Surgical management of uterine fibroids

Surgery continues to be a mainstay of treatment for patients with symptomatic fibroids. Hysterectomy is an option for those desiring definitive treatment and myomectomy is preferred for those that have not yet completed childbearing or wish to retain their uterus. While open laparotomy remains a viable approach to both hysterectomy and myomectomy, minimally invasive techniques for the surgical management of symptomatic fibroids are preferred options for many due to improved patient outcomes. These include hysteroscopic myomectomy, laparoscopic and robotically assisted myomectomy, and vaginal, laparoscopic, and robotically assisted hysterectomy. Patients have a faster recovery and less postoperative pain compared to a laparotomic approach. More recently, uterine-sparing outpatient modalities such as ultrasound-guided radiofrequency ablation and high-intensity focused ultrasound have emerged as promising alternatives for selected patients. Benefits include clinically significant reduction in fibroid size and menstrual bleeding with small or no abdominal incisions and an expedited convalescence. This article reviews preoperative evaluation and imaging for fibroids, as well as the techniques, approach, indications, patient selection, procedural management, and surgical and fertility outcomes for each surgical and procedural management of uterine fibroids.