Abstract
Uterine fibroids are common. They arise from the myometrium and occur in approximately 20–25% of women aged 35 years or more [1]. They may be found at any position within the myometrium from the serosal surface to lying completely within the uterine cavity in 5–10% [2].
14.1 Introduction
Uterine fibroids are common. They arise from the myometrium and occur in approximately 20–25% of women aged 35 years or more [1]. They may be found at any position within the myometrium from the serosal surface to lying completely within the uterine cavity in 5–10% [2].
Submucosal fibroids are found close to the inner myometrium and may protrude into the endometrial cavity to a greater or lesser extent; they have been classified according to their position (see Figure 14.1) [3]. Fibroids that are completely within the uterine cavity are classified as type 0 and are sometimes pedunculated with a narrow stalk; type 1 are those having some intramural component, but more than 50% is within the cavity; type 2 are those with less than 50% in the cavity (see Figure 14.2a and b). Pedunculated fibroids may prolapse through the cervical os, having been expelled from the uterine cavity or cervical canal (see Figure 14.2c).
Figure 14.1 The three types of submucosal fibroids: type 0 is entirely within the uterine cavity; type 1 is more than 50% within the cavity and is distinguished by the sharp angle adjacent to the endometrium; type 2 is more than 50% in the myometrium with a wide angle next to the endometrium [4].
Outpatient or office myomectomy is appropriate for the removal of small and accessible submucosal fibroids, generally those that are less than 2.5 cm diameter and of type 0 or type 1 where most, if not all of the fibroid, is within the uterine cavity. Indications for their removal in an outpatient setting are discussed, and the devices that are available and suitable for use in these circumstances. Additional equipment is considered too, including systems for fluid management. Appropriate analgesia and anaesthesia is reviewed, as it is important to ensure that the procedure is made tolerable and acceptable for the patient. Potential complications that may occur in this context are discussed. The clinical environment that is required is reviewed and consideration is given to the training necessary to perform such procedures in the outpatient setting.
14.2 Indications for Fibroid Removal
Submucosal fibroids are regarded as an important source of symptoms, such as heavy menstrual bleeding (HMB) and increased menstrual-related pain, possibly due to the uterus trying to expel an intracavitary fibroid [2]. There is an association with increased reproductive failure too, with failed implantation and increased spontaneous miscarriage, though the precise mechanism remains uncertain [1]. Indman argues that given the current evidence it is reasonable to offer hysteroscopic resection of submucosal fibroids to women who desire pregnancy [4]. Pritts has shown in a systematic review that in infertile women with fibroids both pregnancy and delivery rates are increased with removal of submucosal fibroids and become comparable to those of infertile women without fibroids (RR for pregnancy after treatment 1.72 [95%CI 1.13–2.58]; delivery rates 0.98 [95% CI 0.45–2.41]) [5]. However, it has been found that the best improvement in fertility follows removal of the larger submucosal fibroids, with a cumulative pregnancy rate of 25% for fibroids less than 20 mm, but 75% when larger than 30 mm [1]. It is proposed that the best prognostic factors in this context are age less than 35 years, a larger fibroid of at least 50 mm and absence of other infertility factors [6]. By contrast, the best resolution of HMB is seen following removal of the smaller submucosal fibroids (≤30 mm), those which are mainly intracavitary, and with a uterus size of less than or equal to a 6-week gestation [4].
Other circumstances when submucosal fibroids may cause symptoms include postmenopausal bleeding (PMB) arising from the surface of an intracavitary fibroid that has rubbed against the opposing atrophic endometrial surface. Also, intermenstrual (IMB) or irregular bleeding may occur in premenopausal women with the vaginal blood loss made heavier, even if not initiated, by the fibroid. Intracavitary fibroids that have been expelled from the uterine cavity through the cervical os, though relatively uncommon, are another important source of heavy vaginal bleeding.
14.3 Fibroid Removal in an Outpatient Setting: Size and Position
It is apparent that resolution of HMB, PMB, IMB and some fertility problems may arise following removal of submucosal fibroids. The important considerations for removal in an outpatient or office setting are the fibroid size, its position within the uterine cavity and relation to the endometrium and therefore its accessibility, and the patient’s willingness to opt for treatment in this context.
The advantages of outpatient treatment and why it is worth considering are similar to those for outpatient endometrial polypectomy and are namely the avoidance of a general anaesthetic with prompter recovery; fewer hospital visits with no requirement for preoperative assessment; shorter stay in hospital, with reduction in associated risks such as hospital-related infections; and quicker return to normal activities including return to work [7]. Patients can be offered a see-and-treat service with a single, short hospital or clinic visit, which may be particularly appreciated by patients awaiting fertility treatment. In addition, in the outpatient setting, the number of clinical staff is lower, with the potential for cost savings; often only the hysteroscopist and usually two nursing and one support staff are required [8]. In the absence of a general anaesthetic or conscious sedation there is no requirement for an anaesthetist or associated support staff.
As for diagnostic hysteroscopy, with an outpatient treatment service it is important to pay attention to minimizing patient anxiety. This is helped by the provision in advance of clearly written information about the procedure, avoiding keeping patients waiting excessively and providing a nurse to support the patient during the procedure [8]. This person, sometimes referred to as the ‘local vocal’, will act as the patient’s advocate and ensure that the clinician is made aware if the patient is distressed and wants the procedure to cease. Some patients wish to have a clear and detailed account of what is going to happen and watch the procedure throughout on the monitor; others ask to be told the minimum without even a glance at the monitor; a few prefer silence and keep their eyes closed. It is important to be responsive to the patient and her wishes.
There are disadvantages too that must be considered: the procedure may be painful during dilatation of the cervix, with distension of the uterine cavity or with activation of some of the hysteroscopic treatment devices, particularly when electrosurgery is involved. It may not be possible to remove all of the fibroid in one session, especially when there is a myometrial component or a larger fibroid. The procedure may take longer than expected, stretching the tolerance of the patient beyond her capacity. An investigation of outpatient endometrial polypectomy found that procedures of up to 15 minutes were well tolerated [9], with a similar finding reported for outpatient fibroid removal [10].
There are, however, important differences between removal of a submucosal fibroid and an endometrial polyp; the latter are softer and so generally easier and quicker to remove [11]. Experience with outpatient see-and-treat hysteroscopic procedures found that polypectomy was successful in 67% compared with only 16% for small submucosal fibroids, though the size and position of the fibroids in this study is not described [12]. The time taken to remove a fibroid is related to its size, as elegantly demonstrated by Emanuel (see Figure 14.3) [13]. The volume of a sphere is determined by the equation 4/3πr3, and this can be used to approximate the volume of a fibroid. The time taken to resect a fibroid has been calculated as 0.5 mL/minute, so that a fibroid with a diameter of 1 cm (volume 0.52 mL) can be expected to be resected in just over 1 minute, and if 2 cm diameter (volume 4.18 mL) it would take 8.36 minutes, but a 3 cm diameter (volume 14.14 mL) would take 28.28 minutes. If the treatment time is confined to a maximum of 20 minutes, and allows for non-continuous resection, then it is necessary to limit the fibroid size to a diameter of less than 2.5 cm. Larger fibroids are therefore likely to require a second procedure, and this should be negotiated with the patient at the outset, as she may prefer to opt for an inpatient setting with the greater potential for a single treatment.
Figure 14.3 Estimated fibroid diameter and volume, with resection time as determined by fibroid removal rate of 0.5 mL/minute [13].
As previously stated, the position of the fibroid within the uterine cavity is important. Lasmar et al. proposed the STEPW classification of submucosal fibroids that provided a score for complexity of removal [14]. Fibroids that were in the lower third of the cavity were noted to be the easiest to remove, with ones at the fundus or arising from the lateral wall the most difficult.
Access to the intramural portion of a fibroid need not be impossible in an outpatient setting, but requires preparation. As with inpatient fibroid resection, shaving of the intracavitary portion allows the intramural component to move into the uterine cavity due to contraction of the surrounding myometrium, allowing for a planned two-stage procedure [15]. Another approach is to make a circular incision with a bipolar needle into the fibroid capsule at the level of the endometrium, several weeks prior to subsequent resection. Bettocchi et al. reported the successful transition of partially intramural fibroids into totally or predominantly intracavitary ones in 55/59 (93%) cases [16]. The mean diameter of the fibroids was 2.9 ± 0.8 cm, all procedures were undertaken in an outpatient setting, and intraoperative pain scores were acceptable and reported as 35.2 ± 12.7 mm on a 100 mm visual analogue score (VAS). However, all subsequent fibroid resections were undertaken as inpatient procedures. Using this preparatory technique, Haimovich et al. adapted the procedure and were able to perform both stages of treatment in an outpatient setting in 34/43 (79%) of patients [17]. They were successful with all fibroids less than 18 mm in diameter and in 85% with 19–30 mm diameter; access was easier for fibroids located in the anterior and posterior walls compared with those in either the fundal or lateral walls.
The removal of a prolapsed cervical fibroid in the outpatient setting is worth considering provided that there is sufficient space in the vagina for insertion of a speculum and manipulation of instruments, such as a monopolar diathermy loop as used in colposcopy (see below).
14.4 Operating Devices and Instruments
14.4.1 Hysteroscopic 5 French Bipolar Needle Electrodes
Small (<15 mm) submucosal fibroids can be resected or vaporized using bipolar needle electrodes passed down the 5 Fr. gauge operating channel found on many diagnostic hysteroscopes. There are several makes of bipolar needles available. The Twizzle and Spring Versapoint™ electrodes are disposable and single-use and must be accompanied by the Gynecare Versapoint™ bipolar generator; they fit down any standard rigid hysteroscope with a 5 Fr. operating channel. They were originally designed to accompany the disposable Versapoint™ sheath and reusable Alphascope™. In the outpatient setting, reduction of the power to its lowest setting (from VC1 to VC3) minimizes myometrial stimulation and pain associated with activation of the device [11]. Reusable bipolar needle electrodes are available from Karl Storz and Richard Wolf (BipoTrode) (see Figure 14.4a and b); these are compatible with most electrosurgical generators, including ones often used in a colposcopy setting.
The difficulties associated with removing solid fibroid fragments larger than the cervical os can be avoided by slicing the fibroid into smaller portions [11]. Otherwise, it may be necessary to dilate the cervix to enable blind removal of the tissue fragments with forceps, though this can cause pain and increases the risk of uterine perforation. A combination of vaporizing and slicing may be used to reduce the fibroid in size before removal; sometimes it can be removed and attached to the tip of the bipolar needle.
14.4.2 TruClear™ Tissue Removal System
The development of mechanical hysteroscopic tissue removal systems has made the resection of intrauterine pathologies significantly easier. The first system, based upon an arthroscope, enables tissue to be excised under direct vision with a moving mechanical device; the tissue is then immediately extracted by suction, so no fragments impede the view [18]. Tissue removal devices are passed down the central core of a rigid hysteroscope with an offset eyepiece; they are attached to a hand piece and activated by a foot-operated control unit.
The larger of the TruClear™ systems has an outer sheath diameter of 7.25 mm (TruClear™ Elite Plus) and so is less amenable for use in an outpatient setting, though this may be possible with a local anaesthetic cervical block. However, since the introduction of the smaller Dense Tissue Shaver Mini for tougher tissue, fibroid removal using the 5 mm hysteroscope (TC5) has become possible (see Figure 14.5) [19]. Cervical dilatation may not be necessary with the TC5. The larger TruClear™ Elite Plus hysteroscope when used with the Dense Tissue Shaver Plus has the advantage over the smaller TC5 hysteroscope of more rapid tissue removal.
Figure 14.5 The Dense Tissue Shaver Mini, for use with the TruClear™ 5C hysteroscope (5.6 mm diameter with outer sheath) or the more recently introduced 6 mm TruClear™ Elite Mini, is suitable for removal of small submucosal fibroids in an outpatient setting.
The technique for fibroid removal with this system differs from the removal of softer endometrial tissue and polyps. Efficient removal of the firmer fibroid tissue is achieved by pressing the device against the fibroid so that the open jaw is buried (see Video 14.1). Intracavitary tissue is generally readily accessible; any myometrial portion may be made more available by reducing the intrauterine pressure of the irrigating fluid thus allowing the deeper fibroid to become more exposed. The smaller Dense Tissue Shaver Mini, when not activated, may also be used to prise the fibroid away from the surrounding capsule and so push it into the cavity for ease of subsequent resection.
Video 14.1 Resection of fundal submucosal fibroid: TruClear™ Tissue Removal System using the Dense Tissue Shaver Mini.
There is evidence that mechanical removal with the TruClear™ 5C system for endometrial polyps is quicker and more effective than electrosurgical resection with Versapoint electrodes [20, 21], and may be less painful [20]; it is not known whether this also applies to the removal of small submucosal fibroids.
14.4.3 MyoSure® Tissue Removal System
The MyoSure® tissue removal system is another hysteroscopic device that combines mechanical excision of intrauterine tissue with immediate extraction by suction. There are two sizes of hysteroscope; the smaller has an outer diameter of 6.25 mm and the larger XL® of 7.25 mm. There are three blades available: (1) the Lite® can be used with either hysteroscope and is best suited for endometrial polyp removal; (2) the newer Reach® blade replaces the previous classic blade and has a shorter tip to improve fundal access and is sufficiently robust to remove small fibroids; it can also be used with both hysteroscopes (see Figure 14.6); and (3) the XL® blade, as its name suggests, is for exclusive use with the larger XL hysteroscope and is suitable for fibroid removal [22]. Cervical dilatation is generally necessary when using either hysteroscope. Recently, Hologic introduced a set of smaller hysteroscopes, the Omni™ set. This consists of a single 0? hysteroscope that may be used with a diagnostic sheath (3.7 mm), or a 5.5 mm operating sheath with either the Lite® or Reach® shaver, or a 6.25 mm operating sheath with the XL® blade.
Figure 14.6 MyoSure® tissue removal system with Reach® and XL® blades; both are suitable for removal of small submucosal fibroids in an outpatient setting. The Reach device can be used with either the smaller 6.25 mm, the larger XL (7.25 mm) hysteroscope, or the recently introduced Omni 5.5 mm and 6 mm hysteroscope sheaths. The XL device may be used with the XL scope or the Omni 6 mm.
As with the previous system, the morcellating blade is passed down the central section of the hysteroscope and operated from a control unit by a foot pedal; tissue fragments are again immediately removed by suction. The most efficient method of removing fibroid tissue is also achieved by pressing the blade against the fibroid with the open jaw buried in the tissue and also allowing any deeper tissue to be exposed by reducing the intrauterine pressure (see Video 14.2).
Video 14.2 Resection of posterior wall submucosal fibroid: MyoSure Tissue Removal System.
14.4.4 Resectoscopes
There may be initial scepticism about the use of a resectoscope in the outpatient setting, but the SHINE project in Cardiff established that it was effective and acceptable to patients for a 10 mm resectoscope to be inserted into the uterine cavity for removal of intrauterine polyps and fibroids following a local anaesthetic cervical block [23]. A monopolar resectoscope was used with glycine for irrigation. The overall pain score for the first 66 patients who responded was an average of 3.3 (SD ± 2.6) on a 0–10 Visual Analogue pain scale, where 0 was no pain and 10 pain as bad as possible. The length of the procedure for 79 patients, from start to finish of treatment, was an average of 30.7 minutes (SD ± 10.4). Patients were asked which anaesthetic they would prefer should they require the procedure again, and 88.6% of 79 women would opt for a repeat local anaesthetic while only 8.9% would want a general anaesthetic.
Successful outpatient resection of fibroids was reported by Papalampros et al., using a narrow 5.3 mm (16 Fr. gauge) diameter prototype monopolar resectoscope [10]. Fibroids of 2–3 cm diameter were removed from four women; the other patients underwent endometrial polypectomy. Importantly, all procedures were completed within 15 minutes and without complication. In total, 16 procedures were accomplished without anaesthesia, and in 14 after an intracervical block with local anaesthetic, as cervical dilatation was required. Patient tolerance was reported as good, with no patients reporting more than slight discomfort.
Resectoscopes currently in use now often use bipolar electrodes, for which an ionic fluid for irrigation is required, such as isotonic normal (0.9%) saline, rather than the non-isotonic glycine or sorbitol.
Standard-sized 9 or 10 mm bipolar resectoscopes are available from several companies, including Karl Storz, Richard Wolf and Olympus, who produce the SurgMaster (Figure 14.7c). There are also now available narrower resectoscopes particularly suitable for outpatient use, with the 15 Fr. (5 mm) bipolar resectoscope from Karl Storz (Figure 14.7a) and the 7 mm resectoscope from Richard Wolf that can be used with the suction device (Chip E-vac™) for removal of resected tissue (see Figure 14.7b). Tissue fragments otherwise need to be removed under direct vision with the resecting loop electrode or blindly with polyp forceps with the risk of uterine perforation.
(a) Bipolar 15 Fr. (5 mm diameter) resectoscope;
(b) The 7 mm Princess resectoscope with the Chip E-vac™ suction system.
(c) The Olympus SurgMaster resectoscope with 8.5 mm outer sheath for transcervical procedures in saline, with loop electrode for resection and Plasma button for vaporizing tissue.
Figure 14.7 Bipolar resectoscopes.
Techniques for excising fibroid tissue with a resectoscope are the same for outpatient as for inpatient procedures. The resectoscope electrode loop is passed beyond the fibroid and, after activation, the direction of cutting is always towards the cervix. For small fibroids, resection of the full diameter of the fibroid may be achieved by moving just the electrode; for larger fibroids, a combination of withdrawing the resectoscope through the cervix with the electrode extended, then finishing with retraction of the electrode is preferable. The cut strip of fibroid is either immediately removed from the cavity with the loop or placed at the fundus for subsequent removal while other strips of fibroid are resected. For efficient resection, the aim is to remove all of the fibroid with as few strips as possible.
14.4.5 Monopolar Diathermy Loops for Prolapsed Cervical Fibroids
Colposcopy clinics are generally furnished with equipment for taking large cervical biopsies using monopolar diathermy loops, plus an electrosurgery generator, a smoke extractor and insulated speculums, and these can be used for excision of prolapsed cervical fibroids. Infiltration of the fibroid neck with local anaesthetic containing a vasoconstrictor provides analgesia and reduced blood flow. The fibroid can be resected with a hand-held loop electrode, taking care to avoid inadvertent contact with the vaginal wall. If the fibroid stalk is inaccessible within the cervical canal or uterine cavity, it may be resected with one of the hysteroscopic tissue removal systems; dilatation of the cervix is often not required in these circumstances as the cervix will already be open. The limiting factor is the size of the fibroid in relation to the capacity of the vagina, as there needs to be sufficient space to insert the speculum and allow manipulation of the fibroid away from the vaginal wall. The patient also needs to be willing, though from the author’s own experience some are keen to avoid a general anaesthetic, if at all possible.
14.5 Fluid Management
Diagnostic hysteroscopy procedures and removal of endometrial polyps can be readily accomplished with less than a single litre of normal saline (0.9%) and a simple gravity feed or a pressure bag. However, the more solid fibroids, apart from the tiniest ones, take longer to remove and are therefore likely to require more fluid. Maintaining a consistent pressure using a 3 L bag of saline is more difficult and is best established with a fluid management system which also tracks accurately the amount of fluid used and any deficit. A constant pressure ensures a good hysteroscopic view and is more comfortable for the patient than when it waxes and wanes with a pressure cuff (unpublished data, Mary E. Connor). Serious fluid deficit is less likely than during an inpatient procedure as the treatment is likely to be of shorter duration with a smaller fibroid that is superficial and not near to the large blood vessels deep within the myometrium.
14.6 Analgesia and Anaesthesia
14.6.1 Preprocedure Analgesia
The RCOG and BSGE Green-top Guideline for Best Practice in Outpatient Hysteroscopy recommends that patients for whom it is not contraindicated should be advised to take a standard dose of a non-steroidal anti-inflammatory drug (NSAID) around 1 hour before their outpatient procedure [8]. There is limited evidence for its effectiveness, but in a small study, mefenamic acid significantly reduced post-procedural pain at 30 and 60 minutes [24]. However, a Cochrane review found insufficient evidence for either NSAIDs or opioids over placebo for providing pain relief 30 minutes after diagnostic hysteroscopy [25]. Parenteral administration of tramadol an hour before diagnostic hysteroscopy was found to reduce procedural pain [26, 27], but this may be difficult to integrate into an outpatient setting.
Debate continues as to whether cervical softening agents are beneficial for easing cervical dilatation and reducing related pain [8]. The side effects can be troublesome, with misoprostol, causing stomach cramps, nausea and sometimes diarrhoea. Other authors use preprocedure laminaria tents to gently open the cervical canal [4]. However, when compared with self-administered misoprostol laminaria tents, though equally effective, were less favoured by patients and doctors, as an additional hospital visit was required for their insertion [28].
Some particularly anxious patients may benefit from a sedative such as a small dose (2–5 mg) of oral diazepam taken beforehand; this would need to be prescribed in advance and may be provided by the patient’s general practitioner.
14.6.2 Cervical Anaesthesia
Cervical anaesthesia is pertinent for patients in this context as relatively large diameter hysteroscopes may be used; at least a 5 mm or so dilatation is often required. There is evidence that intracervical and paracervical blocks are beneficial at reducing pain associated with hysteroscopy [8]. There is insufficient evidence for recommendation of any particular local anaesthetic preparation; the addition of a vasoconstrictive substance is little needed for hysteroscopic procedures, though the duration of action is increased. Care needs to be taken when using local anaesthetics because of the potential for toxicity, with central nervous and cardiac signs and symptoms. In addition, vasoconstrictive substances may also cause cardiac symptoms; these can be avoided by using felypressin-containing preparations rather than adrenaline.
Convenient preparations for intracervical blocks are those commonly used by dentists, and they can be administered with a dental needle (27 gauge) and syringe. Local anaesthetic is inserted initially to the anterior lip of the cervix if it is to be grasped, and then at four points around the cervical os. Inserting the needle up to the hilt (3–4 cm) is recommended, so that the level of the internal cervical os is reached [29]; a long dental syringe can be useful to enable access whilst maintaining a view of the cervix. A single-toothed tenaculum placed on the anterior lip of the cervix can help provide stability during insertion of the needle so that it can be placed slowly and without bending.
Evidence for the optimum time to wait before proceeding with cervical dilatation is limited; the onset of action of mepivicaine without a vasoconstrictor is 3–5 minutes, with 45–90 minutes duration of action [30].
14.6.3 Inhaled Nitrous Oxide
A number of hysteroscopy clinics have patient-controlled nitrous oxide inhalation readily available for use during both diagnostic and operative hysteroscopy. It can be beneficial at any stage of the procedure, including during insertion of local anaesthesia to the cervix, which can hurt, as well as during the actual hysteroscopic treatment, particularly if uterine distension is painful. There is some evidence for its use in this context [31], and its use is well established on most labour wards, and for endoscopic procedures [32]. Besides providing useful pain relief, it reduces anxiety, it is safe and with few associated complications, and recovery from its use is rapid [33].
14.7 Complications of Outpatient Myomectomy
The complications that may occur with inpatient myomectomy may also occur with an outpatient procedure. Incomplete fibroid removal may arise because of poor access to the base of the fibroid due to its position within the uterine cavity or myometrium, poor patient tolerance of the procedure or calcification of the fibroid tissue preventing its resection. The consequence of incomplete removal varies; further treatment may not be necessary if the patient becomes asymptomatic [34].
Uterine perforation may happen during fibroid resection, with a risk of 0.75% [35], though this is unlikely in outpatients when removing small, superficial fibroids. Also, the patient will complain of increased pain with myometrial penetration before full perforation occurs. Even so, sudden loss of uterine distension or a direct view of peritoneal contents should be taken very seriously, especially if this occurs during activation of a resection device, with the assumption of possible bowel damage and appropriate action taken.
Postoperative endometritis or other infections are uncommon, the incidence varying with how the condition is defined, but can be expected to occur in 0.001–1.6% [36, 37]. Patients need to be warned about what symptoms to expect and where to seek help if concerned. A Cochrane review does not advocate the routine use of prophylactic antibiotics, but patients with a history of pelvic inflammatory disease are at increased risk and so more likely to benefit [38]. Hysteroscopic procedures should not be performed if there is active infection present.
Severe pain sufficient to curtail the procedure may occur, though patients who have tolerated a previous diagnostic hysteroscopy are unlikely to find removal of an intrauterine lesion more painful, provided the myometrium is not stimulated [11].
Vasovagal reactions should be anticipated and managed appropriately; reported incidences vary depending upon the definition used. Van Kerkvoorde et al. reported that 10/1,028 (<1%) patients undergoing office hysteroscopy experienced a vasovagal episode, but with a further five reporting nausea [37]. This symptom could be considered as part of a vagal response, which if combined together would still only give an incidence of 1.5%. In a systematic review of local anaesthesia in outpatient hysteroscopy an incidence for vasovagal episodes of 7.6% was identified. Of note, the use of local anaesthetic did not make a difference; neither did how the response was defined [39].
Fluid overload is of importance particularly when resecting large, deep submucosal fibroids. Whilst this particular complication should not be ignored, the likelihood of it occurring when removing small, shallow fibroids with a procedure of short duration is small. However, the same guidelines as for inpatient procedures apply, with a maximum deficit of 2.5 L of saline [40].
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