What are the considerations for performing a Caesarean (C-section) myomectomy?

Caesarean Myomectomy: Clinical Considerations

Primary Recommendation

Caesarean myomectomy is feasible and safe in selected cases at tertiary centers with experienced surgeons, particularly for anterior wall, subserosal, and pedunculated myomas, or when fibroids compromise fetal extraction or uterine closure. 1, 2

When to Perform Caesarean Myomectomy

Clear Indications

• Myomas that interfere with fetal extraction should be removed during caesarean section 1
• Myomas that compromise uterine incision closure warrant removal at the time of delivery 3, 1
• Anterior wall myomas are generally safe to remove during caesarean section 1
• Subserosal and pedunculated myomas can be safely enucleated, particularly when removal is feasible without additional hysterotomy 1

Favorable Characteristics

• Single or few myomas (multiple myomas increase complication risk) 1, 4
• Myomas <10 cm in size (larger myomas significantly increase complications) 4
• Superficial location rather than deep intramural 1

When to Avoid Caesarean Myomectomy

High-Risk Scenarios

• Multiple myomas are associated with increased surgical complications 1, 4
• Deep intramural myomas carry higher complication rates 1
• Fundal and cornual myomas increase surgical risk 1
• Posterior uterine wall myomas are associated with major intraoperative hemorrhage 5, 1
• Myomas >10 cm without secondary degeneration significantly increase risk of complications including blood transfusion, postoperative ileus, and prolonged hospitalization 4

Expected Outcomes and Complications

Surgical Metrics (Meta-Analysis Data)

• Operative time increases by approximately 15 minutes compared to caesarean section alone 3, 2
• Hospital stay increases by approximately 1 day (0.36 days mean difference, clinically insignificant) 3, 2
• Mean hemoglobin decrease of 0.27 g/dL more than caesarean section alone (statistically significant but clinically insignificant) 2

Complication Rates

• Blood transfusion risk increases 1.45-fold compared to caesarean section alone (RR = 1.45,95% CI = 1.05-1.99) 2
• No significant difference in hemorrhage rates between caesarean myomectomy and caesarean section alone (RR = 1.16, p = 0.32) 2
• No significant difference in febrile morbidity between groups (RR = 1.17, p = 0.36) 2
• Hysterectomy is rarely required even with large myomas (>5 cm) 3

Blood Loss Expectations

• Most patients lose 1-1.5 liters during the procedure 3
• Patients with very large myomas (>10 cm) may lose up to 3.2 liters 3
• Stepwise devascularization or preoperative uterine balloon catheter placement may be necessary for large myomas 3

Hemostatic Techniques to Minimize Risk

• Apply tourniquets on vascular pedicles to minimize blood loss 5
• Inject vasopressin or other vasospastic agents into the myometrium 5
• Correct anemia preoperatively to reduce transfusion risk 5
• Consider autologous blood storage for high-risk cases 5

Alternative Approach: Interval Myomectomy

For patients with high-risk features (multiple myomas, posterior wall location, deep intramural, >10 cm), consider delaying myomectomy 4-6 weeks postpartum if expectant delay is feasible, as this may reduce surgical morbidity. 6, 1

Critical Pitfalls to Avoid

• Do not assume all myomas require removal during caesarean section—only those interfering with delivery or closure warrant intervention 1
• Do not attempt caesarean myomectomy without experienced surgical team and tertiary care resources 3, 2
• Do not underestimate blood loss risk with posterior wall or large intramural myomas 5, 1, 4
• Do not perform caesarean myomectomy for asymptomatic serosal fibroids that do not interfere with the surgical field 7

Facility and Surgeon Requirements

• Tertiary care centers with blood bank access are essential 3, 2
• Experienced surgeons should perform the procedure 3, 2
• Appropriate hemostatic techniques and equipment must be available 5, 3