Modified Hysteroscopic Myomectomy of Large Submucous Fibroids

Abstract

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.

Safe techniques in surgery for hysteroscopic myomectomy

“…A study by The Netherlands Multicenter, indicated that six (0.75%) complications occurred in 798 hysteroscopic myomectomies; however, the complications in this report consisted of only fluid overload and uterine perforation 6 . The frequency of complications from hysteroscopic myomectomy are summarized in Table 1 6–17 . The frequency of complications varies widely by surgeon and operative technique.…”

“…The RCT described above showed that vasopressin reduced intraoperative blood loss, although there was no obvious difference in visual clarity during surgery between patients that had received a vasopressin injection and those that had not 23 . An intravenous injection of diluted ergometrine was also used to decrease vascularity 14 …”

Slice and Excise Technique in Hysterscopic Myomectomy for Large G0 Submucous Myoma

“…Moreover, intralesional vasopressin injection was also described [26]. Modified technique in which the base was excised followed by ring forceps extraction after misopristol priming [27]. Morcellators, with no doubt shorten the operative time and fluid deficit [28], but they can't yet concurrence the hysteroscopic resectoscopes for the treatment of large submucous myomas or those with a large intramyometrial involvement [29].…”

“…If the myoma is large, as the cases in our study, it might be difficult to grasp it and in such situation it was suggested to be left in place until it is excreted spontaneously during the first mensis after surgery. The main drawback of this technique is the continuous colicky pain and the risk of intra-uterine infection [27].…”

Reconstructive Endoscopic Myomectomy

“…In a case report, succeeful removal of myoma up to 12 cm in one session is reported (75). A modified hysteroscopic approach for big myoma with or without intramural extension has been introduced by our team (70).This technique has been cited and quoted in subsequent publications (76) and comprehensive review articles (77) on this topic. It comprised combined resectoscopic and mechanical approaches to enucleate the myoma in a shorter time with minimal complication rate if compared to the standard morcellation technique.…”