What is Myoma?
Benign smooth muscle tumours originating from the uterus’s (womb) muscle cells (myometrium) are called myomas. Myon is a name that is mistakenly given to myoma among the people. Myomas appear macroscopically as round, pearly-white, firm, flexible tumours with a curved surface. Typically, there are 6-7 fibroids of various sizes in the uterus. Fibroids have a different autonomy from the surrounding myometrium due to the thin outer connective tissue layer. This allows the capsule of fibroids to be easily peeled off during surgery.
Fibroids are the most common tumours in the female reproductive system. Generally, the incidence among women is stated as 20-25%. In other words, one of every four to five women has a large or small fibroid.
Fibroids are estrogen and progesterone sensitive tumours. Therefore, they develop during the reproductive age, enter a stagnant period after menopause, and do not grow anymore; on the contrary, they tend to shrink.
What Problems Does Myoma Cause? Is There a Relationship Between Myoma and Infertility?
Myomas do not give any symptoms in many women; they are detected in routine examinations and therefore do not need to be treated. It is usually sufficient to follow the size and condition of myomas with regular controls.
However, the number, size, and location of fibroids in the uterus can cause many symptoms in some women. In cases where fibroids give symptoms, the most common complaint is excessive menstrual bleeding and anaemia, which develops accordingly.
Fibroids can cause infertility or recurrent miscarriages in some cases. The location of the fibroid determines its relationship with infertility. While myomas located close to the cornual area where the tubes meet with the uterus may affect the permeability of the tubes, fibroids that disrupt the order of the endometrium may adversely affect the placement of the embryo and the continuation of the pregnancy. Again, postpartum bleeding may be excessive depending on myomas, and the uterus may not contract enough.
Another complaint caused by fibroids is pain due to pressure and effects on neighbouring organs. Very large fibroids can cause swelling in the abdomen.
How is Myoma Diagnosed?
Pelvic examination often reveals uterine enlargement, uterine margin irregularities, or both in fibroids. Urine or serum beta-hCG levels should be determined immediately in case of uterine enlargement in women of reproductive age. Various methods such as ultrasonography, hysteroscopy, hysterosalpingography, colour Doppler and magnetic resonance can be used to diagnose myoma.
How Are Fibroids Treated? What is Myomectomy?
In general, the rule is that if myoma is causing a complaint, or in other words, if it is symptomatic, it should be treated. Asymptomatic fibroids, regardless of size, can be followed without treatment with annual pelvic examinations and sonography.
The treatment of fibroids is surgery. However, there are different forms of myoma surgery. A radical method is the removal of the uterus as a whole, namely hysterectomy. However, many patients do not want the integrity of the uterus to be disrupted. In this case, only fibroids should be removed. This surgical procedure is called a myomectomy.
According to the American Association of Obstetricians and Gynecologists (ACOG), the only situation that requires myomectomy instead of removing the entire uterus in fibroid surgery is when the fibroid causes infertility. On the other hand, myomectomy can be performed in women who do not want their uterus removed, even if there is no infertility problem and the woman has completed her family. For some women, the removal of their uterus is a serious source of psychological problems and keeping it in place is very important in this regard.
Surgery for symptomatic fibroids should be performed close to the planned pregnancy, if possible, to reduce the risk of fibroid recurrence.
Atlee first described myomectomy in 1844, and there has been no significant change in technique since then. The most important development in myomectomy can be considered the use of laparoscopy in the treatment of myoma.
Myomectomy can be performed laparoscopically, hysteroscopically, or by laparotomy (open surgery).
How Does Myoma Treatment Differ According to The Location of Myoma?
If the fibroid has grown outward from the uterine wall, the laparoscopic approach will be much more meaningful. Myoma can be easily removed with a very short procedure.
Fibroids growing into the inner cavity of the uterus are removed by hysteroscopy. In this case, the patient does not need to be hospitalized.
What is The GnRH Analog Application Before Myomectomy?
Some authors suggested putting the woman into menopause for a short time with drugs called GnRH analogues before myomectomy, thus shrinking the myoma.
However, studies have shown that although the fibroid shrinks a little after such an application, its removal becomes much more difficult due to the destruction of the capsule that separates it from its surroundings. In addition, small fibroids shrink after GnRH analogue application and cannot be found during the operation. The recurrence probability of these fibroids increases very much and reaches 63%. This rate is 13% in patients who do not apply analogues.
Laparotomy (Open Surgery) or Laparoscopic Myomectomy?
Laparoscopic myomectomy was first described in the early 1970s by scientists called Semm and Mettler. The first attempts were to remove subserous fibroids growing out of the uterine wall in this way.
Since the beginning of the nineties, in parallel with the developments in both equipment and technique, the idea that intramural fibroids in the uterine wall can also be removed in this way has started to gain popularity.
Surgery performed laparoscopically has some proven advantages over that performed by laparotomy. All of these advantages are due to the fact that the access incisions used for laparoscopy are much smaller than the laparotomy incision.
The most important advantage of laparoscopy compared to laparotomy, in which the abdominal cavity is completely opened, is that the postoperative period is much more comfortable. In these patients, the duration of hospital stay and return to normal life is much shorter. On the other hand, the absence of a certain surgical scar provides a cosmetic advantage.
The most important disadvantage of laparoscopy compared to open surgery is that it is directly dependent on the surgeon’s experience who will operate. However, the longer operation time and the possibility of returning to open surgery due to the problems experienced in the presence of large or multiple fibroids are other disadvantages. Since it is impossible to feel by hand during laparoscopy, very small fibroids that cannot be seen outside may be overlooked.
One of the most difficult stages of laparoscopy is removing the fibroid from the uterine wall to the out of the body. Since laparoscopy is performed with the help of instruments passed through 3 holes, the largest of which is 10 mm in diameter, it is impossible to take the fibroid out of the body using these holes if it is larger than 10 millimetres. This can only be made possible by rupturing the fibroid. Splitting the fibroid is not easy due to its hard and slippery structure. It was used to cut it into pieces with scissors in the abdomen in the past. Still, today, with the help of a tool called an electromechanical morcellator, no matter how big the fibroid is, it is cut into strips with a diameter of 10 mm and taken out of the abdominal cavity. The morcellator, a 10 mm diameter tube with a sharp tip, cuts the myoma cylindrically into it. The cut piece is removed from the 10 mm hole. The process continues until the entire fibroid is removed. Using an electromechanical morcellator is a job that requires experience. A moment of inattention can lead to intestinal scission instead of fibroids. In addition, this procedure prolongs the operation time. Another method is to take the fibroid out of the body through an incision made through the vagina.
Compared to laparotomy, suturing the incision in the uterus with laparoscopy is a very difficult procedure and requires experience. There are still doubts in scientific circles about the reliability of this suture in pregnancies after laparoscopic sutures.
Several researchers have conducted studies to identify suitable candidates for laparoscopic myomectomy and have made some recommendations. However, none of these recommendations was sufficient to reach a consensus. For example, some researchers laparoscopically remove even 15 cm fibroids. In contrast, more conservative ones prefer laparotomy in the presence of fibroids larger than 8 cm or more than 2 cm. The decision on this issue depends on the impression and experience of the surgeon who will operate.
Will There be Adhesions After The Myomectomy?
The purpose of myomectomy, whether performed by laparotomy or laparoscopy, is to preserve the reproductive potential. However, one of the most important disadvantages of this operation is intra-abdominal adhesions that occur after the operation and negatively affect the potential for pregnancy.
Adhesions also bring complications such as chronic inguinal pain, increased risk of ectopic pregnancy and even intestinal obstruction, apart from infertility. Adhesions seen after myomectomy are important after operations performed for infertility or recurrent miscarriages. Adhesions disrupt the normal anatomy, preventing both the permeability of the tubes and their functioning, and in this way, they can cause difficulty in getting pregnant.
The rate of adhesion formation after laparotomy and myomectomy is between 71.4% and 100%. 75% of these adhesions are mild, and the rest are moderate. Suppose the fibroid is on the posterior wall of the uterus. In that case, the probability of adhesion is 93%, while it is 55% when it is on the upper or anterior side.
Another factor that increases the risk of severe adhesions is that the fibroid is very large, or multiple incisions are made on the uterus.
One of the important features of laparoscopic procedures is that they cause minimal surgical trauma. Therefore, the risk of adhesion formation after myomectomy is expected to be lower than after open surgery. A limited number of studies confirm this expectation. In general, 89.6% of patients who underwent myomectomy with laparotomy had adhesions of varying degrees. In comparison, this rate was 51.1% after laparoscopic myomectomy.
Although many different drugs and substances have been tried to reduce the risk of adhesion formation after myomectomy, none is as effective as a meticulous surgery.
Some authors suggest that it may be beneficial to observe the adhesions and open the detected adhesions by performing laparoscopy 3-12 weeks after myomectomy.
What Are The Pregnancy Success Rates After Myomectomy?
Pregnancy rates after myomectomies performed for infertility are quite satisfactory. Depending on the patient’s age, the pregnancy rate after myomectomy varies between 22-66%, with an average of 57%, that is, more than half of the patients getting pregnant.
The rate is significantly higher in women younger than 35 years of age. Pregnancy occurs in 80% of patients who become pregnant without the need for any additional treatment. Pregnancy rates are slightly lower in couples with more than one cause of infertility.
In another study conducted in 1999, it was shown that the rate of spontaneous abortion, which was around 60% before myomectomy, decreased to 24% after the operation.
Which Delivery Method Should Be Chosen After Myomectomy?
During myomectomy, one or more incisions are made on the uterine wall depending on the number of fibroids and their localization, the fibroid is removed, and the resulting gap is closed with sutures. For this reason, just like in a cesarean section, the integrity of the uterine wall is broken. Therefore, the risk of uterine rupture is slightly higher in pregnancies after myomectomy. Because of this risk, many gynaecologists agree that the delivery method after myomectomy should be cesarean section.
Cesarean section is required only after the removal of intramural fibroids in the uterine muscle tissue. Normal delivery can occur after subserous myomectomy or submucous myomectomy with hysteroscopy.
When deciding on the cesarean section after myomectomy, criteria such as the size, number, localization, and intramuscular depth of the removed fibroids are taken into account.
What is Myomectomy During a Cesarean Section?
It is controversial whether fibroids that are known to exist before or noticed during cesarean section can be removed during this operation.
It is stated in the old editions of the classical reference books of obstetrics that this attempt is contraindicated and should not be done. Accordingly, only subserous fibroids attached to the uterus can be removed with a thin stalk during cesarean section.
Intramural fibroids are not removed because of the difficulty of bleeding control. It may even be necessary to remove the uterus to control the bleeding. If the bleeding continues after the surgery, a second surgery may be necessary.
During pregnancy, the blood supply to the uterus increases a lot. Since myomectomy is an intervention that can cause bleeding, it is not very safe to perform in a pregnant uterus during a cesarean section. Since some shrinkage is also seen in fibroids after the puerperal period, it is safer to postpone the operation to the end of this period.
In addition to this classical knowledge, many studies have revealed that cesarean section myomectomy can be performed safely with careful and good surgical techniques in selected patient groups.
What Are The Complications of Myomectomy?
As with any surgical procedure, myomectomy carries risks of complications. However, the incidence of these complications is extremely low.
Some of the complications belong to the surgical technique applied (laparoscopy, hysteroscopy, and open surgery have different risks) and anaesthesia. Some of them belong to the surgery itself.
Complications of myomectomy include:
- Bleeding from the uterine wall where the fibroid is removed. In some cases, the patient needs to be given blood (5%) or very rarely (1%) removal of the uterus. A drain may be placed in the abdomen to monitor bleeding after a myomectomy.
- Open surgery can be performed in laparoscopic procedures. Open surgery (laparotomy) can be performed if a situation arises that was not foreseen before the surgery or cannot be performed by laparoscopy.
- Neighbouring organ injuries are possible. Bladder and urinary tract injuries, bowel perforations, and vascular injuries are rare but classical complications of this type of surgery.
- Postoperative adhesions and related complaints may occur.
- Myoma can recur. The probability of fibroids requiring reoperation within five years is between 4-12%.
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REFERENCES:
https://pubmed.ncbi.nlm.nih.gov/25769434/
https://pubmed.ncbi.nlm.nih.gov/23768623/
https://pubmed.ncbi.nlm.nih.gov/26986742/
