Type 0 myomas are pedunculated, with the myoma lying completely within the endometrial cavity (◘ Fig. 20.1). Type I myomas are described as “sessile” with <50% intramural extension (◘ Fig. 20.2). Type II myomas are submucosal in location, with >50% intramural extension. These include transmural myomas, which extend from the submucosal to serosal edge. When viewed hysteroscopically, type II myomas form a bulge that can be seen in the endometrial cavity.

This system was originally designed to classify myomas exclusively on hysteroscopic appearance. However, this approach has significant limitations. During hysteroscopy, myomas can be compressed and recede into the myometrium as a result of the pressure of the distention media, thereby preventing full visualization of the myoma. For this reason, preoperative evaluation with ultrasonography is required to accurately determine how many myomas are present and how deeply the myomas penetrate the myometrium. Magnetic resonance imaging (MRI) can also be used for this purpose.

For a successful surgical outcome, it is important to preoperatively identify the size, number, location, and intramural extension of uterine myomas. These characteristics predict the surgeon’s ability to completely resect the fibroids during one surgical procedure. Most often, when there is a large type II myoma, the procedure has to be terminated prior to completion due to excessive fluid absorption [26].

The degree of surgical difficulty and, thus, the risk to the patient are related to the depth of penetration and size of the myomas. Pedunculated hysteroscopic type 0 (class 1) myomas up to 3 cm in diameter can usually be easily removed hysteroscopically. Larger hysteroscopic type 0 myomas (>3 cm) and hysteroscopic type I (class 2) myomas can also be approached hysteroscopically. However, the risk of fluid intravasation increases as a result of increased surgical time and the opening of myometrial venous channels during resection. Additionally, there is poorer visibility with larger myomas given the more limited space within the uterus, inability to distend the cavity well, and the large amount of myoma “chips” that accumulate within the cavity. Often, incomplete removal of larger myomas requires two or more separate operative procedures. Only the most experienced hysteroscopist would attempt a hysteroscopic resection of an intracavitary myoma 5 cm or larger.

Likewise, hysteroscopic resection of type II (class 3) myomas should only be approached by high volume hysteroscopists. They are more commonly approached abdominally by laparoscopy or laparotomy. Hysteroscopic removal of type II myomas is also associated with a greater risk of fluid intravasation and uterine perforation and commonly requires two or more procedures for complete removal.

When patients have multiple intracavitary fibroids throughout the endometrial cavity, they would benefit from a “two-staged” operative hysteroscopic myomectomy , in which myomas are removed from only one uterine wall at a time. This is to decrease the risk of apposition of the uterine walls and the development of postoperative intrauterine synechiae.

There are various techniques for removing pedunculated and submucosal myomas, including avulsion, scissors, wire-loop resection with bipolar or monopolar equipment, morcellation, and laser vaporization. However, hysteroscopic wire-loop resection still remains the most popular method of removing myomas and will be the technique discussed in this section.

When monopolar energy is used for wire-loop resection, the current setting should be 60–80 W cutting current and requires an appropriately sized grounding pad. Higher settings may be necessary with very fibrous, dense, or calcified myomas. When the bipolar generator is used, it automatically adjusts the power to default settings.

Once the submucosal myoma is identified, the wire-loop electrode is advanced in clear view and retracted towards the surgeon behind the myoma. As the wire loop is drawn towards the surgeon, small, crescent-shaped “chips” or fragments of myoma are created. The whorled fibrous appearance of the myoma is clearly different from the fascicles of soft underlying myometrium. The fibrous tissue should be methodically resected until the border of the underlying myometrium is reached. However, increased bleeding from the myometrial bed and fluid intravasation may be encountered if the myometrium is breached. The resecting loop should stay within the pseudocapsule of the myoma and not cut this myometrium. If the hysteroscopist stays within the pseudocapsule, the likelihood of a uterine perforation will nearly be zero.

Myoma chips can remain free-floating until they interfere with visualization and are then removed with polyp forceps, Corson graspers, suction curette, or with the loop itself under direct visualization. All free-floating tissue fragments should be removed and sent for histologic examination. Removing all free-floating tissue also prevents delayed vaginal extrusion of this tissue material, malodorous discharge, adhesions, and infection.

Intermittently throughout the procedure, the intrauterine pressure should be lowered to 30 mmHg or the least amount of pressure that is possible while still maintaining visualization. This rapid reduction in intrauterine pressure will aid in enucleation of the myoma via a decompression mechanism that releases the encapsulated myoma from its myometrial bed. The myoma may appear to increase in size. In fact, more myoma protrudes into the endometrial cavity allowing a more complete resection without having to resect myometrium. False-negative views can occur during hysteroscopy because of the high intrauterine pressures. The “disappearing phenomena” refers to the flattening of endometrial polyps or fibroids, resulting in a falsely negative hysteroscopic study. This disappearing phenomenon can be avoided by decreasing the intrauterine pressure at the end of the procedure and reinspecting the endometrial cavity. As a general rule, the distention pressure within the uterine cavity should be the lowest pressure that gives the surgeon adequate flow and visualization. This will allow the myoma to protrude within the cavity and minimize unwanted fluid absorption.

Intraoperative ultrasonography guidance during operative hysteroscopy is useful for resection of myomas that are hard to define. Ultrasound guidance allows constant visualization of the uterine walls, as well as the hysteroscopic instruments. Therefore, the hysteroscopist may know when they are in danger of perforating the uterine wall. This added imaging allows for resection beyond the limit conventionally defined by hysteroscopy [27].

If the patient desires fertility, overzealous resection of the myometrium must be avoided. Asherman’s syndrome may occur when large portions of overlying endometrial tissue are resected with a sessile myoma. Patients who desire fertility and have multiple intracavitary myomas, especially those with myomas on opposite walls, may require resection in two separate occasions to minimize chances of intrauterine synechiae developing postoperatively.

Complications of hysteroscopic myomectomies include uterine perforation, bleeding, infection, and fluid intravasation. Uterine perforation most often occurs with cervical dilation with a blunt dilator. These patients can be observed in the recovery room and sent home when stable.

Major bleeding after a hysteroscopic myomectomy is rare. When excessive bleeding is encountered, it is generally secondary to myometrial bleeding. When the bleeding is excessive, it can be controlled with a 25-cm³ catheter balloon left in place for 4–12 h.

Endometrial ablation was developed as a minor surgical procedure to treat women with intractable heavy menses unresponsive to medical management, who no longer desire fertility. Each year approximately 200,000 women undergo an endometrial ablation. Compared to hysterectomy, endometrial ablation offers the advantages of avoiding the morbidity and prolonged recovery associated with major surgery when patients fail medical management. However, the disadvantages include recurrence of bleeding over time. Up to 35% of women who receive an endometrial ablation will receive a hysterectomy within 5 years of the procedure. Endometrial ablation should only be offered to women who are willing to accept eumenorrhea, hypomenorrhea, or cyclical bleeding rather than amenorrhea as a final clinical result. Only 40% of women having an ablation will be amenorrheic.

There are several methods for endometrial ablation. The three “first-generation” hysteroscopic techniques include electrosurgical laser ablation, endomyometrial resection, and electrosurgical rollerball ablation. Second-generation techniques, also referred to as “global” methods, differ in that they do not require the use of the resectoscope to perform the ablation. Hysteroscopy is an integral part of only one of these systems.

Mimicking the physiologic effect of Asherman’s syndrome, the ultimate goals of endometrial ablation were to create severe endometrial scarification and secondary amenorrhea.

Endomyometrial resection utilizing a resectoscope was first reported by DeCherney and Polan in 1983 [28]. This technique utilizes unipolar electrocautery and is performed with hypotonic nonelectrolyte-containing distention media. This technique was the forerunner of hysteroscopic rollerball endometrial ablation , which has become the “gold standard” to which all emerging endometrial ablation technology is compared. Each of these devices destroys the basalis layer of the endometrium and is designed to result in hypomenorrhea or amenorrhea.

The general concept of hysteroscopic endometrial ablation involves thorough destruction of the basalis layer of the cornua and lower uterine segment. For this reason, the patient should ideally be scheduled during the early proliferative phase. Otherwise, hormonal suppression of the endometrium is required to thin the endometrium and increase the chances of success of the ablation. Hormonal suppression also increases visualization by ridding the cavity of excess blood and tissue. Hormonal options for endometrial suppression include the use of depot leuprolide acetate, danacrine, oral contraceptive pills, or progesterone-only pills 4–8 weeks prior to surgery. Surgical preparation with suction or sharp curettage immediately prior to ablation has also been used with reported success.

Vasopressin is used to decrease the risk of fluid absorption, fluid overload, and intraoperative bleeding [29]. A dilute solution of vasopressin (10 units in 50 mL saline) is injected as 5-mL aliquots into the stroma of the cervix at 12, 3, 6, and 9 o’clock positions. This causes intense arterial and myometrial wall contractions for 20–45 min. Vasopressin is not approved by the FDA for this purpose and should not be used in patients who are hypertensive.

Several varieties and shapes of electrodes are available to perform hysteroscopic endometrial ablation, including ball, barrel, ellipsoid, and large-caliber loops. Most surgeons perform rollerball endometrial desiccation with a 3-mm rollerball probe, with the goal of systematically destroying the entire endometrium to the lower uterine segment and cornual region. The technique of endomyometrial resection is also a popular method for endometrial ablation and is performed with a 90-degree wire-loop electrode.

Following a systematic surgical plan ensures optimal clinical outcomes. Excellent visualization of the entire uterine cavity and endocervix is imperative. All intrauterine landmarks are clearly delineated hysteroscopically before initiating the procedure. Once a panoramic view of the endometrium is accomplished, the surgeon should determine if there is any previously unrecognized pathology. If a subtle lesion is discovered, then a directed biopsy with a wire-loop electrode is performed and the specimen labeled and submitted separately.

Once the surgeon visualizes all of the landmarks, the lower uterine segment is cauterized circumferentially to mark the endpoint and lowest level of endometrial ablation therapy. Ablation of the endocervix is avoided to minimize the risk of cervical stenosis. Cervical stenosis can result in cyclic pain, dysmenorrhea, and, in severe cases, hematometra.

After the lower uterine segment is identified and coagulated circumferentially, the cornua and fundal region are treated initially. With the rollerball, the electrode is advanced to the fundus and then directed at the cornua utilizing a “touch technique” to desiccate the cornua. It must be remembered that the thinnest region of the uterus is at the cornua. Extra care must be taken to avoid forward pressure, which could cause perforation. The most challenging part is the fundus, since the rollerball cannot truly be rolled against the fundus. The fundus should be addressed as the first step. The posterior wall should be resected next, followed by the lateral walls and anterior walls. Traditional technique utilizes direct tissue contact, such that one-half of the rollerball is buried in the endomyometrial juncture. The rollerball should only be activated when the electrode is moving toward the surgeon to avoid perforation. Perforation with the rollerball has the added risk of inflicting burns to the pelvic viscera beyond the uterine wall. Intermittently, the rollerball may need to be cleaned and debris evacuated to provide optimal visualization.

The endomyometrial resection with a wire loop follows the same principles. This loop is generally 3–4 mm deep. The loop should be buried into the endometrium just below the superficial level of the myometrium. The cut is performed using 60–80 W of cutting current. The loop is then advanced under direct view from the fundus to the lower uterine segment. Thus, the endomyometrial junction is shaved off, creating “crescent-shaped” tissue fragments.

At the conclusion of the endometrial ablation procedure, the intrauterine pressure is reduced in order to identify bleeding areas which may be treated with coagulation current.

The majority of patients who undergo endometrial ablation are satisfied with their clinical outcome, and at least 90% will notice symptomatic improvement. However, 5–10% of patients may ultimately be required to undergo additional interventions, such as repeat ablation or hysterectomy [30].

Hysteroscopic endometrial ablation is an outpatient procedure associated with a rapid return to work, minimal complications, and high patient satisfaction. Approximately 20–60% of patients undergoing endometrial ablation with rollerball techniques will achieve amenorrhea, 65–70% will become hypomenorrhic, and 5–10% will fail. Approximately 35% of patients treated by endometrial ablation will require a subsequent operation [30]. Women receiving appropriate preoperative counseling may find this attractive in treating menstrual disorders.

Second-generation or “global” endometrial ablation refers to destruction of the entire endometrium with devices that require little or no hysteroscopic skills. Currently, FDA-approved second-generation devices available in the USA utilize intrauterine balloons, hot saline irrigation, cryosurgery, bipolar radio frequency, and microwave energy.

Second-generation technology offers the advantage of shorter procedure times while retaining the acceptable outcome rates similar to traditional rollerball ablation. However, these second-generation devices have limited or no ability to treat intracavitary pathology. For this reason, it is important for clinicians who routinely use these ablation devices to be skilled in operative hysteroscopy so that they will be equipped to treat any intracavitary pathology that they may encounter prior to performing the ablation procedures.

When energy using heat is used, the most concerning complication is perforation of the uterus with concurrent thermal damage to the surrounding viscera. Perforations of this kind require immediate laparoscopy to determine whether or not thermal injury to the pelvic organs has occurred. Thermal injury to the bowel that is not repaired may result in breakdown of the intestinal wall with spillage of bowel contents into the abdomen. When this occurs, it generally results in massive pelvic infections that may progress to disseminated intravascular coagulopathy. Other complications include skin burns with circulating hot saline, direct coupling vaginal burns from monopolar energy, and unwanted bladder or bowel thermal injuries from cryotherapy.

Most commonly, intrauterine adhesions form in the postpartum or postabortion period. Unfortunately, there is usually no way to avoid this complication during these critical periods, such as when a patient presents with postpartum hemorrhage and requires intrauterine procedures (i.e., D + C) for hemostasis. Early detection of intrauterine synechiae is a key preventative feature following intrauterine surgery, curettage, or spontaneous abortion. This is because early detection allows for identification of adhesions while they are still filmy, thin, and easily resected with prompt adhesiolysis [24, 31–34].

The incidence of Asherman’s syndrome in a select group of women, especially after curettage for missed or incomplete abortion, is reported in the range of 17%, but rates as high as 30% are reported in the literature, the majority of which are mild in severity [35–38]. Furthermore, in at-risk women, such as those who undergo curettage postpartum, the rate is speculated to be even higher [5, 39].

Any intervention that destroys the endometrium may generate adhesions of the myometrium in the opposing uterine walls. The key predictive factor to intrauterine adhesions is the gravid uterus. The gestational changes noted with a gravid uterus soften the uterine wall, resulting in greater denudation of the basalis layer during surgical interventions. The basalis layer is crucial because it is the regenerative layer of the endometrium [40].