Hysteroscopic Resection Of Submucous Fibroids Research Articles

Hysteroscopic Resection of Submucous Fibroids in Symptomatic Women.

This study was conducted at Swapna Health Care (a tertiary centre forendoscopy), to analyse the outcome of hysteroscopic resection of submucous fibroids in 125 symptomatic women. A total of 125 women were diagnosed with submucous fibroids between 1994 and 2017, 83 presented with AUB, 31 with infertility and four with RPL. Seven postmenopausal women had thickened endometrium on routine transvaginal ultrasonography, and hysteroscopy showed submucous fibroids. Out of 83 with AUB, 68 were premenopausal and 15 were postmenopausal. All these patients underwent submucous fibroid resection by hysteroscopy. Out of 83, 75 (90.4%) had total relief from AUB and did not need any further management. Only eight patients needed hysterectomy after submucous fibroid resection. Thirty-one patients came for infertility. Twenty-five patients followed infertility treatment with us after SMFR. 32% of our infertile patients conceived (8/25). Submucous fibroid resection is a safe procedure, giving good results in symptomatic women with AUB and infertility. Hence, all gynaecologists should be trained in diagnostic and operative hysteroscopy and should be able to offer this option to their patients in the spectrum of choices available.

Hysteroscopic myomectomy.

A new International Federation of Gynecology and Obstetrics classification for myomas was recently described. Type 0, 1 and 2 are the submucosal fibroids. Submucous myomas represent one of the main indications for operative hysteroscopy. Hysteroscopic resection of submucous fibroids should be a simple, well-tolerated procedure and ideally finished in a single surgical step. Hysteroscopic myomectomy is an effective procedure. Fertility outcome and menorrhagia are improved by this procedure. However, for menorrhagia, a recurrence can occur mainly during the first year following the surgery. For bleeding outcome, a success rate from 70 to 99% has been reported by different studies. The success rate seems to decline as the follow- up period increases. For fertility outcome, submucosal fibroids have negative impact on pregnancy rates. The size of the fibroids plays a crucial role in completing the hysteroscopic myomectomy in a single step. A diameter greater than 3 cm in type 2 myomas results in a higher risk of a multiple procedure.

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

IntroductionSubmucous 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. MethodsRetrospective 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. Results1090 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. ConclusionThe 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.

SUBMUCOUS FIBROID: DIFFERENT PRESURGICAL CLASSIFICATION METHODS AND THEIR EFFECT ON HYSTEROSCOPIC SURGICAL MANAGEMENT

Objective: To compare the degree of difficulty and outcome measures of hysteroscopic myomectomy of submucous fibroid according to 2 classification systems. Methods: This prospective study conducted in the Cytogenetic & Endoscopy unit, Zagazig University Hospitals during the period from July 2009 to July 2012, included 100 patients candidates for hysteroscopic resection of submucous fibroids. All fibroids were diagnosed and assessed by saline infusion sonohysterography and diagnostic hysteroscopy. Presurgical classification was performed according to the two classification systems; the European Society of Endoscopic Surgery (ESES)–considering only the penetration of the fibroid into the myometrium – and STEPW considering size, topography, extension, penetration and wall affected. Primary outcome measure was incomplete resection of the fibroid. Secondary outcome measures were operating time (in minutes), the fluid deficit (in milliliters) and any intraoperative complications. Sensitivity, specificity and kappa measure of agreement were calculated for each classification at their best cut off. P value less than 0.05 is considered significant. Results: Myomectomy was considered incomplete in 8 out of 104 fibroids (7.7%) According to ESES, 2 belonged to type 0 and 6 belonged to type 1.Risk ratio and 95% confidence interval (CI) was 0.56 (0.07-3.3) and the difference was not significant (p=0.7); whereas according to the STEPW classification, the incomplete myomectomies were one in group I (1/8, 12.5%) and seven in group II (7/8, 87.5%). The risk ratio (95% CI) was 0.02 (0.0-0.18) and the difference was significant (p= 0.000). Considering the area under the ROC curve, the dichotomized STEPW scores performed better than the dichotomized ESES scores (P<.001). Conclusion: The application of STEPW classification of submucous fibroid gives better prediction of myoma removal than ESES classification. Key words: submucous fibroid classification, hysteroscopic myomectomy, ESES, STEPW.

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

To 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. A prospective observational study. A tertiary-level university hospital. Thirteen women with single type II submucous fibroids of ≤ 5 cm in diameter regardless of the myometrial free margin. Hysteroscopic myomectomy and ultrasound evaluation of myometrial free margin before and after each phase of the procedure. The possibility of a complete one-step resection, the incidence of intraoperative or postoperative complications, and the analysis of the dynamic changes occurring in myometrial free margin. Complete resection was performed successfully in all patients. No complications were registered. The myometrial free margin decreased on the distension of the uterine cavity and then increased progressively and significantly after the various phases of resection. In selected cases and in experienced hands, hysteroscopic myomectomy of type II submucous fibroids may be performed successfully and safely regardless of the myometrial free margin. Myometrial free margin increases progressively with each step of the procedure probably leading to an increasing margin of safety.

Hysteroscopic surgery at the Aga Khan Hospital, Nairobi

To determine the experience, acceptability and outcome of hysteroscopic surgery at the Aga Khan Hospital, Nairobi. A retrospective study. Aga Khan Hospital, Nairobi. Between May 2000 and April, 2003, 463 cases of hysteroscopy were undertaken at the Aga Khan Hospital, Nairobi, of these 54 patients (11.7%) underwent various hysteroscopic surgical procedures. A review of these cases and their outcomes are analysed and presented. In a thirty six month period 463 cases of Hysteroscopy were done at the Aga Khan Hospital, Nairobi. Of these 54 cases had operative intervention (11.7%). The case load of diagnostic hysteroscopy increased from 50 in the year 2000, to 206 and 159 respectively in the years 2001 and 2002. By this time, some consultants were performing diagnostic hysteroscopies on their own. The surgical procedures performed included hysterscopic retrieval of "lost" IUCD's, and intrauterine bone spicules and hysteroscopic resection of submucous fibroids (25.9% of the cases), resection of endometrial polyps (25.9%) hysteroscopic synechiolysis, (16.6%) and endometrial resection or ablation (cauterisation) (7.4%). All the patients were reviewed by the consultant pool after one week. Three cases of complications were encountered, two cases of uterine perforation and one case of fluid overload (TURP syndrome) following a resection of a submucous fibroid. Hysteroscopy and hysteroscopic surgery are the established gold standards for the management of intrauterine pathology. The procedures were well accepted amongst patients who had undergone these procedures. In Kenya, gynaecologists still have to embrace change and undergo adequate and sustained training in the various aspects of hysteroscopy, so as to make the proecdures acceptable and accessable to more patients.

Contemporary Management of Fibroids

Introduction: More women are delaying child-bearing such that gynaecologists can no longer resort as frequently to definitive treatments, such as a hysterectomy, in the management of uterine fibroids. A review of newer conservative medical, radiological and surgical therapies and minimal access approaches to the organ-preserving myomectomy operation are discussed. Materials and Methods: Data from published literature describing newer modalities of treatment and reviewing updated information of the impact of fibroids and myomectomy on fertility potential were collated. Results: Medical treatments serve to retard the growth of fibroids temporarily and have short-term success in the amelioration of symptoms. Uterine artery embolisation is a novel non-surgical approach to debulking of uterine fibroids and the relieve of symptoms. Hysterectomy is a treatment choice that is curative. Laparoscopic hysterectomy carries a 3% risk of major complications compared to 1% via a laparotomy. Laparoscopic myomectomy is a viable alternative to open myomectomy but due diligence must be exercised in ensuring meticulous and secure myomectomy defect repair. The risk of uterine dehiscence has been reported to be about 0.5% which is comparable to that in traditional open myomectomy which has been somewhat understated. Hysteroscopic resection of submucous fibroids is very efficacious and preserves reproductive potential. This procedure and myomectomy of intramural fibroids associated with intracavitary distortion are clearly indicated as these types of fibroids have been implicated as a cause of infertility and pregnancy loss at least 2 to 3 times higher than controls. This relationship prevailed in patients undergoing assisted reproduction. Conclusion: The management of uterine fibroids has undergone a revolution in the past few decades with better understanding of its impact on fertility and technical advances in endoscopy and radiologic embolisation techniques and also pharmaceutical alternatives such as gonadotrophin-releasing hormone agonist and progesterone intrauterine contraceptive devices. Advances in molecular biology may provide an opportunity to manipulate receptors and cellular biology in order to arrest tumourigenesis altogether.

Endoscopic management of fibromyomata

Surgical endoscopy has been successfully utilised in most gynaecological conditions with reported benefits which include small scars, reduced hospital stay and early return to normal duties. Myomectomy with uterine conservation has been popularised since the 1930s. The relationship between symptoms, such as menorrhagia and the presence of uterine myomata, has still not been fully evaluated although it appears that there is a causal relationship when sub-mucous fibroids are present. In recent years, laparoscopy has been proposed as the access of choice to remove fibroids up to 10 cm in diameter. Concern and debate continue over the integrity of the scar produced and its strength in a future pregnancy. Pre-operative investigation to assess myoma position within the uterus varies from simple pelvic ultrasound, saline infusion sonography to magnetic resonance imaging (MRI). The technique of laparoscopic myomectomy also varies and different approaches are discussed here-in. Newer non-surgical techniques, such as uterine artery embolisation (UAE), are addressed. The true value of this approach is yet to be assessed as there are no randomised control trials (RCTs) comparing it with myomectomy. Hysteroscopic resection of sub-mucous fibroids is associated with a decrease in menstrual loss. A recent publication using truly evidenced-based medicine questions the accepted surgical tradition of treating fibroids even greater than 16-gestational weeks in size [Aust. N.Z. J. Obstet. Gynaecol. 2001 (41) 125].

A new technique for and additional experience with hysteroscopic resection of submucous fibroids

New instrumentation and a new technique are described which simplify the hysteroscopic removal of the pedunculated submucous fibroid and make possible the partial removal of the sessile variety. Experience with the method is presented including the follow-up of four patients.