Myomectomy is the gold-standard surgical intervention for individuals seeking relief from symptomatic uterine fibroids (leiomyomas) who desire uterine preservation for future pregnancy or personal preference. Uterine fibroids are benign neoplasms arising from the smooth muscle layer of the uterine wall, known as the myometrium. Depending on their location, size, and number, fibroids can disrupt normal pelvic anatomy, impair endometrial receptivity, and exert compressive force on adjacent organs such as the bladder and rectum.

The primary therapeutic goal of a myomectomy is the precise excision of leiomyomatous tissue while reconstructing the uterine wall to restore normal anatomical contours, mitigate heavy menstrual bleeding, alleviate pelvic pressure, and improve reproductive outcomes. The operational approach varies based on fibroid classification, ranging from hysteroscopic resection for submucosal tumors to laparoscopic, robotic-assisted, or open abdominal approaches for intramural and subserosal fibroids. Clinical practice guidelines from the American College of Obstetricians and Gynecologists (ACOG Practice Bulletin No. 228, 2021) and the American Society for Reproductive Medicine (ASRM Practice Committee, 2021) support myomectomy as the definitive organ-sparing surgical treatment for symptomatic leiomyomas.

Myomectomy is performed under general or regional anaesthesia. For hysteroscopic myomectomy, a resectoscope is passed through the cervix to resect submucosal fibroids using fluid distension and electrical energy. For laparoscopic and robotic myomectomy, small abdominal incisions are made, pneumoperitoneum is established, and fibroids are enucleated from the myometrium using specialized instruments, followed by multi-layer uterine suturing and contained tissue extraction. For abdominal myomectomy, a transverse or vertical incision allows direct visualization, dissection, and suture reconstruction of the myometrium.

Myomectomy offers well-established clinical benefits for individuals seeking relief from fibroid-related symptoms while preserving uterine integrity:

• Preservation of Reproductive Capacity: Retains the uterus and endometrial cavity, allowing future pregnancy and gestations, particularly following resection of cavity-distorting submucosal fibroids (ASRM Practice Committee, 2021).
• Resolution of Heavy Menstrual Bleeding: Excision of submucosal and intramural fibroids restores normal endometrial surface area and contractility, reducing menstrual blood loss in over 80% of treated patients (NICE Guideline NG100, 2021).
• Alleviation of Bulk Symptoms: Significant reduction in uterine volume relieves bladder pressure, urinary frequency, bowel dysfunction, and pelvic fullness.
• Relief from Dyspareunia and Pelvic Pain: Surgical removal eliminates localized pressure and inflammation, significantly improving quality-of-life scores.
• Histological Verification: Excision allows comprehensive pathological examination to exclude occult uterine malignancies, such as leiomyosarcoma.

Recovery timelines after myomectomy depend on the surgical approach utilized. Hysteroscopic myomectomy involves a rapid recovery, with most patients resuming routine activities within 24 to 48 hours. Minimal post-operative discomfort and mild vaginal spotting are expected for up to one week.

Minimally invasive approaches—including laparoscopic and robotic-assisted myomectomy—typically require a hospital stay of 24 hours or less. Early physical recovery occurs within 1 to 2 weeks, while full physical recovery, including strenuous exercise and heavy lifting, requires 4 weeks. Light daily activities and walking are encouraged immediately post-surgery to prevent venous thromboembolism.

Abdominal (open) myomectomy requires a longer recovery period due to the larger incision in the abdominal wall. Patients usually remain hospitalized for 2 to 3 days. Initial incisional healing occurs over 2 weeks, with complete recovery and return to full physical exertion expected at 6 to 8 weeks. Unprotected intercourse and pregnancy attempts are restricted for 3 to 6 months following myomectomy involving deep myometrial incisions to allow adequate uterine muscle healing and minimize the risk of uterine rupture during future gestations (ACOG Practice Bulletin No. 228, 2021).

Myomectomy treats benign smooth muscle tumors of the uterus and the clinical syndromes associated with their presence, including:

• Symptomatic Uterine Leiomyomas: Benign neoplasms of the myometrium that cause pelvic pain, heavy menstrual bleeding, or organ compression.
• Submucosal Fibroids (FIGO Types 0, 1, 2): Fibroids protruding into the endometrial cavity, frequently responsible for menorrhagia and implantation failure.
• Intramural Fibroids (FIGO Types 3, 4, 5): Tumors located within the myometrial wall that alter uterine contractility and expand overall uterine volume.
• Subserosal Fibroids (FIGO Types 6, 7): Fibroids projecting outward from the serosal surface, causing localized pain or pressure on the bladder and bowel.
• Fibroid-Induced Infertility and Recurrent Pregnancy Loss: Cavity-distorting fibroids that impair blastocyst implantation, tubal transport, or early gestational maintenance.
• Bulk-Related Pelvic Dysfunction: Urinary frequency, constipation, and pelvic venous congestion secondary to uterine enlargement.

Pre-procedure preparation includes diagnostic mapping via transvaginal ultrasound or MRI. Complete blood count is checked to assess for anaemia, and iron supplementation or GnRH agonist therapy may be prescribed for 1 to 3 months prior to surgery. Patients follow standard fasting protocols before anaesthesia, discontinue antiplatelet medications as directed, and undergo pre-operative bowel preparation if indicated.

Complications include intraoperative hemorrhage requiring blood transfusion, damage to adjacent organs (bladder, bowel, ureters), pelvic infection or endometritis, post-operative adhesion formation, fibroid recurrence over time, uterine scar rupture during subsequent pregnancy, and rare conversion from minimally invasive to open surgery or hysterectomy in emergency situations.

The clinical care pathway for myomectomy spans four distinct phases: pre-operative evaluation, surgical execution, acute post-operative recovery, and long-term follow-up.

Phase 1: Pre-Operative Assessment and Optimization

Patients undergo pelvic imaging—typically transvaginal ultrasound or contrast-enhanced magnetic resonance imaging (MRI)—to map fibroid number, dimensions, and anatomical classification according to the International Federation of Gynecology and Obstetrics (FIGO) system. Laboratory evaluation includes a complete blood count to diagnose and manage anaemia resulting from chronic menorrhagia. Medical optimization using gonadotropin-releasing hormone (GnRH) agonists or selective progesterone receptor modulators may be initiated to reduce fibroid volume and correct pre-operative hemoglobin levels.

Phase 2: Surgical Intervention

Depending on fibroid position and patient characteristics, the procedure is conducted under general or regional anaesthesia using hysteroscopic, laparoscopic, robotic, or open abdominal surgical techniques. The surgeon incises the myometrium, enucleates the fibroid from its pseudocapsule, achieves precise haemostasis, and reconstructs the uterine layers to prevent hematoma formation and minimize adhesion development.

Phase 3: Immediate Post-Operative Management

Patients transition to a recovery unit for monitoring of vital signs, surgical site healing, and urine output. Early ambulation and multimodal analgesia are implemented. Hospital discharge occurs same-day for hysteroscopic approaches, or within 1 to 3 days for abdominal procedures once oral intake and voiding criteria are met.

Phase 4: Recovery and Follow-Up

Post-discharge care focuses on wound management, gradual resumption of physical activity, and pain control. Surgical follow-up is scheduled at 2 and 6 weeks post-procedure. Transvaginal imaging may be conducted at 3 to 6 months to evaluate myometrial healing prior to attempting conception.