What is the recommended treatment for submucosal fibroids using hysteroscopic myomectomy?

Hysteroscopic Myomectomy for Submucosal Fibroids

Hysteroscopic myomectomy is the procedure of choice for submucosal fibroids, particularly pedunculated submucosal fibroids less than 5 cm in diameter, offering shorter hospitalization, faster recovery, and equivalent quality of life outcomes compared to more invasive surgical approaches. 1

Primary Indications and Patient Selection

• Hysteroscopic myomectomy is specifically indicated for patients with submucosal fibroids who desire uterus preservation 1
• The procedure involves transvaginal, transcervical placement of a hysteroscope with removal of fibroids using an electrosurgical wire loop or other instruments 1
• For pedunculated submucosal (FIGO Type 4) fibroids projecting entirely into the uterine cavity, hysteroscopic myomectomy is the definitive first-line treatment 2

Expected Outcomes and Quality of Life

• Symptom improvement and quality of life scores are equivalent to laparoscopic or open myomectomy at 2-3 months, while offering significantly shorter hospitalization and faster return to usual activities 1
• For abnormal uterine bleeding, long-term success rates range from 70-85% at 5 years or more of follow-up 3
• In randomized trials comparing myomectomy to uterine artery embolization, myomectomy showed improved quality of life scores at 2 years, though this difference was no longer significant at 4 years 1

Fertility Considerations and Evidence Gaps

• The impact on fertility remains controversial due to lack of high-quality evidence on live birth rates 1
• Two single-center randomized controlled trials showed conflicting results: one demonstrated no difference in pregnancy rates, while the second showed improvement but had internal reporting inconsistencies that prevented external validation 1
• Neither study reported live birth rates, and miscarriage rates were reported as 30-50% in one study 1
• Retrospective data suggests pregnancy rates of 85% with live birth rates of 65% after hysteroscopic myomectomy 1
• Large prospective registries show no significant difference in fertility outcomes among hysteroscopic, laparoscopic, and open myomectomy approaches 1

Technical Considerations and Surgical Approach

• The choice of technique depends primarily on the intramural extension of the fibroid, with "resectoscopic slicing" representing the gold standard for completely intracavitary fibroids (G0) 4
• For fibroids with intramural development (G1 and G2), the "cold loop" technique appears to be the best option, allowing safe and complete removal in one procedure while preserving healthy myometrium 4
• Both bipolar resectoscope and hysteroscopic mechanical morcellator are appropriate tools, with bipolar systems offering the advantage of using isotonic saline as distension medium, reducing metabolic complications compared to monopolar systems using glycine 5, 6
• The bipolar resectoscope excels at resecting deeper type 2 fibroids, while hysteroscopic morcellators offer shortened operative time but have limited data for type 2 fibroids 5

Important Limitations and Patient Counseling

• 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
• Intramural class 2 fibroids and larger fibroids (>4 cm) constitute the technical limits of the endoscopic approach 3
• Pretreatment with GnRH agonists may be indicated in selected cases involving large myomas or patients with secondary anemia 3

Risks and Complications

• Documented risks include uterine perforation, fluid overload, need for blood transfusion, bowel or bladder injury, endomyometritis, and need for reintervention 1
• Repeat resection is an option after failed primary hysteroscopic operation and may reduce the hysterectomy rate 3
• Intraoperative ultrasound control should be performed when the margin between the deepest part of the myoma and the serosa is less than 5-8 mm to avoid bowel injury 6

Critical Pitfalls to Avoid

• Do not perform endometrial ablation for submucosal fibroids, as there is no relevant literature supporting this approach 1, 2
• Do not recommend hysterectomy as initial treatment for pedunculated submucosal fibroids, as less invasive and equally effective approaches are available 1
• Do not assume fertility improvement without proper counseling, as high-quality evidence on live birth rates is lacking and miscarriage rates may be substantial 1