Even large myomas can be removed transvaginally when the technique is right
Linda D. Bradley, MD
Dr. Bradley is Professor of Surgery at the Cleveland Clinic College of Medicine, Case Western Reserve University School of Medicine. She also is Vice Chair of Obstetrics and Gynecology, Vice Chair of the Women’s Health Institute, and Director of the Center for Menstrual Disorders, Fibroids, and Hysteroscopic Services at the Cleveland Clinic in Cleveland, Ohio. In addition, she directs Hysteroscopic Education for the Residency Program at Cleveland Clinic Lerner College of Medicine. She is Past President of AAGL and serves on the OBG Management Board of Editors.
Dr. Bradley reports that she serves as a speaker for Bayer HealthCare and as a consultant to Allen Medical, BlueSpire, Boston Scientific, Hologic, and Smith & Nephew. She also served as principal investigator and contributor investigator for Bayer Research, is a reviewer for BlueSpire, serves on the Data Safety Monitoring Board of Gynesonics, and holds stock in EndoSee.
Compared with resectoscopy, the mechanical approach offers improved visualization and requires fewer insertions of the hysteroscope, shortening operative time
Uterine fibroids are a common complaint in gynecology, with an incidence of approximately 30% in women aged 25 to 45 years and a cumulative incidence of 70% to 80% by age 50.1,2 They are more prevalent in women of African descent and are a leading indication for hysterectomy.
Although they can be asymptomatic, submucosal fibroids are frequently associated with:
In postmenopausal women, the risk of malignancy in a leiomyoma ranges from 0.2% to 0.5%.1 The risk is lower in premenopausal women.
In this article, I describe the technique for hysteroscopic myomectomy using a mechanical approach (Truclear Tissue Removal System, Smith & Nephew, Andover, MA), which offers hysteroscopic morcellation as well as quick resection and efficient fluid management. (Note: Unlike open intraperitoneal morcellation, hysteroscopic morcellation carries a low risk of tissue spread.)
Classification of fibroids
Preoperative classification of leiomyomas makes it possible to determine the best route for surgery. The most commonly used classification system was developed by the European Society of Gynaecological Endoscopy (ESGE) (FIGURE 1), which considers the extent of intramural extension. Each fibroid under that system is classified as:
A second classification system recently was devised to take into account additional features of the fibroid. The STEP-W classification considers size, topography, extension, penetration, and the lateral wall (FIGURE 2). In general, the lower the score, the less complex the procedure will be, with a lower risk of fluid intravasation, shorter operative time, and a greater likelihood of complete removal of the fibroid.
A multicenter, prospective study of 449 women who underwent hysteroscopic resection of their fibroids correlated the ESGE and STEP-W systems. All 320 fibroids (100%) with a score of 4 or below on the STEP-W classification system were completely removed, compared with 112 of 145 fibroids (77.2%) with a score greater than 4. All 33 cases of incomplete hysteroscopic resection (100%) had a STEP-W score above 4.3
In the same study, 85 of 86 cases (98.9%) with Type 0 fibroids under the ESGE system had complete resection, along with 278 of 298 Type I fibroids (93.3%), and 69 of 81 Type II fibroids (85.2%).3 Complete removal is a goal because it relieves symptoms and averts the need for additional procedures.
Proper patient selection for hysteroscopic myomectomy is extremely important. The most common indications are AUB, pelvic pain or discomfort, recurrent pregnancy loss, and infertility. In addition, the patient should have a strong wish for uterine preservation and desire a minimally invasive transcervical approach.
AAGL guidelines on the diagnosis and management of submucous fibroids note that, in general, submucous leiomyomas as large as 4 or 5 cm in diameter can be removed hysteroscopically by experienced surgeons.4
A hysteroscopic approach is not advised for women in whom hysteroscopic surgery is contraindicated, such as women with intrauterine pregnancy, active pelvic infection, active herpes infection, or cervical or uterine cancer. Women who have medical comorbidities such as coronary heart disease, significant renal disease, or bleeding diathesis may need perioperative clearance from anesthesia or hematology prior to hysteroscopic surgery and close fluid monitoring during the procedure.
Consider the leiomyoma
Penetration into the myometrium. Women who have a fibroid that penetrates more than 50% into the myometrium may benefit from hysteroscopic myomectomy, provided the surgeon is highly experienced. A skilled hysteroscopist can ensure complete enucleation of a penetrating fibroid in these cases.
If you are still in the learning process for hysteroscopy, however, start with easier cases—ie, polyps and Type 0 and Type I fibroids. Type II fibroids require longer operative time, are associated with increased fluid absorption and intravasation, carry an increased risk of perioperative complications, and may not always be completely resected.
Size of the fibroid also is relevant. As size increases, so does the volume of tissue needing to be removed, adding to overall operative time.
Presence of other fibroids. When a woman has an intracavitary fibroid as well as myomas in other locations, the surgeon should consider whether hysteroscopic removal of the intracavitary lesion alone can provide significant relief of all fibroid-related symptoms. In such cases, laparoscopic, robotic, or abdominal myomectomy may be preferable, especially if the volume of the additional myomas is considerable.
To determine the optimal surgical route, the physician must consider the symptoms present—is AUB the only symptom, or are other fibroid-related conditions present as well, such as bulk, pelvic pain, and other quality-of-life issues? If multiple symptoms exist, then other approaches may be better.
How fibroids affect fertility
Fibroids are present in 5% to 10% of women with infertility. In this population, fibroids are the only abnormal finding in 1.0% to 2.4% of cases.4
In a meta-analysis of 23 studies evaluating women with fibroids and infertility, Pritts and colleagues found nine studies involving submucosal fibroids.5 These studies included one randomized controlled trial, two prospective studies, and six retrospective analyses. They found that women who had fibroids with a submucosal component had lower pregnancy and implantation rates, compared with their infertile, myoma-free counterparts. Pritts and colleagues concluded that myomectomy is likely to improve fertility in these cases (TABLE).5
Among the options are monopolar and bipolar resectoscopy and the mechanical approach using the Truclear System, which includes a morcellator. With conventional resectoscopy all chips must be removed, necessitating multiple insertions of the hysteroscope. Monopolar instrumentation, in particular, carries a risk of energy discharge to healthy tissue. The monopolar resectoscope also has a longer learning curve, compared with the mechanical approach.6
In contrast, the Truclear System requires fewer insertions, has a short learning curve, and omits the need for capture of individual chips, as the mechanical morcellator suctions and captures them throughout the procedure.7 In addition, because resection is performed mechanically, there is no risk of energy discharge to healthy tissue.
The Truclear system also is associated with a significantly shorter operative time, compared with resectoscopy, which may be advantageous for residents, fellows, and other physicians learning the procedure (FIGURE 3).7 Shorter operative time also may result in lower fluid deficits. In addition, saline distension may reduce the risk of fluid absorption and hyponatremia. The tissue-capture feature allows evaluation of the entire pathologic specimen.
Besides hysteroscopic myomectomy, the Truclear System is appropriate for visual dilatation and curettage (D&C), adhesiolysis, polypectomy, and evacuation of retained products of conception.
Even large myomas can be removed transvaginally when the technique is right
Careful preoperative assessment and innovative tools facilitate hysteroscopic myomectomy. Can office myomectomy be far off?
Randomized data shed light on AUB associated with fibroids, adenomyosis, and the use of progestins