Fibroid following a myomectomy.
Note the well defined border and solid appearance.
Click the image for larger view.
The majority of myomectomies can be performed in an outpatient surgical center and do not require hospitalization unless mandated by insurance. Our surgeons have been performing outpatient myomectomies for over 20 years. A specialized approach to making the incisions, controlling bleeding, and managing post operative pain result in an approach that is quite different than the approach by many other doctors.
Once an abdominal incision is made, the abdominal muscles are separated (not cut), and the abdomen is entered. Once the fibroid(s) have been located, the surgeon carefully determines a surgical approach to minimize damage to the uterus and to reduce the subsequent risk of scar tissue formation. The surgeon then separates the uterine muscle from the hard and rubbery fibroid. In most cases the fibroid “shell out” from the surrounding tissue. Care must be taken to minimize the damage to the surrounding muscle and blood vessels. The uterine muscle is sewn in layers to provide strength and restore the normal architecture to the uterus as best as possible. The surgical time can range from one hour for a single uterine fibroid to 3 or more hours for multiple uterine fibroids. In most cases, blood loss is less than 200 mL (less than a cup).
Patients are sent home the same day to begin the recovery process. It is normal to experience pain after the procedure, however most patients are able to walk around the house and provide care for themselves. The recovery is very comparable to a cesarean section. While some patients may take longer to recover, most patients are resuming normal activities by 2 weeks. Patients should refrain from driving and intercourse until cleared by their surgeon.
Following surgery, the uterine tissue undergoes remodeling and healing. After this process the uterus can take on a normal appearance and function. In many cases it is difficult to tell a woman has had a myomectomy if the procedure was completed by an experienced surgeon. Depending on the amount of normal muscle that is disrupted by the surgery or displaced by the fibroid, the physician may recommend that labor be avoided in favor of a cesarean section. As the muscle heals scar tissue can form. This scar is prone to rupture during labor. Not all myomectomies require subsequent cesarean section for delivery so be certain you understand your situation after the surgery and patients should follow the instructions provided by their surgeon.
When can you try to get pregnant? The uterus recovers within 2 to 3 months of the surgery. The surgeons at California IVF Fertility Center recommend patients do not attempt pregnancy for at least 2-3 months to give the uterus and abdomen time to heal. When patients are undergoing fertility treatments, the treatment process can usually start after 2 months so the soonest pregnancy will generally occur will be 3 months after the surgery. Patients with multiple uterine fibroids will be at a higher risk of having the fibroids return and may wish to discuss more aggressive treatment such as IVF.
Hysteroscopic Myomectomy for Intrauterine Fibroids
When uterine fibroids occur in the cavity of the uterus, the procedure used to remove the fibroid is known as an operative hysteroscopy, or hysteroscopic myomectomy. A camera is placed through the uterus to visualize the inside of the uterus. Instruments are then passed through the hollow portion of the scope to remove the fibroid. There are several instruments that can be used to remove fibroids from the uterus. One of the older surgical techniques involves using an electrical wire loop to shave pieces off the fibroid. These pieces are then removed from the uterine cavity. The surgeon must be very careful to not go too deep with the electrical loop or cause too much damage to the uterus. The risk of post operative scar tissue is slightly higher when the muscle wall of the uterus is damaged.
An alternative to the operative resectoscope is the hysteroscopic morcellator. This is a specialized instrument designed to grind, or morecellate, the fibroid and evacuate it using suction. The devices are designed in such a way that damage to the normal uterine muscle is greatly reduced. Because the devices are usally combined with a fluid management system to control the inflow and outflow of water, the surgeon can accurately measure fluid volumes and minimize the risk of fluid overload. The outgoing fluid carries away the fragments of the fibroid so the surgical times can be greatly reduced. Most patients are candidates for this newer technique.
Hysteroscopy can only be used for fibroids that are inside the cavity of the uterus. When the fibroids are in the muscle wall of the uterus, they may be able to be removed hysteroscopically. As the fibroid is removed, the uterine muscle contracts and pushes the fibroid more into the cavity of the uterus. The majority of the fibroid will need to be in the cavity for this approach to work. If the majority of the fibroid is in the muscle wall, an abdominal myomectomy will be needed. In some cases, patients may need operative hysteroscopy to remove fibroids in the cavity of the uterus and an abdominal myomectomy to remove fibroids in the muscle wall of the uterus.
Adenomyosis and Adenomyomas
Adenomyosis is a condition in which the glandular tissue that normally lines the inside of the uterus (endometrium) invades into the muscle of the uterus. These glands go through changes during the menstrual cycle like the normal endometrial tissue. The body attempts to remove the tissue from the muscle and scar tissue can result. The normal soft muscle tissue begins to become hard and rubbery with less and less normal blood flow to support a pregnancy. Because the glandular tissue is interwoven with the normal muscle tissue, it can not be removed surgically. When the adenomyosis tissue becomes more hardened and forms a larger mass, it may be referred to as an adenomyoma. Adenomyomas can appear to be fibroids on an ultrasound. Adenomyomas and uterine fibroids can exist together in the same uterus. Adenomyomas can be debulked by removing a portion of the uterine wall or muscle along with the mass. Care must be taken not to damage or destroy too much of the uterine muscle or cavity of the uterus. Adenomyosis can significantly reduce the chances of pregnancy. When adenomyosis is encountered during surgery, the surgeon may attempt to minimize the effect of the adenomyosis though in many cases the prognosis for a successful pregnancy is low. Adenomyosis can be very difficult to identify or diagnose outside of surgery and in many cases it has gone undetected for years before it is discovered. There are some medical treatment strategies that have been used with limited success. Women with adenomyosis should have a consultation with a fertility specialist as soon as possible. The longer adenomyosis is present, the worse the prognosis can become.