Should the myometrial free margin still be considered a limiting factor for hysteroscopic resection of submucous fibroids? A possible answer to an old question

Abstract

Paolo Casadio et al. recently published an interesting paper focusing on the dynamic changes of the myometrial free margin separating type II submucous fibroids from the serosa during hysteroscopic resection (1Casadio P. Youssef A.M. Spagnolo E. Rizzo M.A. Talamo M.R. De Angelis D. et al.Should the myometrial free margin still be considered a limiting factor for hysteroscopic resection of submucous fibroids? A possible answer to an old question.Fertil Steril. 2011; 95: 1764-1768Abstract Full Text Full Text PDF PubMed Scopus (45) Google Scholar). Although the number of patients in this prospective observational study is limited (n = 13), the authors interestingly concluded that “myometrial free margin increases progressively with each step of the procedure probably leading to an increasing margin of safety.” This study updates and reinforces the previous observation by Yang et al., who first demonstrated that the myometrial free margin is not a static parameter but that it “increased gradually after each step of the resection, reaching its maximum after the completion of the procedure” (2Yang J.H. Lin B.L. Changes in myometrial thickness during hysteroscopic resection of deeply invasive submucous myomas.J Am Assoc Gynecol Laparosc. 2001; 8: 501-505Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar). They observed the progressive thickening of myometrium at transabdominal ultrasound while the myoma is progressively enucleated, suggesting two possible mechanisms for this phenomenon: the reshaping of the distended uterine myometrial fibers and the contractions induced by electrosurgery and the myoma grasping by forceps. In the last decade, my group and I have extensively focused on this topic by standardizing the classification of submucous myomas using two- and three-dimensional saline contrast sonohysterography (3Leone F.P. Bignardi T. Marciante C. Ferrazzi E. (2007) Sonohysterography in the preoperative grading of submucous fibroids: considerations on three-dimensional methodology.Ultrasound Obstet Gynecol. 2007; 29: 717-718Crossref PubMed Scopus (18) Google Scholar). During two-dimensional saline infusion, the dynamic changes of the myometrial free margin could be easily observed (see the video clip). Also, we investigated the intraoperative changes of the myometrium during hysteroscopic myomectomy performed by the combined use of electrical monopolar and “nonelectrical” cold loops (unpublished data). By repeated traction maneuvers on the myoma and continuous intrauterine pressure changes obtained by the use of inflow and outflow stopcocks, results similar to those reported were observed but in the presence of adjacent coexisting intramural and/or subserous myomas. In our recently accepted paper on hysteroscopic myomectomy on 169 hysteroscopic procedures for type I and type II submucous fibroids, we reported one uterine perforation (4Leone FP, Calabrese S, Marciante C, Cetin I, Ferrazzi E. Feasibility and long-term efficacy of hysteroscopic myomectomy for myomas with intramural development by the use of non-electrical “cold” loops. Gynecol Surg 2010. DOI: 10.1007/s10397-011-0706-4.Google Scholar). It occurred in a case of a type II 3-cm submucous myoma, with a 5-mm myometrial free margin, located near a 3-cm intramural-subserosal fibroid. During the cold-loop enucleation, at the end of the removal of the deep intramural part, a uterine perforation occurred because of the loss of the described progressive myometrial contraction. Because of the cold loop’s use, no further surgery was needed, and clinicosonographic monitoring was successfully applied. This episode confirmed the indication by Perrot et al., which suggested the presence of coexisting adjacent myomas as a risk factor for uterine perforation (5Perrot N. Mergui J.L. Frey I. Uzan M. Menorrhagia after age 40. Contribution of ultrasonic examination.Gynecol Obstet Fertil. 2002; 30: 523-531Crossref PubMed Scopus (5) Google Scholar). To sum up, I do absolutely agree with the data reported by Casadio et al., which should reassure and strengthen the confidence of the hysteroscopist in the treatment of type II myoma. Furthermore, I would stress the need for a proper presurgical ultrasound evaluation and consideration of the presence of coexisting adjacent myomas as a risk factor for uterine perforation (Fig. 1) because of sliding and the reduced contraction and thickening of the myometrial free margin. Download .mpg (1.59 MB) Help with mpg files Video 1 Should the myometrial free margin still be considered a limiting factor for hysteroscopic resection of submucous fibroids? A possible answer to an old questionFertility and SterilityVol. 95Issue 5PreviewTo evaluate the feasibility of the hysteroscopic resection of type II submucous fibroids regardless of the myometrial free margin separating them from the serosa and to report the dynamic changes the margin undergoes after the various phases of resection. Full-Text PDF Reply of the AuthorsFertility and SterilityVol. 97Issue 1PreviewWe would like to thank Dr. Leone for his comment. His experience and observations on the resection of submucous fibroids are extremely interesting and address some important issues that undoubtedly need further evaluation by other studies. Full-Text PDF