What is a hysteroscopy with dilation and curettage (D&C) polypectomy using the Myosure system?

What is a Hysteroscopy with D&C Polypectomy with MyoSure?

A hysteroscopy with D&C polypectomy using MyoSure is an outpatient procedure that combines direct visualization of the uterine cavity (hysteroscopy) with mechanical removal of endometrial polyps using a hysteroscopic morcellation system (MyoSure), which simultaneously cuts and aspirates tissue without requiring general anesthesia.

Procedure Components

This is a minimally invasive operative procedure that integrates three elements:

1. Hysteroscopy

• Direct visualization of the uterine cavity using miniaturized endoscopic equipment 1
• Performed in an outpatient setting without intravenous sedation or general/regional anesthesia 1
• Uses saline distension medium at the lowest pressure necessary for adequate visualization 1

2. Dilation and Curettage (D&C) Component

• The "D&C" terminology here refers to cervical dilation when needed (not traditional blind curettage)
• Cervical dilation may be required for larger diameter instruments or in cases of cervical stenosis 1
• Local anesthesia should be considered when cervical dilation is anticipated, particularly with hysteroscopes ≥5mm outer diameter 1

3. MyoSure System (Mechanical Hysteroscopic Tissue Removal)

• MyoSure is a mechanical hysteroscopic morcellation system that allows simultaneous cutting and aspiration of polyp tissue 1
• This is the preferred method for endometrial polypectomy over miniature bipolar electrodes 1

Clinical Advantages

Mechanical hysteroscopic tissue removal systems like MyoSure should be preferred over miniature bipolar electrodes for removing endometrial polyps 1. The evidence supporting this is compelling:

• Significantly less painful during the procedure (P <0.001) 1
• Faster procedure time (P <0.001) 1
• Higher success rates for complete polyp removal 1
• Greater patient satisfaction (P = 0.009) 1
• Higher patient acceptability 1

Real-World Performance Data

Recent UK data demonstrates excellent outcomes 2, 3:

• Success rate: 93.1% for outpatient MyoSure procedures 2
• Complete resection rate for polyps: 100% 2
• Completion rate: 92.59% 2
• Discharge rate: 82.75% (same-day discharge) 2
• Median intraprocedure pain score: 5/10 on visual analog scale 3
• Median postprocedure pain score: 1/10 3
• No intra- or post-procedure complications reported in large series 3

Optimal Technique

The procedure should follow these evidence-based principles:

Vaginoscopic Approach

• Vaginoscopy should be the standard technique unless a speculum is specifically required 1
• Significantly less painful during and 15 minutes after the procedure 1
• Significantly faster procedure time 1
• Fewer vasovagal episodes (OR 0.35,95% CI 0.15-0.82) 1

Equipment Selection

• Use the smallest diameter hysteroscope possible 1
• Consider hysteroscopes with expandable outer working channels (associated with less pain) 1
• The MyoSure system typically uses a 5mm diameter device 1

Pain Management

• Advise patients to take standard doses of oral NSAIDs one hour before the procedure 1
• Local anesthesia should NOT be routinely administered when using a vaginoscopic approach 1
• Local anesthesia should be considered only when cervical dilation is anticipated or when using larger-diameter hysteroscopes (≥5mm) 1

Antibiotic Prophylaxis

• Routine antibiotic prophylaxis is NOT recommended for outpatient hysteroscopic procedures 1
• One high-quality RCT found no benefit in reducing post-procedural infection 1

Cost-Effectiveness

Outpatient MyoSure procedures save approximately £1,117 per procedure compared to the same procedure performed under general or regional anesthesia in a day surgery setting 2. Additional benefits include:

• Rapid mobilization post-operatively (0 minutes vs 105 minutes for general anesthesia, P<0.001) 1
• Quicker recovery to pre-operative levels (2 days vs 3 days, P<0.05) 1
• Significantly less time off work (0.8 days vs 3.3 days, P<0.001) 1

Important Caveats

Myometrial Resection Concern

One significant caveat: hysteroscopic morcellation demonstrates a higher prevalence of myometrial tissue in pathology samples compared to hysteroscopic scissors or traditional D&C 4:

• 58.0% of morcellation samples contained myometrium vs 9.8% (scissors) and 15.3% (D&C) 4
• 26.0% had >25% myometrium vs 4.0% (scissors) and 0.6% (D&C) 4
• 11.0% showed isolated myometrium vs 0.7% (D&C) 4

This means the MyoSure system may resect deeper into the uterine wall, which requires careful technique to avoid complications.

Patient Selection

• Patients must be counseled that they can stop the procedure at any point if pain or distress becomes intolerable 1
• Alternative options (general anesthesia, regional anesthesia, intravenous sedation) should be discussed 1
• Written information should be provided prior to the appointment 1

Operator Experience

Success rates improve significantly with operator experience, particularly when combined with appropriate use of local anesthetic and cervical dilation when indicated 2.

1, 4, 2, 3