
Myomectomy is a surgical procedure to remove uterine fibroids and leave the uterus intact. There isn’t a lot written about myomectomy in the medical literature because less than 40,000 are actually performed in the United States each year. Pretty small potatoes compared to hysterectomy. It doesn’t help any that the American College of Obstetricians and Gynecologists (ACOG) recognizes this procedure ONLY for women who want to have more children. Apparently, the rest of us have to learn to fly kites without our uterus.
Myomectomy can, however, actually weaken the uterus and make child bearing more difficult and prone to uterine rupture. Considering that fertility is the only indication for myomectomy that ACOG recognizes, doesn’t this seem a bit ironic?
For women who experience pain and bulk symptoms from uterine fibroids, myomectomy can be the procedure that saves the day. For others, the mere thought of walking around with fibroids growing inside of them is enough to get them to a surgeon to have them removed. They’re benign – but so what – they’re still inside of you and entirely uninvited. Why should any woman have to continue suffering or submit to a hysterectomy when she simply wants her fibroids out? She shouldn’t. Myomectomy can take care of those fibroids and allow any woman to keep her uterus. I do mean, by the way, ANY woman. ANY age. There is no reason whatsoever for women over the age of 40 to be disqualified from a myomectomy. It has no more risk than a hysterectomy – maybe less in a great many cases. If you’re a woman who fits this category with uterine fibroids, keep looking – there are doctors out there who do not participate in age discrimination. They understand that a fibroid is a fibroid – regardless of the age of the patient.
Fibroid Growth After Age 60
With age comes increased risk of leiomyosarcoma. Cancer. Not a lot of increased risk. But up to 1% of women in their 60s and beyond will have a malignancy. That's 1 out of every 100 women over the age of 60. If you are post menopausal and begin experiencing unusual bleeding accompanied with sudden growth of fibroids, it’s important to be checked for the potential of cancer.
There are numerous ways that doctors perform a myomectomy. The type, size, and location of your fibroids determine which of the following myomectomies might be recommended.
In short, laparoscopic myomectomy does a pretty good job of taking out pedunculated subserosal fibroids through the belly button along with a few other "stab" locations in the abdomen, hysteroscopic myomectomy is for submucosal fibroids that can be removed vaginally, and laparotomy takes care of all fibroids no matter their location, size, or number. Laparoscopic Myomectomy with Mini-Lap allows for the removal of slightly larger subserosal fibroids than what the laparoscope alone can handle -- but is a relatively small incision of 3" or less in the abdomen. LAVM allows for the laparoscopic removal of subserosal fibroids from the uterus with the total removal of fibroid material through a vaginal incision.
Clearly, any myomectomy involving the use of laparoscope or hysteroscope requires an endoscopic surgeon with a little more skills underneath his/her belt than what is acquired from most medical schools today. Also, since these tools are relatively new in the timeline of gynecological medicine, physicians trained in an earlier era of medicine (by even a single decade!) may not have the skills or comfort level necessary to perform anything other than a laparotomy. Remember this when discussing your surgical options with your gynecologist as it may bear some weight in the recommendation(s) you receive.
I Said Myomectomy – NOT Hysterectomy!
If you are undergoing a myomectomy and you do not want to wake up without your uterus, you must put it in writing that you do not want a hysterectomy under any circumstances other than those necessary to save your life. Specific instructions to the physician should be noted on the hospital admitting forms as well as the informed consent document for surgery.
Through use of a laparoscope, this type of myomectomy does a pretty good job of removing pedunculated subserosal fibroids and small subserosal fibroids not growing too deeply into the uterus. Since the fibroids are chopped up (morcellated) and suctioned out through the laparoscope, there is no abdominal incision to recover from, less discomfort and pain, and you’re up and around fairly quickly after the procedure. Without an abdominal incision, the complication and infection rates are much lower and the total recovery time is only a few days to a week or so.
The biggest drawback? It’s not always a piece of cake. Sometimes the doctor has to switch over to laparotomy. He might not be able to see everything or safely maneuver your fibroid uterus to remove your fibroids through the laparoscope. If the subserosal fibroids are growing too deeply into the uterus and the surgeon attempts to remove it with the laparoscope, excessive bleeding can occur. A laparotomy might be necessary to stop the bleeding and repair the uterus.
Not all gynecologists do laparoscopic myomectomy or do it well. Many doctors won’t recommend this type of myomectomy if their skill level is insufficient. The bad part is, they won’t refer you to someone else who IS more skilled either. They’ll push for either a laparotomy or hysterectomy instead. This is one of those times when it’s absolutely critical for you to know about your fibroids. What kind, how many, where are they located. You can control, to some degree, the type of recommendation that is made for you when you demonstrate to the doctor you have knowledge of your condition and you know what the appropriate recommendations should be. If you think laparoscopic myomectomy is an appropriate treatment option for your fibroids and find it isn’t being recommended, ask why not. Your doctor may have a very legitimate reason for recommending laparotomy instead. In that case, it is still appropriate to find out what that reason might be.
Hysteroscopic myomectomy involves placing a hysteroscope into the uterus by going up through the vagina and cervical canal to take a look see at your submucosal fibroids. Any fibroids which are definitely visible through this avenue to your uterus can, the majority of the time, be removed through use of an instrument called the resectoscope. Your doctor might tell you he is "resecting" your submucosal fibroids. The resectoscope is a special instrument designed to destroy unwanted tissue invading the uterine lining. Not all submucosal fibroids can be removed with this technique, however. If the fibroids are large or growing broadly across the endometrium and the surgeon attempts to remove it with the hysteroscope, excessive bleeding can occur. Should this happen, a laparotomy might be necessary to stop the bleeding and repair the uterus.
Most of the time this procedure is done under general anesthesia. It’s typically performed on an "outpatient" basis as it usually doesn’t take more than 60 minutes to complete and involves only a few hours of recovery time. Hysteroscopic myomectomy is a fairly safe procedure with complications occurring less than 1% of the time.
About Excessive Bleeding…
During the discussion of potential myomectomy complications you have with your gynecologist, remember to ask the following two questions about blood transfusions:
1. Can you donate your own blood in advance of the surgery so that it can be used if a transfusion becomes necessary?
2. Has your gynecologist ever worked with an interventional radiologist (IR) in any cases where excessive bleeding has occurred?
IRs have been performing uterine artery embolization for over 20 years now to stem the tide of excessive bleeding after childbirth or other pelvic surgery. If excessive bleeding during your surgery becomes a problem, an IR is a great doctor to have on call because they can stop the bleeding, reduce the need for emergency hysterectomy, and, quite possibly, save your life. It’s not a bad idea to find out whether or not your gynecologist has ever worked with one of these doctors before or is willing to work with one now to ensure that your myomectomy doesn’t rapidly convert to a hysterectomy under the guise of "saving your life" due to excessive bleeding.
Don’t you just hate it when fibroids insist upon growing in the middle of your uterine wall? Those intramural fibroids really know how to muck things up. Sometimes the only thing you can do for those "babies" to remove them (and leave the uterus) is a laparotomy. A full blown abdominal incision. Ouch. Sorry. But look on the bright side – if you happen to have a "fruit basket" of fibroids in and on your uterus, you can be rid of them with one procedure. Of course, with that abdominal incision the complication and infection rate does go up a bit. So does the blood transfusion rate. Think about it. This is major abdominal surgery to remove all of your fibroids. That may mean quite a bit of cutting, removing, and repairing of the layers of tissue that are spread open with an incision during this procedure. We aren’t talking about slicing a piece of pie here! This is your body.
Because of the abdominal incision, this procedure generally requires a short hospital stay of around three days. After that, it’s another four weeks or so before you’re completely healed and ready to go back out and conquer the world.
Combine laparoscopic myomectomy with a mini-abdominal incision and voila -- you have this procedure. Depending upon the size and location of a woman's fibroids, it may be necessary to perform mini-laparotomy to allow the surgeon greater access in reconstructing the uterus along with the fibroid removal.
Some doctors will argue that a mini-lap has a quicker recovery time than a full laparotomy but I don't know. An abdominal incision is an abdominal incision and as such has the same inherent risks as a regular laparotomy. The biggest benefit here seems to be cosmetic. Smaller incision means a smaller scar.
This is a relatively new procedure that combines laparoscopic myomectomy with culdotomy or colpotomy -- a vaginal incision. Fibroids are excised via laparoscopy and then an incision is made in the vagina to remove the fibroid through. When an incision through the vagina is made, the uterus folds back and the surgeon can gain access to the fibroids removed via laparoscope sitting in the abdominal area, remove them, and then suture the vagina back up. No abdominal incisions. No abdominal scars. However, fibroids must be of a size that is removable through the vagina.
This particular type of myomectomy may well replace the mini-laparotomy with laparoscopic myomectomy in some surgeon's practices. There is some disagreement among endoscopic surgeons over the use of colpotomy for the sole purpose of fibroid removal. Healing of vaginal incisions and potential for infection carries with it, of course, additional risk with this procedure. But, there have been so few myomectomies performed this way in the United States that specific risk factors have not yet been determined. So far, the infection rate seems to be low. However, thousands more of this particular type of myomectomy would need to be performed before a true picture of potential risk could be adequately calculated.
The American College of Obstetricians and Gynecologists (ACOG) has developed guidelines to determine who and under what circumstances a woman should have a myomectomy when uterine fibroids are present. Basically, their guidelines indicate that myomectomy should be performed when infertility is an issue and you have not been able to get pregnant or hold onto a pregnancy because of the presence of uterine fibroids. That’s it. Since ACOG recognizes no other treatment option for uterine fibroids when they are symptomatic other than hysterectomy, if you don’t happen to want a hysterectomy you are just plain out of luck because myomectomy is for women who want to get pregnant. Well, not exactly.
Even though it is
not explicitly outlined within the ACOG guidelines, many gynecologists will
perform a myomectomy when the patient chooses to keep her uterus for reasons
other than future pregnancy. So, under those circumstances, the ideal patient
for this procedure meets three basic requirements:
Myomectomy VS. Hysterectomy
It’s been argued that gynecologists make the same income from performing a myomectomy as they do from performing a hysterectomy. Because of this, some doctors believe that gynecologists do not, therefore, have a vested stake in either one of those procedures. In the end, I’m told that women will choose a hysterectomy over a myomectomy – hands down – and that THAT is why the hysterectomy numbers are so high in the United States.
Well, gynecologists may earn the same income from myomectomy, but they certainly don’t spend the same amount of time in the surgical suite performing a myomectomy. Isn’t time money? Also, follow-up care from a hysterectomy along with the need for long-term solutions and support for hormonal imbalances due to the removal of ovaries is worth something to a doctor, isn't it? The HRT (hormone replacement therapy) business is a 5 billion dollar/year business. $5,000,000,000.00 PER YEAR. Just for the drugs many (but not all) women require post hysterectomy. Clearly a hysterectomy is worth something to someone out there in the business world. (Actually, the hysterectomy business is also a 5 billion dollar business in and of itself.)
Since the surgical complication rates are no worse with myomectomy than they are with hysterectomy, I can only assume that women are ‘choosing’ hysterectomy over myomectomy because that is what they are being ‘offered’ by their doctors. Frequently, gynecologists paint a myomectomy as a procedure prone to serious complications and, at the same time, paint a hysterectomy as a rather simple procedure without complications. In reality, depending upon the surgical approach, complications of both may be comparatively the same.
Money is definitely an issue. Insurance providers also kick in their 2 cents on this issue and often attempt to influence the patient's decision. Lack of appropriate payout for a myomectomy is definitely a discouraging factor for many women and their physicians.
These days, it's fairly naive to believe that money doesn't play a significant role in influencing the surgical treatment of "choice" that patients subsequently succumb to.
Where uterine fibroids are concerned, success with myomectomy varies depending upon the size, type and number of fibroids present and the type of myomectomy performed. Complications and complication rates also vary depending upon the size, type and number of fibroids present as well as the type of myomectomy performed. In addition to a minor inherent risk of death (much as that with any medical procedure), the following items are considered potential risks of myomectomy.
In addition to this list of complications, there’s a couple of additional items that contribute to the overall, long-term failure of a myomectomy. If you are undergoing myomectomy in the hopes of simply stopping excessive bleeding (possibly due to submucosal fibroids), you should know that nearly 20% of patients do not experience an improvement with their bleeding. There are many reasons for developing menorrhagia (excessive bleeding) in the first place and fibroids are only one of those reasons. If excessive bleeding continues after the removal of your fibroids, it’s important to continue working with your gynecologist to attempt to diagnose a cause and obtain appropriate treatment.
The other item that contributes to the long-term failure of myomectomy is simply that fibroids continue to develop and grow in your uterus. You have them removed. More grow in. As long as the hormonal imbalance that caused the fibroids to develop in the first place is still happening in your body, the likelihood that fibroids will continue to grow is pretty good. A lot of women start using progesterone cream or taking some form of prescribed synthetic progesterone about this time so the hormonal imbalance scale is tipped back a bit.
A second round of fibroid growth after a myomectomy happens about 25% of the time but generally requires additional treatment (such as a second myomectomy or a hysterectomy) only 10% of the time. Generally, the older you are when you have a myomectomy, the less likely the fibroids will recur and the less likely you will need additional treatment.
The first reported case of a myomectomy was, believe it or not, sometime in the mid to late 1800s. No one really knows who performed the first myomectomy but a man by the name of Eugene Koeberle was the first to write about the removal of only the fibroids in 1864. Over time, myomectomy became widely accepted but the death rate from complications of this procedure remained at around 5% until the 1940s. That’s right. Five (5) out of every one hundred (100) women died.
Around 1942, Dr. Rubin at Mount Sanai Hospital wrote about a relatively large (for that time period) case series of patients who underwent myomectomy. There were 171 patients in the study and by applying the previous 5% death rate standards at least 9 women should have died. This was the first time, however, that not a single patient died during a study of myomectomy. Back then, patients stayed in the hospital about three weeks to recover from this major abdominal surgery. But hey, at least they ALL lived to tell about it.
Surviving surgery. What a concept. An excellent trend that has pretty much carried forward to this day with myomectomy.
What You'll Find
|Women's Surgery Group||Detailed description of myomectomy surgery.|
|Dr. Michael Toaff||Discussion of uterine fibroids and myomectomy as an alternative to hysterectomy.|
author The Hysterectomy Hoax
|Dr. West's personal take on myomectomy.|
|Reproductive Science Center ®||Laparoscopic/Hysteroscopic Myomectomy|
Centre International de Chirurgie Endoscopique CICE
|Laparoscopic myomectomy (LM) as an indication of gynecological laparoscopic surgery. A description of the technique and preliminary results.|
|nezhat.com/fibroid.htm||Camran Nezhat, MD, Farr Nezhat, MD, Oleg Bess, MD, Ceana H. Nezhat, MD, Roy Mashiach, MD||
Laparoscopically Assisted Myomectomy: A Report of a New Technique in 57 Cases.
Int J Fertil 39(1):39-44, 1994
Council on Infertility Information Dissemination, Inc.
Gary S. Berger, M.D.
|Outpatient Uterine Myomectomy|
||Visual depiction of hysteroscopic myomectomy.|
|Uterine Fibroids and Myomectomy|
Candolle, D.M. Walker
WHO Collaborating Centre for Research in Human Reproduction
Infertility and Gynecologic Endocrinology Clinic
Department of Obstetrics and Gynecology
Geneva University Hospital
|Practical Training and Research in Gynecologic Endoscopy: Myomectomy|
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This page last updated Wednesday, April 10, 2002