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Uterine fibroids (leiomyomas): Abdominal myomectomy

Author: William H Parker, MD
Section Editor: Howard T Sharp, MD
Deputy Editor: Alana Chakrabarti, MD

All topics are updated as new evidence becomes available and our peer review process is complete.

Literature review current through: Jul 2021. | This topic last updated: Jul 15, 2021.

INTRODUCTION

Uterine fibroids (leiomyomas or myomas) are the most common type of pelvic tumor in women,
with an approximate 70 to 80 percent lifetime risk [1-3]. There are many management options
for fibroid-related symptoms, including expectant management, medical therapy, nonexcisional
procedures (endometrial ablation, uterine artery embolization, magnetic resonance guided
focused ultrasound), and surgery (myomectomy, radiofrequency ablation, hysterectomy).

Open abdominal myomectomy (performed via laparotomy) was developed in the early 1900s as
a conservative treatment for patients with uterine myomas. Myomectomy is the surgical
removal of leiomyomas from the uterus, leaving the uterus in place. This can be accomplished
using an abdominal, laparoscopic, hysteroscopic, or vaginal approach.

Open abdominal myomectomy will be reviewed here. General principles of the treatment of
uterine leiomyomas, as well as laparoscopic, hysteroscopic, and vaginal myomectomy and
techniques to reduce blood loss during myomectomy, are discussed separately. (See "Uterine
fibroids (leiomyomas): Treatment overview" and "Uterine fibroids (leiomyomas): Laparoscopic
myomectomy and other laparoscopic treatments" and "Uterine fibroids (leiomyomas):
Hysteroscopic myomectomy" and "Uterine fibroids (leiomyomas): Prolapsed fibroids" and
"Techniques to reduce blood loss during abdominal or laparoscopic myomectomy".)

PATIENT SELECTION
Open abdominal myomectomy is performed mostly for patients with intramural or subserosal
leiomyomas ( figure 1). Intracavitary myomas (submucosal and some intramural myomas
that protrude into the endometrial cavity) ( figure 2) may also be removed during open
abdominal myomectomy. However, hysteroscopic myomectomy is the procedure of choice
when only small (<5 cm) intracavitary myomas are removed since it offers the advantages of a
faster recovery and less perioperative morbidity. (See "Uterine fibroids (leiomyomas):
Hysteroscopic myomectomy", section on 'Patient selection'.)

Appropriate candidates for open abdominal myomectomy are patients with the following
characteristics:

● Symptomatic uterine fibroid(s)

● Hysteroscopic or laparoscopic myomectomy is not feasible
● A laparotomy is required to treat intraabdominal pathology other than leiomyomas

Indications — The most common indications for open abdominal myomectomy are:

● Abnormal uterine bleeding

● Bulk-related symptoms – pelvic/abdominal pain or pressure; pressure on the urinary or
gastrointestinal tract resulting in urinary (eg, urinary frequency, urinary incontinence,
hydronephrosis) or bowel symptoms (eg, constipation)

Dysmenorrhea is an infrequent indication for myomectomy. Dysmenorrhea is more commonly

associated with conditions (eg, endometriosis) other than with myomas. Myomectomy or other
fibroid-specific treatment for the indication of dysmenorrhea should be performed only when
other therapies for dysmenorrhea have failed. (See "Dysmenorrhea in adult women:
Treatment".)

Myomectomy is occasionally required for necrotic leiomyomas following uterine artery

embolization. In such cases, myomectomy may be performed either through an abdominal or
hysteroscopic route, depending upon the site of the myoma [4]. (See "Uterine fibroids
(leiomyomas): Treatment with uterine artery embolization".)

Unproven indications — Myomectomy should be performed only for patients in whom the

procedure is likely to ameliorate a specific symptom. Indications for which the benefit of
myomectomy remains unproven are discussed in this section.

Evaluation of pelvic malignancy — Leiomyomas may make it difficult or impossible to

evaluate the adnexa in some patients with a pelvic examination or pelvic ultrasound. However,
improving the ability to evaluate the ovaries to exclude ovarian cancer is not an indication for
myomectomy.

There is no evidence that pelvic examination increases early detection or decreases the
mortality related to ovarian cancer [5]. For patients in whom a leiomyomatous uterus makes it
difficult to evaluate the adnexa, pelvic imaging should be performed only if symptoms of
adnexal disease develop (eg, lower quadrant pelvic pain) or for selected patients who require
screening for ovarian cancer. If sonographic visualization of the ovaries is occluded by myomas,
magnetic resonance imaging should be performed. (See "The gynecologic history and pelvic
examination", section on 'Timing issues' and "Approach to the patient with an adnexal mass",
section on 'Role of additional imaging'.)

Likewise, exclusion of uterine sarcoma is not an indication for myomectomy. Uterine sarcoma is
rare and the likelihood of finding sarcoma in patients with a preoperative diagnosis of
leiomyomas is much lower than the risk of severe complications associated with surgery for
benign disease. (See "Uterine fibroids (leiomyomas): Differentiating fibroids from uterine
sarcomas", section on 'Should hysterectomy be performed to exclude uterine sarcoma?'.)

Infertility — The location of a fibroid, and not its size, is the key factor regarding impact on
fertility [6]. Leiomyomas that distort the uterine cavity (submucosal or intramural with an
intracavitary component) result in difficulty conceiving a pregnancy and an increased risk of
miscarriage [6,7].

By contrast, a systematic review of mostly observational studies found that infertility is not
associated with subserosal fibroids and that the role of intramural fibroids is controversial [6,7].
Since open abdominal myomectomy is performed mainly to remove intramural or subserosal
myomas, its role in patients with infertility is uncertain. (See "Uterine fibroids (leiomyomas):
Treatment overview", section on 'Impact of fibroids on fertility'.)

Prevention of obstetric complications — Avoidance of obstetric complications is not an

indication for myomectomy in most patients. There are no high-quality data regarding whether
leiomyomas adversely affect pregnancy outcome. Myomectomy may be appropriate for
selected patients with a history of obstetric complications that appear related to the presence
of leiomyomas. (See "Uterine fibroids (leiomyomas): Issues in pregnancy".)

Contraindications — Open abdominal myomectomy is contraindicated in patients in whom

laparotomy or uterine conservation are contraindicated (eg, medical comorbidities, cervical or
uterine cancer). (See "Overview of the principles of medical consultation and perioperative
medicine".)
MYOMECTOMY VERSUS OTHER TREATMENT APPROACHES

The choice of treatment for patients with uterine leiomyomas is guided by the type of
symptoms in the individual patient.

Abnormal uterine bleeding — Abnormal uterine bleeding in patients with leiomyomas is

treated initially with medical therapy (eg, estrogen-progestin contraceptives, tranexamic acid). If
medical therapy is not sufficiently effective or tolerated, therapeutic options include
interventional radiology procedures (uterine artery embolization, magnetic resonance guided
focused ultrasound), endometrial ablation, myomectomy, and hysterectomy. There is no single
treatment of choice. The decision depends upon patient characteristics and preferences.

The choice of a therapy for chronic abnormal uterine bleeding is discussed separately. (See
"Abnormal uterine bleeding: Management in premenopausal patients", section on 'Choosing a
treatment'.)

Bulk-related symptoms — Treatment options for bulk-related symptoms (pelvic pain or

pressure) include hysterectomy, myomectomy, or interventional radiology procedures (uterine
artery embolization or magnetic resonance guided focused ultrasound). Some pharmacologic
treatments (eg, gonadotropin releasing hormone agonists) reduce uterine size, but are
generally not used because chronic treatment is required and results in menopausal symptoms
and decreased bone density.

The choice of treatment for bulk-related symptoms depends on the patient's desire for future
fertility and/or uterine conservation and the patient's preferences regarding definitive
treatment and the invasiveness of treatment. Size and location of myomas and access to
clinicians with expertise in minimally invasive procedures are also important factors in this
decision.

Choosing between myomectomy and other treatments is discussed in this section; comparisons
among other treatments are discussed separately. (See "Uterine fibroids (leiomyomas):
Treatment overview".)

Patients who desire future pregnancy — Myomectomy is the procedure of choice for

patients who desire future fertility. Laparoscopic myomectomy is a minimally invasive approach
that is appropriate for selected patients. (See "Uterine fibroids (leiomyomas): Laparoscopic
myomectomy and other laparoscopic treatments", section on 'Candidates for laparoscopic
myomectomy'.)
Patients who are planning future pregnancy should be counseled about obstetric issues
following myomectomy. (See 'Uterine rupture during pregnancy following myomectomy'
below.)

Interventional radiology procedures may not be appropriate for patients planning future
pregnancy because of potential safety issues and detrimental effects on ovarian function. As
examples, uterine artery embolization may have a negative effect on fertility and obstetric
outcomes, and the safety of pregnancy following magnetic resonance guided focused
ultrasound has not been established. (See "Uterine fibroids (leiomyomas): Treatment with
uterine artery embolization" and "Uterine fibroids (leiomyomas): Treatment overview", section
on 'Third tier'.)

Choosing the least invasive approach — Traditionally, bulk-related symptoms of myomas

were treated with open abdominal myomectomy or hysterectomy. In current practice, however,
there are a variety of alternatives to laparotomy. Less invasive approaches offer the advantages
of smaller incisions and a shorter recovery period. The options include:

● Interventional radiology procedures

● Laparoscopic myomectomy
● Laparoscopic hysterectomy
● Vaginal hysterectomy

Eligibility for these procedures is limited by fibroid size and location. In addition, some patients
may not have easy access to physicians who have experience with these procedures. (See
"Uterine fibroids (leiomyomas): Laparoscopic myomectomy and other laparoscopic treatments",
section on 'Candidates for laparoscopic myomectomy' and "Laparoscopic hysterectomy" and
"Uterine fibroids (leiomyomas): Treatment with uterine artery embolization".)

Interventional radiology procedures — Interventional radiology procedures have two

important advantages compared with myomectomy:

● General or regional anesthesia is not required.

● Abdominal incisions are not required, which reduces postoperative discomfort and
improves cosmesis.

In addition, the recovery time from interventional radiology procedures is typically two weeks
or less. This is similar to laparoscopic myomectomy but much shorter than open abdominal
myomectomy, which generally requires four to six weeks for recuperation.
Uterine artery embolization has been compared with open or laparoscopic myomectomy in
only one randomized trial (n = 121) [8]. There was no difference between groups in the rate of
symptomatic relief after six months (89 versus 88 percent). This overall outcome does not
specifically address treatment of bulk-related symptoms, since the results for bleeding, pain,
and pressure symptoms were combined. Patients who underwent uterine artery embolization
compared with myomectomy had higher rates of complications (21 versus 16 percent) and of
prolonged hospital stay (16 versus 10 percent), but these differences did not reach statistical
significance. The reintervention rate after an average of two years was significantly higher for
uterine artery embolization (33 versus 3 percent); reintervention was myomectomy in this
study. Of note, however, the indication for most reinterventions in this study was the size of
fibroids, not recurrence of symptoms. A similar difference in the reintervention rate was
reported in a retrospective cohort study that compared uterine artery embolization with
myomectomy (29 versus 3 percent at four years; interventions were myomectomy or repeat
embolization) [9].

Over the long-term, however, myomectomy also has a high rate of intervention. Studies with up
to 7 to 10 years of follow-up report subsequent surgery for fibroid-related symptoms in 10 to 26
percent of patients following myomectomy [10-12]. For embolization, studies with five or more
years of follow-up have reported that 20 percent of patients undergo subsequent surgery. High-
quality and long-term data are needed to address the comparative risk of reintervention for
these two procedures. (See 'Subsequent treatment' below.)

Magnetic resonance guided focused ultrasound is not widely available and has not been
evaluated in comparison with myomectomy.

In summary, uterine artery embolization and laparoscopic myomectomy are both minimally
invasive approaches. Based upon available data, the risk of reintervention appears to be higher
for uterine artery embolization, at least in the first several years after the procedure. As a result,
we suggest laparoscopic myomectomy rather than embolization. Patients who place a high
priority on avoiding any abdominal incisions may reasonably choose embolization. Some
patients are not candidates for laparoscopic myomectomy. For these patients, the advantages
of a minimally invasive procedure outweigh the risk of reintervention. The clinician should
counsel the patient about all options and choose the procedure based upon patient preference.

Myomectomy versus hysterectomy — Patients who choose not to be treated with

interventional radiology procedures may choose between myomectomy and hysterectomy. This
choice largely depends upon the availability of minimally invasive procedures and patient
preference. There are no high-quality data comparing myomectomy and hysterectomy [13].
Traditionally, patients with symptomatic fibroids who have completed childbearing have been
counseled to undergo hysterectomy, but this approach is not supported by evidence or current
practice. The rationale for counseling patients to undergo hysterectomy has been based upon
two presumed benefits: hysterectomy eliminates the risk of future cervical or uterine pathology
and hysterectomy has been thought to be associated with less blood loss and fewer
complications than myomectomy.

Prevention of future cervical or uterine pathology is not a relevant indication for hysterectomy
in current practice. Advances in cervical cancer screening and diagnosis and treatment of
abnormal uterine bleeding have provided less invasive options.

In addition, myomectomy does not appear to have a higher risk of blood loss or complications
than hysterectomy, according to observational data [14,15]. The largest report was a
retrospective study of 394 patients with leiomyomatous uteri who underwent either open
abdominal myomectomy or hysterectomy [14]. Estimated blood loss (227 versus 484 mL) and
the rate of hemorrhage, defined as ≥500 mL blood loss (10 versus 14 percent), were
significantly lower in the myomectomy group. The overall morbidity rate, adjusted for age,
weight, and uterine size, was comparable in the two groups. A meta-analysis found similar
results [16].

The decision between myomectomy and hysterectomy must be individualized. The least
invasive procedure should be chosen. Patients should be counseled regarding the procedures
for which they are eligible. This will depend primarily on the size, number, and location of
fibroids. Based upon these factors, some patients are candidates only for laparotomy.

For patients who are eligible for all procedures, no studies have directly compared outcomes
for the various minimally invasive approaches (laparoscopic myomectomy, with either vaginal
or laparoscopic hysterectomy). Some factors that may affect a patient's decision include:

● Hysterectomy offers the advantage of definitive treatment.

● Some patients prefer myomectomy because they wish to conserve their uterus.

● Studies show a higher risk of injury to ureters, bladder and bowel with hysterectomy
[14,15].

● Hysterectomy is associated with a risk of subsequent pelvic organ prolapse surgery.

● Hysterectomy (with ovarian conservation) is associated with decreased anti-müllerian

hormone levels and may cause some patients to enter menopause two to three years
earlier than normal [17].
Some patients desire definitive therapy, and are willing to accept a more invasive or extensive
procedure to avoid the risk of recurrent symptoms. Hysterectomy rather than myomectomy is
the appropriate choice for these patients since some require further surgery following
myomectomy. (See 'Subsequent treatment' below.)

An increasing number of patients wish to conserve their uterus as an important component of

their body image. Patients who are concerned about effects on sexual function should be
counseled that most studies have found no impact of hysterectomy on sexual outcomes.
Patients who prefer to preserve their uterus, but do not plan future childbearing, are
candidates for either myomectomy or interventional radiology procedures. (See "Choosing a
route of hysterectomy for benign uterine disease".)

In some patients, hysterectomy may be associated with subsequent pelvic organ prolapse.
Consistent results from large observational studies show patients who undergo a hysterectomy
are at risk of having subsequent prolapse repair surgery. However, this risk may be limited to
patients for whom prolapse was the indication for undergoing hysterectomy. It is not certain
whether undergoing a hysterectomy for fibroids is a risk factor for developing symptomatic
prolapse. Also, many patients have several risk factors for prolapse, including parity, advancing
age, and obesity. (See "Choosing a route of hysterectomy for benign uterine disease".)

In general, for subserosal or intramural fibroids, there are more minimally invasive options for
hysterectomy than myomectomy. More patients are candidates for vaginal and laparoscopic
hysterectomy than laparoscopic myomectomy, and more surgeons have the skills for less
invasive approaches to hysterectomy.

Given these considerations, no overall recommendation can be made regarding myomectomy

versus hysterectomy. Patients who prefer definitive surgery require a hysterectomy. By
contrast, those who desire uterine conservation should undergo myomectomy. Other patients
should choose the least invasive surgical approach that is available.

PREOPERATIVE EVALUATION

Informed consent — Patients with symptomatic fibroids should be counseled about other

medical, interventional radiology, and surgical options for treatment. (See "Abnormal uterine
bleeding: Management in premenopausal patients", section on 'Choosing a treatment' and
"Uterine fibroids (leiomyomas): Treatment overview".)

Potential complications of the procedure and the likelihood of recurrence of fibroids or

symptoms should also be reviewed (see 'Complications' below and 'Persistent or new myomas'
below). This discussion should be documented on the surgical consent form and in the medical
record.

History — A thorough medical history is important to determine which fibroid-related

symptoms are present (eg, heavy uterine bleeding, bulk symptoms) and whether these
symptoms affect the patient's quality of life.

The medical history should include questions regarding a personal or family history of bleeding
disorders, as well as other medical comorbidities that may impact the ability to tolerate surgery.
(See "Preoperative medical evaluation of the healthy adult patient".)

Pelvic examination — A thorough pelvic examination should be performed. On bimanual

examination, the size, contour, and mobility of the uterus should be noted, along with any other
findings (eg, adnexal mass, cervical mass). These findings impact the choice of preoperative
imaging and aid surgical planning (eg, choosing a transverse or vertical incision).

Imaging — Patients who are planning myomectomy should undergo imaging to confirm the
presence of uterine leiomyomas rather than other pelvic pathology. In addition, incidental
findings of other lesions (eg, ovarian cyst) may impact surgical planning.

Imaging with ultrasonography rather than other modalities is sufficient for patients in whom
open myomectomy is planned. Ultrasound can confirm the presence of leiomyomas and their
approximate number and location [18].

Magnetic resonance imaging (MRI) is typically not necessary prior to open myomectomy, with
the exception of patients in whom leiomyomas must be differentiated from uterine sarcoma or
adenomyosis. (See "Uterine fibroids (leiomyomas): Differentiating fibroids from uterine
sarcomas", section on 'Imaging' and "Uterine adenomyosis", section on 'Diagnosis'.)

MRI is not required to evaluate the anatomic relationship between fibroids and the ureters.
Fibroids do not engulf the ureters; as they grow, they push the ureters and vessels away. If the
surgeon stays inside the fibroid pseudocapsule, the ureters will always be outside the
pseudocapsule. The only exception is intravenous leiomyomatosis, in which the blood supply of
the uterus near the ureters can be involved. We dissect out the ureters when necessary, but this
is rarely the case. (See "Uterine fibroids (leiomyomas): Variants and smooth muscle tumors of
uncertain malignant potential", section on 'Intravenous leiomyomatosis'.)

Imaging of uterine leiomyomas is discussed in detail separately. (See "Uterine fibroids

(leiomyomas): Epidemiology, clinical features, diagnosis, and natural history", section on
'Imaging and endoscopy'.)
Laboratory evaluation — Myomectomy is a procedure in which significant blood loss (>300
mL) may occur. A baseline complete blood count is suggested for all patients undergoing this
procedure.

We also send a blood sample to the blood bank in case there is a need for transfusion.

Other testing — Abnormal bleeding is a symptom of uterine fibroids, but also of uterine

cancer. Prior to myomectomy, endometrial sampling should be performed in all patients with
bleeding symptoms, particularly intermenstrual bleeding, who are older than 35 years or who
have risk factors for endometrial cancer ( table 1). (See "Overview of the evaluation of the
endometrium for malignant or premalignant disease".)

PREOPERATIVE PREPARATION

Preparing for potential blood loss — Myomectomy may result in significant blood loss.
Myomectomy does not usually result in significant blood loss, but risk factors for increased
blood loss include large or multiple fibroids. For patients with an increased risk of significant
blood loss, preoperative measures such as correction of anemia or autologous blood donation
may reduce the likelihood of receiving a blood transfusion.

A detailed discussion of measures to reduce blood loss associated with myomectomy can be
found separately. (See "Techniques to reduce blood loss during abdominal or laparoscopic
myomectomy".)

Reducing uterine size with GnRH agonists — Preoperative use of gonadotropin releasing

hormone (GnRH) agonists provides some short-term benefits for patients undergoing
myomectomy regarding blood loss and uterine size, but may increase the difficulty of surgery
[19]. In the long-term, their use appears to increase the risk of persistent myomas.

Myomectomy can usually be performed using a Pfannenstiel incision, or if slightly more access
is needed, a Maylard incision. Compared with a large vertical incision (eg, to the umbilicus or
above), these incisions decrease postoperative pain and improve scar cosmesis [20]. For large
uterine size, making the transverse incision slightly higher than usual, extending the incision to
the lateral borders of the rectus muscles and then curving it cephalad to avoid the ilioinguinal
nerves will make myomectomy feasible. Larger fibroids attenuate the rectus muscles and fascia,
making them more pliable and will allow access to the enlarged uterus. (See "Incisions for open
abdominal surgery".)
For some patients with large fibroids, a vertical incision may be required; however, use of GnRH
agonists can reduce uterine size and allow use of a transverse or smaller vertical incision. A
meta-analysis of 11 randomized trials demonstrated that pretreatment with a GnRH agonist
compared with placebo or no treatment prior to open abdominal myomectomy significantly
reduced uterine size (uterine volume: 159 mL smaller; gestational size: 2.2 weeks less) [19]. The
only trial that evaluated choice of incision found that GnRH agonist use was associated with
fewer vertical incisions (0 of 13 versus 5 of 15) [21].

The disadvantages of preoperative GnRH therapy, however, outweigh the advantages for most
patients. Randomized trials have not found that use of these agents reduces the risk of blood
transfusion. Also, many surgeons report that these medications result in increased difficulty
enucleating fibroids and small randomized trials have found that their use increases the risk of
persistent myomas. Thus, we suggest not using GnRH agonist pretreatment for patients
undergoing open myomectomy. Most patients can have an open abdominal myomectomy
through a large Pfannenstiel incision, even for very large fibroids. By dissecting the fascia off of
the rectus muscles, both in the midline and laterally up to the umbilicus, the rectus muscles can
be spread further laterally to give the surgeon more room to deliver the uterus. Use of these
agents (GnRH) may be a reasonable option in patients for whom treatment would allow a
transverse rather than a vertical incision and who place a high priority on type of surgical
incision. (See "Incisions for open abdominal surgery", section on 'Pfannenstiel's incision'.)

A detailed discussion of the effect of GnRH agonists on blood loss during myomectomy can be
found separately. (See "Techniques to reduce blood loss during abdominal or laparoscopic
myomectomy", section on 'GnRH agonists'.)

Prophylactic antibiotics — Myomectomy is classified as a clean procedure, since it does not

involve a vaginal or intestinal incision. The American College of Obstetricians and Gynecologists
has advised that prophylactic antibiotics are not required for this procedure [22]. Other experts
disagree, based upon the rationale that the surgical site infection risk is likely similar to
hysterectomy, for which antibiotic prophylaxis is universally recommended [23]. There are no
high-quality data regarding the use of antibiotic prophylaxis in patients undergoing
myomectomy.

In our practice, we give prophylactic antibiotics for open abdominal myomectomy, since
avoidance of pelvic infection with regard to fertility preservation may be an issue. (See "Long-
term complications of pelvic inflammatory disease", section on 'Infertility'.)

Thromboprophylaxis — Patients undergoing open abdominal myomectomy (major surgery,

defined as >30 minutes duration) are at least at moderate risk for venous thromboembolism
and require appropriate thromboprophylaxis, whether mechanical or pharmacologic. We use
sequential compression devices during surgery and for two days following surgery for all
patients. Those at higher than average risk may require medical anticoagulation. (See
"Prevention of venous thromboembolic disease in adult nonorthopedic surgical patients" and
"Overview of preoperative evaluation and preparation for gynecologic surgery", section on
'Thromboprophylaxis'.)

Anesthesia — Open abdominal myomectomy is typically performed under general anesthesia,

but regional anesthesia may be used.

PROCEDURE

Open abdominal myomectomy is performed through a laparotomy. A transverse incision (eg,

Pfannenstiel) is used whenever possible (see 'Reducing uterine size with GnRH agonists' above).
The basic steps of the procedure are:

● Apply measures to reduce blood loss

● Make uterine incision(s)
● Remove myomas
● Close uterine defects

Measures to reduce blood loss — Blood loss during myomectomy can be prevented or

decreased with mechanical or pharmacologic methods. Allogeneic blood transfusion can be
avoided by using methods of autologous blood transfusion (autologous blood donation,
intraoperative and postoperative blood salvage, or acute normovolemic [isovolemic]
hemodilution).

Techniques to reduce blood loss during myomectomy are discussed separately. (See
"Techniques to reduce blood loss during abdominal or laparoscopic myomectomy", section on
'Intraoperative measures'.)

Uterine incision — The uterus is palpated to locate the leiomyomas. Careful planning and
placement of uterine incisions can avoid inadvertent extension of the incision to the cornua or
ascending uterine vessels.

The uterine incisions may be either vertical or transverse. The common teaching has been to
make vertical incisions, to prevent transection of the arcuate arteries of the uterus, which run
transversely. However, avoiding these vessels is not feasible since myomas distort normal
vascular architecture [24].
Anterior uterine incisions are associated with fewer adnexal adhesions than posterior incisions
[25]. However, if the fibroids are in the posterior uterine wall, it is usually preferable to make a
posterior incision to remove them rather than to go through the uterine cavity to remove them
via an anterior incision.

Many surgeons make a uterine incision at a location through which all or most of the myomas
can be removed. The rationale for this is that limiting the number of incisions reduces the
likelihood of adhesions to the uterine serosa, although there are no data regarding the number
of incisions and the risk of adhesions [26] (see 'Adhesive disease' below). Use of a single
incision, however, requires that tunnels be created within the myometrium to extract distant
myomas. These myometrial defects can be difficult to close, interfering with hemostasis.

Alternatively, an incision can be made directly over each myoma (or group of nearby or
apposing myomas). This approach allows both easy removal of the myomas, as well as prompt
closure of the myometrial defects to secure hemostasis [27].

Removal of myomas — The uterine incision is extended down through the myometrium and
entire fibroid pseudocapsule ( figure 3). The least vascular plane can be reached by extending
this incision a thin layer deeper than the capsule, after the myoma is initially visualized. The
myoma will then clearly be visible and may bulge slightly.

Myomas are surrounded completely by a dense vascular layer supplying the myoma and no
"vascular pedicle" exists at the base of the myoma, as demonstrated by vascular corrosion
casting and examination by electron microscopy [28].

There are many techniques to enucleate myomas. Many surgeons put traction on the
myometrial edges with Allis clamps to expose the myoma ( figure 4). The myomas are then
extirpated by grasping them with a single tooth tenaculum or towel clamp ( figure 5). The
plane between the myometrium and myoma is typically dissected bluntly (eg, using a sponge or
the back end of an empty knife handle) ( figure 6).

Closure of uterine defects — The uterine defects are closed with sutures in layers. If the
myometrial defect is deep (>2 cm), two layers may be needed to reapproximate the tissue and
achieve hemostasis ( figure 7 and figure 8). In our practice, we use a size 0 polyglactin 910
(Vicryl) suture for the myometrium. The serosa is closed with a running suture ( figure 9); we
use size 2-0 polydioxanone (PDS), but any absorbable suture may be used.

Operative challenges
 Large uterus — Myomectomy can be performed safely for patients with a large uterus (≥16
weeks size), but surgical skill and experience are required. As an example, a retrospective study
of 91 patients with uterine fibroids equal to or larger than 16 weeks size who underwent open
abdominal myomectomy reported an average operative duration of 236 minutes (range 120 to
390 minutes) and an average blood loss of 794 mL (range 50 to 3000 mL) [27]. Intraoperative
blood salvage was used in patients with a blood loss >300 mL (70 patients, 77 percent) and only
7 patients (8 percent) received a blood transfusion. (See "Techniques to reduce blood loss
during abdominal or laparoscopic myomectomy", section on 'Autologous blood transfusion'.)

Submucosal myomas — Hysteroscopic myomectomy is the procedure of choice for patients

with primarily intracavitary leiomyomas. For those with myomas in multiple locations including
submucosal, open myomectomy is preferred. Removal of submucosal myomas during open
abdominal myomectomy requires deep myometrial dissection. Often, the uterine cavity is
entered during this process. In our practice, we repair the myometrium at the interface with the
cavity, taking care to avoid entry of suture into the cavity, since this may cause a foreign body
reaction and adhesions.

Cervical or broad ligament myomas — Uterine leiomyomas originate within the

myometrium, but, as they grow, may extend near or displace adjacent structures. Cervical or
broad ligament myomas are a common finding. These lesions are often proximal to vital
structures such as the ureter or major pelvic vessels.

The first step in removing a cervical or broad ligament lesion is careful inspection of the
peritoneum overlying the fibroid to identify a clear area where the peritoneum can be
incised. With careful attention to staying in the proper surgical plane, the fibroid can be
removed with traction and blunt dissection in a direction away from vital structures. Sharp
dissection, especially where the tips of the instrument cannot be seen, should be avoided.
Closure of the defect should also be carefully planned after identification of the ureter and
uterine vessels, in order to avoid injury or ligation of the ureter or injury to vessels. If necessary,
ligation of the uterine vessels may be performed to avoid bleeding.

COMPLICATIONS

Hemorrhage — The average volume of blood loss for open abdominal myomectomy varies
across studies from approximately 200 to 800 mL [14,15,27]. In series of 100 or more open
abdominal myomectomy procedures, the blood transfusion rate has varied widely from 2 to 28
percent [14,15,29]. Increasing size and number of myomas, as well as entering the uterine
cavity, are associated with increased blood loss [30].
Prevention and management of blood loss during myomectomy are discussed in detail
separately. (See "Techniques to reduce blood loss during abdominal or laparoscopic
myomectomy" and "Management of hemorrhage in gynecologic surgery".)

Conversion to hysterectomy — Severe hemorrhage may be addressed with a number of

techniques, including use of intraoperative blood salvage, uterine artery ligation, or conversion
to hysterectomy. Approximately 1 to 4 percent of open myomectomies are converted to
hysterectomy [13,31].

Fever and infection — Fever occurs within 48 hours after surgery in approximately 12 to 67

percent of patients following myomectomy [29,31,32]. However, one retrospective study found
that, compared with those undergoing hysterectomy, patients who had a myomectomy had
similar rates of fever (39 percent within 24 hours), but fewer localized findings (eg, urinary tract
infection or pneumonia: 14 versus 31 percent) [32]. Therefore, evaluation of fever after
myomectomy in the absence of localizing symptoms may not be cost-effective. Proposed
mechanisms for unexplained postmyomectomy fever include factors at the evacuated myoma
sites: hematomas or release of inflammatory mediators [23].

There are few studies of specific sites of infection following open abdominal myomectomy.
Wound infection affects 2 to 5 percent of patients after open abdominal myomectomy [29,31]. A
study of 250 myomectomy patients reported the most infections occurred in the urinary (46
percent) or respiratory tracts (38 percent) [32].

Evaluation and management of postoperative fever are discussed separately. (See "Fever in the
surgical patient".)

Adhesive disease — Adhesion formation after myomectomy has been well documented. In a

study (n = 45) in which second look laparoscopy was performed following open abdominal or
laparoscopic myomectomy, adhesions were found in 36 percent of patients [33]. Factors
associated with adhesive disease were posterior location of a removed myoma and the
presence of sutures. Adnexal adhesions, which may impact tubal fertility, were also associated
with concurrent surgery (eg, ovarian cystectomy) and prior adhesive disease.

A detailed discussion of methods of adhesion prevention can be found separately. (See

"Postoperative peritoneal adhesions in adults and their prevention".)

Other complications — Visceral injury is uncommon during open abdominal myomectomy. As

an example, in one series of 197 patients who underwent the procedure, there was one
cystotomy and two small bowel obstructions [14].
The evaluation and management of these and other complications, such as ileus, wound
infection, or incisional hernia, are discussed separately. (See "Postoperative ileus" and
"Complications of abdominal surgical incisions" and "Management of ventral hernias".)

INPATIENT POSTOPERATIVE CARE

Routine postoperative care includes monitoring of a patient's hemodynamic and fluid status,
pain control, and reintroducing normal diet and activity. Components of inpatient postoperative
care following myomectomy include:

● We use a continuous infusion of bupivacaine via catheters placed above and below the
fascia at the time of wound closure. The pump lasts approximately four days, at which time
the catheters are removed. Postoperative pain management initially with parenteral
administration of analgesics. Patient-controlled anesthesia is also an option. This is
transitioned to the oral route when a patient can tolerate oral intake, usually on the first
postoperative day. (See "Management of acute perioperative pain".)

● Removal of the bladder catheter during the first 24 hours postoperatively. (See "Placement
and management of urinary bladder catheters in adults".)

● Early feeding of a regular diet. (See "Overview of perioperative nutrition support".)

● Ambulation and other measures to prevent pulmonary complications. (See "Strategies to

reduce postoperative pulmonary complications in adults".)

Evaluation and management of complications are discussed above. (See 'Complications' above.)

FOLLOW-UP

Patients are encouraged to resume their normal daily activities as quickly as is comfortable.
Decisions regarding resumption of vaginal intercourse are made by the patient; there are no
medical restrictions on sexual activity [34]. Patients may return to work as soon as they have
regained sufficient stamina and mobility.

Routine postoperative instructions for patients can be found separately. (See "Patient
education: Care after gynecologic surgery (Beyond the Basics)".)

We see patients for a follow-up visit at two weeks postoperatively. The follow-up visit includes
an evaluation for potential complications and an examination of the abdomen and wound. We
review the details of the surgery and pathology results with the patient.

OUTCOME

Relief of symptoms — Myomectomy has been reported to relieve symptoms in 80 percent of

patients [2,9]. Unfortunately, many large series of open myomectomies have not reported data
for relief of symptoms, patient satisfaction, or quality-of-life following surgery [29,35-37].

Persistent or new myomas — Many patients who undergo myomectomy will have

leiomyomas upon subsequent evaluation. However, most of these patients will not require
additional treatment for fibroid-related symptoms. Surveillance for postmyomectomy myomas
is not necessary, since imaging detects many clinically insignificant myomas. The outcome that
is important to patients is the risk of recurrent symptoms that require additional treatment.

Myomas detected after myomectomy, often referred to as recurrent, are more accurately
referred to as persistent or newly developed. Myomas persist when they are not removed or
incompletely removed at the time of surgery.

Five to 10 years after myomectomy, 27 to 62 percent of patients will have myomas detected by
ultrasound [38-40]. Considering the background prevalence of leiomyomas (77 percent in a
posthysterectomy study [41]), it is not surprising that new myomas continue to develop after
excision.

Postmyomectomy myomas are more likely in patients who have multiple versus single myomas
at time of surgery (74 versus 11 percent in one study [42]) and those who do not versus do have
a pregnancy after myomectomy (30 versus 15 percent in one study [39]). Preoperative use of
GnRH agonists is associated with an increase in the risk of postoperative myomas. (See
"Techniques to reduce blood loss during abdominal or laparoscopic myomectomy", section on
'GnRH agonists'.)

Subsequent treatment — Many patients with myomas are asymptomatic, so the most

important outcome is the need for subsequent treatment following myomectomy.

After a first myomectomy, 10 to 25 percent of patients will have a second major surgery
[12,40,42-44]. The largest study (n = 568) was a nested case control study in which 21 percent of
patients who had undergone myomectomy (open abdominal, laparoscopic, or hysteroscopic)
had subsequent surgery within 1 to 10 years; the combination of surgical approaches limits the
ability to apply these data to open abdominal myomectomy [10]. Another retrospective study of
47 patients who had undergone open abdominal myomectomy reported that, at an average of
seven-year follow-up, 34 percent had subsequent surgery [11].

Risk factors for subsequent surgery are not well established. In one study, uterine size <12
weeks was associated with an increased risk of a second surgery, while other data suggest that
a larger uterus or multiple myomas are associated with a lower risk of re-operation [11,42].

There are no data regarding how many patients require medical treatment for fibroids
following myomectomy.

CONCEPTION AND PREGNANCY AFTER MYOMECTOMY

Interval to conception — Patients who undergo myomectomy with significant uterine

disruption should wait several months before attempting to conceive; recommendations for
this interval range from three to six months [45].

Infertility — If a patient is having difficulty conceiving following a myomectomy, early

assessment of the uterine cavity and fallopian tubes with a hysterosalpingogram is advisable
[46].

Issues of fertility and leiomyomas are discussed separately. (See "Causes of female infertility",
section on 'Uterus'.)

Uterine rupture during pregnancy following myomectomy — Myomectomy appears to be

associated with an increased risk of uterine rupture during subsequent pregnancy, but it is
difficult to ascertain the degree of risk and whether opening the uterine cavity adds to this risk.
Many experts advise cesarean delivery as a conservative approach.

Uterine rupture during pregnancy following myomectomy is discussed in detail separately. (See
"Uterine fibroids (leiomyomas): Issues in pregnancy".)

Myomectomy during pregnancy — Myomectomy is performed rarely during pregnancy, and

usually for the indication of intractable fibroid pain. In addition, in rare cases, myomectomy is
required at the time of cesarean delivery to provide access to the uterine incision site.

Antepartum and intrapartum myomectomy are discussed separately. (See "Uterine fibroids
(leiomyomas): Issues in pregnancy".)

SOCIETY GUIDELINE LINKS

Links to society and government-sponsored guidelines from selected countries and regions
around the world are provided separately. (See "Society guideline links: Gynecologic surgery".)

INFORMATION FOR PATIENTS

UpToDate offers two types of patient education materials, "The Basics" and "Beyond the
Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade
reading level, and they answer the four or five key questions a patient might have about a given
condition. These articles are best for patients who want a general overview and who prefer
short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more
sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading
level and are best for patients who want in-depth information and are comfortable with some
medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print
or e-mail these topics to your patients. (You can also locate patient education articles on a
variety of subjects by searching on "patient info" and the keyword(s) of interest.)

● Beyond the Basics topics (see "Patient education: Uterine fibroids (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

● Open abdominal myomectomy (performed via laparotomy) is the surgical removal of

leiomyomas from the uterus, leaving the uterus in place. (See 'Introduction' above.)

● The most common indications for open abdominal myomectomy are abnormal uterine
bleeding or bulk-related symptoms (eg, pelvic/abdominal pain or pressure). Indications for
which the benefit of myomectomy is unproven include: evaluation of pelvic malignancy (eg,
ovarian or uterine cancer), infertility, and prevention of obstetric complications. (See
'Indications' above and 'Unproven indications' above.)

● For patients undergoing open abdominal or laparoscopic myomectomy, we suggest not

pretreating with GnRH agonists (Grade 2B). Use of these agents is a reasonable option in
patients for whom treatment would allow a transverse rather than a vertical incision and
who place a high priority on type of surgical incision. (See 'Reducing uterine size with GnRH
agonists' above and "Techniques to reduce blood loss during abdominal or laparoscopic
myomectomy", section on 'GnRH agonists'.)
● In our practice, we use prophylactic antibiotics for this procedure, since intraabdominal
infection may adversely affect fertility. (See 'Prophylactic antibiotics' above.)

● For patients with bulk-related symptoms of uterine leiomyomas, the decision regarding
procedure depends upon patient characteristics and preferences (see 'Bulk-related
symptoms' above):

• The procedure of choice for patients who desire future pregnancy is myomectomy.

• For patients who do not wish to preserve fertility and do not prefer definitive surgery,
the choice must be individualized. Uterine artery embolization and laparoscopic
myomectomy are the least invasive options; eligibility for each of these procedures
depends upon patient (and fibroid) characteristics. For patients who are candidates for
either of these procedures, we suggest laparoscopic myomectomy rather than uterine
artery embolization (Grade 2B). Patients who place a high priority on avoiding
abdominal incisions may reasonably choose embolization.

• For patients who prefer definitive surgery, hysterectomy is required.

• All other patients should choose the least invasive surgical approach for which they are
eligible and that is available to them (eg, open abdominal myomectomy, laparoscopic
hysterectomy, vaginal hysterectomy).

● Blood loss during myomectomy can be prevented or decreased with mechanical or

pharmacologic methods. Allogeneic blood transfusion can be avoided by using methods of
autologous blood transfusion. (See "Techniques to reduce blood loss during abdominal or
laparoscopic myomectomy".)

● Fever occurs within 48 hours after surgery in approximately 12 to 67 percent of patients

following myomectomy. Many patients with postmyomectomy fever have no localized
findings. (See 'Fever and infection' above.)

● Adhesion formation occurs in approximately 36 percent of patients after myomectomy.

(See 'Adhesive disease' above.)

● Myomectomy relieves symptoms in 80 percent of patients. The rate of subsequent surgery

for fibroids following myomectomy is 21 to 34 percent. (See 'Outcome' above.)

Use of UpToDate is subject to the Subscription and License Agreement.

Topic 14195 Version 23.0
GRAPHICS

Fibroid locations in the uterus

These figures depict the various types and locations of fibroids. An individual may have one or more types of fibroids.

Graphic 53241 Version 6.0

Submucosal leiomyma position: European Society of Hysteroscopy
classification

The European hysteroscopic classification of submucous leiomyomas.

Reproduced with permission from: Baggish MS, Valle RF, Guedj H. Hysteroscopy: Visual Perspectives of Uterine
Anatomy, Physiology and Pathology. Philadelphia: Lippincott Williams & Wilkins, 2007. Copyright © 2007 Lippincott
Williams & Wilkins.

Graphic 59668 Version 2.0

Risk factors for endometrial cancer

Relative risk (RR)

Risk factor
(other statistics are noted when used)

Increasing age 1.4% endometrial cancer prevalence in women 50 to 70 years

old

Unopposed estrogen therapy 2 to 10

Tamoxifen therapy 2

Early menarche NA

Late menopause (after age 55) 2

Nulliparity 2

Polycystic ovary syndrome (chronic anovulation) 3

Obesity For type I endometrial cancer: OR 1.5 for

overweight (BMI 25.0 to <30 kg/m 2), 2.5 for
class 1 obesity (30.0 to <35 kg/m 2), 4.5 for
class 2 obesity (35.0 to 39.9 kg/m 2), and 7.1
for class 3 obesity (≥40.0 kg/m 2).
For type II: OR 1.2 for overweight (BMI 25.0 to
<30 kg/m 2), 1.7 for class 1 obesity (30.0 to
<35 kg/m 2), 2.2 for class 2 obesity (35.0 to
39.9 kg/m 2), and 3.1 for class 3 obesity (≥40.0
kg/m 2).

Diabetes mellitus 2

Estrogen-secreting tumor NA

Lynch syndrome (hereditary nonpolyposis colorectal cancer) 13 to 71% lifetime risk

Cowden syndrome 13 to 28% lifetime risk

Family history of endometrial, ovarian, breast, or colon cancer NA

NA: RR not available; OR: odds ratio; BMI: body mass index.

Data from:

1. Heald B, Mester J, Rybicki L, et al. Frequent gastrointestinal polyps and colorectal adenocarcinomas in a prospective series of PTEN
mutation carriers. Gastroenterology 2010; 139:1927.
2. Pilarski R, Stephens JA, Noss R, et al. Predicting PTEN mutations: an evaluation of Cowden syndrome and Bannayan-Riley-Ruvalcaba
syndrome clinical features. J Med Genet 2011; 48:505.
3. Ramsoekh D, Wagner A, van Leerdam ME, et al. Cancer risk in MLH1, MSH2 and MSH6 mutation carriers; different risk profiles may
influence clinical management. Hered Cancer Clin Pract 2009; 7:17.
4. Riegert-Johnson DL, Gleeson FC, Roberts M, et al. Cancer and Lhermitte-Duclos disease are common in Cowden syndrome patients. Hered
Cancer Clin Pract 2010; 8:6.
5. Setiawan VW, Yang HP, Pike MC, et al. Type I and II endometrial cancers: have they different risk factors? J Clin Oncol 2013; 31:2607.
6. Smith RA, von Eschenbach AC, Wender R, et al. American Cancer Society guidelines for the early detection of cancer: Update of early
detection guidelines for prostate, colorectal, and endometrial cancers. CA Cancer J Clin 2001; 51:38.
7. Tan MH, Mester JL, Ngeow J, et al. Lifetime cancer risks in individuals with germline PTEN mutations. Clin Cancer Res 2012; 18:400.
8. Ten Broeke SW, van der Klift HM, Tops CMJ, et al. Cancer risks for PMS2-associated Lynch syndrome. J Clin Oncol 2018; 36:2961.

Graphic 62089 Version 16.0

Abdominal myomectomy

Vertical incision into the anterior uterine surface.

Courtesy of William J Mann, Jr, MD.

Graphic 72235 Version 1.0

Placement of allis clamps for traction on the myometrium during
myomectomy

Courtesy of William J Mann, Jr, MD.

Graphic 79302 Version 4.0

Towel clamp on myoma during myomectomy

Towel clamp placed on myoma for traction to aid in dissection.

Courtesy of William J Mann, Jr, MD.

Graphic 63325 Version 2.0

Dissection of myoma during myomectomy

Courtesy of William J Mann, Jr, MD.

Graphic 74537 Version 2.0

Closure of myomectomy

Courtesy of William J Mann, Jr, MD.

Graphic 53687 Version 1.0

Closure of the outer myometrium during myomectomy

Courtesy of William J Mann, Jr, MD.

Graphic 77177 Version 2.0

Serosal repair after myomectomy

Courtesy of William J Mann, Jr, MD.

Graphic 54185 Version 1.0

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