Hysteroscopic Myomectomy and Polypectomy, and Removal of Retained Products of Conception
Linda D. Bradley
General Principles
Definition
Uterine leiomyomas also called uterine fibroids, myomas, or fibromyomas are benign proliferative, well-circumscribed, pseudoencapsulated benign growths composed of smooth muscle and fibrous connective tissue. They are the most common benign growth of the uterus. These benign growths may be located in the body of the uterus and cervix including endocervical, intracavitary, submucosal, intramural, transmural, subserosal exophytic may pedunculated positions, and may prolapse through the cervix. The size, number, and location of fibroids are unique to each patient and may be associated with a variety of clinical symptoms or menstrual aberrations. The pathogenesis of leiomyomas remains unknown.
Endometrial polyps are benign growths of the endometrium. They are common throughout the lifespan of women. Most endometrial polyps are asymptomatic. Generally, they are single and may occur anywhere within the uterine cavity or near the tubal ostia. Polyps may occur also within the endocervix and ectocervix. They are usually single, sessile, but may be on a stalk, pedunculated, or prolapse through the ectocervix. In reproductive-aged women, the risk of coexisting endometrial hyperplasia (simple, complex without atypia, or complex hyperplasia with atypia) or malignancy within a polyp is approximately 1.7%. However, among women older than 60 years of age with symptomatic postmenopausal bleeding, there is an 8.3-fold increased risk of premalignant changes. Symptomatic polyps detected during the menopause may be associated with a 5% risk of malignancy. The pathogenesis of endometrial polyps remains elusive; however, increased risk is noted in women who use tamoxifen, are overweight/obese, hypertensive, diabetic, and associated with hormone replacement therapy.
Retained products of conception can be seen following miscarriage, termination of pregnancy (first or second trimester), anembryonic first-trimester miscarriage, incomplete miscarriage, missed abortion, postpartum hemorrhage with “blind suction D&C,” vaginal delivery, manual removal of placenta, C/section, or in pregnancies complicated by Müllerian anomalies.
Most often patients are counseled to undergo expectant management which is associated with 81% success.
However, one out of five women may have persistent bleeding, cramping, leukorrhea, fever, abdominal pain, incessant menstrual bleeding, or transvaginal sonographic findings suggestive of RPOC (homogeneous or heterogeneous echogenic foci or endometrial fluid collection with echogenic foci, coupled with high-velocity, low-resistance flow at color Doppler ultrasonography).
Among women who become pregnant after vigorous curettage, there is an increased risk of abnormal placentation in future pregnancies predisposing patients to placenta accreta/increta/percreta.
For these women, historically, a “blind D&C” with vacuum aspiration has been performed. However, surrounding healthy, normal, viable endometrial tissue may be altered leading to Asherman’s syndrome (mild, moderate, or severe) or resultant hypomenorrhea due to extensive alteration of the endometrial basalis layer.
Differential Diagnosis
Endometrial polyps
Adenomyomatous polyp
Leiomyosarcoma
Endometrial stromal tumor
Stromal tumor of uncertain malignant potential
Calcified retained products of conception
Intracavitary endometrial blood clots
Intracavitary leiomyoma
Atypical leiomyoma
Adenomyoma
Anatomic Considerations
The FIGO classification system is useful in determining the position of the uterine fibroid within the endometrium and the depth of penetration into the myometrium.
Hysteroscopic removal of uterine fibroids in general is limited to patients with FIGO classification type 0 and type 1 leiomyomas. Expert hysteroscopic surgical experience may permit removal of small type 2 leiomyomas (Fig. 18.1).
Type 0 leiomyomas are entirely within the uterine cavity with no myometrial extension. The base can be pedunculated, narrow, or wide (Fig. 18.2).
Type 1 leiomyomas involve <50% of the myometrium. When viewed hysteroscopically, there is >90-degree angle of the leiomyoma surface to the uterine wall (Fig. 18.3).
Type 2 leiomyomas involve >50% myometrial extension. When viewed hysteroscopically, there is a <90-degree angle of the leiomyoma surface to the uterine wall (Fig. 18.4).
While some type 2 leiomyomas may be performed hysteroscopically, expert surgical experience is needed. More commonly, they are removed by a laparoscopic/robotic or laparotomic approach.
It is important to determine the distance from the outer edge of the leiomyoma to the serosa with ultrasound or
pelvic MRI with and without contrast to determine if a hysteroscopic approach is feasible.
Figure 18.1. FIGO classification of types 0 and 1 fibroids.
The myometrium remodels during and after hysteroscopic myomectomy. It is advisable to exclude hysteroscopic resection of a leiomyoma that is within 1.0 cm from the serosal edge. Adherence to this guideline decreases the risk of uterine perforation.
Figure 18.2. MRI with well-defined FIGO type 0 fibroid.
Figure 18.3. SIS demonstrates FIGO type 1 fibroid.
Fluid absorption during hysteroscopic myomectomy is influenced by length of surgery, intrauterine pressure, fibroid size, number of fibroids treated, depth of myometrial involvement, breach of myometrial venous sinuses during surgery, and less significantly transtubal reflux.
The myometrium contains many venous sinuses. When these are opened by resection or morcellation technique, the fluid used during hysteroscopy is absorbed intravascularly. Thus, increased risk of fluid absorption occurs when type 1 and type 2 leiomyomas are treated.
Exceeding fluid absorption guidelines is associated with risks unique to the type of fluid used (isotonic or nonisotonic fluid).
Figure 18.4. MRI depicts FIGO type 2 fibroid.
Leiomyoma size, depth of myometrial involvement, number and location of intracavitary fibroids, and surgical expertise determines feasibility, safety, and ability to perform hysteroscopic removal as a single surgical procedure.
Some hysteroscopic myomectomy procedures will require a two-stage procedure due to the inability to complete the initial surgery due to excessive fluid absorption.
With expert preoperative evaluation, the informed consent will reflect the discussion regarding the possibility of incomplete or two-staged hysteroscopic treatment.
As the size of the leiomyoma increases, so does the volume of resected tissue. This affects the length of surgery, amount of fluid used, ability to complete the hysteroscopic resection, and risk of surgical complications.
The volumetric formula that describes the volume of hysteroscopic tissue removed is:
4/dr3
1 cm = 1/2 cm3 tissue
2 cm = 4 cm3 tissue
3 cm = 14 cm3 tissue
4 cm = 33 cm3 tissue
Anatomic and surgical considerations particular to hysteroscopic resection include:
Presence of blood, clots, and endometrial tissue debris
Endometrium (especially secretory or exaggerated proliferative endometrium)
Intracavitary bubbles
Tissue or “chip” management
Ability to anatomically recognize the pseudocapsule and myometrial fascicles
Navigation within the uterine cavity and determining the depth of fibroid resection
Uterine walls collapsing and increased juxtaposition of the uterine walls as hysteroscopic resection progresses
Fluid absorption
Uterine perforation
Uterine distensibility
C/section scar
Uterine size
Uterine position
Retroversion
Retroflexed
Axial
Deviated
Fixed position
Cervix
Cervical perforation
Cervical stenosis
With multiple insertions and removal of the hysteroscope in women with a stenotic cervix, risk of cervical lacerations, creation of false tracks, or uterine perforation may occur.
Tortuous cervical canal
Cervical laceration
Creation of cervical false tracks
The cervix may become more patulous with multiple insertions of the hysteroscope making it more difficult to maintain intrauterine pressure and intrauterine distention.
Placement of additional cervical tenaculum may be required to occlude a patulous cervix.
Figure 18.5. Monpolar resectoscope.
Hysteroscopic removal of leiomyomas can be accomplished with a hysteroscopic resectoscope: monopolar or bipolar devices (Figs. 18.5 and 18.6).
Increasingly, hysteroscopic morcellators are available and utilize saline as the distension medium and are more commonly employed for type 0 leiomyomas (Figs. 18.7 and 18.8).
Complete removal of type 0 and type 1 fundal leiomyomas and fundal endometrial polyps is more difficult with a hysteroscopic morcellator.
It is more difficult because the fibroid or polyp is flushed with the fundus and the morcellator operating device can not conform to reach the fundal location as well. Use of intermittent uterine decompression may facilitate complete removal.
Increased surgical expertise and experience permits removal of deeper leiomyomas.
Ideally, both hysteroscopic resection surgical expertise and hysteroscopic morcellation should be within a surgeon’s armamentarium, as anatomic variations define choice of surgical equipment and fluid used.
 Figure 18.6. Bipolar resectoscope; note the golden orange halo produced by the energy source. |
 Figure 18.7. Smith & Nephew hysteroscopic morcellator equipment. |
Nonoperative Management
The prevalence of uterine fibroids varies between 20% and 80% in the female population. Risks of developing uterine fibroids are influenced by age, ethnicity, family history, and parity.
The majority of women with uterine fibroids are asymptomatic.
Surgery should not be offered to asymptomatic women, unless the location of the fibroid is clearly associated with infertility or impair fertility treatments such as in vitro fertilization (IVF).
Among patients with recurrent pregnancy loss and preterm labor consultation with a maternal fetal medicine physician or reproductive infertility physician is advisable to determine if the surgical removal would improve pregnancy outcomes.
Medical therapy for heavy menstrual bleeding can include a trial of tranexamic acid (for women with ovulatory heavy menstrual bleeding without thromboembolic risk factors), low-dose oral contraceptive pills, or nonsteroidal medications.
Intrauterine contraceptive progesterone containing devices should not be placed in women with known intracavitary fibroids as it may be associated with increased risk of IUD expulsion, inaccurate placement, malposition, or uterine perforation.
Figure 18.8. Hologic hysteroscopic morcellator equipment.
Patients may also have coexisting anovulatory cycles with intracavitary fibroids or endometrial polyps. Medical therapy for anovulatory may also need to be included.
Expectant management
Anatomic consideration for endometrial polyps differs from uterine fibroids because endometrial polyps are soft growths attached to the endometrium, endocervix, or ectocervix.
More commonly, they are single; however, they can be multiple.
May be associated with other intracavitary pathology including uterine fibroids, endometrial hyperplasia, or malignancy.
If they are asymptomatic and found coincidentally, they usually do not need to be removed.
Endometrial polyps associated with infertile patient should be removed hysteroscopically.
Patients who develop endometrial polyps while using tamoxifen and have abnormal uterine bleeding or leukorrhea should have them removed.
Removal of endometrial polyps should be performed with a hysteroscopic approach to increase the chance of complete removal.
Blind approaches for removal of endometrial polyps such as dilation and curettage are associated with incomplete resection and remnants.
Incomplete resection may be associated with recurrent or persistent symptoms.
Endometrial polyps may be removed with hysteroscopic wire loop resection or a hysteroscopic morcellator. They should not be treated with desiccation technology because tissue sampling would not be possible.
In general, hysteroscopic polypectomy procedures have the same risks as noted in hysteroscopic removal of uterine fibroids.
The same surgical principles and considerations should be followed as hysteroscopic myomectomy.
Endometrial polyps do not involve the myometrium; therefore, hysteroscopic resection or morcellation of polyps should be limited to the endometrium only.
When asymptomatic endometrial polyps are coincidentally found with TVUS, they can be followed for a short length of time 6 to 12 months with repeat TVUS.
If there are no clinical symptoms including pelvic pain, leukorrhea, vaginal spotting, or heavy menstrual bleeding, then imaging can be discontinued.
If the endometrial echo increases, hysteroscopic surgical removal is recommended.
Some endometrial polyps regress over time.
Imaging and Other Diagnostics
Evaluation of the endometrial cavity in patients with suspected intracavitary fibroids, endometrial polyps, and retained products of conception may include:
office hysteroscopy;
diagnostic hysteroscopy in an office or ambulatory surgical center;
transvaginal ultrasound (TVUS);
saline infusion sonography (SIS) with 2D transvaginal ultrasound;
Figure 18.9. Diagnostic hysteroscopy reveals fundal myoma.
3D saline infusion images with transvaginal ultrasound;
MRI of the pelvis with and without contrast (not indicated for primary evaluation of endometrial polyps and retained products of conception unless placental accreta/percreta/increta is suspected).
Diagnostic hysteroscopy can determine the presence of type 0, type 1, and some type 2 leiomyomas (Fig. 18.9).
Type 1 and type 2 leiomyomas viewed hysteroscopically can be suspected by the angle of inclination of a fibroid that abuts the endometrial cavity.
However, if the size of the entire fibroid and the depth of myometrial penetration cannot be ascertained by hysteroscopy, additional imaging is needed.
If there is uncertainty about the depth of myometrial involvement, utilize SIS with 2D or 3D ultrasound.
The 3D SIS coronal view is extremely useful in determining the depth of leiomyoma penetration.
When 2D or 3D SIS is unsatisfactory or cannot be performed, then MRI of the pelvis with and without contrast helps delineate the boundaries of the leiomyoma.
Endometrial polyps are well visualized during diagnostic hysteroscopy, 2D SIS, and 3D SIS ultrasound.
MRI with and without contrast may be considered when bimanual uterine fibroid size is greater than 12 to 14 gestational week size, limited uterine distention with SIS, or in patients who do not tolerate pelvic examinations.
Consider MRI when there are symptoms and signs of adenomyosis:
Boggy and tender uterus on clinical examination
Significant dysmenorrhea
Dysmenorrhea and irregular menstruation
MRI of the pelvis may be considered in virginal patients and those who do not tolerate pelvic examinations and transvaginal imaging.
MRI of the pelvis is useful in cases where uterine distention is limited including:
Patulous cervix
Large intracavitary lesions
Prior endometrial ablation
Adenomyosis
Uterine size greater than 12 to 14 weeks
Limited view of the endometrium due to copious bleeding which is associated with increased false positive results.
Figure 18.10. Two-dimensional saline-infused sonogram, sagittal view, demonstrates FIGO type 1 fibroid.
MRI is not indicated for the evaluation of endometrial polyps. While endometrial polyps may be visualized when MRI is performed for uterine fibroids, the expense of MRI and decreased sensitivity make it impractical for clinical use.
While TVUS is helpful in determining the presence of uterine fibroids, the location and depth of myometrial penetration are more difficult. Therefore, we recommend 2D and 3D SIS for more accurate characterization of leiomyomas (Figs. 18.10 and 18.11).
SIS with both 2D and 3D images helps define the topography of the leiomyoma including: size, number, location, and depth of myometrial penetration of the leiomyoma.
SIS has greater sensitivity and specificity compared to TVUS in detecting endometrial pathology.
In patients who have an inconclusive TVUS SIS is advisable.
Endometrial polyps are well imaged with 2D SIS and 3D SIS.
Accurate preop determination of the topography of intracavitary fibroids, endometrial polyps, and retained products of conception enhances surgical informed consent; predicts length of
surgery, surgical expertise needed, likelihood of incomplete hysteroscopic resection/morcellation, complications, selection of hysteroscopic equipment and fluid needed (Fig. 18.12).
 Figure 18.11. Three-dimensional, saline-infused sonogram with FIGO type 2 fibroid. |
 Figure 18.12. Intracavitary distention of fluid or CO2 may flatten lesions and make them disappear, often referred to as “the disappearing act.” |
Preoperative Planning
The preoperative planning caveats and principles discussed in this section are inclusive to patients being treated for hysteroscopic myomectomy, hysteroscopic polypectomy, and hysteroscopic treatment of retained products of conception.
Operative hysteroscopy requires continuous infusion of fluid in order to distend the uterine cavity and provide clear visualization during surgery. The amount of fluid absorption and length of surgery will vary depending on the pathology encountered.
Pulmonary, cardiac, and renal status should be assessed prior to surgery.
While blood loss is minimal during most hysteroscopic surgical procedures it is important to replete iron stores prior to surgery. This can be accomplished with oral iron supplementation or IV iron infusion symptomatic patients.
Hysteroscopy should not be performed if a patient has active pelvic inflammatory disease, acute endometritis, active herpes infection, or pyometra.
Hysteroscopy should not be performed in febrile patients whose source of fever is attributable to a tubal–ovarian abscess, pelvic inflammatory disease, or acute endometritis.
Patient should not have a viable intrauterine pregnancy.
When possible, hysteroscopy should be scheduled during the proliferative phase of the menstrual cycle due to improved visualization.
Operative hysteroscopic surgery should not be canceled in women that are actively bleeding.
The intraoperative use of a fluid management system irrigates blood, blood clots, and debris, and provides uterine distention.
The ability to vary the intrauterine pressure can facilitate visualization by tamponade of endometrial/myometrial arterioles in patients who are actively bleeding.
Intracervical injection of dilute vasopressin may decrease active bleeding.
Consider misoprostol prior to hysteroscopic surgery because it:
facilitates cervical dilation;
decreases risk of cervical lacerations;
decreases risk of creating of false tracks;
decreases risks of uterine perforation;
enhances myometrial contractility.
Misoprostol-associated myometrial contractions may cause a type 1 leiomyoma become a type 0 or facilitate complete resection of deeper leiomyomas as they are pushed into the endometrial cavity.
Occasionally a type 0 leiomyoma may fully prolapse through the ectocervix and vaginal myomectomy can be performed.
Mix 20 units of vasopressin in 200 mL normal saline and inject in 5 mL aliquots into the intracervical stromal (1 cm depth) at 11, 2, 4, and 8 o’clock position.
Prior to intracervical injection, confirm with the anesthesiologist that patient is hemodynamically stable.
Aspirate and inject the dilute vasopressin slowly into the cervical stroma. Do not inject when blood is aspirated.
Monitor vital signs closely during the injection as vasopressin may cause bradycardia, cardiac arrhythmias, hypertension, and death.
Inform the anesthesiologist of the total amount of vasopressin used.
Perform a pelvic examination and visualize the cervix in the office prior to scheduling surgery. This allows the surgeon to anticipate potential difficulties intraoperatively with cervical dilation or visualization of the cervix.
In addition to prescribing misoprostol for cervical priming, the surgeon may also want to have a transabdominal ultrasound available to facilitate safe cervical dilation in potentially difficult cases.
Cervical stenosis can be anticipated under the following circumstances:
Difficulty in performing a pap smear
Apical vaginal agglutination
The cervix is flushed against the vaginal vault
Prior LEEP or cone biopsy
Nulliparity
Menopausal status with atrophic vaginal changes
Prior Cesarean sections
Consider a two day preoperative course of oral or vaginal misoprostol prior to operative hysteroscopy to facilitate cervical dilation.
Prescribe misoprostol 400 mcg by mouth or vaginally at bedtime 2 days before surgery and misoprostol 400 mcg by orally or vaginally at bedtime the night before surgery.
Side effects of misoprostol may include nausea, uterine cramping, pelvic pain vaginal bleeding, diarrhea, or pyrexia.
Patients may take an NSAID to mitigate these side effects.
Historically laminara has been used as an osmotic cervical dilator; however, it has become less practical due to the need for an additional office visit for placement. Additionally, attempts at placement of an extra thin laminara may not be possible with marked cervical stenosis.
A shallow or “mini” LEEP cone biopsy may be needed to excise the ectocervix in order to successfully dilate the endocervix.
Preoperative anticipation of a difficult dilation allows the surgeon to request ancillary equipment such as the LEEP machine and disposable LEEP wire loop.
Informed consent for a LEEP procedure should be obtained when cervical stenosis is anticipated.
Consider intraoperative transabdominal ultrasound guidance when marked cervical stenosis is anticipated. This permits real-time transabdominal ultrasound guidance during cervical dilation and decreases the creation of false tracts and uterine perforation.
With a full bladder a transabdominal ultrasound probe utilizing the sagittal view permits continuous visualization as cervical dilators are serially inserted.
Transabdominal imaging is continued until serial dilation is completed.
Intraoperative flexible hysteroscopy is often helpful when a circuitous endocervical canal or marked cervical stenosis is encountered.
Most flexible hysteroscopes are less than 3.5 mm and have less risk of uterine perforation than rigid hysteroscopy.
A small flexible hysteroscope has the advantage in that it can navigate a tortuous cervical canal more easily than a rigid hysteroscope.
Utilizing a flexible hysteroscope during difficult cervical dilation provides tactile discrimination of the pathway needed to dilate the cervix.
Once the endocervix is visualized with the flexible hysteroscope, the surgeon using tactile discrimination with Hegar dilators can progressively dilate the cervix.
The cervix should only be dilated to the size needed for the operative hysteroscope used. Overdilation may lead to fluid leakage around the hysteroscope precluding adequate uterine distension.
Surgical Management
Indications for surgical management of intracavitary leiomyoma may include:
Abnormal uterine bleeding
Postmenopausal bleeding
Abnormal bleeding on hormone replacement therapy, tamoxifen therapy, or with hormonal contraceptive therapy
Leukorrhea
Dysmenorrhea
Postcoital bleeding
Abnormal uterine bleeding following uterine fibroid embolization
Reproductive disorders
Infertility
Recurrent pregnancy loss
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