Conventional myomectomy

In addition to the conventional/older treatments of myomectomy and hysterectomy, the options now available to the woman with symptomatic fibroids, especially if she wishes to conserve her uterus, include medical treatments such as mifepristone, minimally invasive therapies such as uterine artery embolization (UAE) or magnetic-resonance-guided focused ultrasound surgery (MRgFUS), and laparoscopic or vaginal myomectomy. It is generally accepted, and with justification, that conventional myomectomy is associated with significant morbidity, especially excessive peri-operative blood loss, recurrence of the fibroids and adhesion formation, which might compromise the very reason, i.e. fertility, which the operation is performed to preserve. However, the newer treatments have significant limitations: medical treatments are promising but, to date, have been found to be of limited efficacy; UAE is still under evaluation and its impact on fertility has yet to be researched; and MRgFUS is an even newer therapy which is limited to centres with high technology and hugely expensive open magnetic resonance imaging facilities. Both UAE and MRgFUS cause shrinkage rather than removal of the fibroids, and have limited efficacy when used with really large, multiple fibroids. Laparoscopic myomectomy is also limited by the size and number of fibroids that can be treated by this approach, and demands laparoscopic skills that are still lacking in most institutions; limitations which also apply to vaginal myomectomy. It is therefore evident that conventional abdominal myomectomy still has a major role to play. There are no limitations on size and number of fibroids, and there are good data showing improvement in outcomes of assisted reproduction treatments following myomectomy. The widespread fallacy is probably the assumption that any gynaecological surgeon can perform a myomectomy; good conventional myomectomy demands no less skill than the laparoscopic approach. There is a need to continue to refine and innovate, especially with regard to reducing blood loss during surgery, reducing the risk of adhesion formation, reducing the risk of recurrence, and reconstruction of uteri to approximate anatomical normality and physiological integrity so that they can carry a pregnancy without complications such as scar rupture. This chapter will review the position of conventional myomectomy and describe approaches to optimizing outcomes following myomectomy.