From the Guidelines
Hysteroscopic myomectomy is a recommended procedure for women with submucosal fibroids desiring uterus preservation, as it is associated with shorter hospitalization and faster return to usual activities compared to laparoscopic or open myomectomy, with equivalent improvement in symptom scores and quality of life at 2 to 3 months 1.
Indications and Contraindications
The procedure is indicated in patients with submucosal fibroids, particularly those with pedunculated submucosal uterine fibroids <5 cm 1. However, patients with significant intramural or subserosal fibroid burden causing bulk symptoms or heavy menstrual bleeding with concomitant adenomyosis are less likely to experience symptom relief from hysteroscopic myomectomy 1.
Procedure and Risks
Hysteroscopic myomectomy involves the transvaginal, transcervical placement of a hysteroscope and removal of submucosal uterine fibroids by an electrosurgical wire loop or other instruments 1. Risks include uterine perforation, fluid overload, need for blood transfusion, bowel or bladder injury, endomyometritis, and need for reintervention 1.
Fertility and Pregnancy
While there is debate about the impact of hysteroscopic myomectomy on fertility, retrospective studies demonstrate pregnancy rates of 85% after hysteroscopic myomectomy with live birth rates of 65% 1. However, patients with no desire for future fertility should be counseled that pregnancy is possible after hysteroscopic myomectomy 1.
Comparison to Other Procedures
Hysteroscopic myomectomy has been compared to other surgical approaches, including laparoscopic or open myomectomy, and uterine artery embolization (UAE) 1. The procedure is associated with shorter hospitalization and faster return to usual activities compared to laparoscopic or open myomectomy, with equivalent improvement in symptom scores and quality of life at 2 to 3 months 1.
From the Research
Hysteroscopic Myomectomy Techniques
- Hysteroscopic myomectomy is a minimally invasive surgical procedure for treating submucous fibroids, with abnormal uterine bleeding and reproductive issues being the most common indications 2.
- The choice of technique mostly depends on the intramural extension of the fibroid, as well as on personal experience and available equipment 2.
- 'Resectoscopic slicing' still represents the 'gold standard' technique for treating fibroids G0, even if several other effective techniques including ablation by neodymium-yttrium-aluminum-garnet laser, morcellation and office myomectomy have been proposed 2.
Comparison of Techniques
- Both the bipolar resectoscope and the hysteroscopic mechanical morcellator are appropriate tools to remove submucosal myomas 3.
- Although the hysteroscopic morcellators have been associated with shortened operative time and a decreased learning curve, the data are limited for their use on type 2 fibroids 3.
- The strength of the bipolar resectoscope lies in its ability to resect deeper type 2 fibroids 3.
Current Evidence and Guidelines
- Hysteroscopic myomectomy has been a popular treatment for symptomatic submucosal fibroids for decades; it is a minimally invasive, low-cost, low-risk procedure, and is associated with high patient satisfaction 3.
- The International Society for Gynecologic Endoscopy (ISGE) recommends the use of STEPW (Size, Topography, Extension of the base, Penetration and lateral Wall position) classification system of submucosal leiomyoma (LM) to predict the complex surgeries, incomplete removal of the LM, long operative time, fluid overload and other major complications 4.
- For type 0 LMs, in addition to resectoscopy (slicing technique), morcellation is recommended, being faster and having a shorter learning curve with respect to resectoscopy 4.
Management of Uterine Myomas
- Many advances have been made in the management of uterine myomas, including watchful waiting; medical therapy; hysteroscopic myomectomy; endometrial ablation; laparoscopic myomectomy; abdominal myomectomy; abdominal, vaginal, and laparoscopic hysterectomy; uterine artery embolization; uterine artery occlusion; and focused ultrasound 5.
- Hysteroscopic myomectomy is the treatment of choice for symptomatic submucosal myomas, with excellent success rate and low complication rate 6.