Myomectomy — Procedure Guide, Recovery & Risks | MyMedicPlus

Myomectomy is the surgical removal of uterine fibroids (leiomyomas) while preserving the uterus, making it the definitive fibroid treatment for women who wish to maintain fertility or preserve their uterus as a personal preference. Uterine fibroids are the most common benign tumours of the female reproductive tract, occurring histologically in up to 70% of women by age 50, though only 25–50% cause clinically significant symptoms. Fibroids are classified by their anatomical relationship to the uterine wall: submucosal fibroids (FIGO type 0–2) protrude into the uterine cavity and most strongly affect fertility and bleeding; intramural fibroids develop within the myometrial wall; and subserosal fibroids project from the outer uterine surface. Symptomatic fibroids cause heavy menstrual bleeding (the most common indication — often causing iron-deficiency anaemia), chronic pelvic pain and pressure, urinary frequency from bladder compression by a large fibroid, and subfertility or recurrent pregnancy loss attributable to cavity-distorting submucosal disease. Three distinct surgical routes are used depending on fibroid number, size, location, and surgeon expertise: open abdominal myomectomy (laparotomy), laparoscopic (keyhole) myomectomy, and hysteroscopic (transcervical) myomectomy for submucosal lesions. Each technique aims to completely enucleate fibroid tissue from the surrounding myometrium and close any uterine defects in anatomical layers with absorbable sutures to restore normal uterine architecture and long-term function.

Myomectomy is indicated for symptomatic uterine fibroids causing heavy menstrual bleeding leading to iron-deficiency anaemia, chronic pelvic pain or pressure, urinary frequency from bladder compression, or subfertility attributable to submucous fibroids distorting the uterine cavity. It is preferred over hysterectomy in women desiring future pregnancy or uterine preservation. Preoperative GnRH analogue (e.g., leuprolide acetate) may be used for 3 months to reduce fibroid volume and vascularity before surgery. Contraindications include current pregnancy, suspected uterine malignancy (leiomyosarcoma), and cases where innumerable fibroids preclude safe uterine reconstruction. Women with a single large fibroid (greater than 10 cm) or symptomatic fibroids who have completed childbearing may be offered hysterectomy as a definitive alternative. All decisions are made after shared decision-making between patient and gynaecologist.

The surgical approach is selected based on fibroid size, number, location (FIGO classification), and surgeon expertise. Hysteroscopic myomectomy is performed via a rigid resectoscope (7–9 mm diameter) introduced through the cervix into the saline-distended uterine cavity without any abdominal incisions. Submucosal fibroids (ESGE/FIGO Type 0 — fully intracavitary; Type I — partially intracavitary with under 50% myometrial extension; Type II — over 50% myometrial extension) are visualised directly and excised using a monopolar or bipolar electrosurgical loop in a shaving technique. The fluid deficit from saline distension media is monitored continuously as a safety marker; surgery is stopped if absorption exceeds 1,500 mL to prevent dilutional hyponatraemia. Laparoscopic myomectomy uses 3–4 trocar ports placed through the abdominal wall. The fibroid surface is scored with monopolar diathermy and the fibroid is enucleated from its pseudocapsule by blunt and sharp dissection; a corkscrew myoma screw provides traction on the fibroid. Uterine defects are closed in 2–3 layers using intracorporeal suturing with size 1 Polyglactin or PDS sutures on a large curved needle. Intracorporeal morcellation (now restricted or banned in many countries due to dissemination risk in occult uterine sarcoma) or mini-laparotomy bag extraction removes the specimen. Open myomectomy (laparotomy) provides the greatest access for large (greater than 10 cm), deeply intramural, or numerous (greater than 5–10) fibroids. A midline or Pfannenstiel incision is used; a vasopressin solution (diluted 1:100 in normal saline) injected submucosally at each fibroid site reduces intraoperative haemorrhage by 40–60%. Uterine tourniquet using a Penrose drain around the broad ligament may supplement haemostasis. Duration ranges from 45 minutes for a single hysteroscopic myomectomy to 3–4 hours for extensive open procedures.

Myomectomy delivers significant symptom relief in 80–90% of patients: heavy menstrual bleeding reduces substantially within one to two menstrual cycles post-operatively as the uterine cavity is restored to normal dimensions and submucous fibroids are removed, allowing the endometrium to regenerate normally. Haemoglobin and iron stores normalise over 2–3 months with oral iron supplementation and improved menstrual blood loss. Pelvic pressure, bulk symptoms, and urinary frequency improve progressively as the uterus returns to normal size over 4–8 weeks. For women with submucous fibroids contributing to infertility or recurrent pregnancy loss, myomectomy significantly improves reproductive outcomes: systematic reviews report post-myomectomy pregnancy rates of 40–65% compared with rates as low as 20–25% in untreated women with cavity-distorting Type 0–1 fibroids. Hysteroscopic myomectomy, being the least invasive approach requiring no abdominal incision, allows same-day discharge, minimal intraoperative blood loss, and return to normal work and activities within 1–5 days. Laparoscopic myomectomy offers excellent outcomes with faster recovery than open surgery. Quality of life measured by the Uterine Fibroid Symptom-Quality of Life (UFS-QOL) questionnaire improves significantly at 6 and 12 months post-operatively across all surgical approaches in published clinical series and randomised trials.

The most significant intraoperative risk is haemorrhage, requiring blood transfusion in approximately 5% of open and 2% of laparoscopic cases. Conversion from laparoscopic to open surgery occurs in 2–3% when bleeding or fibroid burden exceeds laparoscopic control. Adhesion formation in the pelvis and on the uterine surface is a recognised risk — particularly after open myomectomy — and may impair subsequent fertility in a small proportion of cases. Fibroid recurrence occurs in 20–30% within 5 years, with higher rates in younger women and those with multiple fibroids. Uterine rupture at the site of deep intramural myomectomy incisions in a subsequent pregnancy is a rare but serious risk (under 1%), necessitating close obstetric surveillance and consideration of elective caesarean section at 37–38 weeks. Gas embolism is a rare risk of hysteroscopic procedures.

After open myomectomy, patients are hospitalised for 2–3 days, with full recovery expected in 4–6 weeks. Laparoscopic myomectomy allows discharge in 1–2 days and return to desk work within 2 weeks. Hysteroscopic myomectomy is typically a day-case procedure with return to normal activities within 2–5 days. Strenuous physical activity and heavy lifting are restricted for 4–6 weeks regardless of approach. Sexual intercourse is deferred for 6–8 weeks. Conception should be avoided for 3–6 months after intramural or subserosal myomectomy to allow adequate uterine wall healing; the operating surgeon advises the specific interval based on defect depth. If GnRH analogue therapy was used preoperatively, fibroid re-growth may begin after cessation, so timely conception attempts are encouraged once recovery is complete.

The recovery phase following this procedure is structured to ensure safe return of function while minimising complication risk. Immediate post-procedural recovery takes place in a monitored environment where vital signs, wound status, and procedural site are assessed at regular intervals.

Early mobilisation is encouraged as tolerated in line with evidence demonstrating reduced complication rates with physiologically appropriate activity. Pain management follows a multimodal protocol including regular analgesics, and patient-controlled or nurse-administered supplemental analgesia as required.

Discharge criteria are met when the patient is haemodynamically stable, pain is adequately controlled with oral analgesia, oral intake is tolerated, and the patient has received and understands discharge instructions. The typical hospital stay ranges from same-day discharge for minor procedures to 3-7 days for major interventions.

Post-discharge recovery progresses through defined phases: restricted activity during the initial healing phase, gradual return to light activities as healing progresses, and full return to normal function at a timeframe specific to the procedure and individual healing. Physiotherapy input is provided where indicated to optimise functional recovery. Return to work timelines depend on the nature of the procedure and occupational demands.