Long term follow up of hysteroscopic myomectomy assessed by survival analysis.

OBJECTIVE: To identify patient characteristics which affect outcome after hysteroscopic myomectomy for submucous fibroids. DESIGN: Prospective observational study. SETTING: A university teaching hospital. SAMPLE: One hundred and twenty-two consecutive patients treated by hysteroscopic myomectomy for submucous leiomyoma over a period of almost eight years. METHODS: Hysteroscopic electroresection of the leiomyoama using a continuous flow resectoscope. MAIN OUTCOME MEASURES: The avoidance of further surgery and patient satisfaction. RESULTS: The average age of the patients at the time of their surgery was 42.8 years. A total of 194 fibroids were removed. The mean follow up period was 2.3 years (range 1-7.6). Of those asked, 71.4% were satisfied with the results of surgery. Sixteen women required further surgery for fibroids, and six ultimately underwent hysterectomy. Survival analysis showed that the risk of further surgery was 21% at four years after the myomectomy, and 0% thereafter. Univariate regression analysis suggested that outcome was significantly better in older women, and in cases where the uterus was equivalent in size to < or = 6 weeks of gestation, the fibroid was < or = 3 cm in diameter and mainly intra-cavitary, and the procedure time was < or = 20 minutes. The influence of hormonal pre-treatment and the number of fibroids excised was not statistically significant. After multivariate regression analysis, only overall uterine size and the position of the fibroid being removed were found to significantly influence the success of surgery. CONCLUSIONS: Hysteroscopic myomectomy is an effective way to manage patients with symptomatic submucous leiomyomata, particularly when the uterus is not grossly enlarged and the fibroid(s) are mainly inside the uterine cavity.     

Hysteroscopic myomectomy for menorrhagia using Versascope™ bipolar system: Efficacy and prognostic factors at a minimum of one year follow up

Objective

To evaluate the effectiveness of hysteroscopic submucous myomectomy for women with heavy menstrual bleeding (HMB) over a minimum 1-year period and assess prognostic factors associated with treatment success.

Study design

Prospective observational study set in a university teaching hospital in UK involving 92 women symptomatic of HMB with submucous myomas consecutively recruited between June 2003 and November 2006. Hysteroscopic myomectomy was performed under outpatient local anaesthetic (n = 35, 38%) or daycase general anaesthesia (n = 57, 62%) using Gynecare Versascope™ bipolar system. The main outcome measures were: the need for secondary surgical or medical re-intervention, menstrual improvement and patient satisfaction. Other outcome measures include: successful completion of primary resection, type of secondary treatment.

Result

Mean follow up was 2.6 years (95% CI 2.3–2.9). Complete fibroid excision was achieved in 66%. Secondary surgical re-intervention was required in 27 (29%) of which 11 (12%) were repeat hysteroscopic myomectomy and 10 (11%) were hysterectomy procedures. Multiple uterine fibroids and adenomyosis were identified in 80% of hysterectomies. At follow up, improved menstrual symptoms and patient satisfaction were reported by 91% and 86%, respectively. Irregular cycle HMB and incomplete fibroid excision were associated with secondary retreatment. Size of the submucous fibroid resected, presence of intramural and subserosal fibroids, or LA vs. GA setting were unrelated to treatment success.

Conclusion

HMB with submucous myomas may be successfully treated by completely removing the intracavity myoma component, irrespective of co-existent intramural or subserosal fibroids or size of fibroid resected. This effect remains sustained over at least a 1–2 year period.     

Endoscopic management of uterine fibroids

Uterine fibroids are the most common benign tumours of the uterus. Management depends on the symptoms, location and size of the fibroids, and the patient's desire to conceive. Surgical management of uterine fibroids has changed from laparotomy to minimally invasive surgery. Uterine fibroids are usually asymptomatic and do not require treatment. Laparoscopic myomectomy is the best treatment option for symptomatic women with uterine fibroids who wish to maintain their fertility. The authors' criteria for laparoscopic myomectomy are a fibroid of <15 cm in size, and no more than three fibroids with a size of 5 cm. Compared with laparotomy, laparoscopic myomectomy has the advantages of small incisions, short hospital stay, less postoperative pain, rapid recovery and good assessment of other abdominal organs. Due to the concern of decreased ovarian reserve, uterine artery embolization is not advisable for these women. In addition, it is associated with high risks of miscarriages, preterm delivery and postpartum bleeding. Laparoscopic myolysis causes severe adhesion formation. Women with submucous fibroids receive myomectomy by hysteroscopy. For women who have completed their family, laparoscopic hysterectomy could be performed. Most fibroids can be managed endoscopically either by laparoscopy or hysteroscopy. Surgeon expertise, especially laparoscopic suturing, is crucial. Laparoscopic myomectomy is still the best treatment option for symptomatic women with uterine fibroids who wish to maintain their fertility. Hysteroscopic myomectomy is an established surgical procedure for women with excessive uterine bleeding, infertility or repeated miscarriages.     

Hysteroscopic management in submucous fibroids to improve fertility

Objective: To evaluate prospectively the reproductive performance following hysteroscopic myomectomy in women with submucous fibroids and wishing a pregnancy. Study design: Twenty-nine consecutive women wishing a pregnancy with a previously diagnosed submucous fibroid as a sole cause for reproductive failure were treated by hysteroscopic myomectomy. Fourteen women suffered from primary infertility and 15 women had previous pregnancies with a poor obstetric outcome. The myomas were intracavitary (n=25) and intramural class 1 (n=4). None of the patients had type 2 or multiple submucousal fibroids. Myoma size was not larger than 5 cm (the mean was 13.3 mm). Before myomectomy, the outcome reproductive data were recorded prospectively. Following myomectomy, the cumulative rate of first pregnancies, live birth rate and the hysteroscopic anatomical results were assessed and compared with that before surgery. Results: The mean duration of follow-up before and after myomectomy was comparable. Twenty-one women (72.4%) experienced 30 pregnancies after myomectomy. Thirteen women gave birth to16 live infants. Compared with previous pregnancies, the rate of deliveries increased from 3.8% to 63.2% and the abortion rate decreased from 61.6% to 26.3%. No complications occurred during myomectomy. The hysteroscopic anatomical results were good in the majority of cases. Conclusions: This prospective study demonstrates that hysteroscopic myomectomy at present is the method of choice to improve the cumulative pregnancy rate as well as the live birth rate in selected women with submucous myomas and a history of reproductive failure.     

Value of hysteroscopy prior to uterine artery embolisation for fibroids: a hospital based retrospective study

This study was undertaken to evaluate the value of routine hysteroscopy prior to uterine artery embolisation (UAE) for symptomatic uterine fibroids. The study design used is hospital-based retrospective study, and the setting is in a large teaching hospital. We analysed the hospital record of 115 women who were scheduled to undergo UAE at our institution between January 2008 and April 2011. All women had outpatient hysteroscopic assessment of uterine cavity prior the decision to carry out UAE. The mean uterine size on palpation was 15.4 (standard deviation (SD) 3.5) weeks gestation equivalent. Hysteroscopy was successfully completed in 112 (97.4 %). In the women who were hysteroscoped, 50 (44.6 %) had no submucous fibroids; 50 (44.6 %) had type II fibroids, and 12 (10.7 %) were found to have type I or 0 fibroids. All 12 women with type 0 or I submucous fibroids were offered hysteroscopic (n?=?11) or vaginal (n?=?1) myomectomy prior to UAE, but only four agreed. Of these four cases, two cancelled their planned UAE because of symptomatic improvement. The remaining two women, as well as the eight, who declined surgery, underwent UAE. There were no cases of infection, spontaneous expulsion of a fibroid or the need for surgical intervention in this group. This pilot study shows that hysteroscopy prior to UAE changes management in only a small proportion of cases. Selective hysteroscopy, following MRI scanning, may be a more logical protocol to identify women with intracavitary fibroids, who may benefit from hysteroscopic or vaginal myomectomy.     

Follow-up after incomplete hysteroscopic removal of uterine fibroids

BACKGROUND: In this observational study, we analysed whether a period of wait and see was reasonable following incomplete removal of submucous fibroids, with regard to symptoms of abnormal uterine bleeding, and whether factors predicting subsequent surgery could be identified. METHODS: In 3 affiliated hospitals, patients with incomplete removal of submucous fibroids, treated with hysteroscopic myomectomy for abnormal uterine bleeding, between January 1997 and January 2005, were followed over time. Using life-table analysis (Kaplan-Meier method), the cumulative proportion of women having surgery-free survival following incomplete removal of submucous fibroids was calculated. Cox-proportional hazard analyses were used to analyse relationships of variables with recurrence of symptoms. RESULTS: Forty-one consecutive patients met the inclusion criteria, and were followed over time. The mean age was 42.5 years (range 27-55). The majority of patients with incomplete removal of submucous fibroids were diagnosed with type 2 fibroids. Termination of the procedure before complete removal was achieved, was principally caused by reaching the maximum fluid deficit (90.2%). The surgery-free percentages were 70.2% (95%-CI: 55.3-85.1) at 1 year, 54.8% (95%-CI: 38.1-70.7) at 2 years, and 44.2% (95%-CI: 26.9-61.5) at 3 years. Size of fibroid (diameter) pre-operatively turned out to be of statistically significant influence, with a hazard ratio of 1.762 (95%-CI: 1.114-2.787) per cm increase in diameter (p=0.016). CONCLUSIONS: The results indicate that incomplete removal does not always seem to necessitate subsequent surgery. Instead of subsequent surgery immediately post-operatively, a wait and see policy is worth considering after incomplete removal.     

Resectoscopic removal of symptomatic intrauterine lesions

In order to avoid major surgical intervention in women who refused or were poor risks for hysterectomy or myomectomy, a hysteroscopic resectoscope was used for 90 women with uncontrollable uterine bleeding due to submucous fibroids or large polyps or with menorrhagia with normal endometria. Of those patients followed for more than three months, 90% of endometrial ablation patients had an improvement in menstrual flow, with 79% having scant or no periods. For patients with submucous fibroids or polyps, 91% had resumption of normal menses. For the 15 patients who were infertile and underwent submucous fibroid or polyp resection the term pregnancy rate is 33% to date. With only two complications in the series (perforation and endometritis), the conclusion is that resection of submucous lesions and endometrial ablation using the resectoscope is a safe and highly effective alternative to hysterectomy for those conditions.     

Fertility after hysteroscopic myomectomy: effect of intramural myomas associated

OBJECTIVE: The aims of this retrospective study were to evaluate the subsequent fertility and outcome of pregnancies after hysteroscopic myomectomy according to (a) the characteristics of submucous myomas and (b) the association with intramural myomas. MATERIALS AND METHODS: From July 1994 to June 1997, 119 patients had hysteroscopic myomectomy including 31 infertile women. Among these 31 patients, the mean number of removed myomas by hysteroscopy was 1.4 (range 1-4) and the mean diameter of fibroid was 20 mm (range 10 to 50). RESULTS: Eleven out of 31 women (35.5%) became pregnant. Thirteen pregnancies were observed including nine term deliveries, three miscarriages and one premature labor at 24 weeks of amenorrhea. A difference in delivery rate was found between patients with one submucous myoma resected and those with two or more (p=0.02). No difference in pregnancy and in delivery rates was observed according to size and location of submucous myomas. In contrast, in patients without intramural myomas, the delivery rate (p<0.03) was significantly greater and the delay of conception (p=0.05) was significantly shorter than those found in patients with intramural myomas. CONCLUSION: Our study suggest that fertility after hysteroscopic myomectomy depend on (a) the number of submucous myomas resected and (b) the association with intramural fibroids.     

Uterine artery embolisation for the treatment of symptomatic fibroids in 114 women: reduction in size of the fibroids and women's views of the success of the treatment

Objective To assess the reduction in size of fibroids following uterine artery embolisation and to analyse women's views of the success of treatment.
Design An uncontrolled case series of 114 consecutive women who underwent uterine artery embolisation for the treatment of fibroids over two years.
Setting The Diagnostic and Interventional Radiology Department at The Royal Surrey County Hospital, Guildford, UK.
Methods Bilateral uterine artery embolisation was performed for the treatment of symptomatic fibroids. Magnetic resonance imaging was carried out before and six months following embolisation. Women completed outcome questionnaires following their treatment.
Main outcome measures The sites, imaging signal characteristics and percentage reduction in the volume of three dominant fibroids were determined from the magnetic resonance scans. Outcome was measured by questionnaire. Women were asked whether their symptoms resolved completely, improved, remained unchanged or deteriorated.
Results One hundred and sixty-five fibroids of 114 women (mean age 42) were analysed. Forty-five percent of women had complex fibroid masses and 50% had fibroids ≥8.5cm in diameter. The median reduction in the fibroid volume was 58%. The median reduction of the volume of complex fibroid masses, submucous fibroids, fibroids ≥8.5cm and fibroids with high and low signal on T2 weighted sequences were 58%, 63%, 50%, 62% and 51%, respectively. Ninety-one percent of the women's symptoms had resolved or improved following embolisation.
Discussion The majority of women were satisfied with their outcome. We have shown that uterine artery embolisation is a successful treatment for symptomatic fibroids of all types, sizes and signal characteristics.     

Hysteroscopic treatment of symptomatic submucous fibroids using a bipolar intrauterine system: a feasibility study

Objective: To determine the feasibility (safety, potential efficacy and cost effectiveness) of a miniature endoscopic bipolar electrosurgical intrauterine system in the treatment of symptomatic submucous fibroids. Study Design: A total of 37 women with symptomatic submucous fibroids were identified on outpatient hysteroscopy. All underwent hysteroscopic excision or ablation using a bipolar intrauterine system (Versapoint™). The main outcomes measures were change in uterine bleeding symptoms measured on a continuous and ordinal scale, patient satisfaction, time of work and use of health service resources at 6 months following treatment. Results: 36/37 (97%) women returned completed outcome questionnaires. The mean amount of abnormal uterine bleeding was reduced at 6 months compared to immediately prior to treatment (P=0.0001). Improvement in bleeding symptoms was reported by 28/36 (78%) women and satisfaction with treatment by 33/36 (92%) women. All procedures were successfully completed, there were no serious operative complications and at 6 months no repeat hysteroscopic procedures were necessary. The mean cost of diagnosis and treatment of submucous fibroids using an endoscopic bipolar intrauterine system was 40% cheaper at 6 months follow-up than a hysterectomy or open myomectomy (£ 1266 versus £ 2123). Conclusion: Hysteroscopic treatment of symptomatic submucous fibroids appears to be safe, efficacious and cost effective. It seems feasible to launch a randomised controlled trial to confirm these provisional results in both the short and longer term.     

Hysteroscopic myomectomy in a submucous fibroid 3 mm from the serosa: a case report

This is a case report of a 39-year-old black woman, nulliparous, married who presented a heavy menstrual flow with clots and dysmenorrhea. Gynaecological examination of the uterus revealed RVF, mobility, no pain, slight enlargement, and right displacement. Magnetic resonance imaging (MRI) of the pelvis showed a 40 mm submucous fibroid with intramural component less than 50%, type 1, with a 3 mm distance from serosa. In an office hysteroscopy, it was noted a 40 mm submucous fibroid with an intramural component with less than 50%, type 1, classified in STEP-W submucous fibroids classification as a Score 6, Group II. The patient was submitted to partial hysteroscopic myomectomy, removing 60% of the fibroid volume in a 48.75-minute surgery. GnRH analogue was indicated for 3 months before another intervention. In the second evaluation MRI revealed a 22 mm-fibroid with intramural component more than 50%, type 2, with a 7 mm distance from serosa. Hysteroscopy found a 20 mm submucous fibroid, with intramural component more than 50%, type 2, Score 4, Group I on STEP-W classification. The patient was submitted to a second hysteroscopic myomectomy with complete removal and 10.5 minutes operating time, without complications.     

Hysteroscopic myomectomy in a submucous fibroid near from tubal ostia and 5 mm from the serosa: a case report from the Endoscopy Service of Ginendo-RJ

This is a case report of a 27-year-old white woman, nuliparous, single, who presented a heavy menstrual flow with clots, dysmenorrhoea and anaemia. Gynaecological examination of the uterus revealed anteverted position, mobility, no pain, slight enlargement and right displacement. Magnetic resonance imaging of the pelvis showed a 29-mm submucous fibroid with intramural component more than 50%, type 2, in the posterior wall, with a 5-mm distance from serosa. In office hysteroscopy, a 30-mm submucous fibroid with an intramural component with more than 50%, type 2, near around 5 mm from left tubal ostia, classified in STEP-W submucous fibroids classification as score 6, group II, was noted. GnRH analogue was indicated for 3 months before intervention to treat anaemia. The patient was submitted to hysteroscopic myomectomy with direct mobilisation technique, with the fibroid completely removed without complications in a surgery which lasted for 52 min and 20 s.     

Fibroids and infertility: a systematic review of the evidence

A systematic literature review was performed to determine whether leiomyomata are associated with decreased fertility rates, and whether surgical removal increases fertility rates postoperatively. Meta-analysis was conducted when multiple studies addressed a single issue and were sufficiently homogeneous. Data were analyzed for effect of any fibroid upon fertility, as well as specific fibroid location. Results of studies comparing women with infertility and fibroids versus infertile controls showed widely disparate results. Subgroup analysis failed to indicate any effect on fertility of fibroids that did not have a submucous component. Conversely, women with submucous myomas demonstrated lower pregnancy rates (RR 0.30; 95% confidence interval [CI] 0.13--0.70) and implantation rates (RR 0.28; 95% CI 0.10--0.72) than infertile controls. Results of surgical intervention were similar. When all fibroid locations were considered together, myomectomy results were again widely disparate. However, when women with submucous myomas were considered separately, pregnancy was increased after myomectomy compared with infertile controls (RR 1.72; 95% CI 1.13--2.58) and delivery rates were now equivalent to infertile women without fibroids (RR 0.98; 95% CI 0.45--2.41). The current data suggest that only those fibroids with a submucosal or an intracavitary component are associated with decreased reproductive outcomes, and that hysteroscopic myomectomy may be of benefit. TARGET AUDIENCE: Obstetricians & Gynecologists, Family Physicians LEARNING OBJECTIVES: After completion of this article, the reader will be able to summarize the data on the role of fibroids and infertility, describe the effect of myomectomy on fertility, and list the methods used to evaluate intracavitary fibroids.     

Successful Pregnancies in Women with Diffuse Uterine Leiomyomatosis after Hysteroscopic Management Using the Hysteroscopy Endo Operative System

Study ObjectiveTo evaluate the feasibility, effectiveness, and reproductive outcome of hysteroscopic management using the Hysteroscopy Endo Operative system (HEOS) in patients with diffuse uterine leiomyomatosis (DUL).DesignRetrospective study (Canadian Task Force classification III).SettingBeijing Tiantan Hospital, Capital Medical University, Beijing, China.PatientsEight women of reproductive age suffering from menorrhagia and anemia or infertility diagnosed with DUL by ultrasonography and hysteroscopy.InterventionsHysteroscopic surgery using cold graspers combined with electric loop by the HEOS was performed to excise submucous myomas (including types 0, I, and II), leaving other intramural myomas in place. The fenestration method is used in electrical hysteroscopic myomectomy. Postoperative endometrial repair and synechiae, menstrual improvement, conception, and pregnancy were recorded.Measurements and Main ResultsTwo patients underwent a single hysteroscopic myomectomy, whereas 6 patients underwent 2 to 3 myomectomies. No complications were observed. The mean follow-up period was 39.13 ± 17.01 months (range, 21–67). The endometrium recovered 2 to 3 months after the initial surgery, and 100% improvement in menstruation was observed. Two patients had mild synechia after the first hysteroscopic surgery. Seven patients conceived spontaneously (postoperative pregnancy rate, 87.5%), 6 of whom had a full-term pregnancy. One patient suffered a miscarriage in the second trimester (live birth rate, 75%).ConclusionHysteroscopic surgery using cold graspers combined with electric loop by the HEOS is a feasible and effective for treatment of DUL because it preserves the uterus and yields favorable reproductive outcomes. The cold surgery and fenestration method minimizes electrical and thermal damage to the endometrium surrounding the myoma, consequently reducing surgical risks.     

Results of hysteroscopic myomectomy

Main symptoms related to submucous fibroids are menorrhagia, infertility, and postmenopausal bleeding. First experiences of hysteroscopic transcervical resection of fibroids have been published by Neuwirth in the late seventies. Reports with long-term follow-up in patients with abnormal uterine bleeding are available. After a follow-up period of five years and more, results are satisfactory in 70-85% of the patients. Intramural class 2 and larger fibroids (> 4 cm) constitute the limits of the endoscopic technique. Prior to hysteroscopic myoma resection, pretreatment with GnRH agonists may be indicated in selected cases (large myomas, patients suffering from secondary anemia). Repeat resection is an option after failed primary hysteroscopic operation and may reduce the hysterectomy rate. In infertile women with submucosal or intracavitary fibroids, pregnancy and delivery rates are increased after hysteroscopic myomectomy. Operative hysteroscopy is also safe and effective in controlling persistent postmenopausal bleeding. To conclude, hysteroscopic resection is the gold standard for the treatment of symptomatic submucous fibroids.     

Reproductive performance before and after abdominal myomectomy: a retrospective analysis

OBJECTIVE: To evaluate the results of abdominal myomectomy for intramural and subserosal fibroids and to identify factors that influence the reproductive outcome after surgery. DESIGN: Retrospective analysis of a case series. SETTING: An academic department specializing in gynecologic surgery. PATIENT(S): A total of 72 women with intramural and subserosal fibroids submitted to abdominal myomectomy who wished to conceive after surgery. INTERVENTION(S): Data were collected on clinical characteristics, surgical features, and obstetric history before and after surgery. MAIN OUTCOME MEASURE(S): Conception rate, pregnancy loss, and live birth rate before and after surgery, as well as postoperative probability of conception according to selected clinical and fibroid characteristics. RESULT(S): Conception rate was 28% before myomectomy and 70% after surgery. The corresponding figures were 69% and 25% for pregnancy loss and 30% and 75% for live birth rate, respectively. Age <30 years and number of fibroids removed were the only significant and independent predictors of obstetric outcome by multivariate analysis. CONCLUSION(S): Our results suggest that abdominal myomectomy might improve reproductive outcome in patients with intramural and subserosal fibroids. The reproductive performance was particularly good when the patients were younger than 30 years and had a single myoma to remove.     

子宫肌瘤的宫腔镜治疗

宫腔镜下肌瘤切除是黏膜下肌瘤首选的手术治疗方式。手术成功与否及其疗效取决于黏膜下肌瘤的类型和施术者的操作技能。对于手术适应证,黏膜下肌瘤的大小以及肌瘤距浆膜面的距离仍是有争议的问题。最新观点认为：肌瘤边缘距浆膜面的距离不再是手术的限制条件,它是一个动态的指标而非静态指标。     

Long-term impact and risk factors for hysterectomy after hysteroscopic surgery for menorrhagia

The objective of this study was to assess the long-term impact of management and establish the incidence of hysterectomy, and to identify factors predictive of failure of the procedure among women who had undergone hysteroscopic endometrial resection with or without myomectomy for menorrhagia. Clinical history and data on additional treatment and follow-up status were obtained by medical record review and postal questionnaire for 279 women who had undergone hysteroscopic surgery. Follow-up data were available for 259 (93%) cases, and the mean follow-up was 6.0 years. Subsequent hysterectomy was the primary endpoint, and its incidence was calculated by survival analysis. Univariant analysis and Cox regression model were used to identify predictors of failure. Myomas, polyps, adenomyosis, or endometrial hyperplasia were found in 40.9% of hysteroscopic procedures. Perioperative complications occurred in 5.7% and late complications in 7.7%. During the follow-up period, 97 (37.5%) of 259 women underwent at least one gynecological procedure. The incidence of hysterectomy was 23.6% (95% confidence interval: 18.8–29.1%). Positive predictive factors for hysterectomy were long uterine cavity (≥9 cm) and tubal ligation. Most (82.8%) of the 198 women who did not undergo hysterectomy had postoperative oligo- or amenorrhea. Hormone replacement therapy was common (67%) among postmenopausal women after endometrial resection. Hysteroscopic resection of the endometrium and concomitant hysteroscopic resection of fibroids for the treatment of menorrhagia is a suitable alternative to hysterectomy and offers lasting results. A large uterine cavity indicating possible uterine pathology and tubal ligation associated with hematometra increase the risk of hysterectomy.     

Uterine artery occlusion: what is the evidence?

Symptomatic uterine fibroids are a relatively common gynecologic condition. In the past, fibroids were exclusively treated by myomectomy and/or hysterectomy. With the advent of uterine artery embolization or uterine artery occlusion, there now exist minimally invasive approaches to fibroid therapy especially for women in whom surgery is contraindicated or for those who wish to retain their uterus and possibly fertility. Fertility and pregnancy outcomes after these minimally invasive therapies are currently being evaluated.     

Removing a large submucous fibroid hysteroscopically with the two-resectoscope method

Hysteroscopic myomectomy was performed in 25 patients using resectoscopes of two different sizes because of large submucous fibroids causing severe menorrhagia and anemia. The cervix was softened and dilated by inserting a laminaria tent the night before the operation. During the procedure a 7-mm resectoscope was first used to cut the pedicle to a size smaller than 10 mm. A sessile myoma was resected into a pedunculated myoma, and its body resected with a 9-mm resectoscope. The smaller portions were removed with a pair of forceps. Simultaneous ultrasonography was used to monitor the procedure. Specimen weights ranged from 50 to 145 g (mean 78.5 g). The operation time was 13 to 118 minutes (mean 49 min). No complications were encountered, other than a cervical laceration caused by forceps. Postoperatively, 22 patients had improvement of menorrhagia and anemia. Three women underwent the same procedure due to recurrence of the fibroid; two had full-term deliveries. Our method has proved to be safe and efficient for treatment of a sessile or large submucous fibroid.