Myomectomy

You are the gynaecology registrar. A 34-year-old nullipara wants to preserve her fertility but has a 10-week-size uterus with a dominant 7 cm posterior intramural fibroid and a 3 cm FIGO type 1 submucous fibroid causing heavy menstrual bleeding and anaemia. She wants a uterus-sparing operation, has a BMI of 32, and has had no prior surgery. She has heard the word "morcellation" on the internet and asks if it is safe. That is the brief for this topic.^[2][3]

Overview and definition

Myomectomy is the surgical enucleation of leiomyoma(s) from the uterus with uterine conservation. It is the operation of choice for symptomatic fibroids in women who want to preserve their uterus or their fertility, and it competes with uterine artery embolisation (UAE), MRI-guided focused ultrasound (HIFU/MRgFUS), radiofrequency ablation (RFA), and — when family is complete — hysterectomy.^[15]

Three routes are in routine practice, and the route is dictated by the FIGO type, the size, the number, and the operator's expertise:^[7]

• Hysteroscopic myomectomy — through the cervix, no abdominal incision. First-line for FIGO type 0, 1 and selected 2 (cavity-distorting submucous fibroids).
• Laparoscopic (or robotic) myomectomy — through 3–4 ports, contained specimen extraction. For FIGO 3, 4, 5 and 6, in appropriately selected uteri.
• Abdominal (open) myomectomy — pfannenstiel or midline laparotomy. For very large uteri (>14–16-week size), multiple >5 fibroids, cervical or broad-ligament location, or when laparoscopic skill or visualisation is limited.

References25ShowHide

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