When should open surgery be preferred for uterine myomas?—a narrative review

Introduction

Uterine myomas are among the most common benign gynecological neoplasms and may be present in 20–40% of women during reproductive age. It is also a significant health problem that causes an increase in women’s morbidity, has a negative impact on the quality of life and economic burden (1,2). Although fibroids are primarily asymptomatic, in 25% of the women, they are responsible for symptoms such as menstrual abnormalities, as well as heavy or prolonged uterine bleeding, which is the cause of iron deficiency anemia, obstructive symptoms such as pelvic pressure or pain, recurrent pregnancy loss and infertility (3). In the USA, one-third of all hysterectomies are performed due to uterine fibroids (4). However, hysterectomy may not be an appropriate treatment option for patients who wish to have childbearing capabilities or preserve their uterus. For this reason, alternative surgical (myomectomy, radiofrequency ablation) and medical therapies were developed, such as oral contraceptives, gonadotrophin-releasing hormone (GnRH) agonists, progestin intrauterine systems, selective estrogen receptor modulators, aromatase inhibitors, or nonsteroidal anti-inflammatory medications. Most medical therapies treat only the consequences, and symptoms, and myomas and not the myomas themselves. Other non-excisional procedures are endometrial ablation, uterine artery embolization (UAE), and magnetic resonance guided focused ultrasound (5-7). Despite all these treatments, myomectomy remains the gold standard conservative treatment for women with symptomatic fibroids who want to preserve their fertility while risking further interventions in the future (8).

Myomectomy can be performed according to the number, size, and location of fibroids by laparotomy, laparoscopy, hysteroscopy or a combination of these (9). The most important factor determining the type of surgery is preoperative surgical planning and the skills of the surgeon. Surgical planning should be based on accurate mapping of the location, size, and number of fibroids with preoperative imaging. Fibroids may be single or multiple, and their size, location, and vascularity vary considerably. The International Federation of Gynecology and Obstetrics (FIGO) system was developed in order to more uniformly and consistently describe and classify uterine fibroids (Figure 1) (10). The system that includes the tertiary classification of leiomyomas categorizes the submucous group according to the original Wamsteker et al. and adds categorizations for intramural, subserosal, and transmural lesions (11). Intracavitary lesions are attached to the endometrium by a narrow stalk (≤10% or the mean of three diameters of the leiomyoma) and are classified as Type 0, whereas Types 1 and 2 require a portion of the lesion to be intramural, with Type 1 being less than 50% of the mean diameter and Type 2 at least 50%. Type 3 lesions are totally intramural, but also about the endometrium. Type 3 is formally distinguished from Type 2 with hysteroscopy using the lowest possible intrauterine pressure necessary to allow visualization. Type 4 lesions are intramural leiomyomas that are entirely within the myometrium, with no extension to the endometrial surface or to the serosa. Subserous (Types 5, 6, and 7) leiomyomas represent the mirror image of the submucous leiomyomas, with Type 5 being at least 50% intramural, Type 6 being less than 50% intramural, and Type 7 being attached to the serosa by a stalk that is also ≤10% or the mean of three diameters of the leiomyoma.

Figure 1 FIGO leiomyoma subclassification system. FIGO, International Federation of Gynecology and Obstetrics.

At present, there are many related studies on the advantages and disadvantages of abdominal myomectomy and laparoscopic myomectomy (LM) in patients with uterine fibroids. The purpose of this narrative review will seek to answer to/provide guidelines regarding “When should we prefer open surgery in myoma uteri?”. We present this article in accordance with the Narrative Review reporting checklist (available at https://gpm.amegroups.com/article/view/10.21037/gpm-25-48/rc).

Methods

For this narrative review, PubMed (MEDLINE), Google Scholar, Web of Science were searched for records in electronic databases to identify original reports comparing patient outcomes, published up to August 2025. The search strategies were related to human studies, interventions and outcomes around terms for “open abdominal myomectomy”, “laparoscopic myomectomy”, “hysteroscopic myomectomy” and “minilaparotomy myomectomy”, “sarcoma”, “leiomyosarcoma”, “recurrence of myoma”, “morcellation” or “morcellator”. Unpublished reports, case reports or congress abstracts were not considered (Table 1).

Discussion

LM versus abdominal myomectomy

Open abdominal myomectomy is traditionally primary choice in patients with intramural or subserosal leiomyomas. Once popularized by Victor Bonney, it involves the surgical removal of fibroids through an incision in the abdominal wall and closure of the uterine defect (12). However, intracavitary fibroids can also be removed during an open abdominal myomectomy. Although hysteroscopic myomectomy is the first choice for the conservative surgical treatment of submucosal fibroids, removal of fibroids larger than 5 cm in diameter can be technically difficult. The most common indications for open abdominal myomectomy are abnormal uterine bleeding and bulk-related symptoms (pelvic pressure/pain, obstructive symptoms, bowel dysfunction, bladders such as urinary frequency and urgency) or infertility.

Over the past 20 years, gynecological surgery has progressed to include minimally invasive techniques such as LM. The aim of endoscopic procedures is that when a surgical incision is smaller, it causes minor damage to the abdominal wall; therefore, the woman will experience less pain, and the postoperative recovery time will be similarly shorter. In this way, postoperative morbidity and mortality can be reduced. Although it is a technically difficult procedure with a more complex and lengthy learning curve, minimally invasive surgery has become popular with advances in techniques and instruments.

The benefits of the laparoscopic approach are well known. They have proven to be superior to the laparotomic method by reducing the blood loss and postoperative pain, causing fewer overall complications, as well as providing a faster recovery and significant cosmetic advantage (13). The critical factors for a successful LM are number, size, and the location of the myoma. It also depends on the shape of the myomas, weight of the patient. However, laparoscopic removal of huge or multiple myomas in more difficult locations such as the lower segment or cervical junction, has a greater risk of complications such as excessive bleeding. In addition, the prolonged operative time required with the laparoscopic approach should also be considered. In these cases, an open procedure, either laparoscopic-assisted myomectomy or laparotomy, may be a more appropriate choice (Figure 2A,2B and Figure 3) (5).

Figure 2 A 32-year-old female patient presented with complaints of an abdominal mass, compression symptoms, and excessive menstrual bleeding. (A) Multiple leiomyomas in a young patient. (B) Leiomyomas removed in the same patient (F.K.’s personal archive).

Figure 3 Huge leiomyoma in a young girl (F.K.’s collection).

LM versus ultraminilaparotomy (UMLT) or minilaparotomy

Besides laparoscopy, the use of minimal access surgery, such as UMLT or mini-laparotomy, is one of the options for gynecological and reproductive surgery because both can be considered less traumatic surgeries (14). Myomectomy via mini-laparotomy is a surgical technique in which the skin incision does not exceed 5–6 cm (15). UMLT is defined as having an incision length of <4 cm (14). Minilaparotomy myomectomy combines the advantages of classical laparotomy (i.e., easy to perform and learn) and the advantages of minimally invasive surgery such as less blood loss, short hospital stay, less postoperative pain, rapid return to normal activities (16,17). Several randomized prospective studies have compared the results of laparotomy and myomectomy with minilaparotomy (18,19). In their review of 57 cases, the authors concluded that the use of the minilaparotomy incision is a safe alternative to myomectomy by laparotomy. It technically allows a better closure of the uterine defect and may require less time to perform. In their cases, minilaparotomy was performed with a 4–6 cm long suprapubic transverse incision. Subcutaneous adipose tissue and abdominal fascia were crossed, abdominal muscle was opened longitudinally in the midline. The parietal peritoneum was opened longitudinally. A linear uterine incision was made as small as possible in the most protruding part of the fibroid. After identification of the fibroid pseudocapsule, enucleation was possible following the cleavage plane. Uterine defects were closed with Vicryl^® 1 polyglactin 910 single sutures (Ethicon SpA, Rome, Italy). The procedure is far easier to teach than LM, because of the high degree of technical skills required for the latter (17,20).

Perioperative morbidity

A recent Cochrane review [2014] recommended a meta-analysis of nine randomized controlled trials (with a total of 808 women). Here, LM was compared with myomectomy at minilaparotomy and laparoscopically assisted mini-laparotomy myomectomy. The primary outcomes investigated were postoperative pain [defined as the value on the patients-assessed visual analog scale (VAS)—pain scale, at 6, 24 and 48 h] and adverse events (such as febrile morbidity, laparoconversion, and immediate hysterectomy, injury during surgery, thromboembolism and hemoglobin drop). In contrast, parameters such as length of hospital stay, operating time, improvement in menstrual symptoms, recurrence of fibroids (at six months or later after surgery) repeat myomectomy afterward were defined as secondary outcomes (21).

According to the above Cochrane review, LM is a less painful procedure compared with all types of open myomectomy (OM) (myomectomy at minilaparotomy and laparoscopically assisted mini-laparotomy myomectomy). However, no evidence of a difference in pain scores was noted on the VAS at 24 hours after surgery between LM and all types of OM. This heterogeneity could be explained by a study by Tan et al. (22). In their study laparoscopically assisted mini-laparotomy myomectomy, in which laparoscopy is used for fibroid enucleation and dissection, and specimen removal and suturing are done through a small abdominal incision. They reported that this might reduce tissue damage and operating time compared with OM and may skew the results of pain scores.

When perioperative in-hospital side effects, laparoconversion rates, and injury to pelvic organs were examined, no significant difference was observed between the two groups (21). Also, they reported that postoperative febrile morbidity is less common in LM than in all types of OM (21). However, operating time in minutes was significantly longer in the laparoscopy group. All participants in both groups showed improvement in menstrual symptoms. The review noted a reduced hemoglobin drop postoperatively, indicating decreased intraoperative blood loss in LM when LM was compared with OM (21). Another meta-analysis by Palomba et al. evaluated the safety and efficacy of mini-laparotomy through a systematic review of randomized and non-randomized controlled trials. In this meta-analysis, the authors observed that the mini-laparotomy was associated with lower intraoperative blood loss and shorter hospital stay than the laparotomy (15).

Recurrence of myoma uteri

Another controversial issue is the recurrence of myoma after myomectomy. Some authors consider that LM may be a problem in complete removal when dealing with multiple fibroids. Incomplete removal of nuclei may result in the continuous development of new symptomatic lesions (23). According to the Cochrane review, no evidence showed a significant difference in the recurrence rate of fibroids between the two groups (21). On the other hand, in their study, Kotani et al. examined the recurrence rates in 474 patients who underwent LM and 279 patients who underwent OM. The patients were followed for six months to eight years postoperatively. They reported that the cumulative recurrence rates between the two groups were 76.2% (LM) vs. 63.4% (OM) at eight years postoperatively. They said this is likely the result of manual fibroid removal in OM, which is more extensive removal of smaller fibroid masses than during LM (24). The recurrence rate is associated with age, the preoperative number of fibroids, uterine size, and childbirth after myomectomy (25). The cumulative probability of recurrence of new or unremoved fibroids in women who gave birth after myomectomy was 42%, and it was 55% in those who did not give birth (5). For these reasons, patients should be informed of the risk of recurrence regardless of their age.

Fertility outcome

In a recent Cochrane review [2020], two questions have been asked: firstly, whether myomectomy leads to an improvement in fertility outcomes; and secondly, if there is a beneficial effect, what would be the ideal surgical approach? The answer for the first question is in the randomized controlled study of Casini et al. (26). In this study, they examined reproductive outcomes separately for the different types of fibroids. The Cochrane reviewer reported that they were uncertain of the effect myomectomy had on both clinical pregnancy and miscarriage rate compared to no treatment. Unfortunately, this study did not report on either primary outcome (live birth rate or preterm delivery rate), despite the study lasting seven years. Furthermore, the study collectively reported on myomectomies performed either by laparotomy or hysteroscopy, meaning separate analysis of these two very different surgical approaches could not be performed. For the second question, two studies compared myomectomy at laparotomy or mini-laparotomy to LM (27,28). The Cochrane reviewers noted that it is uncertain which surgical method is superior when comparing these approaches on fertility outcomes (live birth, preterm delivery, clinical pregnancy, ongoing pregnancy, miscarriage and caesarean section rate).

Pregnancy outcomes after myomectomy

The management of fibroids in women who wish to preserve their uterus and fertility remains a challenge. Several non-controlled studies in the literature have suggested a decrease in the miscarriage rate following myomectomy in women with myomas distorting the uterine cavity (29). In a review of prospective and retrospective studies, pregnancy rate was reported to be 49% [95% confidence interval (CI): 46–52%] in patients who underwent LM (30). It is also suggested that there are no significant differences in cumulative pregnancy rates or obstetric or perinatal outcomes when laparoscopic and abdominal myomectomy are compared (31).

In a systematic review they compared the pregnancy outcomes after medical [ulipristal acetate (UPA)], surgical (myomectomy) and radiological (UAE or thermal ablation) therapy for fibroids in women. They reported that 1,575 pregnancies after myomectomy were identified and surgical approach was reported in 1,449 women: 1,047 women underwent LM, 107 operations were robotic-assisted, 51 were open surgeries or laparotomies, 26 were mini-laparotomies, whereas 218 cases were not clearly stated (31). They stated that these pregnancies resulted in 1,191 live births (75.6%), 42 ongoing pregnancies (2.7%), 299 miscarriages (19.0%), 24 ectopic pregnancies (1.5%) and two stillbirths. Myomectomy also contributes to postpartum complications by increasing the incidence of placenta praevia and placenta accreta, but the rate of placental abnormalities (four placenta previa, one placenta accreta and one placenta percreta) identified in this review was only 0.25%. Although pregnancy outcomes after myomectomy appear to be better than with other conservative treatments for fibroids, it remains unclear whether myomectomy has any benefits for fertility.

After a myomectomy, practitioners often advise a minimum lapse of time before trying to conceive in order to avoid complications and to let the uterus heal. The myomectomy to conception interval was only reported in four cases, with one patient conceiving 18 weeks after surgery. The other three women conceived more than 12 months after surgery, at 14, 18 and 36 months.

Ginod et al., in their study including 13,868 abdominal and 338 LM patients, reported that hypertensive disorders of pregnancy and gestational diabetes were more frequent after abdominal myomectomy, whereas uterine rupture and severe maternal-fetal complications were more common following LM, and therefore recommended that both groups should be managed as high-risk pregnancies (32).

Adhesion formation

Myomectomy is often associated with adhesion formation, which can cause intestinal obstruction, chronic pelvic pain, and infertility in addition to posing technical difficulties during re-operation. Several investigators have reported that adhesions occur in all patients after laparotomy and myomectomy. Ten Broek et al. reported a high de novo adhesion rate of 98% after myomectomy by laparotomy (33). This rate was found to be lower, with 41.3% after LM (33). The adhesion risk after LM increases in fibroids, especially with posterior location and the suture technique. Application of anti-adhesion barriers has been proposed, and a significant reduction in adhesion formation was reported with some of them (34,35).

Recent evidence highlights that abdominal myomectomy carries a clinically relevant risk of postoperative intrauterine adhesions, with a pooled incidence of approximately 12.9%, and nearly one-third of these cases are classified as severe. Interestingly, cavity breach was not consistently identified as a risk factor, while extensive myomectomy for large and multiple fibroids appeared to increase the likelihood of adhesion formation. These findings are in line with earlier reports indicating that intrauterine adhesions may occur irrespective of the surgical approach, whether minimally invasive or open, and that their impact on fertility can be substantial (36).

Uterine rupture (UR)

Another point of concern regarding endoscopic surgery is the potential for uterine rupture. A laparotomic or laparoscopic approach will, in most cases, cause a scar in the myometrium, which may lead to weakening of the muscular wall. UR can be defined as a full-thickness separation of the uterine wall and the covering visceral peritoneum. Trial of labor is possible after myomectomy but has a known 0.47% risk of uterine rupture (37). It is reported that compared with traditional OM, the risk of uterine rupture during pregnancy is not significantly higher after a laparoscopic approach (P=0.12) (38). In another cohort study, a total of 54,146 myomectomies were performed, and it was reported that 52,917 were completed with laparotomy (97.7%) and 1,229 (2.3%) with laparoscopy between 2005 and 2014. It was shown that uterine rupture had decreased markedly in recent years (39). This may be related to the decrease in the number of myomectomies performed and the increase in the rate of myomectomies performed with the open approach. In this study, they reported that LM increases the risk of uterine rupture more than two times compared to the open process.

In another review, it was reported that a total of 10 cases (0.6%) of uterine rupture occurred of which one resulted in intrauterine fetal death. One out of 10 women had undergone OM, one had undergone robotic-assisted myomectomy and the remaining eight had undergone LM. Two of the women treated with LM had undergone an additional laparotomy for myomectomy and for cornual reanastomosis afterwards. Three cases occurred at term, whereas six cases occurred before 35 weeks (range, 24–34 weeks) (31).

Another risk factor for uterine rupture is excessive use of electrosurgery during myomectomy. This situation may lead to the formation of increasingly coagulated necrotic tissue and subsequently a thinner myometrium (40). In addition, inadequate closure of the uterine incision later may lead to hematoma formation and unsatisfactory healing. Therefore, multi-layer suturing of the uterine incision is recommended (40). On the other hand, a study suggested that the number of suture layers may not completely protect against uterine rupture (41). Other possible risk factors could be obesity and the use of carbon dioxide pneumoperitoneum (40,42). But these findings have not been demonstrated to play an essential role in uterine rupture.

Few studies have evaluated vaginal delivery after abdominal myomectomy, with a reported successful vaginal birth of 81.8% (43,44). In a systematic review of the uterine rupture during a trial of labor after myomectomy (TOLAM), a total of 23 studies, 1,284 (70.4%) deliveries occurred after laparoscopic procedures and 541 (29.6%) after OM. They reported that uterine rupture occurred in 11 cases, with an overall incidence of 0.6% (0.3–1.1%) (41). In this review, they suggest that uterine rupture after myomectomy is a complication that is difficult to predict and can happen at any time during pregnancy, often in the second or early third trimester. In addition, in the previous study, they reported that LM increases the risk of uterine rupture more than two times compared to the open process (39). In another study, Gambacorti-Passerini et al. analyzed retrospectively all women who underwent laparoscopic or laparotomic myomectomy between 2002 and 2014. In their study, in a total of 110 pregnancies, 73 (66.4%) women had a TOLAM, while 24 (21.8%) had a planned cesarean delivery (CD). They reported that a successful vaginal delivery was accomplished by 90.4% of women who previously underwent TOLAM without any case of UR or severe maternal and perinatal complications. Therefore, they suggested TOLAM may be considered and offered as a feasible and relatively safe option (41).

Despite all this, uterine rupture is considered one of the main obstetrical risks for women with a prior myomectomy. For this reason, the mode of delivery during labor is still controversial (43). In their review, Margueritte et al. investigate time interval from myomectomy to pregnancy across the literature (45). They said the articles on post-myomectomy pregnancies do not provide a minimum protective period against the occurrence of obstetric complications like uterine rupture. They reported that information about size and localization of myomas, use of energy, entering the uterine cavity, number of layers of stitches, post-operative infection, seems mandatory in every surgery report, to facilitate the decision for the follow-up of a future pregnancy. Based on these results, individualization for each woman of a time interval after myomectomy before conception should be discussed.

Uterine power morcellation

However, an essential point of safety associated with laparoscopic hysterectomy and myomectomy is uterine power morcellation. Gynecologic surgeons have used morcellation during laparoscopic and robotic-assisted hysterectomies and myomectomies as a less invasive alternative to open surgery. However, the inability to perform surgical staging due to the destruction of the surgical specimen and spread of sarcomatous tissue throughout the peritoneal cavity is of great concern in cases of morcellated occult uterine sarcoma. Unfortunately, morcellation of uterine sarcoma increases abdominal and pelvic recurrences and shortens recurrence-free survival (46). The Food and Drug Administration (FDA) estimated the risk of occult uterine sarcoma as 1/350 according to the data available at that time (47). A systematic review criticized the FDA report, as they found the incidence of unexpected uterine sarcoma as 1/2,000 in total and as 1/8,300 when only prospective studies are considered (48). In another retrospective study, a total of 18,604 women underwent hysterectomy or myomectomy with a pre-operative diagnosis of uterine leiomyoma and 56 cases of uterine sarcoma were identified. In this study, Yorgancı et al. found that the incidence of occult uterine sarcoma was 0.3% (56/18,604) or approximately 1/332 (49). After the 2014 FDA safety communication, Harris et al. analyzed the changes in hysterectomy practice patterns and postoperative surgical complications. It was reported that compared to the preceding 16 months, the utilization of laparoscopy decreased. In addition, they found that overall serious surgical complications and hospital re-admissions increased significantly after the FDA communication. They observed a 24% increase in re-admissions (50). In December 2017, the FDA updated its previous report and reported that the prevalence of uterine sarcoma in women who had surgery for fibroids ranged from about 1 in 225 to 1 in 580 (51). In addition, the FDA still warns against the use of power morcellation. A study by Desai et al. found that, for an indication of fibroids, 50% of minimally invasive gynecologists considered changing the procedure to avoid morcellation due to the November 2014 FDA safety communication (52). The technique of power morcellation in a bag was recently suggested to minimize the risk of tissue spread, but there is no evidence that this technique will not increase the rate of post-operative complications (53). Generally, we can say that to decrease the number of incidentally diagnosed uterine leimyosarcoma after operations, risk groups have to be defined to prevent detrimental surgical procedures using tumor damage and morcellation. Future directions include robotic-assisted approaches and refinement of minimally invasive techniques to reduce recurrence and adhesion formation.

Conclusions

Open abdominal myomectomy remains an essential option in the surgical management of uterine fibroids. It should be preferred in cases of very large (>10–12 cm) intramural fibroids, multiple fibroids requiring several uterine incisions, or fibroids located in technically challenging sites such as the cervical or lower uterine segment. While minimally invasive approaches offer advantages in terms of recovery, blood loss, and cosmetic outcomes, they may be limited when dealing with extensive disease. Ultimately, the choice of surgical method should be individualized, taking into account patient age, fertility desires, fibroid characteristics, and the surgeon’s expertise. Clear preoperative planning and patient counseling are crucial to optimize outcomes and minimize recurrence or complications. Individualized decision-making remains essential.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the Guest Editors (Omer Lutfi Tapisiz and Sadiman Kiykac Altinbas) for the series “Uterine Fibroids: Various Aspects with Current Perspectives” published in Gynecology and Pelvic Medicine. The article has undergone external peer review.

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://gpm.amegroups.com/article/view/10.21037/gpm-25-48/rc

Peer Review File: Available at https://gpm.amegroups.com/article/view/10.21037/gpm-25-48/prf

Funding: None.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://gpm.amegroups.com/article/view/10.21037/gpm-25-48/coif). The series “Uterine Fibroids: Various Aspects with Current Perspectives” was commissioned by the editorial office without any sponsorship or funding. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All clinical procedures described in this study were performed in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patients for the publication of this article and accompanying images.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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