Myomectomy vs. Hysterectomy Part II: How You Can Navigate this Difficult Dilemma

In his previous article, “Myomectomy vs. Hysterectomy, Part I: How You Can Be Put into this Difficult Dilemma,” Dr. Bozdogan of Advanced Endometriosis Center discussed the changes in your uterus that could force you into a difficult, life-changing decision. In this article he shows you how to seek your own path, based on what is right for you, as well as the state-of-the-art options and their pros and cons.

The dilemma.

Your uterus may be giving you problems you never bargained for: irregular bleeding, heavy bleeding, severe cramping, painful sex, and even infertility.

Uterine fibroids cause heavier bleeding that can interfere with implantation or they can pose as mechanical barriers to transmission of semen toward an egg or the passage of the fertilized egg into the uterus for implantation. In spite of uterine fibroids, if pregnancy does occur they can interfere with normal fetal development that increases the risk of miscarriage or later on can cause improper positioning of your baby that can provoke preterm labor or result in a difficult birth.

Because of the extra mass of your uterus when fibroids are present, your uterus can pivot against its supporting ligaments to produce pelvic pain or can press on your bladder or rectum to interfere with urination or having a bowel movement. Additionally, the mechanical act of sexual intercourse can initiate painful movements of your heavier-than-normal uterus; and since demonstrating intimacy physically is crucial in any relationship, fibroids can even jeopardize a marriage.

Herein lies the dilemma: the considerable misery that fibroids or adenomyosis creates must be balanced against both your desire for continued fertility and your quality of life.

• Do you make decisions to save our uterus—even at all costs—or
• do you eliminate the problem—but with it, your fertility as well?

Of course, if fertility is not an issue, you are only weighing your misery index vs surgery, that is, hysterectomy vs living with the problem. However, if you want to keep your pregnancy options open—or if you are an infertility patient because of fibroids—it gets complicated.

Are you ready to “go under the knife”?

Before even getting to the many surgical options for a solution to your problem, you need to answer this question:

Is the misery you experience or your desire for fertility so intense that you are willing to have surgery to fix the problem?

If your answer is yes, you’ll be considering myomectomy vs hysterectomy, depending on fertility wishes.

If you answer no, your options plunge. While certain alternative techniques can be used for fibroids, such as lithotripsy and selective arterial occlusion, these “non-surgery” options are not totally risk-free or benign solutions, presenting both early and late complications. Today, with the state-of-the-art surgery that makes possible cosmetically sensitive, out-patient, and fast-recuperation surgery, the trade-off you seek in avoiding “going under the knife” (a terribly unfair expression by today’s standards) may not be a good trade. (Don’t trade Boardwalk and Park Place for Baltic and Mediterranean Avenue!)

When is Surgery Not Enough, Enough, or Too Much? Is there a Goldilocks Solution? 

• Hysterectomy: removal of your uterus. It does not mean with your tubes and ovaries (which has a different procedure name).
• Myomectomy: removal of the fibroids in your uterus, sparing the uterus for future fertility.

Of course, the decision all hinges on your desire for pregnancy. But how bad can fibroids get such that fertility is not likely or even impossible? Should you have a myomectomy that has little or no chance of success of fertility if you’re destined to have a hysterectomy anyway. 

Yes and no.

While removing fibroids may not give you your fertility back, it can significantly lessen the other problems that fibroids cause, such as heavy bleeding, cramping, pain, painful sex, and urinary incontinence. However, if your fibroids are so numerous or if a single fibroid is so large that removing all fibroid tissue leaves you with little more than a uterine remnant, you might want to consider hysterectomy to end this problem once and for all. Only your surgeon can determine whether or not you’re kidding yourself in trying to hang on to a distorted uterus that would result from an extensive myomectomy. Naturally, doctors like Dr. Bozdogan at Advanced Endometriosis Center take a very conservative position, never wanting to “write off” your fertility without both overwhelming indications and your approval. As such, he is also a teacher, educating you on all of the subtleties involved in making such a momentous decision. 

So you’ve decided to have surgery. Now what?

• First, let’s discuss the “nuclear” option, hysterectomy. “Dr. Boz” feels that the future well-being of the rest of your life depends on the least amount of internal manipulation. Therefore, he uses the da Vinci robotic system for hysterectomy. Its unparalleled ability to use exquisite dexterity through tiny cosmetic incisions, its grand stereoscopic view of your internal pelvis, and its minimal manipulation of tissues (that normally don’t like manipulation) offers same-day, out-patient—and successful—surgery with recovery times of a week or two. It offers the least risk of internal scarring (“adhesions”) that can cause problems later, because the larger the incision, the more risk of adhesion formation.

A final word about hysterectomy: if you have any doubts or troubling feelings about burning your bridges, so to speak, discuss your situation thoroughly before committing to hysterectomy. Besides fertility, there are psychodynamics you need to address, although most women who undergo hysterectomy for reasons of pain or bleeding consider it the best post-fertility decision they’ve ever made.

• Myomectomy means removing only your fibroids. The size and number of fibroids can tip the scales toward a hysterectomy decision, but remember that Dr. Boz wants you to keep your fertility if you want to keep it and will do everything he can to make it so. For him, exploiting the da Vinci robot is a crucial part of this mindset.

Robotic myomectomy 

As technology relentlessly marches on, different versions of myomectomy are emerging, adding to already standard surgical methods for fibroid removal:

• Open laparotomy: this is a large abdominal incision that allows the surgeon to use retractors and work with his or her hands within your abdominal/pelvic cavity. It offers dexterity like the da Vinci robot, but not the visualization. The da Vinci can articulate stereoscopic cameras from below organs upward.
• Laparoscopic myomectomy: this is the historical precursor to the robotic approach, considered the first “minimally invasive GYN surgery.” It uses small incisions, good for recovery and the prevention of adhesions. It is limited, however, by compromised visualization (2D only) and limited dexterity, since it is accomplished by instruments at the end of non-articulating thin metal poles.
• Hysteroscopic myomectomy: this is a surgery done with small devices passed through a scope that looks into your uterus (through your vagina and cervix, into your uterine cavity). While it is very useful for many reasons, it can only address internal fibroids that hang into the uterine cavity. It is unable to address fibroids protruding outward.
• Da Vinci Robotic Myomectomy: based on the above critiques of other myomectomy techniques, the robotic system stands well above as a first choice for doctors like Dr. Boz, who now has done thousands of these procedures.

Surgery on your reproductive organs is serious business. In fact, all surgery is serious, because no one technique or technology is completely immune to complications. But no one takes surgery more seriously than Dr. Boz, who has dedicated his life to methods that give you your best chance for pregnancy, if desired, and also your best recovery and postoperative surgery experience regardless of the reason for surgery.