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Uterine fibroids (leiomyomas): Laparoscopic

myomectomy and other laparoscopic treatments
Author: William H Parker, MD
Section Editor: Tommaso Falcone, MD, FRCSC, FACOG
Deputy Editor: Alana Chakrabarti, MD

All topics are updated as new evidence becomes available and our peer review process is complete.

Literature review current through: Jul 2021. | This topic last updated: Jul 29, 2021.

INTRODUCTION

Laparoscopic techniques provide minimally invasive options for many gynecologic procedures.
Myomectomy, the removal of uterine leiomyomas (myomas or fibroids), can be performed
laparoscopically in selected patients. Other laparoscopic procedures have been developed for
leiomyoma treatment, including uterine artery occlusion and myolysis, but these are not
commonly used.

Uterine leiomyomas are the most common type of pelvic tumor in women, with an
approximately 70 to 80 percent lifetime risk [1-3]. There are a wide variety of treatments for
leiomyomas, both pharmacologic and surgical. The choice of treatments depends upon many
factors, including characteristics of the myomas, the patient, and surgical expertise.

Laparoscopic myomectomy and other laparoscopic procedures for uterine leiomyomas will be
reviewed here. Abdominal, hysteroscopic, and vaginal myomectomy, as well as other
approaches to the management of leiomyomas, are discussed separately. (See "Uterine fibroids
(leiomyomas): Abdominal myomectomy" and "Uterine fibroids (leiomyomas): Hysteroscopic
myomectomy" and "Uterine fibroids (leiomyomas): Prolapsed fibroids" and "Uterine fibroids
(leiomyomas): Treatment overview".)

PATIENT SELECTION
Laparoscopic myomectomy is primarily used to remove intramural or subserosal leiomyomas (
figure 1). Intracavitary myomas (submucosal and some intramural myomas that protrude
into the endometrial cavity) are difficult to remove during laparoscopic myomectomy. In
addition, hysteroscopic myomectomy is the procedure of choice when only intracavitary
myomas are removed, since it offers the advantages of a short recovery and minimal
perioperative morbidity. Patients with both submucosal and intramural/subserosal myomas
may be candidates for concomitant laparoscopic and hysteroscopic myomectomy. (See "Uterine
fibroids (leiomyomas): Hysteroscopic myomectomy", section on 'Patient selection'.)

Appropriate candidates for laparoscopic myomectomy are patients with the following
characteristics:

● Symptomatic uterine leiomyoma(s).

● Leiomyomas are the appropriate size, number, and location for laparoscopic removal. (See
'Candidates for laparoscopic myomectomy' below.)

● Hysteroscopic myomectomy is not feasible.

● An abdominal approach is required to treat intraabdominal pathology other than

leiomyomas.

Indications — The most common indications for laparoscopic myomectomy are:

● Abnormal uterine bleeding.

● Bulk-related symptoms – pelvic/abdominal pain or pressure; pressure on the urinary or

gastrointestinal tract resulting in urinary (eg, urinary frequency, urinary incontinence,
hydronephrosis) or bowel symptoms (eg, constipation).

Dysmenorrhea is an infrequent indication for myomectomy. Dysmenorrhea is more commonly

associated with conditions (eg, endometriosis) other than with myomas. Myomectomy or other
fibroid-specific treatment for the indication of dysmenorrhea should be performed only when
other therapies for dysmenorrhea have failed. (See "Dysmenorrhea in adult women:
Treatment".)

Unproven indications — Myomectomy should be performed only for patients in whom the

procedure is likely to ameliorate a specific symptom. Indications for which the benefit of
laparoscopic (or abdominal) myomectomy remains unproven include:

● Evaluation of ovarian or uterine malignancy

 ● Infertility (removal of fibroids with a submucous component is associated with increased
fertility)
● Prevention of obstetric complications

These indications are discussed in detail separately. (See "Uterine fibroids (leiomyomas):
Abdominal myomectomy", section on 'Unproven indications'.)

Contraindications — Laparoscopic myomectomy is contraindicated in patients in whom

laparoscopy or uterine conservation are contraindicated (eg, medical comorbidities, cervical or
uterine cancer). (See "Overview of the principles of medical consultation and perioperative
medicine".)

CHOOSING A TREATMENT APPROACH

Myomectomy versus other treatments — The choice of treatment for patients with uterine
leiomyomas is guided by the type of symptoms: abnormal bleeding or bulk-related (eg, pelvic
pain/pressure). There are a variety of treatment approaches, both pharmacologic and surgical.

The choice between myomectomy and other treatments is discussed in detail separately. (See
"Uterine fibroids (leiomyomas): Abdominal myomectomy", section on 'Myomectomy versus
other treatment approaches' and "Abnormal uterine bleeding: Management in premenopausal
patients".)

Choosing the surgical approach for myomectomy — Laparoscopic myomectomy offers

several advantages compared with abdominal myomectomy, including decreased morbidity
and a shorter recovery. However, the wide application of laparoscopic myomectomy is limited
by the characteristics of myomas that can be reasonably removed and the surgical expertise
required (eg, laparoscopic suturing) [4]. Robot-assisted myomectomy has similar outcomes to
laparoscopic myomectomy, with longer operating times and higher costs. Hysteroscopic
myomectomy is the procedure of choice for patients with intracavitary myomas (submucosal
and some intramural myomas that protrude into the endometrial cavity).

Candidates for laparoscopic myomectomy — Determining whether a patient is a

candidate for laparoscopic myomectomy depends on the location, size, and number of
leiomyomas, although parameters for these vary with surgical expertise. These criteria are used
to ensure that patients undergoing the procedure avoid perioperative complications and/or
conversion to laparotomy. Preoperative imaging is important to assess the precise
characteristics of the tumors. (See 'Imaging' below.)
Important factors regarding the location of fibroids include the depth of penetration into the
myometrium and position relative to important structures (eg, uterine vessels, fallopian tubes).
Pedunculated subserosal fibroids are the easiest to remove, but myomas in other locations can
also be excised laparoscopically. In addition, many surgeons find anterior or fundal myomas
easier to remove than those that are posterior. Performing laparoscopic myomectomy in
patients with large or numerous myomas is likely to be time consuming, particularly since
morcellation is usually required. In addition, removal of such fibroids may lead to increased
blood loss, which is better prevented and controlled during open myomectomy. (See
"Techniques to reduce blood loss during abdominal or laparoscopic myomectomy", section on
'Intraoperative measures'.)

Few data address the optimal criteria for a successful laparoscopic myomectomy, and the ability
to successfully perform a laparoscopic myomectomy also depends in large part on surgical
expertise. The largest study was a prospective multicenter study of 2050 patients undergoing
laparoscopic myomectomy [5]. Leiomyoma characteristics that were significantly associated
with major complications (eg, bleeding requiring blood transfusion, visceral injury, procedural
failure) included: size of myoma >5 cm; >3 myomas removed; and intraligamentous location;
intramural myomas were significantly associated with an increase in minor, but not major,
complications (eg, fever, uterine manipulator injuries).

Laparoscopic versus open myomectomy — In appropriately selected patients, laparoscopic

myomectomy has lower overall morbidity and a shorter recovery time than open myomectomy.

A systematic review of six randomized trials including 576 subjects compared laparoscopic with
abdominal myomectomy [6]. Laparoscopic myomectomy had a statistically significant increase
in operative duration (13 minutes longer), but a decrease in blood loss (34 mL less). However,
these differences are small and unlikely to be clinically significant. The overall risk of
complication was significantly lower for laparoscopic myomectomy (odds ratio [OR] 0.47, 95% CI
0.26-0.85), but there was no statistically significant difference in the risk of major complications
(eg, hemorrhage requiring transfusion, visceral injury, thromboembolism; OR 0.49, 95% CI 0.09-
2.70); however, the analysis lacked sufficient statistical power to detect this difference. Two of
the trials reported that significantly more patients in the laparoscopic group had fully
recuperated by postoperative day 15. Although the data were too heterogeneous for meta-
analysis, the shorter recovery time for laparoscopic surgery is well established.

Regarding long-term outcomes, follow-up ranged widely across studies in the meta-analysis
from 6 to 52 months [6]. There was no significant difference in the rate of recurrent myomas
laparoscopic and open myomectomy (20 versus 18 percent, OR 1.2, 95% CI 0.4-3.0), although
this analysis also lacked statistical power. Interestingly, some data suggest that a laparoscopic
approach results in less severe adhesive disease, particularly fewer adnexal adhesions, which
may impact fertility [7] (see 'Adhesive disease' below). Further randomized trials are needed to
compare between these two procedures.

In summary, laparoscopic myomectomy is a minimally invasive procedure with a shorter

recovery and a lower overall risk of complications than abdominal myomectomy. More data are
needed about the comparative risks of major complications and fibroid persistence or
recurrence. Patient eligibility and access to trained surgeons limit the availability of this
procedure. Given the available data, we suggest laparoscopic rather than open myomectomy
for patients with leiomyomas when technically feasible (depending upon size, number, and
location) and who have easy access to a surgeon with advanced laparoscopic skills.

Alternative laparoscopic techniques

Robot-assisted laparoscopy — Robot-assisted laparoscopic myomectomy has some

potential advantages compared with conventional laparoscopic and open procedures:
Laparoscopic suturing may be easier than with conventional laparoscopy, and blood loss
appears to be less and recovery time faster than with open procedures [8-14].

It is not known, however, whether robotic suturing results in a more secure myometrial closure
than conventional laparoscopy and, thus, in a lower risk of uterine rupture in a subsequent
pregnancy. In a retrospective cohort study of 872 patients who underwent robotic
myomectomy, 127 pregnancies occurred, which resulted in 92 deliveries and one uterine
rupture [15]. Further discussion regarding uterine rupture after myomectomy with
conventional laparoscopy is found below. (See 'Uterine rupture during pregnancy following
myomectomy' below.)

Radiofrequency fibroid ablation — Radiofrequency ablation (RFA) is a minimally invasive,

energy-based treatment that reduces fibroid-related symptoms by reducing fibroid volume. RFA
of fibroids may be accomplished using a laparoscopic or hysteroscopic approach. Procedures
are performed on an outpatient basis with return to normal activity within approximately one
week. Using ultrasound guidance to identify the fibroid, a conductive needle array punctures
the fibroid. An algorithm calculates the volume of fibroid tissue and duration needed for
treatment. Radiofrequency energy is then transmitted to the fibroid, and oscillation of
intracellular ions heats the tissue to greater than 100°C, which causes coagulative necrosis
[16,17]. The ultrasound probe is used to ensure that the energy does not penetrate the uterine
serosa and to monitor the tissue effect until the bulk of the fibroid is treated [18]. Over
subsequent months, fibroids are reabsorbed with a decrease in fibroid volume and a resultant
reduction in fibroid-related symptoms.
Most studies of RFA include small numbers of patients and are limited to fibroids <10 cm and a
uterine size ≤16 weeks. In a systematic review of 32 studies including 1283 patients with uterine
fibroids treated with RFA, fibroid volume was reduced by 47 and 66 percent at 3 and 12 months,
respectively [19]. The median number of treated fibroids was 1.7 per patient, and the median
fibroid volume was 74 cm3. Quality-of-life scores improved by 30 and 39 points at 3 and 12
months, and fibroid-related symptoms decreased by 29 and 42 points from baseline for the
same time periods. The rates of surgical reinterventions for fibroid-related symptoms were 4.0,
8.0, and 11.5 percent at one, two, and three years of follow-up. Although complications were
not systematically reported, no serious procedural complications, such as death or iatrogenic
injury to the bowel, bladder, or ureter, were noted in any study.

In patients desiring future pregnancy, RFA should be used with caution since pregnancy data
are limited because most studies have excluded patients planning pregnancy. However, in a
review of case reports of nine desired pregnancies after laparoscopic RFA of fibroids, eight
resulted in full-term live births and one miscarried at 10 weeks [20]. Almost all of these patients
underwent a prelabor cesarean delivery for varying indications (eg, breech presentation, prior
cesarean delivery, concerns regarding myometrial strength after RFA). One patient experienced
delayed postpartum hemorrhage and expulsion of the previously ablated fibroid; no other
complications were reported. Further studies are needed to determine if RFA is appropriate for
patients who desire future fertility.

Single port laparoscopy — Single port laparoscopy, or laparoendoscopic single-site surgery

(LESS), is the most recent laparoscopic innovation. Successful LESS myomectomy has been
reported, but the data are limited to small case series and small fibroids [21-23]. Further study
is needed to evaluate this procedure. (See "Abdominal access techniques used in laparoscopic
surgery", section on 'Single-incision surgery'.)

The technique for LESS myomectomy was described by one surgeon [24]. The technique
involved the placement of three 5 mm trocars through a common umbilical incision, but
through separate fascial perforations. A harmonic scalpel and blunt dissection were used to
remove a 4 cm transmural posterior fundal myoma and the uterine defect was repaired in
layers using bidirectional barbed suture. After removal of the trocars, a fascial incision
connecting the perforations was made to facilitate removal of the myoma.

PREOPERATIVE EVALUATION AND PREPARATION

Preoperative evaluation and preparation are similar for laparoscopic and abdominal
myomectomy. Information specific to laparoscopic myomectomy is discussed in this section.
The remainder of the information can be found separately. (See "Uterine fibroids (leiomyomas):
Abdominal myomectomy", section on 'Preoperative evaluation' and "Uterine fibroids
(leiomyomas): Abdominal myomectomy", section on 'Preoperative preparation'.)

Informed consent — We counsel patients with symptomatic fibroids about the following
issues, which are documented on the surgical consent form and in the medical record:

● Alternative medical, interventional radiology, and surgical options for treatment.

• (See "Uterine fibroids (leiomyomas): Treatment overview".)

• (See "Abnormal uterine bleeding: Management in premenopausal patients".)

● Potential complications of the procedure, including conversion to laparotomy and the

likelihood of recurrence of fibroid-associated symptoms should also be reviewed.

• (See "Uterine fibroids (leiomyomas): Abdominal myomectomy", section on

'Complications'.)

• (See "Uterine fibroids (leiomyomas): Abdominal myomectomy", section on 'Persistent

or new myomas'.)

● Risk of malignancy. (See "Uterine fibroids (leiomyomas): Differentiating fibroids from

uterine sarcomas".)

● Risks and benefits of power morcellation. (See "Uterine tissue extraction by morcellation:
Techniques and clinical issues".)

Imaging — Patients who are planning myomectomy should undergo imaging to confirm the
presence of uterine leiomyomas rather than other pelvic pathology. In addition, incidental
findings of other lesions (eg, ovarian cyst) may impact surgical planning.

Pelvic sonography is typically the initial imaging study. Ultrasound can confirm the presence of
leiomyomas and their approximate number and location [25]. Magnetic resonance imaging
(MRI) provides more accurate information regarding myoma size, number, and location than
other imaging modalities [25]. For patients who are being evaluated for possible laparoscopic
myomectomy, this information may help the surgeon determine whether laparoscopic surgery
is feasible and may help avoid missing myomas not palpable during laparoscopic surgery. MRI
is also the best modality to diagnose adenomyosis, which can mimic leiomyomas and/or make
myomectomy more difficult. MRI is also indicated if uterine sarcoma is suspected. (See "Uterine
adenomyosis", section on 'Diagnosis' and "Uterine fibroids (leiomyomas): Differentiating
fibroids from uterine sarcomas", section on 'Choice of imaging modality'.)

Imaging of uterine leiomyomas is discussed in detail separately. (See "Uterine fibroids

(leiomyomas): Epidemiology, clinical features, diagnosis, and natural history", section on
'Imaging and endoscopy' and "Uterine fibroids (leiomyomas): Differentiating fibroids from
uterine sarcomas", section on 'Imaging'.)

GnRH agonists — Preoperative use of gonadotropin-releasing hormone agonists reduces the

size of myomas and may theoretically allow a laparoscopic rather than abdominal approach in
some patients. No studies have evaluated this approach. Disadvantages of these agents are
that they may make removal of myomas more difficult and may increase the risk of persistent
myomas. In our practice, we do not pretreat with these agents prior to laparoscopic
myomectomy.

The use of gonadotropin releasing hormone agonists prior to myomectomy is discussed in

detail separately. (See "Uterine fibroids (leiomyomas): Abdominal myomectomy", section on
'Reducing uterine size with GnRH agonists' and "Techniques to reduce blood loss during
abdominal or laparoscopic myomectomy", section on 'GnRH agonists'.)

Thromboprophylaxis — Patients undergoing laparoscopic myomectomy (major surgery,

defined as >30 minutes duration) are at low to moderate risk for venous thromboembolism and
require appropriate thromboprophylaxis, whether mechanical or pharmacologic. (See
"Prevention of venous thromboembolic disease in adult nonorthopedic surgical patients" and
"Overview of preoperative evaluation and preparation for gynecologic surgery", section on
'Thromboprophylaxis'.)

Prophylactic antibiotics — Antibiotic prophylaxis is typically not administered for laparoscopic

procedures in which the vagina or bowel is not entered as the risk of surgical site infection is
low [26,27]. Based on information supporting an intrauterine microbiome [28], the author gives
prophylactic antibiotics when he anticipates the uterine cavity will be entered [29]. (See
"Overview of preoperative evaluation and preparation for gynecologic surgery", section on
'Antibiotic prophylaxis'.)

Anesthesia — Laparoscopic myomectomy requires general anesthesia, since

pneumoperitoneum and potential upper abdominal manipulation make it preferable to have
full abdominal anesthesia [30].

PROCEDURE
The basic steps of laparoscopic myomectomy are:

● Insert laparoscopic ports

● Apply measures to reduce blood loss
● Make uterine incision(s)
● Remove myomas
● Close uterine defects

Laparoscopic port placement — Port placement is based upon the position and size of the
myomas to be removed, usually higher than the uterine fundus to allow access to the myomas.
A left upper quadrant approach may be used for initial access if uterine size is near or above the
umbilicus [31]. (See "Overview of gynecologic laparoscopic surgery and non-umbilical entry
sites".)

Once the initial port has been placed, the camera is inserted and the pelvis and abdomen
surveyed. The feasibility of the procedure is assessed. If there are unexpected findings (eg,
extensive adhesive disease) that preclude laparoscopic myomectomy, the procedure should be
converted to laparotomy. (See "Uterine fibroids (leiomyomas): Abdominal myomectomy",
section on 'Procedure'.)

Placement of two ports on either the patient's right side for right-handed surgeons or left side
for left-handed surgeons makes laparoscopic suturing more ergonomic. These include a 12 mm
port at approximately 2 cm medial to the iliac crest to allow access for adequately sized curved
needles and an ipsilateral 5 mm port medial and slightly cephalad to the larger port [32]. A
contralateral 5 mm port is also placed.

Measures to reduce blood loss — Myomectomy may involve significant blood loss. Bleeding
can be prevented or decreased with mechanical or pharmacologic methods. Allogeneic blood
transfusion can be avoided by using methods of autologous blood transfusion (autologous
blood donation, intraoperative and postoperative blood salvage, or acute normovolemic
[isovolemic] hemodilution).

Techniques to reduce blood loss during myomectomy are discussed separately. (See
"Techniques to reduce blood loss during abdominal or laparoscopic myomectomy", section on
'Intraoperative measures'.)

To control bleeding from large vessels within a myometrial defect, we desiccate briefly with
bipolar electrosurgical paddles. Excessive desiccation devascularizes the myometrium and
should be avoided, since it may increase the risk of uterine rupture in subsequent pregnancy.
(See 'Uterine rupture during pregnancy following myomectomy' below.)
Uterine incision — A transverse myometrial incision, rather than a vertical incision, allows
more ergonomic laparoscopic suturing of the uterine defect. The incision is made directly over
the myoma and carried deeply until definite myoma tissue and the avascular plane just deep to
the capsule of the myoma are noted.

Removal and morcellation of myomas — Techniques for removing myomas vary [33,34]. In

our practice, we grasp each myoma with a tenaculum for traction and use blunt and sharp
dissection to separate the plane between the myometrium and myoma.

For myomas that cannot be removed through the existing ports, morcellation of the myoma
with an electromechanical device is one option.

Concerns have been raised about uterine morcellation and the risk of dissemination of
malignant tissue if an unsuspected uterine malignancy is present. The US Food and Drug
Administration has provided guidance that limits use of power morcellation of uterine tissue.
This is discussed in detail separately. Based on a thorough analysis from the Agency for
Healthcare Research and Quality, the risk of unsuspected leiomyosarcoma in a patient having
surgery for presumed fibroids ranges from "fewer than one and up to 13 of every 10,000
surgeries performed for symptomatic fibroids" [35]. (See "Uterine tissue extraction by
morcellation: Techniques and clinical issues".)

In our practice, we review these issues and as part of the consent process for patients who
consider laparoscopic myomectomy with morcellation. We think patients should consider the
issues pertinent to their situation and have the freedom to undertake shared decision making
with their surgeon and to select the procedure that is most appropriate for them.

Closure of uterine defects — Delayed absorbable sutures are placed in one, two or three
layers, depending upon the depth of the myometrial defect. In our practice, we use size 0
polydioxanone (eg, PDS). Other sutures, including polyglactin (Vicryl) or barbed suture, may be
used, although no studies have compared the use of different sutures with regard to strength
of the uterine wound. Entrance into the uterine cavity can usually be detected due to the
different texture and color of the endometrium. Some surgeons place methylene blue into the
cavity via a transcervical catheter so that the dye can be seen if the cavity is entered. We close
all defects, including the serosa following removal of a pedunculated fibroid.

We adhere as closely as possible to the surgical technique for abdominal myomectomy. It is

controversial whether reapproximation of the myometrium via laparoscopic suturing gives the
uterine wall the same strength as multilayer closure at laparotomy [36-38]. The security of the
closure may impact the risk of uterine rupture in subsequent pregnancy. (See "Uterine fibroids
(leiomyomas): Abdominal myomectomy", section on 'Closure of uterine defects' and 'Uterine
rupture during pregnancy following myomectomy' below.)

At the close of the procedure, the pelvis and abdomen are irrigated, the fluid suctioned, and
measures to prevent adhesion formation are applied, if desired. (See "Postoperative peritoneal
adhesions in adults and their prevention".)

COMPLICATIONS

Complications are similar for laparoscopic and abdominal myomectomy. Information specific to
laparoscopic myomectomy is discussed in this section. The remainder of the information can be
found separately. (See "Uterine fibroids (leiomyomas): Abdominal myomectomy", section on
'Complications'.)

Hemorrhage — In series of 500 or more laparoscopic myomectomies, the rate of hemorrhage

or blood transfusion varied widely from 0.1 to 6 percent [5,39,40]. The average blood loss
reported was 80 to 248 mL (range 20 to 1000 mL) [39,40].

Prevention and management of blood loss during myomectomy are discussed in detail
separately. (See "Techniques to reduce blood loss during abdominal or laparoscopic
myomectomy" and "Management of hemorrhage in gynecologic surgery".)

Fever and infection — Fever occurs in many patients following myomectomy, but a localized
source is often not identified. (See "Uterine fibroids (leiomyomas): Abdominal myomectomy",
section on 'Fever and infection'.)

Evaluation and management of postoperative fever are discussed separately. (See "Fever in the
surgical patient".)

Bowel or bladder injury — Visceral injury during laparoscopic myomectomy is rare. In series of

500 or more laparoscopic myomectomies, the rate of bowel injury was 0 to 0.04 and of bladder
injury was 0 to 0.3 percent [5,39].

Conversion to laparotomy — Conversion to laparotomy occurs in 1 to 2 percent of

laparoscopic myomectomy procedures [41-43]. A laparoscopic myomectomy may be converted
to a laparotomy if initial evaluation reveals pathology that precludes a laparoscopic approach or
to aid management of an intraoperative complication (eg, hemorrhage).

Adhesive disease — Adhesion formation after myomectomy has been well documented.

Studies in which second look laparoscopy has been performed following laparoscopic
myomectomy have reported intraabdominal adhesions in 36 to 66 percent of patients [44-46].

As noted above, laparoscopic myomectomy may result in fewer adhesions than abdominal
myomectomy. This was suggested by a prospective cohort study (n = 28) in which second look
laparoscopy following laparoscopic compared with abdominal myomectomy revealed
adhesions in fewer patients (4 of 14 versus 9 of 14) and less dense adhesions [7]. Further study
is needed to validate these findings. (See 'Choosing the surgical approach for myomectomy'
above.)

A detailed discussion of the various adhesion barrier methods can be found separately. (See
"Postoperative peritoneal adhesions in adults and their prevention".)

Other complications — The evaluation and management of other complications, such as ileus

or wound infection, are discussed separately. (See "Urinary tract injury in gynecologic surgery:
Identification and management" and "Postoperative ileus" and "Complications of abdominal
surgical incisions" and "Management of small bowel obstruction in adults".)

OUTCOME

Relief of symptoms — There are no data regarding the rate of relief of symptoms following
laparoscopic myomectomy. It is uncertain whether success rates can be extrapolated from
abdominal myomectomy, which has been reported to relieve symptoms in approximately 80
percent of patients [2,47].

Persistent or new myomas — In a multicenter retrospective cohort study of 512 patients who
underwent laparoscopic myomectomy, the rates of postmyomectomy myomas at five and eight
years were 53 and 84 percent; however, the rates of reoperation were much lower, 7 and 16
percent [48]. Risk factors for the presence of leiomyomas were similar to those for open
myomectomy, including: multiple myomas at time of surgery, uterine size ≥13 weeks, and age
<36 years. In this study, pregnancy after myomectomy was associated with an increased risk of
subsequent myomas, but this was contrary to findings of other studies of laparoscopic and
open myomectomy [49]. (See "Uterine fibroids (leiomyomas): Abdominal myomectomy", section
on 'Persistent or new myomas'.)

A systematic review of six randomized trials including 576 patients that compared laparoscopic
with open myomectomy found no significant difference in the rate of recurrent myomas
between the two surgical approaches [6].
INPATIENT POSTOPERATIVE CARE

Laparoscopic myomectomy is typically performed as an outpatient procedure or with a one day

hospital stay.

Routine postoperative care following myomectomy is reviewed separately. (See "Uterine

fibroids (leiomyomas): Abdominal myomectomy", section on 'Inpatient postoperative care'.)

FOLLOW-UP

Patients are encouraged to resume their normal daily activities as quickly as is comfortable.
Decisions regarding resumption of vaginal intercourse are made by the patient; there are no
medical restrictions on sexual activity [50]. Patients may return to work as soon as they have
regained sufficient stamina and mobility.

Routine postoperative instructions for patients can be found separately. (See "Patient
education: Care after gynecologic surgery (Beyond the Basics)".)

We see patients for a follow-up visit at two weeks postoperatively. The follow-up visit includes
an evaluation for potential complications and an examination of the abdomen and wounds. We
review the details of the surgery and pathology results with the patient.

CONCEPTION AND PREGNANCY AFTER MYOMECTOMY

Interval to conception — Patients who undergo myomectomy with significant uterine

disruption should wait several months before attempting to conceive; recommendations for the
interval to conception range from three to six months [51]. A Japanese study that used
magnetic resonance imaging reported that uterine myometrial healing was complete and
blood flow to the area of hysterotomy was normal three months after surgery [51].

Fertility — If a patient is having difficulty conceiving following a myomectomy, early

assessment of the uterine cavity and fallopian tubes with a hysterosalpingogram is advisable
[52].

Issues of fertility and leiomyomas are discussed separately. (See "Uterine fibroids (leiomyomas):
Abdominal myomectomy", section on 'Infertility' and "Causes of female infertility", section on
'Uterine fibroids (leiomyomata)'.)
Uterine rupture during pregnancy following myomectomy — Myomectomy is associated
with an increased risk of uterine rupture during subsequent pregnancy. Operative techniques,
instruments, and energy sources used during laparoscopic myomectomy often differ from
those employed during laparotomy. Whether reapproximation of the myometrium via
laparoscopic suturing gives the uterine wall the same strength as multilayer closure at
laparotomy is an area of controversy [52,53]. Failure to adequately suture myometrial defects,
lack of hemostasis within uterine defects with subsequent hematoma formation, or the
excessive use of electrosurgery with devascularization of the myometrium have all been
postulated to interfere with myometrial wound healing and increase the potential for rupture
[32].

In the largest study of laparoscopic myomectomy, in which 2050 patients were followed for an
average of 42 months, there were 386 pregnancies and one uterine rupture (spontaneous
rupture at 33 weeks) [5]. A review of published and unpublished cases yielded 19 instances of
uterine rupture, invariably all in the third trimester, during pregnancy following laparoscopic
myomectomy [54]. Almost all of the cases contained a deviation from standard technique, as
described for abdominal myomectomy. In seven cases, the uterine defect was not repaired; in
three cases, it was repaired with a single suture; in four cases, it was repaired in only one layer;
and, in one case, only the serosa was closed. A multi-layered closure was employed in only
three cases. In 16 of the 19 cases, primarily monopolar or bipolar energy was used for
hemostasis, which could lead to devascularization of the myometrium.

Presently, it appears prudent for surgeons who perform laparoscopic myomectomy to adhere
to time-tested techniques developed for abdominal myomectomy, including limited use of
electrosurgery and use of multi-layered closure of myometrium. Yet, even with ideal surgical
technique, individual wound healing characteristics may predispose to uterine rupture [55].

Many experts advise cesarean delivery as a conservative approach. However, patients who have
had myomectomy for pedunculated subserosal or mostly exophytic fibroids (types 5, 6, or 7)
might be considered for a trial of labor.

Uterine rupture during pregnancy following myomectomy is discussed in detail separately. (See
"Uterine fibroids (leiomyomas): Issues in pregnancy", section on 'Management of patients with
prior myomectomy'.)

ALTERNATIVE LAPAROSCOPIC TECHNIQUES

There are ongoing efforts to develop minimally invasive treatments for fibroids. Methods that
are performed laparoscopically are discussed in this section.

Uterine artery occlusion — Laparoscopic uterine artery occlusion procedures have been

investigated [56-60]. However, such techniques have distinct disadvantages compared with
other minimally invasive approaches, such as laparoscopic myomectomy or uterine artery
embolization.

Myomas may shrink after uterine artery occlusion, but uterine volume is not reduced to the
same extent as myomectomy. This, combined with the exposure of patients to general
anesthesia and abdominal incisions for both procedures, makes myomectomy the preferred
procedure. No studies have compared these two procedures.

Uterine artery embolization has been compared with laparoscopic uterine artery occlusion,
since both treat fibroids with occlusion of the uterine blood supply. Laparoscopic occlusion has
some advantages compared with uterine artery embolization, including: (1) avoids introduction
of foreign bodies (eg, polyvinyl alcohol particles, coils); (2) provides laparoscopic assessment of
the pelvis and abdomen; and (3) was associated with less postoperative pain in a prospective
cohort study of 46 subjects [56]. However, these advantages are superseded by several
disadvantages, including that laparoscopic occlusion requires general anesthesia, is invasive,
and requires a skilled laparoscopic surgeon. Also, uterine artery embolization performed better
in a small randomized trial (n = 58) comparing the two methods, as measured by the mean
uterine volume reduction (51 versus 33 percent) and rate of recurrent symptoms (17 versus 48
percent) [61]. Thus, patients who are planning treatment of leiomyomas with blockage of the
uterine blood supply are better treated with uterine artery embolization than laparoscopic
uterine artery occlusion.

Thus, we suggest either laparoscopic myomectomy or uterine artery embolization rather than
laparoscopic uterine artery occlusion. Choosing between myomectomy and uterine artery
embolization is discussed separately. Use of concurrent laparoscopic myomectomy and uterine
artery ligation has been reported [62]. (See "Uterine fibroids (leiomyomas): Abdominal
myomectomy", section on 'Interventional radiology procedures'.)

Myolysis — Myolysis refers to laparoscopic thermal coagulation or cryoablation (cryomyolysis)

of leiomyoma tissue to reduce myoma size (by approximately 50 percent) by means of myoma
destruction and interference with local vascular supply [63-65]. Laparoscopic myolysis has been
performed using a number of energy sources, including bipolar electrosurgery, Nd:YAG laser,
radiofrequency, and cryogenic probes [66,67].
Radiofrequency myolysis is easier to master than laparoscopic myomectomy since it does not
require laparoscopic suturing. A meta-analysis including 581 patients who underwent
laparoscopic radiofrequency ablation for symptomatic leiomyoma reported improvements in
quality-of-life and symptom reduction scores compared with pretreatment, and most of the
improvements were maintained at 36 months of follow-up [68].

In patients with menorrhagia, myolysis combined with endometrial ablation may be more
effective therapy than either procedure alone, but this is investigational. An observational study
comparing ablation alone versus with the combined procedure found that the risks of a second
surgery were 38 and 13 percent, respectively [69].

SOCIETY GUIDELINE LINKS

Links to society and government-sponsored guidelines from selected countries and regions
around the world are provided separately. (See "Society guideline links: Uterine fibroids
(leiomyomas)" and "Society guideline links: Gynecologic surgery".)

INFORMATION FOR PATIENTS

UpToDate offers two types of patient education materials, "The Basics" and "Beyond the
Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade
reading level, and they answer the four or five key questions a patient might have about a given
condition. These articles are best for patients who want a general overview and who prefer
short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more
sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading
level and are best for patients who want in-depth information and are comfortable with some
medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print
or e-mail these topics to your patients. (You can also locate patient education articles on a
variety of subjects by searching on "patient info" and the keyword(s) of interest.)

● Beyond the Basics topics (see "Patient education: Uterine fibroids (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

● Laparoscopic myomectomy is the laparoscopic removal of leiomyomas from the uterus,
leaving the uterus in place. (See 'Introduction' above.)

● The most common indications for laparoscopic myomectomy are abnormal uterine
bleeding or bulk-related symptoms (eg, pelvic/abdominal pain or pressure). Indications for
which the benefit of laparoscopic (or abdominal) myomectomy is unproven or not likely to
be helpful include evaluation of pelvic malignancy (eg, ovarian or uterine cancer), infertility,
and prevention of obstetric complications. (See 'Indications' above and 'Unproven
indications' above.)

● Determining whether a patient is a candidate for laparoscopic myomectomy depends upon

the location, size, and number of leiomyomas. Pedunculated subserosal fibroids are the
easiest to remove, but myomas in other locations can also be excised laparoscopically.
Performing laparoscopic myomectomy in patients with large or numerous myomas is likely
to be time consuming, particularly since morcellation is usually required. (See 'Candidates
for laparoscopic myomectomy' above.)

● We suggest laparoscopic rather than abdominal myomectomy for patients with

leiomyomas for whom laparoscopic removal is technically feasible (by size, number, and
location) and who have access to a surgeon with advanced laparoscopic skills (Grade 2B).
(See 'Laparoscopic versus open myomectomy' above.)

● The risk of uterine rupture in a pregnancy subsequent to laparoscopic myomectomy is not

well established. To optimize myometrial wound repair, we limit the use of electrosurgical
desiccation of bleeding vessels and use a multi-layered closure of myometrium. (See
'Measures to reduce blood loss' above and 'Closure of uterine defects' above and 'Uterine
rupture during pregnancy following myomectomy' above.)

● Alternative laparoscopic techniques for treatment of leiomyomas have been investigated.

For patients with symptomatic leiomyomas:

• We suggest laparoscopic myomectomy rather than laparoscopic uterine artery

occlusion or myolysis (Grade 2C).

• We suggest uterine artery embolization rather than laparoscopic uterine artery

occlusion (Grade 2B). (See 'Alternative laparoscopic techniques' above.)

● The most common complications of laparoscopic myomectomy are hemorrhage, fever, and
conversion to laparotomy. Visceral injury and other complications occur rarely. (See
'Complications' above.)
 ● Following laparoscopic myomectomy, the five-year rate of persistent or new myomas is
approximately 53 percent, but the rate of patients undergoing reoperation is approximately
7 percent. (See 'Persistent or new myomas' above.)

● Robotic myomectomy may benefit some surgeons who have difficulty with laparoscopic
suturing, but there are no data to show meaningful benefit to patients over the outcomes
achieved with laparoscopic myomectomy. (See 'Robot-assisted laparoscopy' above.)

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Topic 15780 Version 31.0

GRAPHICS

PALM-COEIN AUB leiomyoma locations

(A) Submucous leiomyomas.

(B) Intramural and subserous leiomyomas, "other" or outside the endometrial cavity.

(C) Hybrid (transmural) leiomyomas.

Reproduced with permission from Malcolm G Munro, MD, FRCSC, FACOG.

Graphic 108139 Version 2.0

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