What are the principles of myomectomy, including indications, pre‑operative evaluation, choice of surgical approach, operative technique, postoperative care, potential complications, and alternative treatment options?

Principles of Myomectomy

Goal and Fundamental Principle

The primary goal of myomectomy is to remove all identifiable leiomyomata with the least possible distortion of the reproductive tract, while minimizing blood loss and adhesion formation. 1

Indications for Myomectomy

• Symptomatic fibroids causing abnormal uterine bleeding, pelvic pain, or pressure symptoms in women who wish to preserve the uterus. 2
• Women desiring fertility preservation when fibroids are associated with menorrhagia, pelvic discomfort, or palpable abdominal masses. 3
• Submucosal fibroids are the only type consistently shown to improve spontaneous fertility or assisted reproduction outcomes when removed. 4
• Prophylactic myomectomy is NOT recommended for preventing obstetrical complications or leiomyosarcoma risk. 4
• Concern about possible pregnancy complications related to fibroids is NOT an indication for myomectomy except in women who had previous pregnancies with fibroid-related complications. 5

Pre-operative Evaluation and Optimization

Diagnostic Imaging

• Pelvic ultrasound is the initial imaging modality to distinguish leiomyomata from other pelvic masses such as ovarian tumors. 1
• Endovaginal sonography with saline infusion improves detection of the proximity of fibroids to the endometrial cavity by using the endometrial stripe as a reliable marker. 1
• Surgical planning should map the location, size, and number of fibroids using appropriate imaging. 5

Risk Stratification

• Uterine size ≥16 weeks' gestation markedly increases the risk of intraoperative transfusion and requires enhanced preparation. 2
• Posterior uterine fibroid location significantly increases the risk of major intraoperative hemorrhage. 2

Medical Optimization

• Preoperative anemia must be corrected before elective surgery. 5
• Selective progesterone receptor modulators and GnRH analogues effectively correct anemia and should be considered preoperatively in anemic patients. 5
• Autologous blood storage should be considered for high-risk patients. 2
• GnRH agonist therapy can reduce fibroid volume preoperatively, though severe side effects and prompt recurrences limit utility to short-term goals such as reversing anemia or shrinking intracavitary tumors before hysteroscopic resection. 1

Choice of Surgical Approach

Hysteroscopic Myomectomy

• Indicated for pedunculated submucosal fibroids ≤5 cm in diameter. 2
• Should be considered first-line conservative surgical therapy for symptomatic intracavitary fibroids. 5
• If the tumor is completely intracavitary, hysteroscopic resection is the most cost-effective method. 1
• Provides the shortest hospital stay, fastest postoperative recovery, and quality-of-life outcomes comparable to abdominal approaches at 2–3 months. 2
• NOT advisable as sole treatment for patients with substantial intramural or subserosal fibroid burden or co-existing adenomyosis. 2
• Potential complications include uterine perforation, fluid overload, transfusion need, bowel/bladder injury, endomyometritis, and possible re-intervention. 2

Laparoscopic Myomectomy

• Recommended for subserosal or intramural fibroids when the overall fibroid burden is limited. 2
• Pedunculated, serosal, and superficial intramural leiomyomas can be removed via laparoscopy, but surgery is lengthy and technically difficult, requiring the most experienced endoscopic surgeons. 1
• Associated with shorter hospital stay, quicker return to daily activities, and lower wound-infection rates compared with open surgery. 2
• Does not reduce adhesion rate at the surgical site but does reduce de novo adhesion formation elsewhere in the pelvis. 1
• Carries a measurable risk of uterine rupture in later pregnancies. 2

Open (Abdominal) Myomectomy

• Preferred for multiple fibroids or very large uteri where minimally invasive techniques are not feasible. 2
• Offers durable improvement in quality of life maintained for up to 10 years. 2
• Disadvantages include higher incidence of postoperative adhesions, longer recovery time, and increased wound-infection rates. 2
• Carries a measurable risk of uterine rupture in later pregnancies. 2

Operative Technique and Hemostatic Measures

Blood Loss Prevention

• Application of tourniquets to vascular pedicles effectively reduces intraoperative blood loss. 2
• Intramyometrial injection of vasopressin is recommended to diminish hemorrhage during fibroid enucleation. 2
• Use of vasopressin, bupivacaine with epinephrine, misoprostol, peri-cervical tourniquet, or gelatin-thrombin matrix reduces blood loss and should be considered. 5
• When vasopressin is used, ensure postoperative myometrial incisional bleeding does not occur after clearance of the vasopressin. 1
• Intraoperative blood scavenger systems can reduce net surgical blood loss. 1

Surgical Technique Principles

• Posterior uterine incisions should be avoided when possible because they are associated with higher risk of severe bleeding. 2
• Confine incisions to the anterior uterine surface to protect bowel and adnexal structures. 1
• Myomectomy at the time of operative delivery is particularly hazardous due to increased vascularity during pregnancy. 1

Adhesion Prevention

• A major risk of myomectomy is postoperative adhesion formation at incision sites and de novo adhesions from peritoneal trauma. 1
• These can result in reduced subsequent fertility or bowel obstruction. 1
• Minimize surgical trauma and use adhesion prevention barriers such as oxidized regenerated cellulose, polytetrafluoroethylene, or hyaluronic acid-carboxymethylcellulose combination. 1

Specimen Removal

• When morcellation is necessary, patients must be informed about possible risks including the fact that fibroids may rarely contain unexpected malignancy and that laparoscopic power morcellation may spread cancer, potentially worsening prognosis. 5

Postoperative Care and Pregnancy Timing

• Patients should wait 2–3 months after myomectomy before attempting conception to allow adequate healing of the uterine incision and lower the risk of uterine rupture in subsequent pregnancy. 2, 6
• Symptom relief and quality-of-life scores become comparable across all surgical approaches by 2–3 months postoperatively. 2
• Both open and laparoscopic myomectomy are associated with improved quality of life for up to 10 years. 7, 6

Fertility Outcomes

• Large prospective registries show no statistically significant difference in subsequent fertility outcomes among hysteroscopic, laparoscopic, and open myomectomy. 2
• Among women who attempt conception after myomectomy, fewer than 50% achieve pregnancy within three years, and fewer than half of those pregnancies result in a live birth. 2
• Clinicians must not assume myomectomy will automatically improve fertility; high-quality evidence demonstrating increased live-birth rates is lacking. 2

Potential Complications

• Significant intraoperative blood loss is frequently encountered due to the well-vascularized uterus. 1
• Uterine size ≥16 weeks' gestation significantly increases transfusion risk. 7
• Posterior uterine incision is a significant risk factor for major intraoperative hemorrhage. 7
• Postoperative adhesion formation can reduce fertility or cause bowel obstruction. 1
• Rare instances of uterine rupture during subsequent pregnancy after both laparoscopic and open myomectomy. 7, 2
• Up to 50% recurrence rate after surgical removal. 1

Critical Pitfalls to Avoid

• Endometrial ablation should never be performed in women desiring future fertility, as it markedly increases the risk of pregnancy complications. 2
• Recommending hysterectomy as initial treatment for patients who wish to preserve fertility is contraindicated. 2
• Do not perform prophylactic myomectomy to prevent obstetrical complications or leiomyosarcoma. 4

Alternative Treatment Options

• Hysterectomy is the most effective and definitive treatment for symptomatic uterine fibroids in women not desiring fertility preservation. 5
• Uterine artery embolization may be offered to selected women with symptomatic fibroids who wish to preserve their uterus, though fecundity and pregnancy may be impacted. 5
• Medical management options include levonorgestrel intrauterine system, GnRH analogues, selective progesterone receptor modulators, oral contraceptives, progestins, and danazol for abnormal uterine bleeding. 5
• Newer focused energy delivery methods and radiofrequency thermal ablation are promising but lack long-term data. 5, 8