Version May 2024
INTRODUCTION — Uterine leiomyomas (myomas or fibroids) are the most common type of pelvic tumor in females. For patients who desire treatment, there are a wide variety of options, including medical therapy, nonexcisional procedures (eg, uterine artery embolization [UAE], magnetic resonance-guided focused ultrasound), and surgery (eg, myomectomy, radiofrequency ablation [RFA], hysterectomy). The choice of treatments depends on many factors, including characteristics of the myomas and patient, surgical expertise, and patient preference.
Myomectomy is the removal of uterine leiomyomas, leaving the uterus in situ. This can be accomplished using an open abdominal, laparoscopic, hysteroscopic, or vaginal approach. Other laparoscopic procedures, including uterine artery occlusion and myolysis, are infrequently used.
Laparoscopic myomectomy and other laparoscopic procedures for treatment of 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): Open abdominal myomectomy procedure" and "Uterine fibroids (leiomyomas): Hysteroscopic myomectomy" and "Uterine fibroids (leiomyomas): Prolapsed fibroids" and "Uterine fibroids (leiomyomas): Treatment overview".)
INDICATION AND ALTERNATIVES — Laparoscopic myomectomy is generally performed for patients with symptomatic intramural or subserosal leiomyomas (figure 1) in whom future childbearing is desired. (See "Uterine fibroids (leiomyomas): Treatment overview".)
Determining whether a patient is a candidate for laparoscopic rather than open abdominal myomectomy depends on the location, size, and number of leiomyomas, although parameters for these vary with surgical expertise (eg, laparoscopic suturing) [1]. While preoperative use of gonadotropin-releasing hormone (GnRH) agonists may reduce the size of the uterus allowing for a laparoscopic rather than open abdominal approach, they may make removal of myomas more difficult (by obscuring the tissue plane between the myoma and normal myometrium) and increase the risk of persistent myomas; thus, we do not routinely use these agents in our practice. (See "Uterine fibroids (leiomyomas): Treatment overview", section on 'Choosing the approach' and "Techniques to reduce blood loss during abdominal or laparoscopic myomectomy", section on 'GnRH agonists'.)
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".)
PREOPERATIVE ISSUES — Preoperative evaluation and preparation are similar for laparoscopic and open abdominal myomectomy; information specific to laparoscopic myomectomy is discussed in this section.
Informed consent — Informed consent includes counseling about:
●Other medical, interventional radiology, and surgical options for treatment. (See "Uterine fibroids (leiomyomas): Treatment overview" and "Abnormal uterine bleeding in nonpregnant reproductive-age patients: Management".)
●Potential complications of the procedure, including conversion to laparotomy, the likelihood of recurrence of fibroid-associated symptoms, and reproductive issues following myomectomy. (See 'Complications' below and 'Outcomes' below and 'Counseling about future pregnancy' below.)
●The risk of malignancy and risks and benefits of power morcellation. Concerns have been raised about morcellation and the risk of dissemination of malignant tissue if an unsuspected uterine malignancy is present, and many expert groups and professional organizations have issued policy statements regarding this issue. (See "Uterine fibroids (leiomyomas): Differentiating fibroids from uterine sarcomas" and "Uterine tissue extraction by morcellation: Techniques and clinical issues".)
In our practice, we review these issues as part of the consent process and use shared decision-making to select the procedure that is most appropriate for them.
Imaging — Patients who are planning laparoscopic myomectomy should undergo imaging to confirm the presence of uterine leiomyomas and identify other lesions (eg, ovarian cyst) which, if present, may impact surgical planning.
While pelvic sonography is typically the initial imaging study to confirm the presence of leiomyomas and their approximate number and location, magnetic resonance imaging (MRI) provides more accurate information regarding myoma size, number, and location [2]. This information helps the surgeon determine whether laparoscopic surgery is feasible, to optimize surgical planning [3,4], and avoid missing myomas not palpable during laparoscopic surgery. MRI is also the superior modality to diagnose adenomyosis, which can mimic leiomyomas and/or make myomectomy more difficult. (See "Uterine fibroids (leiomyomas): Epidemiology, clinical features, diagnosis, and natural history", section on 'Imaging and endoscopy' and "Uterine adenomyosis", section on 'Imaging'.)
MRI is also indicated if uterine sarcoma is suspected. (See "Uterine fibroids (leiomyomas): Differentiating fibroids from uterine sarcomas", section on 'Choice of imaging modality'.)
Measures to reduce blood loss — As with open abdominal myomectomy, laparoscopic myomectomy may involve significant blood loss. Bleeding can be decreased with pharmacologic (eg, gonadotropin-releasing hormone [GnRH] agonists, vasopressin, tranexamic acid) methods. Mechanical (eg, tourniquet) methods are difficult to secure with laparoscopic instruments and thus infrequently used. Allogeneic blood transfusion can be avoided by using methods of autologous blood transfusion (eg, intraoperative and postoperative blood salvage).
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'.)
Prophylactic antibiotics — The use of prophylactic antibiotics prior to laparoscopic myomectomy varies. Two of our contributors administer prophylactic antibiotics to all patients undergoing laparoscopic myomectomy to decrease the risk of surgical site infection. By contrast, one of our contributors administers prophylactic antibiotics only to selected patients (eg, patients in whom the uterine cavity is expected to be entered based on imaging, when a prolonged operating time or increased blood loss is anticipated, patients with comorbid conditions [eg, obesity, diabetes]).
The American College of Obstetricians and Gynecologists states that prophylactic antibiotics are not recommended for laparoscopic procedures in which the bowel or vagina are not entered [5]. However, it may be difficult to predict which patients will require entry into the uterine cavity, even with preoperative imaging.
There is conflicting evidence regarding antibiotic prophylaxis prior to clean (ie, not involving entry into the vagina or intestine) laparoscopy. In a retrospective study including over 1200 patients undergoing myomectomy (any type), patients receiving prophylactic antibiotics compared with those not receiving prophylactic antibiotics had lower rates of surgical site infection (2.9 versus 6.8 percent, adjusted odds ratio 3.8, 95% CI 1.3-11) [6]. By contrast, in a randomized, nonblinded study including 450 females undergoing laparoscopy (for treatment of infertility, pelvic pain, endometriosis, or for permanent sterilization) and followed for seven days postoperatively, patients receiving and not receiving prophylactic antibiotics had similar rates of postoperative infection and length of hospital stay [7].
The use of antibiotic prophylaxis prior to gynecologic surgery is discussed in more detail separately. (See "Overview of preoperative evaluation and preparation for gynecologic surgery", section on 'Antibiotic prophylaxis'.)
Thromboprophylaxis — Patients undergoing laparoscopic myomectomy (laparoscopic surgery >45 minutes duration; Caprini risk score: 2 points) are at least at low risk for venous thromboembolism and require appropriate thromboprophylaxis (table 1). This is discussed in detail separately. (See "Uterine fibroids (leiomyomas): Open abdominal myomectomy procedure", section on 'Thromboprophylaxis' and "Prevention of venous thromboembolic disease in adult nonorthopedic surgical patients" and "Overview of preoperative evaluation and preparation for gynecologic surgery", section on 'Thromboprophylaxis'.)
Anesthesia — Laparoscopic myomectomy requires general anesthesia, since pneumoperitoneum and potential upper abdominal manipulation make it preferable to have full abdominal anesthesia [8].
PROCEDURE
Laparoscopic port placement — Port placement is based on the position and size of the myomas to be removed and is 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 [9]. (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 are 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): Open abdominal myomectomy procedure", 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 typically 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 [10]; a contralateral 5 mm port is also placed. However, location and size of the ports may vary based on surgeon preference, and some surgeons prefer the larger (12 mm) port at the umbilicus.
Uterine incision — We inject approximately 10 mL of vasopressin (20 units dissolved in 100 mL saline) into the myometrium overlying each fibroid, although other dilutions may be used. A transverse myometrial incision (picture 1), 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 [11,12]. In our practice, we grasp each myoma with a tenaculum for traction and use blunt and sharp (electrosurgical or ultrasonic) dissection to separate the plane between the myometrium and myoma (picture 2).
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 'Counseling about future pregnancy' below.)
For myomas that cannot be removed through the existing ports, morcellation of the myoma with an electromechanical device (with [13] or without an in-bag containment system) is an option. This is described in detail separately. (See 'Informed consent' above and "Uterine tissue extraction by morcellation: Techniques and clinical issues".)
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 suture. 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 (picture 3)), avoid placement of suture within the uterine cavity, and adhere as closely as possible to the surgical technique for open abdominal myomectomy. (See "Uterine fibroids (leiomyomas): Open abdominal myomectomy procedure", section on 'Closure'.)
Laparoscopic suturing and knot tying (if barbed suture is not used) are technically challenging, difficult to master, and critical to performing laparoscopic myomectomy. Given the security of the closure may impact the risk of uterine rupture in subsequent pregnancy (see 'Counseling about future pregnancy' below), the technique used for closure of the myomectomy incision should be similar to the multilayered closure used for open myomectomy.
At the close of the procedure, the pelvis and abdomen are irrigated, the fluid suctioned, and measures to prevent adhesion formation may be applied (picture 4); however, the safety and effectiveness of these barriers in laparoscopic surgery have not been established. (See "Postoperative peritoneal adhesions in adults and their prevention".)
COMPLICATIONS — Complications are similar for laparoscopic and open abdominal myomectomy; however, in appropriately selected patients, laparoscopic myomectomy has lower overall morbidity and a shorter recovery time than open myomectomy. (See "Uterine fibroids (leiomyomas): Treatment overview", section on 'Choosing the approach'.)
In a prospective multicenter study including 2050 patients undergoing laparoscopic myomectomy, major complications (eg, bleeding requiring blood transfusion, visceral injury, procedural failure) were associated with the following leiomyoma characteristics: size >5 cm, >3 myomas removed, and intraligamentous location [14]. Intramural myomas were associated with an increase in minor (eg, fever, uterine manipulator injuries), but not major, complications.
Hemorrhage — The rate of hemorrhage or blood transfusion varies widely. In series of 500 or more laparoscopic myomectomies, rates of hemorrhage and blood transfusion ranged from 0.1 to 6 percent [14-16]. The average blood loss reported was 80 to 248 mL (range 20 to 2000 mL) [15,16].
Prevention and management of blood loss during myomectomy are discussed in detail separately. (See 'Measures to reduce blood loss' above and "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): Open abdominal myomectomy procedure", 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 (see 'Hemorrhage' above), the rate of bowel and bladder injury was ≤0.04 and ≤0.3 percent, respectively [14,15].
Conversion to laparotomy — Conversion to laparotomy occurs in <1 percent of laparoscopic myomectomy procedures [14-16]. A laparoscopic myomectomy may be converted to a laparotomy if initial evaluation reveals pathology that precludes a laparoscopic approach (eg, dense adhesions, malignancy) 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 is performed following laparoscopic myomectomy have reported intraabdominal adhesions in 29 to 66 percent of patients [17-20]. However, laparoscopic myomectomy may result in fewer adhesions than open abdominal myomectomy. In a prospective cohort study including 28 patients undergoing second-look laparoscopy, laparoscopic compared with open abdominal myomectomy was associated with fewer adhesions (29 versus 64 percent, respectively) and less dense adhesive disease [20]. Further study is needed to validate these findings.
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".)
POSTOPERATIVE CARE AND FOLLOW-UP — Laparoscopic myomectomy is typically performed as an outpatient procedure or with a one-day hospital stay.
Routine postoperative care and follow-up are similar to open abdominal myomectomy and discussed separately. (See "Uterine fibroids (leiomyomas): Open abdominal myomectomy procedure", section on 'Postoperative care' and "Uterine fibroids (leiomyomas): Open abdominal myomectomy procedure", section on 'Follow-up'.)
COUNSELING ABOUT FUTURE PREGNANCY
●Interval to conception – Interval to conception after laparoscopic myomectomy is similar to open abdominal myomectomy and patients with significant uterine disruption should wait three to six months before attempting to conceive [21].
●Infertility – If a patient is having difficulty conceiving following a myomectomy, early assessment of the uterine cavity and fallopian tubes with a hysterosalpingogram is advisable [22].
Issues regarding fertility and leiomyomas are discussed separately. (See "Female infertility: Causes", section on 'Uterus'.)
●Uterine rupture – Myomectomy (both open abdominal and laparoscopic) is associated with an increased risk of uterine rupture during subsequent pregnancy and many experts advise cesarean birth as a conservative approach in most patients. (See "Uterine fibroids (leiomyomas): Open abdominal myomectomy procedure", section on 'Counseling about future pregnancy' and "Uterine fibroids (leiomyomas): Issues in pregnancy", section on 'Patients with prior myomectomy'.)
Whether reapproximation of the myometrium via laparoscopic suturing gives the uterine wall the same strength as multilayer closure at open abdominal myomectomy is an area of controversy [22,23]. Operative techniques, instruments, and energy sources used during laparoscopic myomectomy often differ from those employed during laparotomy and 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 [10]. Thus, it appears prudent for surgeons who perform laparoscopic myomectomy to adhere to time-tested techniques developed for open 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 [24].
In the prospective study including 2050 patients undergoing laparoscopic myomectomy (see 'Complications' above), there were 386 pregnancies and one uterine rupture (spontaneous rupture at 33 weeks) during the 42 month (average) follow-up period [14]. A subsequent review of published and unpublished case reports of uterine rupture subsequent to laparoscopic myomectomy yielded 19 instances of uterine rupture, invariably all in the third trimester [25]. Almost all the cases contained a deviation from standard technique, as described for open 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 can lead to devascularization of the myometrium.
OUTCOMES
Relief of symptoms — Data regarding the rate of relief of symptoms following laparoscopic myomectomy are limited. In a prospective cohort study including 28 patients undergoing laparoscopic myomectomy, symptom severity and health-related quality of life scores (as measured by validated questionnaires) improved during the 27-month follow-up period [26].
Persistent or new myomas — Many patients who undergo myomectomy will have leiomyomas on subsequent evaluation. In a multicenter retrospective cohort study including 512 patients treated with laparoscopic myomectomy, 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, respectively) [27]. Risk factors for the presence of leiomyomas were similar to those for open myomectomy and included 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 conflicts with findings from other studies of laparoscopic and open myomectomy [28].
Rates of recurrence and subsequent treatment may be similar to those undergoing open abdominal myomectomy and are discussed in detail separately. (See "Uterine fibroids (leiomyomas): Treatment overview", section on 'Choosing the approach' and "Uterine fibroids (leiomyomas): Open abdominal myomectomy procedure", section on 'Outcomes'.)
ALTERNATIVE LAPAROSCOPIC TECHNIQUES
Alternatives to conventional laparoscopy
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 [29-35]. Overall outcomes are similar to laparoscopic myomectomy, but with longer operating times and higher costs.
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 including 872 patients who underwent robotic myomectomy, 127 pregnancies occurred, which resulted in 92 deliveries and one uterine rupture, which occurred at approximately 33 weeks and resulted in a fetal demise [36]. Uterine rupture after myomectomy with conventional laparoscopy is discussed above. (See 'Counseling about future pregnancy' above.)
Single port laparoscopy — Single port laparoscopy, or laparoendoscopic single-site surgery (LESS), refers to a laparoscopic access technique that uses a single incision, usually at the umbilicus. Successful LESS myomectomy procedures have been reported, but data are limited to small case series and small fibroids [37-41].
The procedure, as described in one case report, is performed as follows [40]: Three 5 mm trocars are placed through a common umbilical incision, but through separate fascial perforations. A harmonic scalpel and blunt dissection are used to remove the myoma(s), and the uterine defect(s) are repaired in layers using bidirectional barbed suture. After removal of the trocars, a fascial incision connecting the perforations is made to facilitate removal of the fibroid tissue.
Further study is needed to evaluate this procedure. (See "Abdominal access techniques used in laparoscopic surgery", section on 'Single-incision laparoscopic surgery'.)
Other techniques — Several other techniques can be used as an alternative to myomectomy and include radiofrequency ablation (RFA), uterine artery occlusion, and myolysis. While use of RFA is increasing, uterine artery occlusion and myolysis are used infrequently and data supporting their use are limited.
Radiofrequency fibroid 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 (transcervical) approach (see "Uterine fibroids (leiomyomas): Hysteroscopic myomectomy", section on 'Radiofrequency ablation'). 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 [42,43]. 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 [44]. Over subsequent months, fibroids are reabsorbed with a decrease in fibroid volume and a resultant reduction in fibroid-related symptoms [45].
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 [46]. 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, 8, 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. Complications of RFA were further evaluated in a review of the US Food and Drug Administration Manufacturer and User Facility Device Experience (MAUDE) database from 2012 to 2022, in which 43 adverse events were included [47]. Of these events, the most common was infection (35 percent), followed by bowel injury (14 percent), uterine perforation (12 percent), and bladder injury (9 percent). As these events were reported by surgeons, hospitals, or device manufacturers, the total number of procedures performed to yield these complications is unknown.
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 [48]. Almost all of these patients underwent a prelabor cesarean birth for varying indications (eg, breech presentation, prior cesarean birth, 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.
Infrequently used techniques
Uterine artery occlusion — Laparoscopic uterine artery occlusion procedures have been investigated [49-53]. However, such techniques have distinct disadvantages compared with other minimally invasive approaches, such as laparoscopic myomectomy or uterine artery embolization (UAE). Thus, for most patients, we suggest either laparoscopic myomectomy or UAE rather than laparoscopic uterine artery occlusion.
UAE 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 UAE, including: avoids introduction of foreign bodies (eg, polyvinyl alcohol particles, coils); provides laparoscopic assessment of the pelvis and abdomen; and may be associated with less postoperative pain (as demonstrated in one prospective cohort study including 46 subjects [49]). However, these advantages are superseded by several disadvantages, including that laparoscopic occlusion requires general anesthesia, is invasive, and requires a skilled laparoscopic surgeon. In addition, UAE may also have more favorable outcomes. In a randomized trial including 58 patients with uterine fibroids, UAE compared with uterine artery occlusion resulted in a greater mean uterine volume reduction (51 versus 33 percent) and lower rates of recurrent symptoms (17 versus 48 percent) [54].
Choosing between myomectomy and UAE is discussed separately. Use of concurrent laparoscopic myomectomy and uterine artery ligation has been reported [55]. (See "Uterine fibroids (leiomyomas): Treatment overview", section on 'Uterine artery embolization' and "Uterine fibroids (leiomyomas): Treatment overview", section on 'All fibroids other than submucosal'.)
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 [56-58]. Laparoscopic myolysis has been performed using a number of energy sources, including bipolar electrosurgery, Nd:YAG laser, radiofrequency, and cryogenic probes [59,60].
Radiofrequency myolysis is easier to master than laparoscopic myomectomy since it does not require laparoscopic suturing and patient outcomes appear favorable. In a meta-analysis including 581 patients with symptomatic leiomyomas undergoing treatment with laparoscopic RFA, quality-of-life and symptom severity scores (as reported on validated questionnaires) improved posttreatment, and most of the improvements were maintained at 36 months of follow-up [61].
In patients with menorrhagia, myolysis combined with endometrial ablation may be more effective therapy than either procedure alone, but this is investigational. In an observational study comparing myolysis plus ablation (88 patients) versus ablation alone (52 patients), the risks of a second surgery was lower in the combined therapy group (13 versus 38 percent, respectively) [62].
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
●Definition – Laparoscopic myomectomy is the laparoscopic removal of leiomyomas from the uterus, leaving the uterus in place. (See 'Introduction' above.)
●Patient selection
•Laparoscopic myomectomy is generally performed for patients with symptomatic intramural or subserosal leiomyomas (figure 1) in whom future childbearing is desired. (See 'Indication and alternatives' above.)
•Determining whether a patient is a candidate for laparoscopic rather than open abdominal myomectomy depends on the location, size, and number of leiomyomas. (See 'Indication and alternatives' above and "Uterine fibroids (leiomyomas): Treatment overview", section on 'Choosing the approach'.)
●Preoperative issues
•Risk of malignancy – The risk of malignancy and risks and benefits of power morcellation must be discussed as part of the informed consent process. (See 'Informed consent' above and "Uterine tissue extraction by morcellation: Techniques and clinical issues".)
•Imaging – Compared with pelvic ultrasound, magnetic resonance imaging (MRI) provides more accurate information regarding myoma size, number, and location and helps the surgeon with preoperative planning. (See 'Imaging' above.)
•Prophylactic antibiotics – For patients undergoing laparoscopic myomectomy, practice varies whether prophylactic antibiotics are given to all patients or only to selected patients. (See 'Prophylactic antibiotics' above.)
•Thromboprophylaxis – Patients undergoing laparoscopic myomectomy are at least at low risk for venous thromboembolism and require appropriate thromboprophylaxis (table 1). (See 'Thromboprophylaxis' above and "Prevention of venous thromboembolic disease in adult nonorthopedic surgical patients" and "Overview of preoperative evaluation and preparation for gynecologic surgery", section on 'Thromboprophylaxis'.)
●Procedure
•Port placement is based on the position and size of the myomas to be removed and is usually higher than the uterine fundus to allow access to the myomas. (See 'Laparoscopic port placement' above.)
•A transverse rather than vertical myometrial incision is made to allow more ergonomic laparoscopic suturing of the uterine defect. (See 'Uterine incision' above.)
•To control bleeding within a myometrial defect, we desiccate briefly with bipolar electrosurgical paddles and avoid excessive desiccation since it may increase the risk of uterine rupture in subsequent pregnancy. (See 'Removal and morcellation of myomas' above and 'Counseling about future pregnancy' above.)
•We close all uterine defects, including the serosa, and adhere as closely as possible to the surgical technique for open abdominal myomectomy. (See 'Closure of uterine defects' above.)
●Complications – The most common complications of laparoscopic myomectomy are hemorrhage, fever, and conversion to laparotomy. Visceral injury and other complications occur rarely. (See 'Complications' above.)
●Future pregnancy – The risk of uterine rupture in a subsequent pregnancy is not well established, and laparoscopic suturing may not give the uterine wall the same strength as a multilayer closure at laparotomy. To optimize myometrial wound repair, we limit the use of electrosurgical desiccation of bleeding vessels and use a multi-layered closure of myometrium. (See 'Closure of uterine defects' above and 'Counseling about future pregnancy' above.)
●Outcomes – Following laparoscopic myomectomy, the five-year rate of persistent or new myomas is approximately 53 percent, but the rate of patients undergoing reoperation is much lower (approximately 7 percent). (See 'Persistent or new myomas' above.)
●Alternative laparoscopic techniques – Alternative laparoscopic techniques for treatment of patients with symptomatic leiomyomas may be used. (See 'Alternative laparoscopic techniques' above.)
•Robotic myomectomy may allow for easier laparoscopic suturing compared with conventional laparoscopy, but is associated with longer operating times and higher costs; overall outcomes appear to be similar. (See 'Robot-assisted laparoscopy' above.)
•Other techniques include single port laparoscopy, radiofrequency fibroid ablation, uterine artery occlusion, and myolysis. (See 'Single port laparoscopy' above and 'Other techniques' above.)
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