Hysteroscopic Myomectomy Safe and Easy

Each surgeon develops his or her own technique, with the underlying goal being to maintain a balance between a pressure that gives adequate flow, distention, and visualization, and a pressure that minimizes fluid absorption. With an understanding of the underlying principles and the importance of fluid management, you will find an approach that keeps you from getting frustrated and leads to good outcomes.

Use of the Morcellation System

The new fibroid morcellation system offers some advantages—particularly when the surgeon is new to hysteroscopic procedures—because it continuously suctions away fibroid strips and eliminates the need to remove debris and redistend the cavity.

Its disadvantage, however, is that it does not allow the same breadth of surgery as can be performed with a wire loop. Generally, the new system is to be used to resect fibroids that are completely or mainly in the uterine cavity. Type II myomas, as well as large fibroids, are very difficult to deal with using this technique.

Starting Out

With any of the available devices and systems, hysteroscopic myomectomy is not nearly as technically challenging as other procedures gynecologists do. In our experience, it is not difficult to teach residents. To start, beginners should work with other physicians and remove smaller fibroids until they gain confidence. They could even start with polyps, which are easier to remove.

Those new to this procedure will soon appreciate the fact that the fears of complications are unfounded. The overall complication rate is less than 3%–-no higher, and probably lower, than the rate for other procedures like endometrial ablation—and rates of infections, hematomas, and other injuries are significantly lower than those for other procedures.

Uterine artery embolization has been gaining popularity for treatment of symptomatic uterine fibroids, and it is a procedure that patients will probably want to discuss. In many institutions, however, the procedure is not even an option for submucous fibroids, because the fibroids can separate, subsequently blocking the cervix, going through necrosis, and eventually causing sepsis and other complications. In fact, at least two deaths have been reported.

In general, patients' symptoms tend to continue after uterine artery embolization, and patients often ultimately require hysteroscopic resection.

Hysteroscopy, on the other hand, has it all for most patients: low invasiveness, high efficacy, extremely low recurrence, and excellent patient safety.

A 2-cm intracavitary fibroid is shown before surgery.

Versapoint 4-mm wire loop approaches the fibroid.

The 4-mm wire loop is placed behind the fibroid.

The postoperative resection bed is shown here. Photos courtesy Dr. Linda Bradley

Submucous Uterine Fibroids

Uterine fibroids are the most common benign tumor of the female genital tract. Almost 40% of the 600,000 hysterectomies performed each year in the United States are performed for symptomatic fibroids. Given the fact that many fibroids occur in women who want to maintain fertility, have serious health concerns, or desire the most minimally invasive option, hysterectomy often cannot be considered. When the fibroid is submucous in location, a hysteroscopic approach to myomectomy is the procedure of choice. Despite this, few gynecologists maintain this technique in their surgical armamentarium.

It is my desire that this article will spur many readers to safely proceed with hysteroscopic myomectomy. In order to accomplish this, I have asked Dr. Linda Bradley, director of hysteroscopic services at the Cleveland Clinic, and Dr. Keith Isaacson, medical director of the center for minimally invasive gynecologic surgery at Newton-Wellesley Hospital in Newton, Mass., to join me in a discussion on the advantages of the hysteroscopic approach to myomectomy.

Both Dr. Bradley and Dr. Isaacson are noted internationally for their expertise in hysteroscopic surgery. Not only are they gifted hysteroscopic surgeons, but they have written, lectured, and been principal researchers in this area as well.

On that note, let us proceed.