Is Cold Loop Hysteroscopic Myomectomy a Safe and Effective Technique for the Treatment of Submucous Myomas With Intramural Development? A Series of 1434 Surgical Procedures

Revolutionizing diffuse uterine leiomyomatosis treatment: A case report and literature review on "no-distension" hysteroscopic myomectomy with thoracic tissue forceps

Diffuse uterine leiomyomatosis (DUL) is a prevalent leiomyoma variant in women of childbearing age, characterized by a uniformly enlarged uterus with numerous interconnected small myomas. Given that most DUL patients are in their reproductive years, treatments that preserve fertility are increasingly vital. This case report introduces an innovative hysteroscopic technique that forgoes uterine distension to remove multiple submucosal fibroids in a single procedure, maintaining endometrial integrity and fertility. A 27-year-old single woman experienced prolonged and heavier menstruation. Magnetic resonance imaging (MRI) scans showed an enlarged uterus with several round-like masses in the uterine wall/submucosa. Addressing the patient's financial limitations and treatment preferences, a groundbreaking hysteroscopic surgery was performed using thoracic tissue forceps, alongside bedside ultrasonography, enabling fibroid excision without uterine distension. In total, 38 uterine fibroids were successfully excised without complications such as uterine perforation or hyponatremia. According to the FIGO classification system: three were type III, nine were type II, 15 were type I, and 11 were type 0. Postoperative follow-up indicated normalized menstrual cycles, improved hemoglobin levels, and no recurrence of fibroids. A hysteroscopic examination 1 month after surgery revealed no significant fibroids or endometrial thickening. This case report underscores the effectiveness of a novel hysteroscopic surgical approach in treating DUL. This method eliminates the need for multiple staged surgeries and the risks of endometrial damage inherent in traditional techniques. It offers a minimally invasive, fertility-preserving alternative for young DUL patients, marking a significant advancement in gynecologic surgery.

Prostaglandin Injection for Myoma Expulsion (PRIME): Case Series of a Novel Approach to Hysteroscopic Resection of FIGO Type 2 Myomas

STUDY OBJECTIVE

To evaluate the use of dilute carboprost tromethamine injection at the endometrium/myoma junction during hysteroscopy to facilitate myoma expulsion and removal in a single procedure.

DESIGN

Case series.

SETTING

Single high-volume academic medical center.

PATIENTS

Seven patients aged 32 to 51 years old with FIGO type 2 uterine myomas and symptoms of abnormal uterine bleeding or infertility undergoing hysteroscopic resection with a morcellation device from November 2022 to July 2023.

INTERVENTION

Dilute injection of carboprost tromethamine (10 µg/mL) at time of hysteroscopic myomectomy.

MEASUREMENTS AND MAIN RESULTS

The main outcome measure was ability to complete the hysteroscopic myomectomy in a single procedure using a hysteroscopic morcellator. Secondary outcomes included total operative time, fluid deficit, and postoperative pharmacologic side effects and/or surgical complications. Among our 7 patients, all had successful single procedure complete resections of myomas ranging from 0.9 to 4.6 cm in maximal diameter. Average operative time was 30 minutes, and average fluid deficit was approximately 839 mL. The carboprost dosages used ranged from 30 to 180 µg. One patient experienced prolonged postoperative nausea and vomiting that resolved with antiemetics. One patient experienced postoperative endometritis that improved with antibiotics.

CONCLUSION

In this pilot study, injection of dilute carboprost intraoperatively facilitated one-step hysteroscopic myomectomy of FIGO 2 myomas, via enhanced extrusion of the intramural portion of the fibroid into the uterine cavity, with both short operative times and acceptable fluid deficits.

Feasibility, safety and efficacy of high intensity focused ultrasound ablation as a preoperative treatment for challenging hysteroscopic myomectomy

PURPOSE

To investigate the feasibility, safety and efficacy of high intensity focused ultrasound ablation (HIFU) as a preoperative treatment for challenging hysteroscopic myomectomies.

MATERIALS AND METHODS

A total of 75 patients diagnosed with types 0-III of uterine fibroids were enrolled. Based on the Size, Topography, Extension of the base, Penetration and lateral Wall position (STEPW) classification scoring system, 25 cases with a score ≥ 5 points were treated with HIFU followed by hysteroscopic myomectomy (HIFU + HM group), whereas 50 cases with a score < 5 points were treated with hysteroscopic myomectomy (HM group).

RESULTS

The median preoperative STEPW score was 7 in the HIFU + HM group and 2 in the HM group. The average non-perfused volume (NPV) ratio achieved in fibroids after HIFU was 86.87%. Patients in the HIFU + HM group underwent hysteroscopic myomectomy one to four days after HIFU, and downgrading was observed in 81.81% of fibroids. The operation time for patients in the HIFU + HM group was 73 min and the success rate of myomectomy in a single attempt was 60%. The volume of distention medium used during the operation was greater in the HIFU + HM group than in the HM group (15,500 ml vs. 7500 ml). No significant difference was observed between the two groups in terms of intraoperative blood loss, the incidence of intraoperative and postoperative complications, menstrual volume score, or uterine fibroid quality of life score.

CONCLUSION

HIFU can be utilized as a preoperative treatment for large submucosal fibroids prior to hysteroscopic myomectomy. HIFU offers a novel approach in the management of this subset of patients.

The challenge of FIGO type 3 leiomyomas and infertility: Exploring therapeutic alternatives amidst limited scientific certainties

Uterine leiomyomas (ULs) are non-cancerous tumors composed of smooth muscle cells that develop within the myometrium and represent the most prevalent pathological condition affecting the female genital tract. Despite the volume of available research, many aspects of ULs remain unresolved, making it a "paradoxical disease" where the increase in available scientific literature has not been matched by an increase in solid evidence for clinical management. Fertility stands at the top of the list of clinical issues where the role of ULs is still unclear. The leiomyoma subclassification system, released by the International Federaion of Gynecology and Obstetrics (FIGO) in 2008, introduced a new and more effective way of categorizing uterine fibroids. The aim was to go beyond the traditional classification "subserosal, intramural and submucosal", facilitating a detailed examination of individual ULs impact on the female reproductive system. The "type 3 UL" is a special type of myoma, characterized by its complete myometrial development while encroaching the endometrium. It is a unique "hybrid" between a submucous and an intramural UL, that may exert a detrimental "double hit" mechanism, which is of particular interest in patients wishing pregnancy. To date, no robust evidence is available regarding the management of type 3 ULs. The aim of this narrative review is to provide a comprehensive overview of the physiopathological mechanisms that type 3 UL may exert on fertility, and to present new perspectives that may help us to better understand both the need for and the methods of treating this unique type of fibroid.

Management of Uterine Fibroids and Sarcomas: The Palermo Position Paper

BACKGROUND

Uterine fibroids are benign monoclonal tumors originating from the smooth muscle cells of the myometrium, constituting the most prevalent pathology within the female genital tract. Uterine sarcomas, although rare, still represent a diagnostic challenge and should be managed in centers with adequate expertise in gynecological oncology.

OBJECTIVES

This article is aimed to summarize and discuss cutting-edge elements about the diagnosis and management of uterine fibroids and sarcomas.

METHODS

This paper is a report of the lectures presented in an expert meeting about uterine fibroids and sarcomas held in Palermo in February 2023.

OUTCOME

Overall, the combination of novel molecular pathways may help combine biomarkers and expert ultrasound for the differential diagnosis of uterine fibroids and sarcomas. On the one hand, molecular and cellular maps of uterine fibroids and matched myometrium may enhance our understanding of tumor development compared to histologic analysis and whole tissue transcriptomics, and support the development of minimally invasive treatment strategies; on the other hand, ultrasound imaging allows in most of the cases a proper mapping the fibroids and to differentiate between benign and malignant lesions, which need appropriate management.

CONCLUSIONS AND OUTLOOK

The choice of uterine fibroid management, including pharmacological approaches, surgical treatment, or other strategies, such as high-intensity focused ultrasound (HIFU), should be carefully considered, taking into account the characteristics of the patient and reproductive prognosis.

Impact of FIGO type 3 uterine fibroids on in vitro fertilization outcomes: A systematic review and meta-analysis

BACKGROUND

The effect of FIGO (the International Federation of Gynecology & Obstetrics) type 3 myomas on in vitro fertilization (IVF) is uncertain.

OBJECTIVES

To evaluate whether FIGO type 3 myomas affect IVF outcomes, through a systematic review and meta-analysis (CRD42022379700).

SEARCH STRATEGY

Electronic databases were searched until November 15, 2022.

SELECTION CRITERIA

Studies evaluating the effects of FIGO type 3 myomas on IVF outcome.

DATA COLLECTION AND ANALYSIS

Pooled results were expressed as odds ratios (OR) with 95% confidence intervals (CI). Heterogeneity was assessed using Higgins I2 . Sources of heterogeneity were explored with sensitivity and subgroup analyses.

MAIN RESULTS

In total, 1020 patients were included: 324 with FIGO type 3 myomas and 696 controls (without myomas). A pooled data analysis showed a significantly lower live birth rate (OR 2.16, 95% CI 1.55-3.01, I2  = 0%, P < 0.00001), clinical pregnancy rate (OR 2.06, 95% CI 1.52-2.81, I2  = 0%, P < 0.00001), and implantation rate (OR 1.77, 95% CI 1.35-2.32, I2  = 0%, P < 0.00001) in women with untreated myomas compared with controls. The number and size of fibroids correlated with a worsening of IVF outcomes.

CONCLUSIONS

FIGO type 3 myomas are significantly associated with a lower implantation rate, cumulative pregnancy rate, and live birth rate. Furthermore, their deleterious effect on the outcome of IVF increases further with increasing size and number. Nevertheless, no firm conclusions could be drawn about the potential benefits of surgery for FIGO type 3 uterine fibroids on IVF outcomes.

High-intensity focussed ultrasound and hysteroscopy endo-operative system cold device procedures for treating >4cm diameter FIGO Type 2 uterine myoma and ensuring successful pregnancy

PURPOSE

Laparotomic or hysteroscopic myomectomy, and high-intensity focussed ultrasound (HIFU), can be used in the treatment of Type 2 myomas with a > 50% intramural component. Hysteroscopic electroresection may damage the remaining endometrium and complete ablation of myomas may not be realised via HIFU treatment. We report and examine the results of 1 case of HIFU treatment, accompanied with the hysteroscopy endo-operative system (HEOS) cold device procedure.

MATERIALS AND METHODS

These were used for treating a > 4cm diameter Type 2 uterine myoma and ensuring successful pregnancy. HIFU treatment of uterine myomas can achieve point-by-point ablation of lesions as far as possible without damaging the endometrium. The HEOS cold device procedure was implemented 3 months after HIFU treatment.

RESULTS

The patient got pregnant naturally in the third month after receiving treatment, with no complications during her pregnancy. The patient gave birth to a healthy male via full-term cesarean section.

CONCLUSIONS

HIFU treatment, accompanied with the HEOS cold device procedure, ensured complete myoma removal. It also preserved the integrity of the myometrium and prevented uterine perforation during surgery.

Optimal treatment options for uterine submucosal fibroids: Percutaneous microwave ablation versus transcervical resection of myoma

OBJECTIVES

To compare the efficacy and safety of percutaneous microwave ablation (PMWA) and transcervical resection of myoma (TCRM) for submucosal fibroids.

METHODS

From January 2019 to January 2021, we conducted a randomized controlled study involving patients with symptomatic uterine submucosal fibroids. Questionnaires were also used to measure the uterine fibroid symptom (UFS) scores and quality of life (QoL) scores before and after treatment at 3, 6, and 12 months. Outcomes, adverse events, hemoglobin recovery, and submucosal fibroid volume of both groups were also compared. Operation time, amount of bleeding, hospital stay time, and occurrence of complications were compared in groups with fibroids of different lengths.

RESULTS

Follow-up after surgery showed that UFS scores at 3, 6, and 12 months were significantly lower in each group, while QoL scores increased significantly. For fibroids less than 3 cm, surgical time was 34.2 ± 9.9 min, incidence of perioperative complications was 4.2%, and both decreased significantly, compared to the surgical time of the PMWA group (40.0 ± 8.1 min) and incidence of perioperative complications (24%; p < .05 for both). For uterine submucosal fibroids >5 cm, the operation time in the PMWA group was 92.7 ± 16.0 min, intraoperative bleeding volume was 22.7 ± 6.4 mL, and hospital stay was 2.7 ± 1.1 days, which were significantly less than the procedural time (107 ± 11.9 min), intraoperative bleeding loss (45.9 ± 12.8 mL), and length of hospital stay (5.0 ± 1.1 days) in the TCRM group. The differences were statistically significant (p < .05).

CONCLUSIONS

PMWA and TCRM were both effective treatments for uterine submucosal fibroids. For fibroids shorter than 3 cm in length, especially pedicled submucosal fibroids, TCRM has absolute advantages; however, for uterine submucosal fibroids >5 cm, PMWA avoids perioperative complications, such as uterine perforation, water poisoning syndrome, and the need for repeat surgery, and is considered the preferred mode of treatment. Therefore, personalized treatment should be used for different patients with uterine submucosal fibroids.

Intrauterine adhesion after hysteroscopic myomectomy of submucous myomas

PURPOSE

To evaluate the frequency of intrauterine adhesion (IUA) after hysteroscopic myomectomy, and to analyze the association of IUA and the location of submucous myomas and the use of postoperative barrier (POB).

METHODS

Hysteroscopic myomectomy was performed in 217 patients with submucous myomas. The retrospective investigation was performed, and the cases were divided into three groups: cases with solitary submucous myoma (SSM; group 1), cases with apposing submucous myomas (ASMs; group 2) and cases with submucous myomas that were far from each other or not in apposition to one another (not apposing submucous myomas: NASMs; group 3). As POB, intrauterine device with oxidized regenerated cellulose and silicon sheet was inserted immediately after surgery.

RESULTS

IUA formation after hysteroscopic myomectomy was more frequent in group 2 than groups 1 and 3 (p = 0.03 and 0.01, respectively), despite the higher rates of POB use (p = 0.02). There was no significant difference in IUA formation in cases with POB between each group (p = 0.06 and 0.21, respectively). But in cases without POB, group 2 showed higher rates of IUA formation than group 1 (p = 0.04) and group 3 (p = 0.03). Multivariable analysis for IUA formation demonstrated that ASMs were a risk factor of IUA (hazard ratio [HR] = 27.9, p < 0.01), and the use of POB was a prognostic factor for reduction of IUA formation (HR = 0.08, p < 0.01).

CONCLUSION

ASMs appear to be a risk factor for IUA formation. The use of POB may be associated with preventing IUA formation after hysteroscopic myomectomy.

Hysteroscopic Endometrial Ablation: From Indications to Instrumentation and Techniques-A Call to Action

The development of minimally invasive techniques has led to the creation of innovative alternatives in cases where traditional methods are not applicable. In modern gynecology, hysteroscopy has become the gold standard for the evaluation and treatment of intrauterine pathology. Endometrial ablation (EA) is a procedure that uses different types of energy to destroy the endometrium and is currently used as an alternative technique in cases of heavy menstrual bleeding when medical treatment has failed and uterine preservation is desired. The aim of this review was to evaluate the feasibility, safety, and clinical outcomes of hysteroscopic EA as an alternative in patients with abnormal uterine bleeding. A detailed computerized search of the literature was performed in the main electronic databases (MEDLINE, EMBASE, Web of Science, PubMed, and Cochrane Library), from 1994 to June 2022, to evaluate the outcomes in patients with abnormal uterine bleeding (AUB) undergoing EA using hysteroscopic and non-hysteroscopic techniques. Only scientific publications in English were included. Twelve articles on the current use of endometrial ablation were included. Data on patient symptoms, tools used for EA, primary outcomes, and adverse events were recorded. EA should be considered an effective and safe approach in the management of patients with abnormal uterine bleeding caused by benign pathology, in whom medical treatment has failed or is contraindicated. Due to the lack of evidence, it would be interesting to determine whether EA would also have a role in the treatment of women with premalignant lesions, avoiding invasive surgical procedures or medical treatment in those patients for whom hysterectomy or the use of hormonal treatment is contraindicated.

Post-surgical Intrauterine Adhesions After Hysteroscopic Myomectomy Using the Myoma Pseudocapsule Preservation Technique Evaluated bv Second-look Hysteroscopy: A Retrospective Comparative Study

STUDY OBJECTIVE

To analyze the frequency and risk factors of post-surgical intrauterine adhesions (IUA) using second-look hysteroscopy (SLH) in patients undergoing hysteroscopic myomectomy carried out by the myoma pseudocapsule preservation technique for submucosal myoma.

DESIGN

Retrospective cohort study.

SETTING

University hospital from January 2017 to December 2019.

PATIENTS

A total of 124 patients underwent hysteroscopic myomectomy and SLH.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Surgical duration, intraoperative blood loss, number of enucleated myomas, volume of specimen, post-surgical IUA evaluated by SLH. Post-surgical IUA were found in 5/124 cases (4.0%) at SLH. There were no cases of intrauterine adhesion formation in cases in which a single myomas was resected (0/83 cases, 0%), all cases were multiple myomas (5/41 cases, 12.2%), and significantly occurred more frequently in cases of multiple myoma (p = 0.003). Univariate analyses showed that the IUA group contained a significantly larger number of enucleated uterine myoma (p < 0.001), required a longer operation (p = 0.003), displayed an increased volume of intraoperative bleeding (p = 0.007), and the heavier the specimen, the greater the number of patients that had inserted an IUD than the group that did not display post-surgical IUA. Multivariate logistic regression analysis of the risk factors of post-surgical IUA showed that the number of enucleated myomas was strongly associated with IUA (odds ratio 1.45,95% confidence interval 1.06-1.97).

CONCLUSION

The frequency of post-surgical IUA after hysteroscopic myomectomy was high in cases of multiple myoma and may be a risk factor. SLH should be actively pursued in cases where the patient desires to bear children, and informed consent should be attained before carrying out surgery.

Research on myoma in Northeastern Romania and socio-medical outcomes

Myomas are the most common benign uterine tumors in women of childbearing age, with an incidence of up to 77% and a major impact on women's health. The aim of our study was to provide information concerning the incidence and prevalence of myomas in the patients admitted to a tertiary referral center in Northeastern Romania. This retrospective study conducted at the Iasi 'Cuza Voda' University Hospital of Obstetrics and Gynecology (Romania) included 11,538 patients, representing all patients admitted to the gynecology department between January 2013 and December 2019. During the study interval, the number of hysterectomies (total and for myomas) had increased. The rate of laparoscopic surgery showed a small decrease (31.3% from 34%), classic therapy showed a decrease by more than 10% and the hysteroscopy rate was tripled. There are few studies in the literature that have established with accuracy the incidence of myomas. In the present study, the prevalence of hysterectomy for myomas was 54.42%. Our results are in agreement with the data in the literature, namely that 40-60% of all performed hysterectomies are for myomas. The vast majority of admissions for myomas involve a surgical procedure most commonly hysterectomy.

A Modified Technique of Bipolar Loop Resectoscopic Slicing for Treating Submucous Fibroids With Enucleation Makes the Operation Safer

Background: In this study, a modified technique of resectoscopic slicing with a common bipolar loop was introduced, which facilitated the complete removal of the submucous fibroid inside the uterine cavity without any novel equipment.

Results: Compared with the classical technique, our modified procedure possessed a shorter operation time (22.9 ± 7.3 vs. 38.9 ± 13.0 min, p < 0.05) and a smaller distending media volume (1,495.6 ± 540.1 vs. 2,393.1 ± 719.4 ml, p < 0.01).

Conclusion: As a result, the current study suggested that the enucleation of submucous fibroid under hysteroscopy could be achieved by using only the bipolar loop, which reduced the consumption for novel equipment and enhanced the safety of the technique.

Hysteroscopic myomectomy: The guidelines of the International Society for Gynecologic Endoscopy (ISGE)

OBJECTIVE

With this publication, the International Society for Gynecologic Endoscopy (ISGE) aims to provide the clinicians with the recommendations arising from the best evidence currently available on hysteroscopic myomectomy (HM).

STUDY DESIGN

The ISGE Task Force for HM defined key clinical questions, which led the search of Medline/PubMed and the Cochrane Database. We selected and analyzed relevant English-language articles, published from January 2005 to June 2021, including original works, reviews and the guidelines previously published by the European Society for Gynecological Endoscopy (ESGE) and the American Association of Gynecologic Laparoscopists (AAGL), in which bibliographies were also checked in order to identify additional references, using the medical subject heading (MeSH) term "Uterine Myomectomy" (MeSH Unique ID: D063186) in combination with ''Myoma" (MeSH Unique ID: D009214) and ''Hysteroscopy" (MeSH Unique ID: D015907). We developed the recommendations through multiple cycles of literature analysis and expert discussion.

RESULTS

The ISGE Task Force did develop 10 grade 1A-C and 4 grade 2A-C recommendations. For planning HM, evaluation of the uterus with saline infusion sonohysterography (SIS) or combined assessment by transvaginal ultrasound (TVUS) and diagnostic hysteroscopy is recommended (Grade 1A). The use of STEPW (Size, Topography, Extension of the base, Penetration and lateral Wall position) classification system of submucosal leiomyoma (LM) is recommended to predict the complex surgeries, incomplete removal of the LM, long operative time, fluid overload and other major complications (grade 1B). 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 (grade 1C). For type 1-2 LMs, slicing technique is currently recommended (grade 1C). A fluid deficit of 1000 mL also in case of bipolar myomectomy with saline solution, in healthy women of reproductive age, contains low risk for major complications. Lower thresholds (750 mL) for fluid deficit should be considered in the elderly and in women with cardiovascular, renal or other co-morbidities (Grade 1B).

CONCLUSION

HM is the most effective conservative minimally invasive gynecologic intervention for submucous LM. The set of 14 ISGE recommendations can significantly contribute to the success of HM and the safety of patients for whom the choice of appropriate surgical technique, as well as the surgeon's awareness and measures to prevent complications are of the utmost importance.

Successful management of a submucosal fibroid using a hysteroscopic morcellator system in a patient with a history of total proctocolectomy: A case report

Transcervical resection is widely used in the management of submucosal fibroids. However, uterine perforation and thermal bowel injuries are known complications associated with the procedure. This is a case report of a 44-year-old woman who presented with heavy menstrual bleeding and anemia. Magnetic resonance imaging and hysteroscopy revealed multiple fibroids, including a submucosal type 1 fibroid. She had previously undergone a total proctocolectomy with intestinal pouch-anal anastomosis for ulcerative colitis. Because there was a high risk of permanent colostomy in the event of a bowel injury, an electrode-free, operative hysteroscopy using the Intrauterine Bigatti Shaver (IBS), a hysteroscopic morcellator system, was employed to prevent thermal bowel injury. The fibroid was completely removed using the IBS system with no complications. Therefore, we recommend the electrode-free use of a hysteroscopic morcellator system in patients with a history of extensive pelvic surgery.

The role of magnetic resonance-guided focused ultrasound in fertility-sparing treatment of uterine fibroids-current perspectives

Uterine fibroids (UFs) are the most common benign tumours of the female reproductive system and the most frequent reason for hysterectomy worldwide. UFs are reported in 20%–70% of women of reproductive age depending on a study group. Although most women with UFs are asymptomatic, over 30% of them will present with different symptoms. Abnormal uterine bleeding, pain, pressure and infertility are the most common. Lesions that cause these kinds of symptoms may require medical intervention.

Trends in UF treatment change along with patient awareness and the introduction of new methods and techniques. Selecting an appropriate treatment option should be individualised and adjusted to the patient’s expectations as much as possible. This choice will mostly depend on the patient’s age, UF location, the size and number of lesions, severity of symptoms and, most importantly, the patient’s expectations concerning the preservation of fertility. Observations made for the past few years showed an increasing number of pre- and perimenopausal women who wish to preserve their uterus or decline surgery. In line with current trends and demands in medicine, great importance is attached to the development and upgrade of new minimally invasive or noninvasive procedures in UF therapy.

Magnetic resonance-guided high-intensity focused ultrasound (MR-HIFU) is not associated with severe destruction of the uterine cavity and walls. For this reason, this method may be considered as a kind of hope in fertility-sparing UF therapy and the data about its use in this indication raises future hope. In this review, we summarise the available data on the use of MR-HIFU as a fertility-sparing method in the treatment of UFs. We also indicate how it could evolve in the future.

According to the available data, MR-HIFU is a relatively safe noninvasive method which seems not to deteriorate fertility compared to the pre-treatment status. MR-HIFU may constitute an alternative solution and be chosen in patients who meet the qualification criteria and deny other methods, which also facilitates the use of other treatment options in case the procedure is ineffective. Further randomised studies are necessary to confirm the above information.

Likelihood of Accomplishing an In-Patient Hysteroscopic Myomectomy in a One-Step Procedure: A Systematic Review and Meta-Analysis

PURPOSE

To assess the feasibility rate of one-step hysteroscopic myomectomy according to the technique adopted.

METHODS

In July 2016, PubMed, ClinicalTrials.gov, SCOPUS, Scielo, and AJOL databases were used for searching references. Series of in-patient hysteroscopic myomectomies reporting success rate in only one-step procedure, categorization of submucous fibroids, explanation of the surgical technique, and description of patients were considered eligible for meta-analysis (retrospective, prospective randomized studies). Two authors extracted the data. Rate of myomectomies accomplished in only a surgical step and rate of intraoperative complications were extracted per protocol. A modified GRADE score was used for quality assessment. Random-effect models were already assumed. Mean rates were compared among subgroups.

RESULTS

One thousand two hundred and fifty-seven studies were screened and 241 of these were read for eligibility. Seventy-eight series were included in qualitative synthesis and 24 series were included in quantitative synthesis. Wide heterogeneity was found. In series with <50% of G2 myomas treated, the slicing technique feasibility rate was 86.5% while techniques for enucleating the deep portion of the myomas showed a feasibility rate of 92.3% (p < 0.001). In series with ≥50% of G2 myomas treated, the slicing technique feasibility rate was 70.6% while techniques for enucleating the deep portion of myomas showed a feasibility rate of 88.4% (p < 0.001). In series with ≥50% of G2 myomas treated, the slicing technique feasibility rate was 70.6% while techniques for enucleating the deep portion of myomas showed a feasibility rate of 88.4% (.

CONCLUSION

In case of submucous myomas with intramural development, the slicing technique was correlated with a lower rate of in-patient hysteroscopic myomectomies accomplished in a one-step procedure and a higher complications rate.

Successful Pregnancies in Women with Diffuse Uterine Leiomyomatosis after Hysteroscopic Management Using the Hysteroscopy Endo Operative System

STUDY OBJECTIVE

To evaluate the feasibility, effectiveness, and reproductive outcome of hysteroscopic management using the Hysteroscopy Endo Operative system (HEOS) in patients with diffuse uterine leiomyomatosis (DUL).

DESIGN

Retrospective study (Canadian Task Force classification III).

SETTING

Beijing Tiantan Hospital, Capital Medical University, Beijing, China.

PATIENTS

Eight women of reproductive age suffering from menorrhagia and anemia or infertility diagnosed with DUL by ultrasonography and hysteroscopy.

INTERVENTIONS

Hysteroscopic surgery using cold graspers combined with electric loop by the HEOS was performed to excise submucous myomas (including types 0, I, and II), leaving other intramural myomas in place. The fenestration method is used in electrical hysteroscopic myomectomy. Postoperative endometrial repair and synechiae, menstrual improvement, conception, and pregnancy were recorded.

MEASUREMENTS AND MAIN RESULTS

Two patients underwent a single hysteroscopic myomectomy, whereas 6 patients underwent 2 to 3 myomectomies. No complications were observed. The mean follow-up period was 39.13 ± 17.01 months (range, 21-67). The endometrium recovered 2 to 3 months after the initial surgery, and 100% improvement in menstruation was observed. Two patients had mild synechia after the first hysteroscopic surgery. Seven patients conceived spontaneously (postoperative pregnancy rate, 87.5%), 6 of whom had a full-term pregnancy. One patient suffered a miscarriage in the second trimester (live birth rate, 75%).

CONCLUSION

Hysteroscopic surgery using cold graspers combined with electric loop by the HEOS is a feasible and effective for treatment of DUL because it preserves the uterus and yields favorable reproductive outcomes. The cold surgery and fenestration method minimizes electrical and thermal damage to the endometrium surrounding the myoma, consequently reducing surgical risks.

Submucous Fibroids, Fertility, and Possible Correlation to Pseudocapsule Thickness in Reproductive Surgery

Background and Objectives

Fibroids are related to infertility. Fibroid pseudocapsule is a neurovascular bundle surrounding leiomyomas rich of neurofibers involved in myometrial biology. Authors evaluated, by a case-control study, the fibroid pseudocapsule (FP) thickness by ultrasound (US) and the histological measurements, according to uterine location of fibroids.

Methods

137 consecutive patients undergoing hysterectomy for uterine myomas were enrolled and 200 myomas were evaluated. Before surgery, patients underwent an ultrasound (US) investigation to evaluate the number, the size, and the location of fibroids. After surgery, myoma-pseudocapsule-myometrium specimens were measured and evaluated by a single expert pathologist. Both US and histological data were collected and statistically analyzed.

Results

Our results confirm the relevant difference of FP thickness, particularly represented under the endometrium for submucous LMs. FPs near the endometrial cavity were considerably thicker than those of both intramural fibroids and subserous fibroids measured by US (P=0.0001) and histology (P=0.0001). A clear cut-off measurement at 2 mm (P=0.0001) was found between endometrial FPs and all other FPs for either US or histology measurements.

Conclusion

The thickness of FP is considerably higher near the endometrial cavity when compared to those of both intramural and subserous LMs, suggesting a potential role either in fertility or in myometrial healing.

Risk Factors for the Completion of the Cold Loop Hysteroscopic Myomectomy in a One-Step Procedure: A Post Hoc Analysis

Introduction

The aim of the study was to analyze which variables influenced the completion of a cold loop hysteroscopic myomectomy in a one-step procedure in a large cohort of patients.

Materials and Methods

A retrospective cohort study of 1434 cold loop resectoscopic myomectomies consecutively performed. The study population was divided into two groups according to the number of procedures needed to accomplish the treatment. Variables influencing the completion of hysteroscopic myomectomy in a one-step procedure were investigated.

Results

A total of 1434 resections were performed and 1690 myomas in total were removed. The procedure was accomplished in a one-step procedure in 1017 patients (83.7%), whereas 198 women (16.3%) needed a multiple-step procedure. The multivariate analysis showed that the size, the number of myomas, and the age of patients were significantly correlated with the risk of a multiple-step procedure. No correlation was revealed with the grading of myomas, parity, and the use of presurgical GnRH-agonist therapy.

Conclusions

In case of multiple fibroids, the intramural development of submucous myomas did not influence the completion of cold loop hysteroscopic myomectomy in a one-step procedure. The size of myomas and the age of patients were significantly correlated with the need to complete the myomectomy in a multiple-step procedure.

Clinical evaluation of improved MyoSure hysteroscopic tissue removal system for the resection of type II submucosal myomas

This study aims to determine whether clinical evaluation of improved MyoSure hysteroscopic tissue removal system can remove type II submucosal myomas with safety and high success rate of the first operation.Fifty-three patients with type II submucosal myomas hospitalized in the Huzhou Maternity and Child Care Hospital were enrolled in this study. The submucosal myomas were with the diameter of >2 cm and ≤5 cm. All patients have surgical indications.Fifty-one of 53 hysteromyomas were successfully resected through 1-time operation. The average time was 37.92 ± 18.57 minutes, average amount of bleeding: 24.80 ± 12.12 mL, average length of stay: 2.02 ± 0.14 days. One patient had a transient postoperative fever and one patient had slight fluid overload with hyponatremia.The success rate of the first operation for resecting type II submucosal myomas showed an increase using improved MyoSure hysteroscopic tissue removal system, which can be a new, safer, and more efficient operation for treating type II submucosal myomas.

Hysteroscopic Morcellation of Submucous Myomas: A Systematic Review

Hysteroscopic surgery is the actual gold standard treatment for several types of intrauterine pathologies, including submucous myomas (SMs). To date, the availability of Hysteroscopic Tissue Removal systems (HTRs) opened a new scenario. Based on these elements, the aim of this article is to review the available evidence about HTRs for the management of SMs. We included 8 papers (3 prospective studies and 5 retrospective studies). A total of 283 women underwent intrauterine morcellation of SM: 208 were treated using MyoSure and 75 using Truclear 8.0. Only 3 articles reported data about procedures performed in outpatient/office setting. Only half of the included studies included type 2 SMs. HTRs significantly reduced operative time compared to traditional resectoscopy in some studies, whereas others did not find significant differences. Despite the availability of few randomized controlled trials and the cost of the instrument, according to our systematic review, the use of HTRs seems to be a feasible surgical option in terms of operative time and complications. Nevertheless, the type of SM still remains the biggest challenge: type 0 and 1 SMs are easier to manage with respect to type 2, reflecting what already is known for the "classic" hysteroscopic myomectomy.

Resectoscopic Surgery for Polyps and Myomas: A Review of the Literature

Resectoscopic surgery is routinely performed to remove endometrial polyps and uterine myomas. A search of Medline, PubMed, and the Cochrane Library was conducted through November 2016 for studies written in English, regardless of sample size or study type. The studies were then filtered by selecting those evaluating resectoscopic surgery. An analysis of peer-reviewed, published literature was performed to examine the clinical application of this treatment modality on patients requiring polypectomy and myomectomy. Different surgical techniques were also compared: hysteroscopy with scissors, forceps, or a cold loop; resectoscopy with radiofrequency energy; and mechanical resection. The literature finds that operative time during resectoscopic surgery is significantly longer than with mechanical resection. Resectoscopic myomectomy, however, may be necessary for removal of larger or more deeply embedded myomas. Ultimately, both techniques result in symptom resolution and a low recurrence rate.

Uterine fibroid management: from the present to the future

Uterine fibroids (also known as leiomyomas or myomas) are the most common form of benign uterine tumors. Clinical presentations include abnormal bleeding, pelvic masses, pelvic pain, infertility, bulk symptoms and obstetric complications.Almost a third of women with leiomyomas will request treatment due to symptoms. Current management strategies mainly involve surgical interventions, but the choice of treatment is guided by patient's age and desire to preserve fertility or avoid 'radical' surgery such as hysterectomy. The management of uterine fibroids also depends on the number, size and location of the fibroids. Other surgical and non-surgical approaches include myomectomy by hysteroscopy, myomectomy by laparotomy or laparoscopy, uterine artery embolization and interventions performed under radiologic or ultrasound guidance to induce thermal ablation of the uterine fibroids.There are only a few randomized trials comparing various therapies for fibroids. Further investigations are required as there is a lack of concrete evidence of effectiveness and areas of uncertainty surrounding correct management according to symptoms. The economic impact of uterine fibroid management is significant and it is imperative that new treatments be developed to provide alternatives to surgical intervention.There is growing evidence of the crucial role of progesterone pathways in the pathophysiology of uterine fibroids due to the use of selective progesterone receptor modulators (SPRMs) such as ulipristal acetate (UPA). The efficacy of long-term intermittent use of UPA was recently demonstrated by randomized controlled studies.The need for alternatives to surgical intervention is very real, especially for women seeking to preserve their fertility. These options now exist, with SPRMs which are proven to treat fibroid symptoms effectively. Gynecologists now have new tools in their armamentarium, opening up novel strategies for the management of uterine fibroids.

Dienogest as preoperative treatment of submucous myomas for hysteroscopic surgery: a prospective, randomized study

The aim of this single-center, prospective, randomized, parallel-group study was to compare Dienogest and Danazol as endometrial preparation in patients who have to undergo hysteroscopic surgery for submucous myomas. We enrolled 80 consecutive eligible patients, in reproductive age, affected by submucous myomas. Pre- and posttreatment characterization of endometrium was performed by hysteroscopic visual observation and histologic confirmation. The enrolled patients were randomly assigned to two groups: 40 were treated with 2 mg of Dienogest/die, 40 with 100 mg of Danazol/die, both orally for 5 weeks, starting on day 1 of menstruation. Posttreatment comparison of endometrial patterns showed a significant more marked effect of Dienogest, respect to Danazol, in atrophying endometrium ("normotrophic non-responders" versus "hypotrophic"-"atrophic", p = 0.028). Intraoperative data showed no significant difference between the two groups for cervical dilatation time (p = 0.326), while in the Dienogest group, we found a significant reduction of operative time (p = 0.001), infusion volume (p = 0.001), and severity of bleeding (p = 0.042). Moreover, Dienogest caused less side effects (p = 0.008). According to our data analysis, Dienogest, respect to Danazol, is more effective for the preparation of the endometrium in patients who have to undergo hysteroscopic surgery for submucous myomas, and causes less side effects.

Predicting success of single step hysteroscopic myomectomy: A single centre large cohort study of single myomas

INTRODUCTION

Submucous myomas represent one of the main indications of operative hysteroscopy. Hysteroscopic resection of submucous fibroids should be a simple, well-tolerated and effective procedure and ideally accomplished in in only one surgical step.

METHODS

Retrospective cohort single Centre study of 1244 women undergoing hysteroscopic myomectomy. Data analysis included patients' and the myomas characteristics. A multiple logistic regression was carried out in order to assess which variables were able to determine a multiple step procedure.

RESULTS

1090 myomas (87.62%) were completely resected in a single-step procedure (SS group) whereas a multiple-step procedure (MS group) was needed for the removal of 154 fibroids (12.38%). The mean size of myomas resected in the SS group was 22.83 ± 9.36 mm whereas fibroids of the MS group measured 29.67 ± 10.76 mm. The overall feasibility of hysteroscopic myomectomy in one surgical procedure was 88.28%. All hysteroscopic myomectomies of G0 fibroids were completed in a single step. The chance of success to accomplish the treatment in a single-step for G1 and G2 myomas were 88.59% and 82.55%, respectively. The multivariate analysis revealed an inverse correlation between age and multiple step procedures and size of myomas were all directly correlated to multiple step procedures.

CONCLUSION

The grading, the size of the myomas and the age of patients play a crucial role in completing the hysteroscopic myomectomy in a single step. Only the diameter greater than 3 cm in G2 myomas is correlated to a higher risk of a multiple procedure.