Abstract
Fibroids represent an extremely common benign uterine pathology, being a major cause of abnormal uterine bleeding disorders. Although most myomas are of benign origin, it is important to have a correct diagnostic procedure prior to endoscopic myoma resection. Preoperative imaging techniques as well as histological criteria have to be taken into account. The true prevalence of uterine sarcoma in presumed fibroids is not known, given the wide range of prevalence (0.014–0.45%) from meta-analyses mainly based on retrospective trials. Age and certain imaging characteristics are associated with a higher risk of uterine sarcoma, although the risks remain low [1, 2].
12.1 Introduction
Fibroids represent an extremely common benign uterine pathology, being a major cause of abnormal uterine bleeding disorders. Although most myomas are of benign origin, it is important to have a correct diagnostic procedure prior to endoscopic myoma resection. Preoperative imaging techniques as well as histological criteria have to be taken into account. The true prevalence of uterine sarcoma in presumed fibroids is not known, given the wide range of prevalence (0.014–0.45%) from meta-analyses mainly based on retrospective trials. Age and certain imaging characteristics are associated with a higher risk of uterine sarcoma, although the risks remain low [1, 2].
The incidence of myomas increases with age, and although the association between uterine myoma and infertility is still controversial, evidence exists that subserosal myomas do not impair pregnancy rate in IVF, whereas submucosal myomas significantly decrease implantation rate. Unfortunately, the effect of intramural myomas upon reproduction outcomes remains unknown and, until now, no adequate diagnostic and therapeutic guidelines have been established.
Recently, magnetic resonance imaging (MRI) has contributed greatly to the correct anatomical and functional mapping of myomas. Functionally, MRI differentiates the muscle layer into the junctional zone (JZ) myometrium, where the cells are responsible for the implantation and growth of the placenta. The outer myometrium, normally contributing two-thirds of the diameter, provides the muscular power for the delivery. Submucosal fibroids (SF), originating from the JZ myometrium, differ also from subserosal fibroids that originate from the outer myometrium because they have fewer cytogenetic abnormalities and the expression of sex steroid hormone receptors are more responsive to GnRH analogue treatment, providing fewer recurrences after surgery [3].
Junctional zone myomas are responsible for abnormal uterine bleeding disorders and reproductive failure. The physiological pathway to access the JZ myometrium is the hysteroscopic approach, and as such hysteroscopy plays a major role in the diagnosis and treatment of symptomatic myomas.
Since 1976, when Neuwirth and Amin reported the first five cases of excision of submucosal myomas [4], several techniques have been developed in order to render hysteroscopic myomectomy a safe and effective procedure.
This chapter will demonstrate the newest techniques of hysteroscopic diagnosis, the therapy of submucosal and intramural myomas, as well as the new instrumentation and tips and tricks to prevent complications.
12.2 Diagnosis and Preoperative Treatment
12.2.1 Classification
Several classification systems are proposed, but the most frequently used are the FIGO [5] and the European Society of Gynaecological Endoscopy (ESGE) classifications [6].
Figure 12.1 shows the different myoma locations according to the FIGO classification accessible for hysteroscopic treatment.
(a) Different locations accessible for hysteroscopic surgery, hysteroscopic view of a type 0 myoma, with detail view on the base.
(b) Type 1 myoma – more than 50% is in the cavity, type 2 myoma – more than 50% is intramural but myoma is visible in the cavity.
(c) Type 3 myoma – only bulging of the endometrial line visible, capsula identification with overlying endometrium; intramural part is dissected with the 5 Fr. instrument.
Figure 12.1 Different myoma locations.
Type 0 defines a pedunculated myoma into the cavity, while type 1 myoma has a significant intramural portion, but the largest diameters into the cavity. The type 2 myoma, on the other hand, is recognized with a small portion into the cavity, but with its largest diameter in the myometrium. Type 3, only referred to in the FIGO classification, does not have a portion into the cavity, but originates from the JZ myometrium and has sufficient security zone towards the uterine serosa. Today, with the help of concomitant ultrasound, that myoma also can be removed using hysteroscopic techniques.
12.2.2 MRI
A study on inter-observer reproducibility in MRI versus transvaginal ultrasonography (TVS), hysteroscopy (HSC) or hysterosalpingography (HSG) demonstrated that the agreement on evaluation of myomas was significantly greater by magnetic resonance imaging (MRI) than by any other technique [3].
Unlike ultrasound, MRI demonstrates that the non-pregnant myometrium is not a homogeneous smooth muscle mass, but consists of two different structural and functional entities. The myometrium adjacent to the endometrium is a hormone-dependent different uterine compartment called junctional zone (JZ) myometrium, and it is seen as a smaller central zone of increased density due to its higher nuclear/cytoplasm ratio, decreased extracellular matrix and lower water content. The JZ is an entity functionally important in reproduction and it is ontogenetically related to the endometrium. Indeed, cyclic changes in sex steroid hormone receptor expression in the JZ mimic those of the endometrium. Highly specialized contraction waves originate exclusively from the JZ and participate in the regulation of diverse reproductive events, such as sperm transport and embryo implantation. Evidence exists that structural changes in the JZ also play an important role during pregnancy by regulating trophoblast invasion and the formation of a functional placenta [7].
The most commonly used classifications of myomas are related to their location, namely submucosal, intramural or subserosal. Based on the information gathered by MRI, it must be stated that the intramural myoma must be seen as a misnomer, and a myoma should be classified either as JZ myometrium or outer myometrium myoma (Figure 12.2).
In agreement with this evidence, the physiological pathway to access the JZ myometrium is obviously the hysteroscopic approach.
12.2.3 One-Stop Uterine Diagnosis by Combining Hysteroscopic and Ultrasound Exam
A one-stop uterine diagnosis includes a transvaginal ultrasound followed by a fluid mini-hysteroscopy using the vaginoscopic technique, and it concludes with a vaginal ultrasound, using the fluid of the hysteroscopy as contrast, to finally evaluate the uterus as a whole (Figure 12.3a).
(a) Normal findings.
(b) Intrauterine myoma type 0.
(c) Combination ultrasound and HSC for type 1 myoma.
Figure 12.3 The one-stop diagnostic exam includes transvaginal ultrasound (2 or 3D) followed by hysteroscopy and contrast sonography of the uterine cavity.
Especially for the diagnosis of myoma, the combination of ultrasound and hysteroscopy is very beneficial; size and location can be defined correctly in this manner (Figure 12.3b).
The feasibility of ambulatory ultrasound has been greatly accepted, but even nowadays diagnostic hysteroscopy can be performed under the same conditions. The scientific evidence provided shows that small-bored 30° rigid scopes are needed, as well as saline as a distension medium, while employing the vaginoscopic approach [8–11].
Based on these findings, the CAMPO TROPHYSCOPE® was invented. The publication in The Lancet demonstrates that in 350 hysteroscopies performed in eight different centres in patients with failed IVF, no complication and no access failure occurred [11].
The CAMPO TROPHYSCOPE® consists of an all-in-one system, where the exam is started with the compact 2.9 mm atraumatic rigid 30° single-flow optic. If necessary, a second sheath can be forwarded by a visually controlled dilatation, without removing the scope (Figure 12.4a). This reduces the risk of discomfort, perforation or involuntarily lesion to the fragile endometrium.
(a) CAMPO TROPHYSCOPE® 30° rigid optic single flow of 2.9 mm in diameter with Continuous-Flow Examination Sheath in passive position, 7 cm from top of instrument. By forward movement it is possible to perform visually guided dilatation up to 3.7 mm, creating also the double flow function.
(b) The Continuous-Flow Operating Sheath uses the same dilatation methodology and enlarges the diameter from 2.9 to 4.4 mm, giving access to 5 Fr. instrumentation for surgical action.
Figure 12.4 CAMPO TROPHYSCOPE®.
The exam always starts with an instrument diameter of 2.9 mm and is increased to a diameter of 3.7 mm for the Continuous-Flow Examination Sheath and 4.4 mm for the Continuous-Flow Operating Sheath.
A very important feature of the CAMPO TROPHYSCOPE® is that, by removal of the scope, the Continuous-Flow Examination Sheath can be used to insert instruments like the TROPHY Curette or an endo–myometrial tissue sampler, like the Spirotome, to perform tissue sampling of the endo- and myometrium under ultrasound control.
In this way, correct anatomo-pathological examination of the endometrium and JZ myometrium is possible without the need for a speculum. Both ultrasound and post-sampling hysteroscopy control the correctness of the procedure.
With use of the Continuous-Flow Operating Sheath, the instrument diameter is visually enlarged to 4.4 mm, providing the possibility to enlarge the diagnostic procedure with minimally invasive actions, using the mechanical and bipolar 5 Fr. instruments (Figure 12.4b).
Combining ultrasound and hysteroscopy makes it possible to enlarge the diagnostic procedure with safe and ambulatory tissue sampling, which is certainly an advantage if myoma dignity is questioned.
12.2.4 Myometrial Biopsy with the Spirotome® (Figure 12.5)
Today, uterine exploration in patients with infertility, abnormal uterine bleeding and pain should not be restricted to the visual exploration of only the uterine cavity, but should also include the exploration of the inner and outer myometrial structures. In case of suspicion of abnormality in the JZ myometrium or in case of myoma in a patient above 40 years of age with a suspicious image on ultrasound, a biopsy should be performed prior to hysteroscopic surgery (ESGE) [12, 13].
(a) 2D ultrasound image shows focal hyperechogenic zone; TROPHY Continuous-Flow Examination Sheath is used as atraumatic guide to insert the Spirotome.
(b) Introducing the Spirotome in an enlarged (>2 cm) anterior uterine wall under ultrasound guidance.
(c) Spirotome inserted in the TROPHY Continuous-Flow Examination Sheath.
(d) Hysteroscopic view of the puncture place showing the atraumatic character.
(e) Biopsy specimen, corkscrew and cutting device.
Figure 12.5 Spirotome biopsy.
The Spirotome consists of a specially designed helix, which is turned clockwise under ultrasound control to enter the target, then the sample is cut from the surroundings by turning the cutting cannula clockwise over the helix until the distal ends meet.
The TROPHY hysteroscopy offers the possibility to facilitate the introduction of the Spirotome into the uterine cavity. After the diagnostic hysteroscopy is performed, the 2.9 mm scope is removed and the atraumatic Continuous-Flow Examination Sheath remains in the uterine cavity. Under ultrasound guidance, the TROPHY Continuous-Flow Examination Sheath is positioned exactly towards the sonographic suspicious area.
Once the position is agreed on, the helix is introduced in the TROPHY Continuous-Flow Examination Sheath and, thanks to its specific navigation features under ultrasound control, a precise navigation and a correct direction and position of the helix point can be achieved. There tends to be minimal or no bleeding during helix navigation and the (ultrasound) image remains unchanged without confounding by blurring, as it may otherwise occur in the event of bleeding. The sample is preserved inside the helix. In other words, it is as if the histology is untouched except for the spiral wire that traverses through the tissue.
Subsequently, the cutting cannula is turned clockwise and a sample of up to 20 mm in length can be taken.
During cutting, the sample is fixed by the contours of the helix and by the tissue fibres running through it. This means that the suspicious target tissue is cut at a stage when the sample is not dislocated by ballistics or aspiration. It is noteworthy that there is no need for additional cutting of the sample at the (open) distal end of the helix. The sample remains in the helix when retracted. This is achieved through the tissue fibres that run through the helix when exposed during navigation. This keeps the sample in the helix at the moment of retraction. The Spirotome, also used in numerous other applications, claims to have the lowest possible risk of cell spreading by performing the biopsy [14, 15].
12.2.5 Preoperative Treatment
The increased size of a myoma exponentially increases surgical time, using the conventional resection technique with the resectoscope [16]. Surgery time correlates directly with operative risks. For this reason, it is advisable to pretreat large myomas to reduce their size prior to hysteroscopic resectoscopy. For the combined medical–surgical treatment, we administer long-acting GnRH analogue prior to menstruation, preventing a flare-up reaction, and surgery is planned following 10–12 weeks of treatment. Possible anaemia can be corrected during this period. It has been demonstrated that this treatment is effective in reducing operative times, fluid absorption and the difficulty of the procedure [17]. Although reports describe the removal of very large intrauterine myomas [18], we recommend individualizing the combined medical–surgical approach according to the size, location, amount of myoma and concomitant pathology.
GnRH preoperative treatment is recommended for single myomas type 0 larger than 4 cm, type 1 myomas larger than 3 cm and type 2 myomas larger than 2.5 cm. In case of multiple myomas, medical treatment is advised when the total diameter exceeds 4 cm. Concomitant pathology, like anaemia or adenomyosis, are arguments in favour of a combined therapy.
Ulipristal acetate (UPA) or progesterone is not as effective in reducing size, but can soften the hardness of the tissue and facilitate the use of the shaving procedure. Unlike the resectoscope, the shaver is not limited by size only, but additionally by the hardness of the tissue. In case of soft pathology, the shaver can remove more than 3 cm of tissue within a few minutes [19–21].
Experience today in the use of progesterone or UPA to prepare a myoma for appropriate shaver use is insufficient to draw up guidelines, and their application for this indication is limited to research.
12.3 Hysteroscopic Treatment of Myoma
12.3.1 Instrumentation
The newest generation of operative instruments has brought a revolution to the hysteroscopic surgical possibilities (Figure 12.6).
Figure 12.6 Newest hysteroscopic operative instrumentation for minimally invasive myoma removal. (a) 9–15 Fr. Optical dilatation CAMPO TROPHYSCOPE®, 30°, size 3.7 mm, length 22 cm, Continuous-Flow Operating Sheath, size 5.8 mm, length 16 cm, with channel for semi-rigid instruments 5 Fr. (KARL STORZ SE & Co. KG, Germany) (b) 19 Fr. Intrauterine BIGATTI Shaver (IBS®). Wide-angle straight, forward telescope 6°, with parallel eyepiece, length 20 cm, 19Fr., obturator, with integrated outflow channel with LUER-Lock connector replaceable with Shaver Blades (KARL STORZ SE & Co. KG, Germany). The blades have an opening of 25 mm2 with either a flute beak shape (A) or an elliptically open shape, similar to shark jaws (B). (c) 15 Fr. Office Resectoscope, Straight Forward telescope 0°, diameter 2.9 mm, with bipolar and cold loop electrodes. 15 Fr. Office Resectoscope: Vascularized and dense pathology (KARL STORZ SE & Co. KG, Germany). The current runs between the active (d) and passive (e) electrode. The electrical pathway is local, reducing risk of adhesion formation and complications. To provide the necessary tissue, cutting firm tissue contact at the start is necessary.
The most important evolution is the miniaturization of the different operative hysteroscopes to a similar diameter of 15–19 Fr. and the visual dilatation with the CAMPO TROPHYSCOPE®. This provides the possibility to make a diagnosis and perform therapy without the need for blind dilatation, use of tenaculum or speculum insertion. The operative hysteroscopes, such as the CAMPO TROPHYSCOPE®XL, 15 Fr. Office Resectoscope and 19 Fr. Intrauterine BIGATTI Shaver (IBS), can be interchanged depending on the individual needs of the surgery. Also, the newest-generation pump systems have improved safety and patient compliance.
The HYSTEROMAT E.A.S.I.® is an intelligent, pressure-controlled double roller pump that maintains a constant intrauterine pressure control, in contrast to conventionally used pump systems that work with a predefined extrauterine pressure [20].
12.3.2 Basic Principles for Surgical Strategy in Hysteroscopic Myoma Removal
The surgical strategy is related to the size, position and hardness of the myoma.
12.3.3 Myoma Resection with the Resectoscope
Until recently, the resectoscope was the only and most frequently used instrument for removing intrauterine myomas, using the same technique of slicing as in prostate resection [22–24].
The uterine application, however, has the problem of tissue removal after resection and the uterus as an organ has a higher risk for fluid overload syndrome.
Traditionally, the monopolar resectoscope was used for myoma resection, but nowadays, bipolar resectoscopes are used with ever-increasing frequency (Figure 12.7).
In order to prevent complications, it is recommended to choose either monopolar or bipolar current in operative hysteroscopy, as both surgical handling and OR room organization are quite different for each technique.
12.3.3.1 Monopolar or Bipolar System
In the monopolar system, the body of the patient is integrated into the electrical circuit. The generator produces high-frequency current, which is conducted via the resectoscope into the uterine cavity. The ‘active’ electrode touches the surface of the pathology with a very small diameter. Therefore, current density is the highest at the tip of the ‘active’ electrode leading to maximum heat creation for cutting and coagulation. The current disperses through the tissue ‘myometrium’. The surrounding fluid may cool the electrode, but, as long as it is non-conductive, it acts as an insulator. Electrical current is only passing through the electrode and cannot spread through the fluid. The current is dispersed in the patient’s body and wanders via the uterine wall, parametrium and connective tissue to the so-called neutral electrode. The neutral electrode should usually be placed on one of the patient’s thighs. Monopolar electro-surgery needs non-conductive solutions; glycine or sorbitol–mannitol solutions are often used as distension medium. Ideally, the operation should not exceed 45 minutes and the fluid deficit should not be over 500–1,000 mL with a maximum of 6 L of glycine to avoid serum electrolyte alteration (fluid overload syndrome) [25–27]. The above drawbacks of the monopolar current are the main reasons for most users to change to bipolar surgery.
The bipolar system is one of the major achievements of the last years.
Also, in bipolar electrosurgery, we have heat created by alternating current. The only, but decisive, difference is that ‘active’ and ‘neutral’ electrodes are brought close together in one instrument and the distension fluid must be conductive. Current sparks from one electrode to the other and, when tissue is brought into this electric arc, it will be cut, coagulated or vaporized, dependent on the voltage. As current always searches for the easiest way, it is only spreading from one electrode to the other and not wandering through the patient’s body. Therefore, a plate on the patient’s thigh is not needed and it is possible to use saline solution as distension medium.
Overhydration becomes less dangerous and the amount of fluid loss that can be tolerated is less restrictive in bipolar surgery than with anionic solutions. It provides surgeons with a more comfortable environment and they will be able to finalize the interventions in a single step more frequently.
Not only is the distension medium of advantage, but also the localized current pathway in bipolar surgery decreases the risks of electrosurgical hazards and the overall surgical risk.
Some bipolar resectoscopes have a rather voluminous electrode design, where active and neutral electrodes are placed one in front of the other. Although this kind of electrode reduces the field of movements of the surgeon, it also obliges the surgeon to adapt surgical manoeuvres to this specific type of electrode and reduces the risk of involuntary electrical perforation of the uterine wall (Figure 12.7b).
12.3.3.2 Surgical Technique
The classical resectoscopic excision of an intracavitary fibroid is carried out by using the electric loop (monopolar or bipolar). Resection usually begins from the top of the fibroid, progressing in a uniform way towards the base, also in the case of a pedunculated fibroid [23, 28]. During the resection of the fibroid, particularly when it is large or the cavity is small, the fragments that are sectioned and then accumulated into the cavity may interfere with a clear vision. Thus, they must be removed from the uterine cavity by taking out the resectoscope after grasping the loose tissue elements with the loop electrode. Frequent in and out movement of the resectoscope is related with a risk of laceration of the cervical branch of the uterine artery and the risk of air embolism. To minimize the risk of air embolism, it is recommended not to use speculum and tenaculum but the vaginoscopic approach of filling up the vagina with fluid.
When using monopolar current, mechanical forces must never be used and forward movements of the electrodes are not allowed while the current is activated. The loop should be in view at all times when the electrode is activated. Due to the absence of combined mechanical and electrical manoeuvres, J. Hamou proposed the technique of hydromassage to deal with the intramural part.
It is performed through rapid changes of intrauterine pressure, using an electronically controlled irrigation and suction device. Indeed, by interrupting and restarting the supply of distension liquid several times, myometrial contraction is stimulated, obtaining the maximum possible migration of the intramural component of the fibroid into the cavity. This technique developed starting from the observation that the intramural portion of a submucosal fibroid squeezes out of its base after contractions of the uterus during the removal of the intrauterine portion.
Using a bipolar resectoscope, the surgical technique to deal with the intramural part is different.
The conventional bipolar resectoscope has a stronger and more voluminous loop, which can combine mechanical and electrical energy; firm tissue contact is necessary prior to activation of the cutting current. The cutting procedure concentrates at first in the middle part of the myoma, removing as much tissue as possible toward the deepest part of the intramural location. As soon as sufficient volume has been removed, the sidewalls will collapse under gentle mechanical pressure (Figure 12.8a). Hydromassage is not necessary and the myoma can be resected totally by clear identification of the capsule due to the combined use of mechanical and electrical power.
12.3.3.3 Removal of the Intramural Part by the Cold Loop Resectoscope Technique
This surgical procedure uses a resectoscope with cold and electrical loops [29, 30, 31].
It is performed in a sequence of three steps.
The first step consists of the excision of the endocavitary component of the fibroid with the usual technique of slicing, using the angled cutting loop. The surgeon must stop the slicing at the level of the plane of the endometrial surface.
The second step consists of the enucleation of the intramural component of the myoma through traction and leverage manoeuvres with a non-electrical cold loop. Once the cleavage plane has been identified, the rectangular loop is inserted into the plane between the fibroid and myometrium and then used mechanically along the surface of the fibroid, thus achieving a progressive blunt dissection from the myometrial wall. The single tooth loop is then used to hook and lacerate the slender connective bridges that join the fibroid and the adjacent myometrium. During this phase of enucleation, electric energy must not be used in the thickness of the wall and the loop must be used in a cold manner.
Step three consists of the excision of the intramural component, which has been totally dislocated inside the uterine cavity with an angled cutting loop [24, 29, 30].
Concomitant transabdominal or transrectal ultrasound improves safety and the possibility of removing the intramural part of the myoma in one step. As such the permanent presence of an ultrasound machine, preferably integrated into the endoscopic tower, is highly recommended [32–34].
12.3.4 Myoma Resection with a Shaver
The 19 Fr. Intrauterine BIGATTI Shaver (IBS®) or TruClear shaver have the advantage that the tissue is suctioned, grasped, cut and simultaneously removed [35–39].
The 19 Fr. Intrauterine BIGATTI Shaver (IBS®) consists of two hollow reusable metal tubes fitting into each other. The inner tube, rotated within the outer tube, is connected to a handheld (DRILLCUT-X® II KARL STORZ SE & Co. KG) motor drive unit (UNIDRIVE® S III by KARL STORZ SE & Co. KG) and to a roller pump (HYSTEROMAT E.A.S.I.® KARL STORZ SE & Co. KG) controlled by a foot pedal.
The TruClear hard tissue shaver (Medtronic) is equipped with a rotation shaver blade, shielded by a sheath and connected to a suction system. Fragments are directly removed.
Inflow of distension medium is through the inflow channel of the scope and behind the shaving blade. This results in a fluid passage, which allows working in very narrow spaces, proving of advantage compared with the resectoscope. On the other hand, a performant fluid administration system is necessary for optimal shaver use. Inappropriate fluid pressure management will result in cavity collapse and will provoke bleeding, disturbing the vision.
When the tissue is removed by the shaver, the surgery becomes very easy and fast. Unlike the resectoscope, the shaver is not really limited by the size of the pathology, but rather by the hardness of the tissue.
This approach does not introduce an electrical current inside the uterus and has no risk of potential thermal damage to healthy endometrium.
Bigatti has shown that the use of the 19 Fr. Intrauterine BIGATTI Shaver (IBS®) is less difficult than the use of a resectoscope. Based on his experience, the shaver should be recommended as the primary approach to intrauterine tissue
12.3.5 Myoma Removal with Mechanical Instruments and Bipolar Needle
Both dissections, as slicing of the myoma, can be performed with the mechanical and bipolar instruments. The intracavitary part of the myoma is first divided in long small slices and sectioned at the endometrial line. The slices are now easily removed through the cervical channel with the grasping forceps. In a second step, the myoma is dissected out of the capsule and sliced in the same way as the intracavitary part (Figure 12.8b).
12.3.6 Combined Approach to Myoma Resection
12.3.6.1 Intramural Dissection with the 5 French Instruments and CAMPO TROPHYSCOPE®
For type 1 to 3 myomas, the first step is the dissection of the myoma out of its capsule with the blunt microscissor using the CAMPO TROPHYSCOPE® or the cold loop technique of the resectoscope.
After localizing the myoma, an incision is made at the transition zone with the endometrium of a type 1 or type 2 myoma. For a type 3 myoma, the site of incision is determined under concomitant ultrasound control.
Once the capsule is identified, the incision is enlarged and the CAMPO TROPHYSCOPE® is inserted in the space between the myoma and myometrium, the capsule space (Figure 12.9).
(a) Type 3 and 2 myoma overview.
(b) Dissection with 5 Fr. scissor with identification of the space of the capsula.
(c) Identification and coagulation of the vascular steal; capsule after total resection of the myoma.
Figure 12.9 Capsule identification.
The myoma is liberated from the surrounding myometrium by hydro dissection, mechanical dissection with the scope tip and section with the 5 Fr. scissors. Pinpoint coagulation of vessels is performed with the bipolar probe to reduce bleeding and to improve visual conditions; this considerably facilitates the subsequent surgical procedure. It is important to perform the coagulation and section of the important afferent and efferent vessels prior to myoma resection.
The liberation of the myoma out of its surroundings is performed for 80% including the vascular steal. The myoma has to remain partially attached to the wall in order to facilitate the resection and removal.
The cold technique avoids myometrial stimulation or damage of the surrounding healthy myometrium and is to be preferred, especially in patients of childbearing age.
12.3.6.2 Resection and Removal
The myoma that is devascularized and still partially attached to the wall still has to be removed. Depending on the size, tissue hardness and position, the surgeon can choose amongst three options:
a. Continue with the 5 Fr. instruments and cut the myoma into long and small strips, which can easily be removed with the grasping forceps.
b. Insert the 19 Fr. Intrauterine BIGATTI Shaver (IBS®) and remove the myoma with the shaver. The success of this procedure depends on the hardness of the tissue. One can combine the above technique with the shaver to improve the accessibility of the shaver. As soon as the myoma is shaped with the bipolar resectoscope into small pieces, the shaver can be used to remove the chips (Figure 12.8c).
c. The 15 Fr. Office Resectoscope can be used to resect the avascular myoma in the typical way as described previously.
12.3.7 Complete Excision of Fibroid by a Two-Step Procedure
Classically, the technique consists of the following steps:
The surgery starts with the excision or incision of the intracavitary portion of the fibroid.
With the use of the bipolar resectoscope, the shaver or the bipolar needle, the myoma is progressively resected up to the endometrial line, then the surgery is stopped. The surgeon does not enter the intramyometrial part, but haemostasis must then be performed carefully.
A hysteroscopic reassessment is carried out 20–30 days after the operation or after the first menstruation to verify that the intracavitary migration of the residual intramural component of the fibroid has taken place; once this has been verified, the second operation can be done with complete excision, by means of slicing, of the residual component of the fibroid, which has now become a type 0 myoma.
Recently, several authors have described a new ambulatory surgical technique to prepare large (>1.5 cm) submucosal myomas with partially intramural development (G1 and G2) in an outpatient setting with miniaturized Office Hysteroscopes either using bipolar current [40] or the laser [41]. In a second phase approximately 4 weeks later, final excision of the myoma is performed. This technique consists of an incision into the endometrial mucosa and the pseudo-capsule that covers the myoma in the first step. Hereby, the myoma is pushed into the uterine cavity by the main force operated by the myometrial fibres and readied for final removal in a second step [40, 41].
12.4 Complications and their Management
12.4.1 Intraoperative Complications
12.4.1.1 Uterine Perforation
Uterine perforation most often occurs during cervical dilatation, hysteroscope insertion or intramyometrial tissue resection. It is more likely to occur in those with cervical stenosis, retroverted or anteverted uterus and in nulliparous or postmenopausal women. The danger of a uterine injury is especially great during the resection of intramural myoma components with the use of energy conductors; injury of organs behind the uterus, especially the intestine, may occur.
In the case of an electrical uterine perforation with the resectoscope, a diagnostic laparoscopy should be conducted for the exclusion of intra-abdominal injuries. With injuries of the intestine, an adequate surgical treatment should follow. It should be kept in mind that the zone of thermal necrosis can be bigger than the visible trauma. Even if there are no further injuries visible in the abdomen, an intensive surveillance of the patient should follow for the next few days to exclude an unidentified intestine lesion or a secondary necrosis (Figure 12.10).
(a) Laparoscopic view after perforation.
Figure 12.10 Uterine perforation.
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