Hysteroscopic myomectomy for submucosal uterine myoma

Hysteroscopic myomectomy for submucous uterine fibroids

Hysteroscopic access is currently considered optimal for the removal of submucous myomatous nodes. This operation serves as an alternative to laparotomy with minimal invasiveness and better results.

Indications for hysteroscopic myomectomy:

1. The need to preserve fertility.
2. Reproductive dysfunction caused by the presence of a submucous node.
3. Pathological uterine bleeding.

Contraindications to hysteroscopic myomectomy:

1. General contraindications to any hysteroscopy.
2. The size of the uterine cavity is more than 10 cm.
3. Suspected endometrial cancer and leiosarcoma.
4. Combination of a submucous node with pronounced adenomyosis and the presence of myomatous nodes in other locations.

After preliminary diagnostics and classification characteristics of the submucosal node, a decision is made on the method of its removal, the timing of the operation, the need for preoperative preparation and the method of anesthesia.

Most often, hysteroscopic myomectomy is performed under intravenous general anesthesia or epidural anesthesia, but when removing a large node with a large interstitial component, the expected long duration of the operation and the need for laparoscopic control, the operation is performed under endotracheal anesthesia.

Preoperative hormonal preparation is best done with GnRH agonists (zoladex, decapeptyl), usually 2 injections with an interval of 4 weeks are enough. If such treatment is impossible due to high cost or unavailability, treatment with gestagens is carried out (nemestrane 2.5 mg 2 times a week, norethisterone 10 mg daily or danoval 600-800 mg daily) for 8 weeks, although it is less effective. According to the authors of the book, preoperative hormonal preparation before transcervical myomectomy should be carried out in the following cases:

• if the size of the submucous node exceeds 4-5 cm;
• in the presence of a submucous node on a broad base, regardless of its size.

The goal of preoperative hormonal preparation is not so much to reduce the size of the node, but to reduce the size of the uterus itself, while the node is squeezed into the uterine cavity and becomes more submucous. According to the authors, the use of a GnRH agonist - the drug Zoladex (Zeneca, UK) - made it possible to reduce the size of the nodes by 25-35%.

Preoperative hormonal treatment results in endometrial atrophy, which improves the conditions for performing the operation due to good visibility and reduces blood loss during the operation. Such preparation also allows restoring red blood counts to normal values and performing the operation in more favorable conditions. Along with the positive aspects, sometimes during treatment with GnRH agonists, large-diameter myomatous nodes located in the uterine wall become interstitial, which complicates the choice of the surgical method. In such cases, it is often necessary to postpone the operation indefinitely or perform myomectomy using laparotomy access.

Depending on the nature of the node (submucous node on a narrow base or submucous-interstitial node), the operation can be performed in one stage or in two stages. One-stage removal is more risky. When removing the interstitial part of the node, one must always remember the depth of damage to the uterine wall, which increases the risk of bleeding and possible fluid overload of the vascular bed. If the operation is performed in one stage, especially when removing a node with an interstitial component, it is recommended to perform a control hysteroscopy or hydrosonography after 2-3 months to confirm the absence of remaining fragments of the myoma.

A two-stage operation is recommended for nodes, the majority of which are located in the uterine wall (type II according to the EAG classification). After preoperative hormonal preparation, hysteroscopy and partial myomectomy (myolysis of the remaining part of the node using a laser) are performed. Then the same hormones are prescribed again for 8 weeks and a repeat hysteroscopy is performed. During this time, the remaining part of the node is squeezed into the uterine cavity, which makes it possible to easily excise it completely. When removing submucous nodes of type II, control of the operation is necessary (transabdominal ultrasound or laparoscopy).

Taylor et al. (1993) proposed the following tactics for managing patients with submucosal nodes.

Patients with infertility and multiple myomas are recommended to remove nodes on one wall of the uterus during the first operation, and nodes located on the opposite wall after 2-3 months to avoid the formation of intrauterine adhesions.

Tactics of management of patients with submucous myomatous nodes

The size of the submucosal component	Knot size, cm
	< 2.5	2.5-5	> 5
>75%	Instantaneously	Instantaneously	Hormones + one-time
75-50%	Instantaneously	Hormones + one-time	Hormones + one-time
<50%	Hormones + one-time	Hormones + one- or two-stage	Hormones + two-stage

For women over 40, many authors recommend combining myomectomy with endometrial resection or ablation, which reduces their risk of recurrence of menorrhagia by 1/3 in the following 2 years. This issue is still being debated.

There are currently three approaches to hysteroscopic myomectomy:

1. Mechanical.
2. Electrosurgical.
3. Laser surgery.

Technique of mechanical hysteroscopic myomectomy

Mechanical myomectomy is used for pure submucosal nodes on a narrow base, with node sizes not exceeding 5-6 cm. The possibility of mechanical node removal also depends on the location of the node; nodes located in the bottom of the uterus are easiest to remove.

In case of large node sizes, it is advisable to perform preoperative hormonal preparation. To remove the node, it is necessary to ensure sufficient expansion of the cervical canal with Hegar dilators up to No. 13-16 (depending on the size of the node). The authors of the book use two methods of removing submucous nodes.

1. The node is precisely fixed with an abortion forceps and removed by unscrewing, then a hysteroscopic examination is performed.
2. Under the control of a hysteroscope, the capsule of the node or its stalk is dissected with a resector, then the node is removed from the uterine cavity.

If it is impossible to remove the severed node from the uterine cavity, which happens very rarely, it is permissible to leave it in the uterus; after some time (usually during the next menstruation)

If the medical facility does not have a resector, the capsule of the myomatous node or its pedicle can be cut with scissors inserted through the operating channel of the hysteroscope, but such an operation takes longer.

Doctors have become convinced that the possibility of mechanical removal of a submucous node depends not so much on its size as on its shape and mobility. Elongated nodes easily change their configuration and can be removed at once, even if they are large (up to 10 cm).

In some cases, large myomatous nodes can be removed by cutting, under constant visual control using a hysteroscope.

Advantages of mechanical myomectomy

1. Short duration of the operation (5-10 minutes).
2. No need for additional equipment or special liquid medium.
3. Possibility of avoiding complications of electrosurgical operation (fluid overload of the vascular bed, possible damage to large vessels and burns to adjacent organs).
4. The operation can be performed in any operating room of a gynecological hospital.

However, transcervical myomectomy with an abortion forceps can only be performed by an experienced gynecologist who has experience working with instruments in the uterine cavity.

Electrosurgical resection technique for submucosal node

In 1978, Neuwirth et al. reported the first use of a hysteroresectoscope to remove a submucosal node. Since then, many researchers have demonstrated the efficacy and safety of this endoscopic procedure.

To perform electrosurgical resection of a submucosal node, the same equipment is required as for ablation (resection) of the endometrium: a hysteroresectoscope with cutting loops with a diameter of 6 to 9 mm and a ball or cylindrical electrode for coagulation of bleeding vessels.

The uterine cavity is expanded using non-electrolyte liquid media (1.5% glycine, 5% dextran, 5% glucose, polyglucin or rheopolyglucin may be used). After the cervical canal is expanded using Hegar dilators to No. 9-9.5, the resectoscope with a diagnostic body is inserted into the uterine cavity, and the node is identified. Then the diagnostic body is replaced with an operating one with an electrode, and the node tissue is gradually cut off in the form of shavings, while the loop must be constantly moved towards the surgeon.

The accumulated pieces of the node are periodically removed from the uterus with forceps or a small blunt curette.

Resection of the interstitial portion of the node should not be deeper than 8-10 mm of the mucous membrane level. The interstitial portion of the node itself is squeezed into the uterine cavity as the node is removed. If such squeezing does not occur, the operation must be stopped. After this, repeated resection of the remaining portion of the node is recommended in 2-3 months.

Usually this operation is non-bleeding, but if the deep layers of the myometrium are damaged, bleeding is possible, so you need to be careful. The electric current power is adjusted during the operation under visual control, it is 80-110 W in the cutting mode. At the end of the operation, the loop electrode is replaced with a ball electrode, the intrauterine pressure is reduced and the bleeding vessels are coagulated in the coagulation mode at a current power of 40-80 W in many places of the remaining part of the node, after which the surface of this part remains covered with numerous crater-like depressions with brown borders. This technique, called hysteroscopic myolysis, causes necrobiosis of the node tissue. The purpose of the procedure is to reduce the size of the remaining part of the fibroid and worsen its blood supply. After this, hormones are prescribed again for 8 weeks, then a repeat hysteroscopy is performed to remove the remaining part of the node, which has decreased in size and squeezed out into the uterine cavity.

In case of multiple submucous nodes of small size, myolysis of each node is performed using the method described above.

Thus, hysteroscopic myomectomy is a very effective operation that allows avoiding hysterectomy, which is especially important for women of reproductive age. The choice of the surgical method depends on the following factors:

1. The type of submucosal node, its location and size.
2. Equipped with endoscopic equipment.
3. Operational skills of a surgeon in endoscopy.

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