Myomectomy should be considered a safe alternative to hysterectomy. Victor Bonney, an early advocate of abdominal myomectomy, stated in 1931 that “The restoration and maintenance of physiologic function is, or should be, the ultimate goal of surgical treatment.” Case-controlled studies suggest that there may be less risk of intraoperative injury with myomectomy when compared with hysterectomy (111). A retrospective review of 197 women who had myomectomies and 197 women who underwent hysterectomies with similar uterine size (14 versus 15 weeks) found operating times were longer in the myomectomy group (200 versus 175 minutes), but estimated blood loss was greater in the hysterectomy group (227 versus 484 mL) (111). The risks of hemorrhage, febrile morbidity, unintended surgical procedure, life-threatening events, and rehospitalization were no different between groups. However, 26 (13%) women in the hysterectomy group suffered complications, including 1 bladder injury, 1 ureteral injury, 3 bowel injuries, 8 women with ileus, and 6 women with pelvic abscesses. In contrast, complications occurred in 11 (5%) of the myomectomy patients, including 1 bladder injury, 2 women with reoperation for small bowel obstruction, and 6 women with ileus.
Myomectomy may be considered even for those women who have large uterine fibroids and wish to retain their uterus. A study of 91 women with uterine size larger than 16 cm (range 16– 36 cm) reported one bowel injury, one bladder injury, and one reoperation for bowel obstruction, but no women had conversion to hysterectomy (112). The cell saver, which is a devise used to collect blood intraoperatively and reinfuse, was used in 70 women, and only 7 required homologous blood transfusion. A retrospective cohort study compared 89 women having abdominal hysterectomy for fibroids (mean uterine size 15 cm) to abdominal myomectomy in 103 women (mean uterine size 12 cm) (113). Although selection bias was likely, the hysterectomy group suffered two ureteral, one bladder, one bowel, and one nerve injury and two reoperations for bowel obstruction, while there were no visceral injuries in the myomectomy group.
In carefully selected women, myomectomy may be safely accomplished at the time of cesarean section by experienced surgeons. One series reported 25 women with removal of 84 fibroids (2 to 10 cm) at the time of cesarean section without the need for cesarean hysterectomy (114). Estimated blood loss was 876 mL (range 400 to 1,700 mL) and five women required blood transfusion. Another study compared 111 women who had myomectomy at the time of cesarean section with 257 women with fibroids who were not subjected to myomectomy during cesarean section (115). Only one of the women in the myomectomy group required transfusion and none required hysterectomy or embolization. There were no differences in mean operative times, incidence of fever, or length of hospital stay between the two groups. Although the cases were likely selected carefully, the authors concluded that, in experienced hands, myomectomy might be safely performed in selected women during cesarean section.