Editorial••

Bleeding during myomectomy: reasons and new concept

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Introduction

Uterine fibroids are the most common tumours among women of reproductive age, originating from uterine smooth muscle cells and stimulated by hormones. Their prevalence ranges from 20% to 40% in premenopausal women,1 although most fibroids are asymptomatic and diagnosed incidentally.2 When symptomatic, fibroids may cause mass-related issues (pelvic pressure, pain), menorrhagia or dysmenorrhoea, urine frequency, constipation and potential adverse pregnancy outcomes such as preterm labour or malpresentation. Their negative impact on a patient’s quality of life can be significant.3

The main procedure for intramural and subserosal fibroids: myomectomy

Abdominal myomectomy is a time-honoured procedure that can be done hysteroscopically, laparoscopically, robotically, vaginally or by laparotomy. The first documented myomectomy dates back to 18444 and is still the standard of care for women looking for fertility preservation. Surgical complications include excessive intraoperative bleeding, visceral injury, thrombosis or unplanned hysterectomy due to surgical complications.5

When fertility is planned, hysterectomy is often avoided. Moreover, with the evolution of assisted reproduction, the need to preserve the uterus has grown. Minimally invasive surgeries have become more frequent for myomectomy. Meta-analyses comparing laparoscopy to laparotomy show less blood loss, shorter hospital stays and lower need for analgesics with endoscopy use, but the operative choice also depends on the individual expertise of the surgeon and the local healthcare policies.6

The problem of blood loss during myomectomy

Recent studies have shown that the rate of complications during myomectomy has increased with the increase in procedures. Excessive blood loss during laparoscopy is one of the most frequent and serious intraoperative complications and can necessitate blood transfusions or conversion to laparotomy.7

The fibroid-induced neovascularisation, the number, size and the locations of the fibroids, next to the surgical technique, can influence the haemorrhage risk. Historically, reported rates of perioperative blood transfusion have ranged from 8% to 28%,8 although modern surgical strategies have improved this. Nevertheless, large or multiple fibroids can still lead to average blood losses of 800 mL or more.9 Blood transfusions themselves can increase postoperative morbidity. In a large study of 15 446 myomectomies, the risk of transfusion was found to be approximately 10%, correlating with elevated morbidity.10 As many patients wish to avoid hysterectomy, optimal management of fibroids by myomectomy, along with minimising blood loss, is important for the surgical and reproductive outcomes.

The biology of fibroid vascularisation

The uterus is vascularised mainly by the uterine arteries but also from the ovarian arteries. While the uterus has multiple vascular sources, fibroids typically depend on branches of the uterine arteries.11 Fibroids often cause distortion and enlargement of these arteries.12

A key concept is the myoma pseudocapsule, a peripheral fibromuscular structure compressed by the growing fibroid. The pseudocapsule is highly vascularised and rich in neurotransmitters.13 These vessels, arranged in a plexus beneath the pseudocapsule, supply the fibroid through circumferential small ‘bridges’.14 During myomectomy, maintaining the pseudocapsule can be beneficial for myometrial innervation and recovery.15

Traditional techniques to reduce bleeding

Historically, pharmacological and mechanical measures have been used to control bleeding (figure 1):

Figure 1

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Mechanical traditional measures to control bleeding include clamping of the uterine arteries, use of a tourniquet and injection of vasoconstrictor substances near the fibroid. Created with BioRender.com

Preoperative therapy

Gonadotropin-releasing hormone (GnRH) analogues can shrink fibroids but may blur cleavage planes, making the shelling-out difficult and offering limited benefit in reducing intraoperative blood loss.16 Pharmacologic measures: local injection of saline, vasopressin, uterotonics (oxytocin, misoprostol) or tranexamic acid.16

Mechanical strategies

Uterine artery clamp or tourniquet application17 ,18 and uterine artery embolisation (UAE).18 A 2014 Cochrane review concluded there is moderate-quality evidence that vasopressin or misoprostol reduces bleeding.19

Pharmacologic options

Vasopressin

Vasopressin (antidiuretic hormone analogue) has been used for decades to reduce blood loss by local vasoconstriction. Intramyometrial injection can significantly decrease bleeding and the need for transfusion. Nevertheless, vasopressin use may provoke transient hypertension or bradycardia and it is contraindicated in some countries due to serious cardiovascular risks (eg, arrhythmias, cardiac arrest). Despite these concerns, vasopressin remains a cost-effective means to reduce bleeding in countries where it is permitted and used under proper monitoring.20

Octreotide acetate

Octreotide (inhibitor of growth hormone approved by the Food and Drug Administration (FDA) in 1988) induces local vasoconstriction and has been studied as an alternative to vasopressin. Research shows it reduces blood loss, yet its effect is not as marked as vasopressin, likely due to lower vasoconstriction potency.21

Tranexamic acid

Widely used in surgery to reduce bleeding, tranexamic acid stops fibrinolysis, thereby stabilising the clots. Randomised trials in elective surgeries have shown that it can diminish intraoperative blood loss and the need for transfusions, without increasing thromboembolic events. In myomectomy, its intravenous usage effectively reduces total blood loss and post-op haemoglobin drops, and often shortens the hospital stay.22

Uterotonics

Agents such as oxytocin, ergometrine and misoprostol are occasionally administered intraoperatively to reduce bleeding by encouraging uterine contraction. However, the non-pregnant uterus has fewer oxytocin receptors, and therefore, the haemostatic effect can be limited compared with obstetric scenarios. Some clinicians have used synthetic vasopressin analogues like glypressin, reporting reduced bleeding in laparoscopic myomectomy with minimal circulatory side effects.19

Mechanical options

Uterine artery clamp/occlusion

Because fibroids receive their primary blood supply from the uterine arteries, mechanical occlusion of these arteries can reduce intraoperative bleeding. Temporary occlusion (by clips, sutures or clamps) can decrease blood loss while preserving future fertility, although a learning curve of the surgeons exists for the retroperitoneal dissection needed to isolate and clamp these vessels. Permanent occlusion during myomectomy (eg, bipolar coagulation or vascular clips) can further lower fibroid recurrence, but raises concerns about future fertility and obstetric outcomes. Most studies report decreased blood loss and transfusion risk, shorter hospital stays and no significant increase in complications with uterine artery occlusion.23

Tourniquet application

Introduced in 1938 during surgery, a pelvic or pericervical tourniquet (such as a Foley catheter or Penrose drain) can be used around the cervix or uterine isthmus to reduce uterine blood flow and haemorrhage.24 This is a simple, low-cost and effective technique that does not require specialised instruments.25 Tourniquets may also be combined with tranexamic acid to further reduce blood loss. Studies suggest this approach does not compromise subsequent fertility.26

Uterine artery embolisation

Embolisation (UAE) is a radiologic procedure to occlude the uterine arteries.27 While it is minimally invasive and effective for some women, reducing hospital stay and immediate blood loss, concerns about subsequent fertility remain. The UAE carries risks of ovarian compromise, tissue ischaemia and potentially decreased obstetric outcomes, generally reserved for cases where myomectomy is contraindicated or declined.28

The intracapsular myomectomy: a technique to reduce bleeding

A frequently overlooked factor in minimising haemorrhage is identifying the correct surgical plane for fibroid enucleation. The intracapsular myomectomy technique capitalises on the pseudocapsule, since small vessels that branch through the pseudocapsule nourish the fibroid itself, creating a natural cleavage plane for fibroid enucleation.9 13 15 29 Therefore, accurate enucleation combined with selective coagulation of these arteries can significantly minimise bleeding.13 14

Key biological rationale

Neurotransmitters and angiogenic factors detected in the myoma pseudocapsule initiate the muscle healing process after myomectomy.13 14 Maintaining the blood arteries and neurofibres within the pseudocapsule facilitates improved myometrial repair and wound healing.30

The surgical steps31

Uterine incision

A serosal or myometrial incision is performed until reaching the fibroid surface and its pseudocapsule.31

Identification and coagulation

Fibrovascular bridges of the pseudocapsule are selectively coagulated (using bipolar, ultrasonic scalpel or monopolar energy), ensuring minimal trauma to healthy myometrium.31

Enucleation

Gentle traction on the fibroid with a myoma screw or forceps separates fibroid from the pseudocapsule in the correct plane.31

Myometrial closure

Restoring normal uterine anatomy with interrupted or continuous sutures that minimise severe tissue traction helps prevent tissue hypoxia, ischaemia and necrosis, or haematomas. Intracapsular myomectomy, with these biological capabilities, can reduce the need for supplemental pharmacological or mechanical haemostatic methods.31 ,32

Applicability

Intracapsular myomectomy is feasible in laparotomy, laparoscopy, robotic surgery, vaginal approaches and even during caesarean section. Postoperative outcomes often include minimal blood loss, stable haemodynamics and high-quality myometrial scarring, with potentially improved reproductive outcomes.31 ,13

Discussion

Surgeons must be aware and be prepared with all available strategies to manage myomectomy-related bleeding, particularly when vasopressin is contraindicated. While using uterine artery clamping or tourniquets can be beneficial, they require surgical skill and have theoretical implications for fertility, especially if arterial occlusion is permanent. Uterine artery embolisation is reserved for select patients, often those who do not seek fertility, due to potential uterine ischaemia. Pharmacologic agents such as GnRH analogues16 and antagonists32 or selective progesterone receptor modulators16 can reduce the fibroid size and bleeding. However, they may also blur cleavage planes, making the fibroid too soft and deteriorating the pseudocapsule, making it more difficult to enucleate the fibroid from the adjacent myometrium.33 Hence, these measurements can be costly and carry adverse effects. By contrast, the intracapsular technique directly acting on the pathophysiology of uterine fibroids can (1):

Minimise tissue damage (2).
Reduce the risk of unnecessary vascular occlusion (3).
Preserve myometrial architecture and crucial neuropeptides (4).

Potentially improve uterine healing

Finally, in the context of preserving fertility, the understanding of the fibroid vascularisation and performing precise myomectomy with minimal myometrial damage is very important. The pseudocapsule’ plane permits selective coagulation of fibroid-feeding vessels,34 obviating global uterine devascularisation manoeuvres (eg, uterine artery clamping, vasopressin injection). Thus, intracapsular myomectomy can be considered a central pillar in modern fertility-preserving surgery for fibroids, putting aside the methods with no fibroid surgical removal to treat uterine fibroids.35

Conclusions

Controlling blood loss in myomectomy is of utmost importance for patient safety, preserving fertility and maintaining normal uterine function. Skilled surgeons may combine or selectively employ:

Pharmacological measures (vasopressin, tranexamic acid, uterotonics).
Mechanical measures (uterine artery occlusions, tourniquet, UAE).
Biologically based intracapsular approach (preserving the myoma pseudocapsule).

Among these, the intracapsular myomectomy stands out as a technique based on knowledge of the uterine anatomy and biology.36 Reducing biological damage to the myometrium surrounding the fibroid, the fibroid can be enucleated minimising blood loss without need to rely on vasoconstrictive agents or vascular occlusion. This can enable safer and more reproducible myomectomy, better myometrial healing and the potential for improved fertility outcomes.

Overview

Introduction
Discussion
Conclusions
References
Footnotes
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