Reply

Abstract

We are very grateful to Dr Youssef and colleagues for their interest in our study. We agree with them in that preoperative measurement of the thickness of the myometrium between a submucous fibroid and uterine serosa (‘myometrial-free margin’) is unlikely to be helpful in selecting women for hysteroscopic resection. We did not actually perform these measurements in any of our patients. Our study differs from that of Casadio et al.1 as we did not use ultrasound to assess the ‘myometrial-free margin’ during hysteroscopic surgery. Intraoperative transvaginal or transrectal scanning is difficult to perform without interfering with the conduct of surgery to an extent that most surgeons would find unacceptable. Transabdominal scanning often fails to provide images of sufficient clarity, particularly in overweight women. Movements of the resectoscope are difficult to follow on ultrasound and visualization of the uterine cavity is difficult due to air bubbles generated during electrosurgery. In view of this, we do not feel that intraoperative ultrasound examination would necessarily enhance the safety of the procedure. The rules for stopping the procedure are devised by endoscopic surgeons and they usually take into account the depth of resection as assessed on hysteroscopy. They are clearly subjective and determining whether the depth of myometrial penetration is 1 cm or more is difficult and subjective. The safety of the operation is paramount, however, and most surgeons prefer to opt for a two-stage procedure, rather than running the risk of uterine perforation, with its potentially catastrophic consequences. We agree that variations in the skill of hysteroscopic surgeons will result in different rates of successful fibroid resection. We do believe, however, that by eliminating interoperator variability in our study, we were able to identify various parameters that are likely to make surgery difficult regardless of the experience of the operating surgeon. This should be helpful in counseling women regarding their risk of requiring a two-stage procedure. In addition, women in whom resection is likely to be technically challenging could be referred to surgeons with particular expertise in hysteroscopic surgery. D. Mavrelos*, J. Naftalin , W. Hoo , J. Ben-Nagi*, T. Holland , D. Jurkovic , * Early Pregnancy and Acute Gynaecology Unit, 3rd Floor, Golden Jubilee Wing, King's College Hospital, London SE5 8RX, UK, Gynaecology Diagnostic and Outpatient Treatment Unit, University College Hospital, London, UK