What is myoma?

Benign tumors originating from the muscle cells of the uterus are called myomas. Myomas are the most common tumors in the female reproductive system.

One of every 4-5 women has a large or small myoma. Myomas do not usually cause any symptoms and are detected in routine examinations and therefore do not need to be treated. Regular checks and monitoring of their size and condition are usually sufficient. These masses enter a stagnant period after menopause and do not grow anymore, on the contrary, they tend to shrink. In case of symptoms, the most common complaint is excessive menstrual bleeding and associated anemia. Myomas can cause infertility or recurrent miscarriages in some cases.

The location of the myoma determines its relationship with the infertility. While myomas located close to the corneal area where the tubes unite with the uterus may affect the permeability of the tubes, myomas that disrupt the order of the endometrium may adversely affect the settlement of the embryo and the continuation of the pregnancy. Again, depending on myomas, bleeding may be excessive after delivery, and the uterus may not contract enough. Another complaint caused by myomas is pain due to pressure and effects on neighboring organs. Very large myomas can cause swelling in the abdomen.

Identification of myomas according to their localization

As a general rule, if myoma is causing a complaint or in other words, if it is symptomatic, it should be treated. The treatment of myomas is surgery. However, there are different forms of surgery. The most common method is removal of the uterus as a whole, that is, hysterectomy. However, in some cases, it may be necessary to remove only myomas without disturbing the integrity of the uterus. This surgical procedure is called myomectomy.

According to the American College of Obstetricians and Gynecologists (ACOG), the only situation that requires a myomectomy instead of removing the entire uterus is when myoma 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, removal of their uterus is a source of serious psychiatric problems, and keeping it in place is very important in this regard.

Myomectomy was first described by Atlee in 1844 and there has been no significant change in technique since then. The most important development in the field of myomectomy can be considered as the use of laparoscopy in the treatment of myoma.
If myoma has grown outward from the uterine wall, then the laparoscopic approach will be much more meaningful. Myoma can be easily removed with a very short procedure. On the other hand, in the presence of a large intramural myoma embedded in the uterine wall, the laparotomic approach may be more beneficial for the patient. Myomas growing into the inner cavity of the uterus are removed by hysteroscopy. In this case, the patient does not need to be hospitalized.

It has been suggested by some authors to put the woman into menopause with medications called GnRH analogues for a short time before myomectomy and thus to shrink the myoma. However, studies have shown that although the myoma 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 myomas shrink after GnRH analogue application and cannot be found during the operation. The probability of recurrence of these myomas increases very much and goes up to 63%. This rate is 13% in those who do not undergo analogue application.

Laparotomy or laparoscopic myomectomy

Laparoscopic myomectomy was first described in the early 1970s by scientists named Semm and Mettler. The first attempts were to remove subserous myomas 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 myomas in the uterine wall can be removed in this way has started to gain popularity.

The most important advantage of laparoscopy compared to laparotomy, in which the abdominal cavity is completely opened, is that the post-operative 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 experience of the surgeon who will perform the operation. However, the longer duration of the operation, the problems experienced in the presence of large or multiple myomas, and the possibility of returning to open surgery when a problem arises are other disadvantages. Since it is not possible to feel by hand during laparoscopy, very small myomas that cannot be seen from the outside may be overlooked.

One of the most difficult stages of laparoscopy is to remove the myoma separated from the uterine wall out of the body. Since laparoscopy is performed with the help of instruments that are passed through 3 holes, the largest of which is 10 mm in diameter, it is impossible to take the myoma out of the body using these holes if it is larger than 10 millimeters.

This can only be made possible by splitting the myoma. Splitting the myoma is not easy due to its hard and slippery structure. In the past, it was tried to cut it into pieces with scissors in the abdomen, but today, with the help of a tool called an electromechanical morcellator, no matter how big the myoma is, it is cut into strips with a diameter of 10 mm and taken out of the abdominal cavity.

The morcellator, which is a 10 mm diameter tube with a sharp tip, cuts the myoma cylindrically into it and the cut piece is removed from the 10 mm hole. The process continues until the entire myoma is removed. Using an electromechanical morcellator is a job that requires experience. A moment of inattention can lead to the cutting of the intestines instead of myomas. In addition, this procedure prolongs the operation time. Another method is to take the myoma out of the body through an incision made through the vagina.
When 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 safety of this suture in pregnancies occurring after laparoscopic sutures.

A number of 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 consensus. For example, some researchers remove even 15 cm myomas laparoscopically, while more conservative ones prefer laparotomy in the presence of myomas larger than 8 cm or more than 2 myomas. The decision on this issue depends on the observation and experience of the surgeon who will perform the operation.

Adhesions

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. Apart from infertility, adhesions also bring some complication risks such as chronic inguinal pain, increased risk of ectopic pregnancy and even intestinal obstruction. Adhesions (adhesions) seen after myomectomy are of particular importance 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. If the myoma is on the posterior wall of the uterus, the probability of adhesion is 93%, while it is 55% if it is on the upper or anterior side. Another factor that increases the risk of severe adhesions is that the myoma 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 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, while this rate was 51.1% after laparoscopic myomectomy.

Although many different medications and substances have been tried to reduce the risk of adhesion formation after myomectomy, none of them is as effective as a carefully performed surgery.
Some authors suggest that it may be beneficial to observe the adhesions and to open the detected adhesions by performing laparoscopy again 3-12 weeks after myomectomy.

Pregnancy after myomectomy

Pregnancy rates after myomectomies performed for infertility are quite satisfactory. Depending on the age of the patient, 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. In 80% of patients who get pregnant, pregnancy occurs 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 miscarriage, which was around 60% before myomectomy, decreased to 24% after the operation.

Mode of delivery after myomectomy

During myomectomy, one or more incisions are made on the uterine wall according to the number of myomas and their localization, the myoma is removed, and the resulting gap is closed with sutures. For this reason, just like in cesarean section, the integrity of the uterine wall is disrupted. Therefore, the risk of uterine rupture is slightly higher in pregnancies after myomectomy. Because of this risk, many gynecologists agree that the mode of delivery after myomectomy should be cesarean section.

Cesarean section is required only after removal of intramural myomas in the uterine muscle tissue. Normal delivery can occur after subserous myomectomy, or submucous myomectomy with hysteroscopy.

When deciding on cesarean section after myomectomy, criteria such as the size, number, localization, and intramuscular depth of the removed myomas are taken into consideration.

Myomectomy during cesarean section

It is a very controversial issue whether myomas 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 intervention is absolutely contraindicated and should not be done. Accordingly, only subserous myomas attached to the uterus can be removed with a thin stalk during cesarean section. The reason why intramural myomas are not removed is the difficulty of bleeding control. It may even be necessary to remove the uterus to control the bleeding, or 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 itself 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 myomas 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 shown that cesarean section myomectomy can be performed safely in selected patient groups with careful and good surgical technique.

Complications

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 and anesthesia, and some of them belong to the surgery itself.

• Complications of laparotomy, laparoscopy or hysteroscopy
• Complications of general anesthesia
• Bleeding. A drain may be placed in the abdomen to monitor bleeding after myomectomy. In some cases, if the patient is given blood or, very rarely, if the bleeding continues, a reoperation may be necessary.
• Open surgery can be performed in laparoscopic procedures.
• Postoperative adhesions and related complaints may occur.
• Myoma can recur. The probability of myomas requiring reoperation within 5 years is between 4-12%.