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Myomectomy - Indications and Complications

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This is part of the Gynsurgery guidelines used in an educational setting for residents in Ob-Gyn.

Indications for myomectomy

  1. Infertility/pregnancy loss
    1. History of one or more pregnancy losses or 1 year infertility and evidence of fibroid impingment on uterine cavity, endocervical canal or near tubal ostia
  2. Pelvic Pain
    1. Urinary pressure, voiding difficulty or frequency and anterior fibroid
    2. Secondary dysmenorrhea and evidence of multiple fibroids
    3. Low back pain and posterior uterine fibroid(s) greater than 2 cm diameter
    4. Dyspareunia and fibroids impinging upon cervix or posterior cul de sac
  3. Enlarging fibioids (> 2cm change over 6 months)
    1. Enlarging uterine mass producing worry for a possible sarcoma
    2. Enlarging post menopausal fibroid

Complications

  1. Bleeding
    1. Intraoperative hemorrhage (1%)
    2. Post operative hematoma (0.5%)
  2. Uterine infection/abscess
  3. Bladder injury
  4. Ureteral injury
  5. Bowel injury
  6. Pain (post op) due adhesions
  7. Decreased fertility due to adhesions (40-60%)
  8. Failure to complete laparoscopically (0.5%)
  9. Spontaneous uterine rupture in subsequent pregnancy (0.25%)

Prevention of Complications

  1. Bleeding
    1. Intraoperative hemorrhage (1%) (Any of the following)
      1. Use pitressin injection (20U/100/cc saline) into surrounding myometrium intraoperatively
      2. Administer vaginal misoprostol (400mcgm) 1 hour prior to surgery)
      3. Use tourniquets on ascending uterine vessels and ovarian vessels
    2. Post operative hematoma (0.5%)
      1. Close all dead space with layered closure of fibroid capsule
  2. Uterine infection/abscess
    1. Use rapidly absorbable suture to close fibroid capsule
  3. Bladder injury
    1. If fibroid is anterior behind bladder, instill fluid to disten and outline the bladder prior to dissection off of the fibroid
  4. Ureteral injury
    1. For broad ligament fibroids, identify ureter by dissection and approach fibroid from uterine side
  5. Bowel injury
  6. Pain (post op) due adhesions
  7. Decreased fertility due to adhesions (40-60%)
    1. Use adhesion prevention materials and avoid cautery/necrosis of uterine musclature
  8. Failure to complete laparoscopically (0.5%)
    1. Do not use preoperative LHRF injection
  9. Spontaneous uterine rupture in subsequent pregnancy (.25%)
    1. Recommend primary cesarean section for delivery if myomectomy results in entry into uterine cavity
  10. Recurrence of fibroids
    1. Do not use preoperative LHRF injection

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