It has long been known that myomas are estrogen dependent, their size increases during pregnancy and shrink during menopause. GnRH analogues (GnRHa) induce hypogonadism through pituitary desensitization, down regulation of receptors and inhibition of gonadotrophins, this leads to decrease vascularity, resulting in the case of fibroids in a shrinkage of the mass. Because of these features, GnRHa has been found useful in the management of various hormone-dependant tumours, endometriosis and uterine fibroids.

The first successful report of the effect of GnRHa on uterine myomas was by Filicori et al. (1983). Since then many studies were published on this issue. We know that surgery is less technical demanding when myomas are smaller and a complete surgery can be achieve in a single session. The resection of large myomas is associated with increased bleeding during surgery, longer operative time, risk of fluid overload and sometimes with the necessity of repeated operations [10, 15]. GnRHa are commonly used pre-operatively before myomectomy so as to reduce the size of a fibroid in order to make surgery easier and safer [16, 17]. On the other hand GnRHa are expensive and have many unpleasant side effects such as menopausal symptoms due to estrogen deprivation.

Although the experience in the use of GnRHa for pre surgical preparation of fibroids, the medical evidence to support this practice has been weak. In one side we have observational studies such as Perino et al. [18] and Donnez et al. [19] that reported the use of GnRHa prior to hysteroscopic resection of myomas as useful, while in the other side we have Campo et al. [20] the found that this practice prolonged surgery time.

Recently was published a systematic review of the literature focused on the benefit of the preoperative use of GnRHa in women with submucous myomas, trying to determinate whether this treatment was more effective than placebo/no treatment prior to hysteroscopic resection, in terms of symptomatic relief, ability to complete surgery, operating time, complications and technical difficulties [21]. This publication shows with good quality evidence that there were no differences in terms of symptomatic relief, achieving a complete resection of the fibroid, operative difficulty and surgeon´s satisfaction. Cost analysis was not done in the included studies. There seems to be some benefit in terms of reduction in both operating time and fluid deficit. Kamath et al. conclude that there is inadequate evidence to support the routine use of preoperative GnRHa before hysteroscopic resection of submucous myomas.

Since February 2012, ulipristal acetate (UPA) 5 mg/day, is approved in Europe for preoperative fibroid treatment [22].

UPA is a selective Progesterone receptor modulator (SPRM) that potently modulates P-receptor activity [23] with proapoptotic/ antiproliferative effects on fibroid cells [24] and with pharmacokinetic properties supporting once daily dosing [25]. Two short-term (3 months) randomized clinical trials showed that UPA effectively controls HMB and shrinks fibroids [26, 27]. After treatment cessation, menstruation usually returns within 4–5 weeks, but fibroid volume reduction can be sustained for up to 6 months. In addition, treatment with UPA reduced fibroid-associated pain, improved QoL, and revealed no safety concerns [26, 27].

When compared with a GnRHa like leuprolide acetate, both were effective in controlling bleeding with a difference the median times to amenorrhea were 7 days for patients receiving 5 mg of ulipristal acetate and 21 days for those receiving leuprolide acetate. In terms of myoma size reduction there were not significative differences between the treatments, but in the case of the patients treated with leuprolide, the size increased again by 84 % compared with the UPA group in which the sized remained stable during 6 month after treatment was finished [27]. But the big difference is found in the tolerance, moderate-to-severe hot flashes were reported only for 11 % of patients receiving 5 mg of ulipristal acetate and for 40 % of those receiving leuprolide acetate (P < 0.001).

Recently a new study on long-term safety of the use of UPA 10 mg/day in the treatment of symptomatic myomas was published. It seems that repeated 3-month courses of oral UPA 10 mg once daily effectively control bleeding and pain, reduce fibroid volume, and restore QoL over the long term in many women with symptomatic fibroids, providing an effective and well-tolerated long-term medical treatment for fibroids [28]. It looks like UPA could be an alternative medical treatment for symptomatic myomas avoiding in some cases necessity of surgery.

Clinical trials have also shown that UPA administration can lead to a pattern of benign, nonphysiological, nonproliferative, histological features of the endometrium termed P receptor modulator associated endometrial changes (PAEC). These changes spontaneously reverse over a few weeks to months after cessation of the 3-month UPA treatment. It is important to remember this fact prior to schedule hysteroscopic surgery, sometimes the endometrial thickness is above 16 mm and it will difficult the correct visualization of the endometrial cavity and even will cause the suspension of the procedure. The solution can be either wait until we can check the endometrium’s thickness with an ultrasound or to give a gestagene thinning the endometrium prior to the hysteroscopic procedure [29].

Misoprostol is a stable synthetic prostaglandin E1 analogue used for the prophylaxis and treatment of peptic ulcers resulting from long-term use of nonsteroidal anti-inflammatory drugs. It is inexpensive, can be kept at room temperature, and is associated with few adverse effects. The systemic bioavailability of misoprostol is three times higher after vaginal insertion than after oral administration. Misoprostol has a cervical ripening effect and induces uterine contractions Its ripening effect was shown by numerous clinical studies [30, 31], and is consistent with biological data.

The last systematic review and meta-analysis published by the Cochrane library [32] the conclusion was that misoprostol administration prior to hysteroscopy appears to have a beneficial role in premenopausal patients undergoing hysteroscopy in both the diagnostic and operative setting. In cases in which cervical dilatation is considered as easy, misoprostol may not be routinely administered as it may only increase patients’ discomfort without any substantial benefit.

It seems that the use of 400 mg of vaginal misoprostol 12–24 h before hysteroscopy may reduce the pain and the force needed to dilate the cervix, with only mild side effects.

This is the most commonly employed approach. The resectoscope is the instrument that resects under direct and constant visual control. The sheath has an outer diameter of 7–9 mm, and includes both inflow and outflow ports for distending media. The resectoscope is equipped with continuous flow and provides excellent irrigation for operative procedures. If surgical debris or the so-called ‘chips’ block the operative field, the resectoscope can be removed while the sheath is left in place. This allows for removal of large tissue while maintaining cervical dilatation. It has a straight-forward or a slightly fore-oblique telescope 12/30° [37].

Because of the diameter of the endoscope, most of the times it requires cervical dilatation. It is performed with an inpatient in surgery room under anesthesia (see Fig. 9.6).

The distending solution depends on the electrosurgical system, if it is a monopolar system it will require a non conducting distending solution such as sorbitol 5 % or glycine 1.5 %, but if the system is bipolar the use of normal saline solution is allowed, avoiding the risk for the patient of excessive fluid absorption and the potential electrolyte imbalance [38, 39]. Fluid input and output should still also be monitored. If excessive intravasation occurs, the isotonic fluid overload is generally readily treatable with diuretics (e.g. furosemide 20 mg intravenously). Therefore, a higher amount of intravasation during surgery can be accepted. Generally, most protocols and guidelines mention about 2,500 ml as the upper limit of saline intravasation.

This endoscope uses a radiofrequency electrosurgical generator. The electrosurgical system can be monopolar or bipolar: in the monopolar one, from the extremity of the resectoscope (active electrode) the flow of current, in order to close the circuit, must reach the plate (passive electrode). The use of a bipolar set of instruments, in which both electrodes are introduced into the thermal loop, would be much safer. In this way the current will only have to pass through the tissue with which the thermal loop comes into contact, thus minimizing the danger deriving from the random passage through the corporeal structures. The passage of the electrical energy from the thermal loop to the tissues determines the cutting or coagulation action of the resectoscope. There are various types of thermal loops with different shapes and sizes. The diameters of thermal loops for bipolar resectoscopes are usually smaller than loops for a monopolar instrument with the same outer diameter, thus increasing the time required for resection (Indman 2006). The bipolar loop operates in a similar way to a monopolar electrode; however, as tissue contact is not necessary for activation, the electrodes do not ‘stick’ in the tissue while cutting (Stamatellos and Bontis 2007). Although bipolar techniques are less hazardous because of intravasation and electrolyte blood-imbalances, more gas-bubbles may hamper visualisation, and gas-embolimight even cause spasms in the lung capillaries, potentially disturbing gas diffusion in the lungs.

The removal of type-0 and most type-1 lesions is generally straightforward. It consists of repeated and progressive passages of the cutting loop beyond the myoma, with cutting only taking place during the backward or return movement of the loop. Excision usually begins from the top of the fibroid, progressing in an uniform way towards the base, it is also the technique for pedunculated fibroids. The surgery is considered finished when the fasciculate structure of the myometrium is visualized. In some cases this technique is associated to a lack of clear vision due to the accumulated fragments of fibroid in the cavity, the classical removal of tissue under visual control with the resectoscope may consume a lot of time, a resectoscope with automatic chip aspiration could be of help, or consider the use of a morcellator.

G1 and G2 fibroids should not exceed 5–6 and 4–5 cm respectively in order to succeed to remove them hysteroscopically. Although in some cases they can be removed by one-step procedure, most surgeons prefer to remove this kind of myomas through a two-steps procedure (Loffer 1990).

Myoma growth within the uterine wall produces dislocation, compression, and stretching without rupture of adjacent muscle fibers. When the intramural portion is resected by classic slicing technique, direct cut with the loop and thermal damage may cause injury to adjacent healthy myocytes.

For deep type 1 and type 2 there is a high risk of damage of the healthy myometrium during electrosurgery, both by cutting and by thermal damage. Other risks are bleeding, intravasation and the risk of perforation. In case of lesions that extend close to the serosa, within a few millimeters, sometimes there may be a role for the concomitant performance of laparoscopy, not necessarily because it reduces the chance of perforation, but because it allows for the creation of a safe buffer of gas around the uterus should perforation occur. Alternatively, intraoperative transabdominal ultrasonography can be performed when performing dissection of leiomyomas that are believed to be close to the uterine serosa [40].

In some cases it is possible to use a cold loop, those are structurally more robust than others as they are used in a mechanical way without electrical energy to carry out enucleation of the intramural component of the myoma.

Currently we can find in the market three different hysteroscopic morcellators, the Truclear (Smith and Nephew, Andover MA, USA), the Myosure by Hologic (Bedford MA, USA) and another company that recently introduced an alternative device is Storz (Tuttlingen, Germany).

The TRUCLEAR system approved by the FDA in 2005, is based on an instrument that consists of a set of two metal hollow rigid tubes that fit into each other [35]. The inner tube rotates within the outer tube, is driven mechanically by an electrically powered control unit, and is controlled by a foot pedal that activates the rotation and regulates the direction of rotation of the inner tube. The control unit is connected to a handheld motor drive unit in which the morcellator is inserted.

Both tubes have a window-opening at the end with cutting edges. By means of a vacuum source connected to the inner tube, the tissue is sucked into the window-opening, cut and ‘shaved’ as the inner tube is rotated [41]. The system uses no electrocoagulation, and there is no lateral thermal or electrical energy spread. Haemostasis occurs by spontaneous myometrial contraction. The removed tissue is discharged through the device, is collected in a tissue-trap, and is available for pathology analysis. As only one introduction is needed, the number of perforations is extremely low. The 4.0-mm morcellator is introduced in the uterine cavity through a straight-forward working-channel of a continuous flow 8–9 mm rigid hysteroscope. After dilatation of the internal orifice of the uterine cervix, atraumatic insertion is accomplished with the use of an obturator in the outer sheath of the hysteroscope.

Saline solution is used for distension and irrigation.

van Dongen et al. [42], conducted a randomised-controlled trial (RCT) to compare conventional resectoscopy and hysteroscopic morcellation among residents in training. The mean operating time for resectosocpy and morcellation was 17.0 (95 % confidence interval [95 % CI] 14.1–17.9, standard deviation (SD) 8.4) and 10.6 (95 % CI 7.3–14.0, SD 9.5) min, respectively (P < 0.008). Subjective surgeon and trainer scores for convenience of technique on a visual analogue scale were in favour of the morcellator.

A new development in hysteroscopic morcellation is the recent availability of a smaller outer diameter TRUCLEAR system, with a 2.9-mm cutting-blade and a 5.0-mm hysteroscope for office or ambulatory use with no or local anaesthesia. Polyps, small myomas, and retained products of pregnancy can be removed in that way.

MyoSure® Tissue Removal System (Hologic, Bedford, MA), was approved by the FDA in 2009; this morcellator consists of an electrical control box, a foot pedal, and a morcellator hand piece that features a rotating/reciprocating 2 mm OD cutter blade encased in a 3 mm OD outer tube. The cutter is connected to a vacuum source that aspirates resected tissue through a side-facing cutting window in the morcellator’s outer tube. Resected tissue is captured in a standard vacuum canister tissue trap and is available for pathological examination [43].

Regardless of the methodology used to resect intrauterine pathology, it is important to remember that resected tissue must be thought of in terms of three-dimensional rather than two-dimensional measurements. Thus, increasing pathology diameter yields a exponential rather than linear increase in volume following the equation ν = πd ³/6. This mathematical consideration becomes important as one plans a surgical approach for submucous myomas in which the resection rate and procedure time will be a function of the volume, density, and type of myoma tissue. With loop resectoscopy, the amount of tissue removed per minute will depend on:

On the other hand, with hysteroscopic morcellation, the amount of tissue removed per minute will only be a function of [1] how much contact the cutting window maintains with the myoma and [2] how quickly the device can cut tissue and aspirate it out. Because the devices’ cutting speeds are relatively fixed by their design characteristics, minimizing procedure time mostly depends on maintaining tissue contact between the cutting window and the pathology. Learning the correct resection technique, although not difficult, is of prime importance with hysteroscopic morcellation.

Although in vivo accurate measurements of tissue resection speed are challenging to conclusively determine due to surgeon and pathology variations, in vitro measurements have been performed to assess the tissue resection characteristics of the different devices. As part of an IRB-approved FDA submission study in 2008, the author (JAG) compared a working MyoSure device prototype with a TRUCLEAR device to assess tissue resection speed. Fresh, discarded uterine leiomyoma tissue was placed in a saline-filled container and each device was placed directly on the tissue in alternating 5-min intervals for 30 min. The trial was repeated on three different myoma specimens. The study was designed to compare tissue cutting on identical tissue and to assess decline of cutting speed over time as a result of blade dulling [44]. As these data demonstrate, both devices are capable of resecting submucous myomas 3 cm in diameter (~15 cc³) in 15 min or less, although the MyoSure device was consistently faster at tissue removal at every time interval despite its smaller diameter.

In addition, the smaller diameter of the MyoSure hysteroscope (6.25 mm) compared with the TRUCLEAR hysteroscope (9.0 mm) makes the MyoSure device potentially more compatible with an oral sedation/cervical block anesthesia protocol and therefore amenable to office-based treatments of polyps and Type 0 or I submucosal fibroids [45].