Hysteroscopic Myomectomy

Myomectomy is, quite simply, removing uterine fibroids and leaving the uterus behind. This can only be done surgically. The location and size of the fibroids determine which of three routes - traditional, hysteroscopic or laparoscopic - makes the most sense. No matter what type of myomectomy is planned, pre-operative preparation is absolutely the key to a good outcome. Ultrasound is generally used to determine the number and location of fibroids. Magnetic Resonance Imaging (MRI), Saline Infused Sonography, or Hysterosalpingograms are also useful to determine exact locations and types of fibroids.

Traditional Myomectomy

In a traditional myomectomy, an abdominal incision is made. Usually this is in the bikini line; however, in some situations, a vertical (pubic to belly button) incision is needed. The fibroids are then removed by separating and cutting them away from normal uterine tissue. An attempt is made to remove as many fibroids as possible through a single incision in order to minimize blood loss and scarring, but sometimes multiple uterine incisions are necessary. Once the fibroids are removed, the uterus is reconstructed by sewing the uterine wall closed in multiple layers.

Hysteroscopic Myomectomy

Hysteroscopic myomectomy utilizes a hysteroscope (a tube with a camera and light attached to it) that is inserted through the cervix in order to visualize the uterine cavity. In operative hysteroscopy, an instrument can be passed through the scope to cut fibroids into small pieces, which are then removed through the cervix. This procedure can only be utilized if a fibroid is a sub-mucous or intracavitary fibroid that protrudes into the uterine cavity.

Laparoscopic Myomectomy

Laparoscopic myomectomy is used to remove subserosal or pedunculated fibroids. A subserosal fibroid is the fibroid, which is under the outermost layer of the uterus. It doesn’t protrude through the muscle into the cavity; it goes the other direction. The pedunculated version is entirely outside the uterus and attached only by a stalk. If it is difficult to tell the exact location, or if a stalk is present, a 3-D ultrasound, sonohysterogram or MRI may give additional information.

A laparoscope and other instruments are inserted through tiny incisions that can then cut the fibroid away from the uterine wall. Laparoscopic myomectomy gets considerably more complicated if the fibroid is not pedunculated, but is incorporated into the muscle of the uterus. Usually the uterine wall must then be reconstructed. Robotic surgery is often utilized to facilitate this process.

Dr. Streicher has literally "written the book" on alternative treatments for fibroids. Detailed information about all of the above options can be found in The Essential Guide to Hysterectomy.

Watch Dr. Streicher talk about the treatment of fibroids on NBC's In the Loop with iVillage.