Myomectomy is surgery to remove uterine fibroids. Uterine fibroids are non-cancerous growths of tissue (almost always noncancerous) that develop in the uterus. Myomectomy leaves the uterus intact, so people can still become pregnant after the procedure.

Maria Vargas, M.D., a fellowship-trained Gyn/Ob at Johns Hopkins’ Sibley Memorial Hospital, explains the different types of myomectomies and their risks and benefits.

What is a myomectomy?

Myomectomy removes uterine fibroids. Fibroids are defined according to where they occur in the uterus:

• Intramural fibroids: within the muscular uterine wall
• Submucosal fibroids: just beneath the uterine lining
• Subserosal fibroids: on the outside of the uterine wall

For people who still want to get pregnant, myomectomy is an alternative to hysterectomy (surgery to remove the uterus) for the treatment of fibroids.

“We recommend myomectomy when fibroids become symptomatic or when their location affects fertility,” explains Vargas. “If the fibroids are larger than 4 centimeters, are intramural or submucosal and the patient still desires fertility, they should be surgically removed.”

Myomectomy can help relieve:

• Bleeding between periods
• Heavy menstrual bleeding
• Iron-deficiency anemia caused by blood loss
• Pelvic pain and pressure

The procedure can also reduce the risk of serious health complications. “If fibroids are located within the endometrial cavity, they increase the chances of a miscarriage within the second trimester of pregnancy,” says Vargas. In rare cases, fibroids can cause compression of major veins and lead to life-threatening blood clots.

Types of Myomectomies

There are several types of myomectomies. The procedure that is right for you will depend on several factors, including the location, number and size of uterine fibroids to be removed.

Abdominal myomectomy

An abdominal, or open, myomectomy requires the longest recovery and carries some additional risk compared with the other approaches to myomectomy, but it is recommended in specific cases when the benefits outweigh the risks. The decision to recommend an abdominal myomectomy depends on the size and number of fibroids present. During the procedure, your surgeon makes an incision (cut) in your abdominal wall. The incision is usually horizontal and low on your belly, around the same location as a C-section incision. Or, if a woman has a large uterus, fibroids high in the uterus or a scar from previous abdominal surgery, your surgeon may make a vertical midline incision.

For an abdominal myomectomy, you can expect:

• Anesthesia: general, with a breathing tube
• Hospitalization: one to two days
• Incision size: Horizontal incisions are about 4 inches; midline incisions are longer.
• Procedure time: two to three hours
• Recovery: four to six weeks

Abdominal myomectomy benefits and risks

An abdominal myomectomy carries more risks than a less invasive procedure, including:

• Excessive bleeding
• Infection
• Longer recovery
• Pain
• Scarring

Uterine rupture during pregnancy is a risk for the abdominal and laparoscopic approaches,

“But there are some benefits to an abdominal myomectomy,” says Vargas. “The surgeon has greater access to the fibroids, so we are able to palpate, or touch, them within the uterine wall and locate them more easily. It’s also a quicker procedure than minimally invasive alternatives like laparoscopic, robotic or hysteroscopic myomectomy. We might recommend an open surgery if a patient has many fibroids or very large fibroids.”

Abdominal myomectomy recovery

Recovery after abdominal myomectomy takes four to six weeks. During this time, avoid heavy lifting or any type of strenuous activity. Depending on your job, you may need to take four to eight weeks off work.

But Vargas stresses that it’s important to stay mobile during recovery by walking each day. “Becoming sedentary can increase the risk of deep vein thrombosis, which are blood clots in your legs that can travel to your lungs (pulmonary embolism) and be life-threatening. You can also lose muscle mass and become deconditioned, which further prolongs recovery.”

Robotic-assisted or laparoscopic myomectomy

Laparoscopic myomectomy is a minimally invasive procedure to remove uterine fibroids. A surgeon makes four tiny incisions in your abdomen then uses a laparoscope, which is a special instrument that contains a light and video camera, to operate through the incisions. Your surgeon views the surgery on a video monitor.

Robotic-assisted myomectomy is another minimally invasive procedure. Your surgeon uses the guidance of a robotic arm to remove fibroids that are numerous, complex or deep in the uterine wall.

For a laparoscopic or robotic-assisted myomectomy, you can expect:

• Anesthesia: general
• Hospitalization: none (usually an outpatient procedure)
• Incision size: 5–12 millimeters
• Procedure time: three to four hours
• Recovery: two to three weeks

Robotic-assisted and laparoscopic myomectomy benefits and risks

“Most myomectomies should be performed laparoscopically,” says Vargas. “We can even remove very large fibroids using this technique. It’s a longer procedure in the operating room, but it carries fewer risks than abdominal myomectomy.”

There is less bleeding during surgery, so patients are less likely to need a blood transfusion. It also causes less trauma to the abdominal wall, which lowers the risk of adhesions. Patients recover faster and with less pain.

Similar to the abdominal approach, robotic-assisted and laparoscopic procedures require uterine incisions that weaken the myometrium. The incisions of the myometrium seen with the abdominal, laparoscopic and robotic approaches to myomectomy can increase the risk of uterine rupture during pregnancy and labor, so women who have had these procedures need C-sections during delivery.

Robotic-assisted and laparoscopic myomectomy recovery

Recovery after minimally invasive myomectomy takes two to three weeks. Plan on taking three weeks off work. “People tend to be more mobile after a laparoscopic or robotic-assisted myomectomy,” says Vargas. “There’s less pain due to the small incisions. But you may still feel fatigued as your body heals.”

Hysteroscopic myomectomy

Hysteroscopic myomectomy is the most minimally invasive procedure to treat fibroids. A surgeon removes fibroids by inserting a hysteroscope into the uterine cavity through the vagina and cervix. A hysteroscope is a rigid tube with a light that has an operative element that can remove fibroid tissue. Hysteroscopic myomectomy is performed entirely through the natural orifices of the vagina and cervix, so no incisions are made.

For a hysteroscopic myomectomy, you can expect:

• Anesthesia: general or sedation
• Hospitalization: none
• Incision size: none
• Procedure time: under 90 minutes
• Recovery: 48 hours

Hysteroscopic myomectomy benefits and risks

Only certain types of fibroids can be removed with hysteroscopic myomectomy, so not everyone will be a candidate for this procedure. Your surgeon may recommend the procedure if you have fibroids that are:

• Not deep in the uterine wall
• Smaller than 4 centimeters
• Submucosal

A hysteroscopic myomectomy does not cause any trauma to the uterine wall, so it does not increase the risk of complications during pregnancy. And since it does not require any incisions, patients have no scarring and a fast recovery.

Hysteroscopic myomectomy recovery

Most people only need one to two days to recover from a hysteroscopic myomectomy and can return to work as soon as they feel ready.

Myomectomy and Pregnancy

The main benefit of myomectomy is that it preserves fertility, so people can still become pregnant after fibroid removal. The procedure may even improve fertility if fibroids are preventing pregnancy. However, abdominal and laparoscopic myomectomies require incisions that compromise the myometrium. This increases the risk of uterine rupture during pregnancy and labor. People who have had an abdominal or laparoscopic myomectomy will often need a C-section during delivery.