Transcervical resection of submucous myoma

Thirteen women with chief complaints of menorrhagia and metrorrhagia underwent transcervical resection (TCR) of pedunculated submucous myoma using either an operating hysteroscope or urologic resectoscope. Eight women received TCR with a urologic resectoscope without further operation. Subsequent vaginal hysterectomy was performed on one woman after TCR of a large prolapsed submucous fibroid with a urologic resectoscope because of adenomyosis. Three women underwent TCR of the same type of large prolapsed submucous myoma with an operating hysteroscope. Later, due to other pathologic lesions of the uterus, subsequent vaginal hysterectomies were done on two women and a subsequent abdominal hysterectomy on another woman. Without TCR of these large prolapsed submucous myoma, subsequent vaginal hysterectomies were not possible. Only one woman underwent TCR of submucous myoma with an operating hysteroscope without further operation. All patients showed improvement in such clinical symptoms as menorrhagia, metrorrhagia, and anemia. Before TCR, we make it a rule to use a new diagnostic hysteroscope (4mm external sheath) to reevaluate the position and size of the fibroid. The fluid media used were 10% dextrose for diagnostic hysteroscopy, 5% dextrose for therapeutic hysteroscopy and 10% urigal for urologic resectoscopy. Three months after the operation, second look hysteroscopy is arranged. All patients except one have been followed up at our outpatient department.     

Fertility after hysteroscopic resection of submucous myomas

STUDY OBJECTIVE: To analyze fertility outcomes after resection of submucous myomas by operative hysteroscopy in infertile women. DESIGN: Retrospective analysis (Canadian Task Force classification II-2). SETTING: Academic tertiary referral center. PATIENTS: Forty-one women (age 28-42 yrs) old with primary and secondary infertility, and histologically proved submucous myomas. Intervention. Hysteroscopic myomectomy performed with a rigid resectoscope. MEASUREMENTS AND MAIN RESULTS: Of the 41 patients, 25 (60.9%) became pregnant overall and 20 (48.7%) delivered at term. Seventeen patients delivered a single fetus. Five delivered twins, three at term and two at 33 and 35 weeks. One woman delivered triplets at 31 weeks. The total delivery rate was 56.0%. Two women miscarried, at 6 and 8 weeks. One patient developed postoperative Asherman's syndrome. CONCLUSION: Our results indicate that hysteroscopic myomectomy improves fertility in previously infertile women. Resection is a viable alternative to abdominal myomectomy for submucous myomas. (J Am Assoc Gynecol Laparosc 6(2):155-158, 1999)     

One-step hysteroscopic removal of sinking submucous myoma in two infertile patients

OBJECTIVE: To report one-step resectoscopic removal of submucous myomas that were pushed back into the muscular layer by increased intrauterine pressure during hysteroscopic procedures. DESIGN: Case report. SETTING: Kawasaki Municipal Hospital, Kawasaki, Japan. PATIENT(S): Two infertile women presenting with menorrhagia in whom submucous myoma with a broad base was diagnosed. INTERVENTION(S): One patient was pretreated with GnRH agonist for 4 months; the other patient did not receive this treatment. Resectoscopic myomectomies were performed under close sonographic monitoring. MAIN OUTCOME MEASURE(S): Clinical symptoms and conception status. RESULT(S): Tumor sinking occurred during the hysteroscopic procedures, but complete resectoscopic removal of the submucous myomas was achieved under sonographic and hysteroscopic visualization. One patient experienced hyponatremia but recovered after conservative treatment. Both patients conceived after myoma removal. CONCLUSION(S): Sinking myomas, which may cause infertility, can be removed with a one-step hysteroscopic procedure. Sinking of submucous myomas during hysteroscopy might be caused by pretreatment with GnRH agonist and by increased intrauterine pressure during hysteroscopy. We recommend that intrauterine pressure be <45 mmHg, equivalent to hanging a bag of fluid under gravity control 70 cm above the patient's uterus, at the beginning of operations for sinking myomas.     

Use of carboprost to facilitate hysteroscopic resection of submucous myomas

Ten women with submucous myomas that could not be completely resected hysteroscopically were treated with intracervical carboprost. This caused uterine contraction and extrusion of the unresectable intramural component into the endometrial cavity. Eleven of 13 myomas in these patients could then be completely resected. One intramural myoma extruded into the endometrial cavity after injection of carboprost and was also completely resected.     

Immediate and late outcome of vaginal myomectomy for prolapsed pedunculated submucous myoma

During a 10-year period, vaginal myomectomy was attempted in 46 women with a symptomatic prolapsed pedunculated submucous myoma. The procedure was successful in 43 and failed in three patients, necessitating an abdominal operation. Vaginal myomectomy for this condition was simple and quick, and the postoperative course was usually uneventful. Only 8.8% of 34 patients with a median follow-up of 5.5 years required a repeat vaginal myomectomy, and only 5.9% needed a hysterectomy. Vaginal myomectomy is recommended as the initial treatment of choice for prolapsed pedunculated submucous myoma, except in those cases in which other indications necessitate an abdominal approach.     

Repeat hysteroscopic surgery reduces the hysterectomy rate after endometrial and myoma resection

STUDY OBJECTIVE: To assess the efficacy of repeat transcervical resection of the endometrium (TCRE) in patients with dysfunctional uterine bleeding and myomas in whom primary resection failed. DESIGN: Retrospective analysis (Canadian Task Force classification III). SETTING: University hospital endoscopic unit. PATIENTS: Six hundred sixty-eight women. INTERVENTION: Repeat TCRE or transcervical resection of a myoma (TCRM). MEASUREMENTS AND MAIN RESULTS: Of 668 patients, 118 (17%) required repeat resection for the following reasons: pain (52, 44%), menorrhagia (39, 31%), myomas (15, 13%), perforation at the primary TCRE (6, 5%), and large fluid deficit during the procedure (6, 5%). Of 118 women undergoing repeat TCRE or TCRM, 33 (28%) eventually required hysterectomy due to pain (17, 48%), persistent bleeding (7, 27%), pain and bleeding (3, 10%), regrowth of myomas (3, 14%), and other reasons (3, 14%). CONCLUSION: Repeat resection is an option after failed primary hysteroscopic operation and may reduce the hysterectomy rate.     

A new technique for and additional experience with hysteroscopic resection of submucous fibroids

New instrumentation and a new technique are described which simplify the hysteroscopic removal of the pedunculated submucous fibroid and make possible the partial removal of the sessile variety. Experience with the method is presented including the follow-up of four patients.     

Changes in myometrial thickness during hysteroscopic resection of deeply invasive submucous myomas.

STUDY OBJECTIVE: To evaluate the efficacy of hysteroscopy in resecting submucous myomas with deep intramural invasion. DESIGN: Prospective, observational study (Canadian Task Force classification II-2). SETTING: Department of gynecology at a general hospital. PATIENTS: Sixteen women with a solitary submucous myoma, in which myometrial thickness between the outer edge of the myoma and inner edge of the serosa was between 5 and 10 mm. INTERVENTION: One-step hysteroscopic myomectomy. MEASUREMENTS AND MAIN RESULTS: Median myoma diameter and weight were 3.3 cm and 30 g, respectively. Myometrial thickness between the myoma and serosa increased gradually and significantly from 6.7 mm before, to 8.9 mm during, to 16.1 mm immediately after hysteroscopic myomectomy (p <0.001). The thickness of the opposite uterine wall increased from 10.1 mm before, to 11.4 mm during, to 18.8 mm after operation (p <0.001). CONCLUSION: One-step hysteroscopic myomectomy may be performed to remove deeply infiltrating submucous myomas when myometrial thickness at the implantation site is as thin as 5 mm.     

Combined treatment for big submucosal myoma with High Intensity Focused Ultrasound and hysteroscopic resection

ObjectiveBig submucosal myoma often causes heavy menstrual bleeding and are complicated in hysterscopic surgery. High Intensity Focused Ultrasound (HIFU), is a method for myoma ablation therapy, which may benefit on size reduction, and assist following hysterscopic myomectomy.Case reportTwo cases, case one,. 44-year-old female with 3.8 cm submucosal myoma, STEPW (Size, Topography, Extension, Penetration and Wall) score 6 and case 2. 48-year-old female, with 6.0 cm submucosal myoma, STEPW score 8, both received HIFU treatment before hysterscopic myomectomy was done. The myomas reduced after 5 months with improvement of anemia. The following hysterscopic myomectomy shows less operative time and fewer blood loss.ConclusionHIFU reduce size of submucosal myoma and may improve anemia after months. Less operating time and blood loss were demonstrated in the following hysterscopic myomectomy. For well selected patients, combined treatment with HIFU and hysteroscopic resection may decrease complication rate.     

Sonographically guided extraction of a submucous myoma

Under ultrasonographic guidance, a 5-cm, symptomatic submucous myoma was removed from the uterus during a second-trimester pregnancy termination. The procedure was rapid and well tolerated and suggests that intraoperative sonography may provide a transvaginal alternative to laparotomy in the treatment of submucous myomata.     

Modified hysteroscopic myomectomy of large submucous fibroids

OBJECTIVE: To compare the efficacy, feasibility, operative time and possible complications of a modified technique of hysteroscopic removal of large submucus myomata versus traditional morcellation technique, and to assess the efficacy of preoperative sonohysterography (SHG). DESIGN: A prospective comparative study. SETTING: Gynecologic Endoscopy Unit, Assiut University Hospital, Assiut, Egypt. SUBJECTS: One hundred forty-two women of childbearing age with a clinical and transvaginal sonographic diagnosis of large solitary submucous myomata (>3 cm in diameter) with or without an intramural element. INTERVENTIONS: The patients were divided into two groups. In group A (65 patients), a modified resectoscopic technique was used where the base of the myoma was excised followed by ring forceps extraction after misoprostol priming. In group B (77 patients), the myoma was cut using traditional resectoscopic morcellation. MAIN OUTCOME MEASURES: For each patient, operating time, intra- and postoperative complications and feasibility of the procedure were recorded. The accuracy of preoperative SHG in localizing submucous myoma and detecting intramural extension was assessed by diagnostic hysteroscopy. RESULTS: Transvaginal SHG showed good agreement with hysteroscopy in localizing submucous myomata and detecting intramural extension (k = 0.83). The operating time was significantly shorter in group A (15.6 +/- 3.02 min) than in group B (28.9 +/- 4.3 min). The procedure was completed in 60 (92%) and 51 patients (66%), whereas a second session was required in 2 (3%) and 20 patients (25.9%) in both groups respectively. Glycine volume was highly significantly less in group A (2.3 +/- 0.86 vs. 6.3+/- 1.7 liters, p = 0.001). Intraoperative complications were encountered in 9 (13.8%) and 22 patients (28.5%) in both groups respectively (p = 0.03). Cervical laceration was diagnosed in 3 cases (4.6%) in group A. Postoperative visual disturbances were diagnosed in 4 cases (5%) in group B. CONCLUSIONS: Hysteroscopic resection of large submucous myomata with minimal intramural encroachment is feasible using a modified technique. It shows a minimal complication rate and fluid deficit and a shorter operative time than the standard morcellation technique. If the excised myoma is extracted as one mass, this carries a minimal risk of cervical lacerations and possible cervical incompetence in a subsequent pregnancy. Transvaginal SHG is a reliable diagnostic aid to assess submucous myomata.     

Feasibility of a new two-step procedure for office hysteroscopic resection of submucous myomas: results of a pilot study

Objective

To assess the feasibility of a new two-step technique for office hysteroscopic resection of submucous myomas.

Study design

Between January 2010 and December 2011, all consecutive patients of reproductive age with symptomatic lesions sonographically diagnosed as single mainly intracavitary (G1 or G2) myoma ≤4.0 cm were eligible to participate in a prospective study. They underwent a two-step hysteroscopic procedure, which included preparation of partially intramural myomas with incision of the endometrial mucosa and the pseudocapsule covering the myoma in the first step, and excision of the myoma by means of diode laser four weeks later. All procedures were performed on an outpatient basis and without anesthesia.

Results

A total of 43 women (mean age 36.7 years) were included. The two-step myomectomy technique was successfully performed in 34 (79.1%) patients. All myomas ≤18 mm were successfully enucleated as compared with 85% of 19–30 mm, and 0% of ≥30 mm (P < 0.001). Also, myomas located in the anterior/posterior walls and those located in the fundus/lateral walls were enucleated in 87.9% and 50% of cases, respectively (P = 0.020). Success of surgery was not influenced by the initial type of myoma.

Conclusion

The new two-step hysteroscopic myomectomy carried out as an outpatient procedure and without anesthesia is feasible for the excision of symptomatic submucous fibroids.     

Reproductive outcome following hysteroscopic septal resection in patients with infertility and recurrent abortions

Objectives  

To evaluate the outcome of hysteroscopic septal resection in patients with infertility and recurrent abortions.     

Long-term outcome of hysteroscopic endometrial resection with or without myomectomy in patients with menorrhagia

Objectives  To evaluate the long-term outcomes and hysterectomy rates after hysteroscopic endometrial resection with or without myomectomy for menorrhagia. Study design  Fifty-three women who had submucous myomas with intramural extension of less than 50% and smaller than 5 cm in diameter underwent endometrial resection and concomitant hysteroscopic myomectomy. Each of them was matched with a patient who had no submucous myomas and who had been treated by endometrial resection only. These two groups were compared for operative outcomes, additional procedures, outcome of menstrual bleeding and for subsequent hysterectomy, which was the endpoint of this study. Results  During the mean follow-up period of 6.5 years, 18 (34.6%) women with endometrial resection and myomectomy and 21 (39.6%) without myomectomy underwent at least one gynecological procedure. Hysterectomy was performed in 26.9% [95% confidence interval (CI) 16.8–40.3] of the patients with myomectomy and in 17.0% (95% CI 9.2–29.2) of the patients without myomectomy (P = 0.22). The main indications for hysterectomy were pain and spotting bleeding in seven out of 14 cases with myomectomy and in four out of nine with endometrial resection only. Leiomyomas were found in 12 out of the 14 women who had hysterectomy after hysteroscopic myomectomy and in four out of nine with hysterectomy after endometrial resection only (P = 0.06). Most (75.6%) of the 82 women who had not required hysterectomy had reached menopause. All the patients without hysterectomy in both groups reported amenorrhea or slight bleeding, and this response maintained for years after the treatment. Conclusion  Endometrial resection may be combined with hysteroscopic myomectomy without a significant increase or decrease in hysterectomy rates during a long-term follow-up.