Submucosal Myomas Research Articles

Laparoscopic blockage of uterine artery and myomectomy

The goal of this study was to evaluate the effects of laparoscopic coagulation or blockage of the uterine arteries and myomectomy in treating symptomatic myomas. A total of 142 women with symptomatic fibroids warranting surgical treatment and wanting to retain their uteri were treated by laparoscopic coagulation or blocking of the uterine arteries and myomectomy. Most of the 142 patients had multi-myomas of the uterus, as intramural myomas (54), subserous myomas (65), and submucosal myomas (25). The number of myomas in each patient varied from 1 to 4. The size of the myomas in all patients ranged from 2 to 12 cm. In 86 cases (60.4%) the uterine wall was sutured in one layer. Average operating time was 124.2 +/- 33.1 min, and average blood loss was 117.8 +/- 48.6 ml. Mean postoperative hospital stay was 4.8 +/- 1.2 days. All patients underwent technically successful laparoscopic coagulation or blocking of uterine arteries and myomectomy without intraoperative complications. The mean follow-up time was 16.2 months (16-26). Symptomatic improvement was achieved in all patients. Five patients experienced recurrence of myomas. Laparoscopic coagulation or block of the uterine arteries and myomectomy appears to be a safe, effective, and promising new method for treating symptomatic uterine myomas.

3275: The diagnostic accuracy of transvaginal sonography in uterine pathology

Objectives: The purpose of this study is to evaluate the diagnostic accuracy in uterine pathology between transvaginal ultrasound and hysteroscopy. Methods: During the period from January 1995 to May 2005, 277 women underwent hysteroscopy combined with transvaginal ultrasound due to evaluate the cause of infertility and endometrial pathology at Department of Obstetrics and Gynecology in Korea University Hospital. Results: Mean age of the study group was 37.3 and mean parity was 1.13. According to pathologic reports, final diagnosis were normal finding (43.5%), polyp (20.8%), submucosal myoma (11.1%), endometritis (9.7%), endometrial hyperplasia (2.8%) and endometrial cancer (1.4%) etc. The transvaginal ultrasound showed 57.89% sensitivity, 65.26% specificity and 75.0% positive predictive value in detecting endometrial lesions. The sensitivity, specificity and positive predictive value of hysteroscopy were 92.61%, 69.66% and 85.5%, respectively. Overall agreement of transvaginal ultrasound and hysteroscopic finding was 58.7%. Hysteroscopy showed much higher detection rate in case of synechiae and endometritis compared with transvaginal ultrasound. Conclusions: Hysteroscopy was significantly better diagnostic procedure than transvaginal ultrasound. But transvaginal ultrasound also helpful in diagnosis of polyp, submucosal myoma and in evaluation of myometrium and adnexa. So, we concluded that both hysteroscopy and transvaginal ultrasound are useful methods in detection of endometrial lesion.

Differentiation of the various lesions causing an abnormality of the endometrial cavity using MR imaging: emphasis on enhancement patterns on dynamic studies and late contrast-enhanced T1-weighted images

The objectives of this study were to determine the usefulness of magnetic resonance (MR) imaging in the differentiation of various lesions causing an abnormality of the endometrial cavity by evaluating the imaging features on dynamic contrast-enhanced study and late contrast-enhanced T1-weighted images (T1WI). Contrast-enhanced MR imaging of 59 pathologically proven lesions that showed an abnormality of the endometrial cavity, including 32 endometrial cancers, five sarcomas, nine hyperplastic polyps, nine submucosal myomas, three hyperplasia, and one adenomyoma, were retrospectively reviewed. The enhancement degree and patterns on dynamic contrast-enhanced study and late contrast-enhanced T1WI were compared among different pathologies. On dynamic contrast-enhanced study, 72% (23/32) of endometrial cancers showed early peak enhancement to be reached within 1 min following intravenous administration of contrast material. On late-contrast-enhanced T1WI, lesions showed weak enhancement with gradual washout. Ninety-five percent (21/22) of benign lesions and 100% (5/5) of sarcomas showed late peak enhancement to be reached in 2-3 min following intravenous administration of contrast material. On late contrast-enhanced T1WI, both of these lesions showed persistent strong enhancement. Different enhancement patterns on dynamic contrast-enhanced MR imaging and late contrast-enhanced T1WI can provide a useful clue in the differentiation of various lesions causing an abnormality of the endometrial cavity.

Uterine Perforation Occurred During Hysteroscopic Myomectomy in Two Cases of Big Submucosal Myomas with Broad Base from Fundal Area

Uterine Perforation Occurred During Hysteroscopic Myomectomy in Two Cases of Big Submucosal Myomas with Broad Base from Fundal Area

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Study ObjectiveTo evaluate the safety and effectiveness of microwave endometrial ablation (MEA) in women with excessive menstrual bleeding.DesignA multi-center, prospective analysis of 318 subjects is underway with a 2:1 ratio of treatment (MEA) versus control, rollerball endometrial ablation (REA) with evaluation at 3, 6, 12, 24, and 36 months.SettingEight study sites consisting of private practice and academic centers.PatientsInclusion criteria were pre-menopausal women, 30 years or greater, with documented menorrhagia and pictorial blood loss assessment chart (PBLAC) score of 185 or higher, with uterine cavity size between 6–14 cm, and an absence of endometrial pathology. These women failed, were unable to tolerate, or refused medical therapy. Submucosal myomas were included unless they were greater than 3 cm in diameter or obstructed access to the endometrial cavity based on pre-operative diagnosis. Pre-treatment with GnRH was used for all subjects. Anesthesia included local, local combined with IV sedation, or general.InterventionMEA or REA based on randomization assignment.Measurements and Main Results64% MEA and 56% REA subjects are amenorrheic, with a preliminary analysis at 36 months post-op. Satisfaction rates are 95% and 90% respectively for MEA and REA. The clinical outcomes have been maintained across the 3 years and will be presented based on age, cavity size, and presence of fibroids.ConclusionMicrowave endometrial ablation is an effective, simple, safe, and rapid treatment for excessive menstrual bleeding, offering continued high amenorrhea rates 3 years after ablation. Study ObjectiveTo evaluate the safety and effectiveness of microwave endometrial ablation (MEA) in women with excessive menstrual bleeding. To evaluate the safety and effectiveness of microwave endometrial ablation (MEA) in women with excessive menstrual bleeding. DesignA multi-center, prospective analysis of 318 subjects is underway with a 2:1 ratio of treatment (MEA) versus control, rollerball endometrial ablation (REA) with evaluation at 3, 6, 12, 24, and 36 months. A multi-center, prospective analysis of 318 subjects is underway with a 2:1 ratio of treatment (MEA) versus control, rollerball endometrial ablation (REA) with evaluation at 3, 6, 12, 24, and 36 months. SettingEight study sites consisting of private practice and academic centers. Eight study sites consisting of private practice and academic centers. PatientsInclusion criteria were pre-menopausal women, 30 years or greater, with documented menorrhagia and pictorial blood loss assessment chart (PBLAC) score of 185 or higher, with uterine cavity size between 6–14 cm, and an absence of endometrial pathology. These women failed, were unable to tolerate, or refused medical therapy. Submucosal myomas were included unless they were greater than 3 cm in diameter or obstructed access to the endometrial cavity based on pre-operative diagnosis. Pre-treatment with GnRH was used for all subjects. Anesthesia included local, local combined with IV sedation, or general. Inclusion criteria were pre-menopausal women, 30 years or greater, with documented menorrhagia and pictorial blood loss assessment chart (PBLAC) score of 185 or higher, with uterine cavity size between 6–14 cm, and an absence of endometrial pathology. These women failed, were unable to tolerate, or refused medical therapy. Submucosal myomas were included unless they were greater than 3 cm in diameter or obstructed access to the endometrial cavity based on pre-operative diagnosis. Pre-treatment with GnRH was used for all subjects. Anesthesia included local, local combined with IV sedation, or general. InterventionMEA or REA based on randomization assignment. MEA or REA based on randomization assignment. Measurements and Main Results64% MEA and 56% REA subjects are amenorrheic, with a preliminary analysis at 36 months post-op. Satisfaction rates are 95% and 90% respectively for MEA and REA. The clinical outcomes have been maintained across the 3 years and will be presented based on age, cavity size, and presence of fibroids. 64% MEA and 56% REA subjects are amenorrheic, with a preliminary analysis at 36 months post-op. Satisfaction rates are 95% and 90% respectively for MEA and REA. The clinical outcomes have been maintained across the 3 years and will be presented based on age, cavity size, and presence of fibroids. ConclusionMicrowave endometrial ablation is an effective, simple, safe, and rapid treatment for excessive menstrual bleeding, offering continued high amenorrhea rates 3 years after ablation. Microwave endometrial ablation is an effective, simple, safe, and rapid treatment for excessive menstrual bleeding, offering continued high amenorrhea rates 3 years after ablation.

136: Hysteroscopic Myomectomy in Postmenopausal Women

To review the findings in post menopausal patients undergoing hysteroscopic myomectomy. Retrospective case controlled study, Canadian Task Force classification II-2. Private practice. Eighteen women with post menopausal bleeding whose only demonstrable uterine abnormality was submucosal myoma and 2 asymptomatic women with abnormal ultrasounds. Hysteroscopic myomectomy in 19 patients with the concomitant destruction of the endometrium in 4 patients and resectoscopic biopsy in 1 patient. A sarcoma was found in 2 of the 18 patients with post menopausal bleeding. Three patients underwent a subsequent gynecologic surgery; a hysteroscopy to evaluate and remove an asymptomatic residual myoma found on an ultrasound and 2 patients who underwent a hysterectomy. One hysterectomy was for a sarcoma and the other for a carcinoma of the cervix. One patient has had further unexplained post menopausal bleeding. Only 1 of the 7 patients who were on hormonal placement therapy after their resection had further bleeding. Women who have a submucosal myoma that becomes symptomatic in the menopausal period may be at increased risk for a sarcoma.

Hysteroscopic myomectomy in postmenopausal women

Study objective To review the findings in postmenopausal patients undergoing hysteroscopic myomectomy. Design Retrospective case-controlled study (Canadian Task Force classification II-2). Setting Private practice. Patients Eighteen women with postmenopausal bleeding and two asymptomatic women with abnormal ultrasounds. Interventions Hysteroscopic myomectomy in 19 patients, with concomitant destruction of the endometrium in 4 patients, and resectoscopic biopsy in 1 patient. Measurements and main results Three patients underwent subsequent gynecologic surgery. One had hysteroscopy to evaluate and remove an asymptomatic residual myoma found on ultrasound. A sarcoma was found in two of the symptomatic patients. Two patients underwent hysterectomy—one for a sarcoma and the other for a carcinoma of the cervix. One patient has had further postmenopausal bleeding. Conclusion Women who have a submucosal myoma that becomes symptomatic in the menopausal period may be at increased risk for a sarcoma.

Successful treatment of submucosal myoma with acute severe uterine hemorrhage by emergency uterine arterial embolization followed by early hysteroscopic myomectomy: a report of two cases

Two submucosal myoma cases with acute severe uterine hemorrhage were initially treated by emergency uterine arterial embolization for hemostasis. Then, after improvement of the general condition, early hysteroscopic myomectomy was performed. In one patient, complete resection was achieved. In another patient, the initial resection was incomplete because of the large tumor size. However, the remaining myoma tissue was spontaneously expelled later with no complications. Red blood cell transfusion was not required in either patient.

Clinical application of virtual hysteroscopy by CO 2-multidetector-row computed tomography to submucosal myomas

Study objective We produced virtual hysteroscopy (VH) images from the images obtained after expanding the uterine cavity of patients with submucosal myomas and performing multidetector-row computed tomography scans, and assessed them in comparison with hysteroscopic imaging and in relation to the advantages of VH. Design Cohort-control study (Canadian Task Force classification II-2). Setting Tokyo Medical University Hospital department of obstetrics and gynecology. Patients Thirty-one patients with submucosal myomas treated by endoscopic surgery. Measurements and main results The expandability of the uterine cavity by CO 2 gas was favorable in all 31 patients in whom imaging was performed, and it was possible to obtain clear VH images. The sites of origin of the submucosal myomas were clearly visualized; their imaging was consistent with imaging by hysteroscopy; and as a method of establishing the orientation of the uterine cavity, it was possible to obtain a greater amount of information than by hysteroscopy. Conclusion Although the invasiveness of radiation exposure and contrast medium cannot be denied, the possibilities of and indications for VH, which by expanding and visualizing the uterine cavity enables the acquisition of navigation images of the uterine cavity that varies in morphology from patient to patient, are expected to continue to expand.

Improving results of hysteroscopic submucosal myomectomy for menorrhagia by concomitant endometrial ablation

Study objective To evaluate the effect of endometrial ablation on the outcome of premenopausal patients undergoing hysteroscopic myomectomy for menorrhagia or menometrorrhagia Design Retrospective cohort study (Canadian Task Force classification II-2). Setting Private practice. Patients One hundred seventy-seven women with one or more submucosal myomas experiencing menorrhagia or menometrorrhagia. Intervention Hysteroscopic myomectomy without endometrial ablation in 104 patients and with concomitant endometrial ablation in 73 patients. Measurements and main results Bleeding was controlled in 95.9% of patients with endometrial ablation and in 80.8% of patients without endometrial ablation (p = .003). Complete removal of the myoma led to better results (p = .039), which were further improved by endometrial ablation (p = .022). Endometrial ablation improved bleeding in patients whose myomas could not be completely removed, but the difference was not statistically significant (p = .23). Subsequent hysterectomies were not decreased by endometrial ablation (p = .48) or by complete removal of the myoma (p = .83). Hysterectomies for bleeding problems were decreased by endometrial ablation. Pain and dysmenorrhea were a frequent cause of hysterectomy. Conclusion Endometrial ablation at the time of hysteroscopic myomectomy improves results in the control of bleeding.

Uterine restoration after repeated sloughing of fibroids or vaginal expulsion following uterine artery embolization

The aim of our study is to present our experience with uterine restoration after repeated sloughing of uterine fibroids or transvaginal expulsion following uterine artery embolization (UAE) and to determine its safety and outcome. One hundred and twenty-four women (mean age, 40.3 years; age range, 29-52 years) with symptomatic uterine fibroids were included in this retrospective study. We performed arterial embolization with poly(vinyl alcohol) particles (250-710 microm). Clinical symptoms and follow-up information for each patient were obtained through medical records. At an average of 3.5 months (range, 1-8 months) after embolization, magnetic resonance imaging examinations with T1- and T2-weighted and gadolinium-enhanced T1-weighted images were obtained for all patients. The mean follow-up duration was 120 days (90-240 days). Eight (6.5%) patients experienced uterine restoration after repeated sloughing of uterine fibroids or spontaneous transvaginal expulsion. The locations of the leiomyomas were submucosal (n=5), intramural (n=2) and transmural (n=1). The maximum diameter of the fibroids ranged from 3.5 to 18.0 cm, with a mean of 8.4 cm. The time interval from embolization to the uterine restoration was 7-150 days (mean 70.5 days). The clinical symptoms before and during vaginal sloughing or expulsion were lower abdominal pain (n=4), vaginal discharges (n=3), infection of necrotic myomas (n=2) and cramping abdominal pain (n=1). Gentle abdominal compression (n=1) and hysteroscopic assistance (n=1) were required to remove the whole fibroid. No other clinical sequelae, either early or delayed, were documented. Magnetic resonance images revealed the disappearance of leiomyomas, intracavitary rupture resulting in transformation of intramural or transmural myomas into submucosal myomas and localized uterine wall defects. Although the small size of this study precludes a strict conclusion, there appear to be few serious complications directly related to vaginal expulsion. Vaginal expulsion or fibroid sloughing is a possible course following UAE that is manageable, and the patients should be informed about this possibility.

A Clinical Usefulness of Office Hysteroscopy

Background: Hysteroscopy is considered to be the gold standard not only for visualizing the cervical canal and the uterine cavity, but also for treating many different types of benign pathologies localized to those regions. The advent and evolution of endoscopic imaging and surgery during the last two decades has added new dimensions to the armamentarium of a gynecologist to combat intrauterine lesions. Office hysteroscopy is increasingly being used as a first line investigation for abnormal uterine bleeding and other diseases involving the uterine cavity. The aim of our study is to assess the diagnostic and operative efficacy of office hysteroscopy. Materials and Methods: In our department, 140 patients underwent a hysteroscopy examination and 18 of these underwent an office based hysteroscopy examination from September 1995 to March 2005. The cases who underwent an office based hysteroscopy examination were reviewed in order to assess the clinical usefulness and significance in the management of intrauterine lesions. Results: Major indication was abnormal uterine bleeding(12 cases, 66.7%). The others were a missed IUD and infertility. The hysteroscopic findings were a normal uterine cavity(6 cases, 33.3%), IUD in situ, polyp, submucosal myoma, endometrial hyperplasia and a placenta remnant. Conclusion: Office hysteroscopy is a safe, quick and effective method for making an intrauterine evaluation. In addition, it provides immediate results, offers the capacity of direct targeted biopsies of suspicious focal lesions, and offers the direct treatment of some intrauterine conditions.

Outcome of hysteroscopically transcervical resection of submucosal myomas for infertility

Outcome of hysteroscopically transcervical resection of submucosal myomas for infertility

Study of effects on fertility of submucosal myomas and endometrial polyps

Study of effects on fertility of submucosal myomas and endometrial polyps

One-Step Hysteroscopic Myomectomy: Unusual Cases and a Review of the Literature

Operative hysteroscopy has enabled us to resect submucosal myomas transcervically as a minimally invasive surgery. However, not all submucosal leiomyomas are easily treated by hysteroscopic resection. We report two unusual and difficult cases of submucosal myomas associated with infertility, treated successfully by one-step hysteroscopic resection. One was a large (20 cm diameter) intracavitary submucosal myoma, and the other was a deeply invasive submucosal myoma invading into the broad ligament. Hysteroscopic myomectomy of such myomas has not been reported in the literature. Since hysteroscopic myomectomy is a relatively minor procedure associated with lower morbidity, submucosal myomas with infertility should be resected hysteroscopically whenever possible.

One-Step Hysteroscopic Myomectomy: Unusual Cases and a Review of the Literature

Operative hysteroscopy has enabled us to resect submucosal myomas transcervically as a minimally invasive surgery. However, not all submucosal leiomyomas are easily treated by hysteroscopic resection. We report two unusual and difficult cases of submucosal myomas associated with infertility, treated successfully by one-step hysteroscopic resection. One was a large (20 cm diameter) intracavitary submucosal myoma, and the other was a deeply invasive submucosal myoma invading into the broad ligament. Hysteroscopic myomectomy of such myomas has not been reported in the literature. Since hysteroscopic myomectomy is a relatively minor procedure associated with lower morbidity, submucosal myomas with infertility should be resected hysteroscopically whenever possible.

Hysteroscopy in the evaluation of patients with recurrent pregnancy loss: a cohort study in a primary care population

The purpose of this study was to determine the prevalence of structural uterine defects (SUD) in patients with recurrent pregnancy loss (RPL) attending a large family medicine practice and to determine the effectiveness of the therapeutic intervention. This prospective cohort study from October 1995 to October 1998 included 23 patients aged 23 to 35 years (mean, 28.1) with an otherwise unexplained history of three or more 1st- or 2nd-trimester miscarriages and no live births. None of the couples were tobacco or alcohol users, all of them and had normal cytogenetic examinations and testing. Their jobs were unrelated to chemical handling. All patients had a complete history taken and underwent physical examination and hysteroscopy with directed biopsy. They had normal values for complete blood count, sedimentation rate, urinalysis and culture (gonorrhea, Chlamydia, syphilis, hepatitis B, HIV), lupus anticoagulant, anticardiolipin antibodies, spermiogram, progesterone, and pelvic ultrasound. Fourteen patients (60.9%) had a normal hysteroscopy (with biopsies). Nine patients (39.1 %) had SUD, as follows: Five patients (21.8%) had intrauterine adhesions, two patients (8.7%) had a septated uterus, one patient (4.3%) had submucosal myoma, and one patient (4.3%) had multiple factors. After appropriate therapy of the SUD, seven patients (77.8%) achieved successful pregnancy and two patients (22.2%) had recurrent miscarriage. In the normal hysteroscopy group, eight patients (57.1%) had recurrent miscarriages, two patients (14.3%) had infertility, and four patients (28.6%) achieved successful pregnancy with no further therapy. The prevalence of SUD in our studied population was 39.1 %. After appropriate treatment, the rate of live-birth pregnancies in these patients was 77.8%. Because SUD are the most treatable cause of RPL, these patients should be identified early after other potential causes of RPL are eliminated.

Doppler Ultrasound as an Additional Parameter for the Evaluation of Myomas and the Indication of Myomectomy during Pregnancy

Objective: Pregnancies with myomas are known to have an increased risk for complications such as abruptio placentae, dysfunctional labor, growth of the tumor, necrosis and delivery problems, but prediction is still difficult based on clinical and real-time ultrasound evaluations alone. Methods: We evaluated 15 patients with submucosal, intramural and subserous myomas, respectively. Results: We found that in the submucosal myomas, the resistance index in the spiral and radial arteries decreased from 0.80–0.95 to 0.60–0.75 when choriogonadin and aspirin were given. In 3 cases in whom the resistance index increased before delivery, intrauterine growth retardation and the need for surgical delivery occurred. In 9 cases with intramural myomas, a normal decrease in the resistance indexes was seen, but 6 cases had a sharper drop related to necrosis. In 3 of the 5 cases with myomectomies, there were not only signs of necrosis but also of sarcomatous degenerations on histology. The cases with subserous myomas had no complications and the classical physiologic conversion pattern on Doppler evaluations. Conclusion: We feel that the Doppler results helped us with the management issues and gave insights into the typical pathophysiologic sequences, but the clinical role of Doppler flow analysis in pregnancies with myomas needs to be further evaluated.

Preoperative Evaluation of Submucosal Myoma by Virtual Hysteroscopy

Study Objective To assess the utility of a new technique called virtual hysteroscopy in the evaluation of the size and location of submucosal myomas before hysteroscopic myomectomy. Design Retrospective analysis (Canadian Task Force classification II-1). Setting Department of gynecology at a general hospital. Patients Thirteen consecutive women. Intervention Sixteen-slice computed tomography (CT) scanner. Measurements and Main Results Thirteen women with submucosal myomas were examined by virtual hysteroscopy. The lesions were filmed by multislice CT scanner, immediately after CO 2 injection into the uterine cavity with an intravenous dosage of iodide contrast media. The filmed image was subsequently reconstituted and analyzed by endoscopy mode and volume mode using three-dimensional computer graphics software. The size and depth of invasion of the submucosal myoma were clearly identified by the procedure. Conclusion Accurate preoperative evaluation of the size and location of submucosal myomas before hysteroscopic myomectomy is important for a safe surgical procedure. Virtual hysteroscopy can provide such information with good reproducibility and is superior to previously described diagnostic procedures.

P06.08: The accuracy of sonohysterographical versus hysteroscopic evaluation of submucosal myomas penetrating myometrium in terapeutic qualification

P06.08: The accuracy of sonohysterographical versus hysteroscopic evaluation of submucosal myomas penetrating myometrium in terapeutic qualification