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Myomectomy

INTRODUCTION

Uterine leiomyomas (fibroids or myomas) are benign clonal tumors arising from the smooth muscle cells of the uterus and containing an increased amount of extracellular matrix. They may be asymptomatic or associated with uterine bleeding, pain, or reproductive problems.

The surgical technique for resection of uterine leiomyomas (ie, surgical myomectomy) will be reviewed here. The diagnosis, clinical manifestations, pathogenesis, and an overview of treatment of these tumors are discussed separately. (See "Epidemiology, clinical manifestations, diagnosis, and natural history of uterine leiomyomas" and "Overview of treatment of uterine leiomyomas".)

INDICATIONS

Asymptomatic uterine leiomyomas are usually managed expectantly [1]. Indications for surgical removal of fibroids are listed in the table (table 1). These are not absolute indications; factors that should be considered prior to initiating treatment include:

  • Size of the myoma(s)
  • Location of the myoma(s) (figure 1)
  • Symptoms
  • Menopausal status
  • Reproductive plans

The type and timing of intervention should be individualized based upon the woman's discomfort, pregnancy plans and obstetrical history, and the likelihood of age or hormonal therapy-related progression or regression of the tumors. Size alone as an indication for surgical removal of asymptomatic fibroids is controversial. A uterine size equivalent to 12 weeks of gestation has generally been the threshold for a surgical procedure [2]. However, there are no objective data to support a particular uterine size or sonographically determined myoma size as an absolute indication for intervention. A large uterus makes it difficult to palpate the adnexa and, rarely, a rapidly enlarging uterine mass may be suggestive of a leiomyosarcoma; however, not all adnexa can be palpated (even when the uterus is absent or small) and uterine sarcoma are rare [2,3]. Some physicians perform myomectomy if large myomas interfere with ovarian access during in vitro fertilization (IVF) [4]. (See "Epidemiology, clinical manifestations, diagnosis, and natural history of uterine leiomyomas" and "Uterine sarcoma: Classification, clinical manifestations, and diagnosis", section on .) Clinical manifestations).
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