Myomectomy and Fibroid Removal

Myomectomy is the surgical removal of uterine fibroids (leiomyomas, also called myomas) while leaving the uterus in place. It is the principal uterus-conserving operation for symptomatic fibroids and is chosen particularly by people who wish to retain the uterus or preserve fertility. Fibroids can be removed abdominally, laparoscopically, or — when they project into the uterine cavity — hysteroscopically.

Definition

Myomectomy is the surgical removal of one or more uterine fibroids (leiomyomas) with preservation of the uterus, performed by abdominal, laparoscopic, or hysteroscopic routes depending on the number, size, and location of the fibroids.

Scope

This topic covers what myomectomy is, how it differs from hysterectomy, the surgical routes used according to fibroid location and size, and the role of preoperative medical therapy. It is a reference entry within gynecologic surgical procedures and does not give individualized surgical or medical advice.

Core questions

• When is uterus-conserving myomectomy preferred over hysterectomy?
• How does fibroid location (submucosal, intramural, subserosal) determine the surgical route?
• What is the role of preoperative medical therapy before fibroid surgery?

Key concepts

• Uterine leiomyoma (fibroid, myoma)
• Uterus- and fertility-sparing surgery
• Submucosal, intramural, and subserosal fibroids
• Abdominal, laparoscopic, and hysteroscopic myomectomy
• Preoperative medical (hormonal) therapy
• Risk of fibroid recurrence

Mechanisms

Fibroids are benign monoclonal smooth-muscle tumours of the myometrium and a leading cause of heavy menstrual bleeding, bulk symptoms, and reproductive problems (Stewart, 2001). Myomectomy enucleates the fibroid from its surrounding myometrium and repairs the defect, conserving the uterus. The route follows the fibroid's relationship to the cavity: submucosal fibroids that project into the cavity are accessible hysteroscopically, while intramural and subserosal fibroids are removed abdominally or laparoscopically. Preoperative medical therapy — for example GnRH analogues — can reduce fibroid and uterine size and correct anaemia before surgery, with trade-offs in cost and side effects (Lethaby et al., 2017).

Clinical relevance

Myomectomy offers symptom relief while preserving the uterus, but fibroids can recur and the operation carries surgical risks, so it is one of several options for symptomatic fibroids alongside medical therapy, uterine-artery embolization, and hysterectomy. This entry describes the procedure and the evidence around it; it is not a basis for individual treatment decisions.

Epidemiology

Uterine fibroids are very common, are a frequent indication for gynecologic surgery, and disproportionately affect women later in their reproductive years; they account for a large share of operations performed for benign uterine disease (Stewart, 2001).

History

Abdominal myomectomy is a long-established uterus-conserving operation. The development of operative hysteroscopy and laparoscopy extended fibroid surgery to minimally invasive routes for cavity-distorting and accessible lesions, and preoperative hormonal therapy was introduced to shrink fibroids and improve preoperative haematologic status (Lethaby et al., 2017).

Debates

Should fibroids be removed by myomectomy or treated by alternatives?

For symptomatic fibroids, myomectomy, uterine-artery embolization, medical therapy, and hysterectomy each trade off symptom control, uterine and fertility preservation, recurrence risk, and invasiveness, and the best choice depends on symptoms, fibroid characteristics, and the patient's reproductive goals.

Is preoperative medical therapy worthwhile before fibroid surgery?

Preoperative GnRH-analogue and related therapy can reduce fibroid and uterine volume and correct anaemia, but it adds cost and side effects and its benefit varies by surgical plan, so its routine use is debated.

Seminal works

• stewart-2001
• lethaby-2017

Frequently asked questions

How is myomectomy different from hysterectomy?

Myomectomy removes only the fibroids and leaves the uterus in place, preserving the possibility of future pregnancy, whereas hysterectomy removes the entire uterus. Because the uterus is conserved, new fibroids can develop after a myomectomy.

Can all fibroids be removed without an abdominal incision?

No. Fibroids that bulge into the uterine cavity (submucosal) can often be removed hysteroscopically, and some others laparoscopically, but large or numerous intramural fibroids may require an abdominal approach. The route depends on the size, number, and location of the fibroids.