REVIEW URRENT C OPINION
New hysteroscopic techniques for submucosal uterine fibroids Tarita Pakrashi
Purpose of review To review the preoperative preparation, intraoperative equipment and techniques to facilitate hysteroscopic resection of submucous fibroids. Recent findings The use of preoperative ultrasound can guide safe resection of submucous fibroids and should be an integral part of a preoperative workup. The data regarding misoprostol use for cervical dilation prior to hysteroscopy is somewhat conflicting and the decision to preoperatively administer misoprostol should be on a case-by-case basis. Hysteroscopic resection of submucous intrauterine fibroids can now be performed under low-dose spinal anesthesia and with the development of smaller instruments and bipolar technology, in an office-based setting without any anesthesia and, sometimes, analgesia. Although the complete removal of type 1 and 2 submucous fibroids remain a challenge, the development of newer techniques such as office preparation of partially intramural myomas and cold-loop myomectomy can result in better removal of these submucous fibroids with an intramural component. Summary Hysteroscopic resection of submucous uterine fibroids should be a simple, well tolerated and effective procedure. Innovations to the existing hysteroscopic techniques and the development of the hysteroscopic morcellator will hopefully result in a greater number of gynecologic surgeons being able to safely perform hysteroscopic resection of submucous uterine fibroids. Keywords fibroids, hysteroscopy, leiomyoma
INTRODUCTION Fibroids are benign smooth muscle cell tumors that are affected by estrogen and progesterone [1]. In the United States, there are approximately 540 000 hysterectomies being performed annually [1]. The most common indication for a hysterectomy is a leiomyoma [1]. However, in reproductive aged women desirous of fertility preservation, a myomectomy may be a more appropriate form of surgical therapy. The International Federation of Gynecology and Obstetrics leiomyoma classification system includes the Wamsteker classification for submucous uterine fibroids, in which type 0 is a pedunculated intracavitary fibroid, type 1 less than 50% intramural and type 2 submucous fibroids have an at least 50% intramural component (Fig. 1) [2,3]. Submucous fibroids may be associated with heavy menstrual bleeding, pain and infertility. Advancement of endoscopic surgical techniques has resulted in a better ability to perform hysteroscopic removal of submucous uterine fibroids. The techniques have come a long way since the hysteroscopic resection of www.co-obgyn.com
submucous uterine fibroids in five cases as reported by Neuwirth and Amin [4] in 1976. This review discusses the evolution of newer surgical techniques and instrumentation for hysteroscopic resection of submucous uterine fibroids.
PREOPERATIVE EVALUATION In addition to a detailed history and physical assessment, an evaluation of the thickness of the myometrium between any intramural portion of the submucous uterine fibroid and the serosa of the
Department of Obstetrics and Gynecology, Jones Institute for Reproductive Medicine, Eastern Virginia Medical School, Norfolk, Virginia, USA Correspondence to Tarita Pakrashi, MD, MPH, Department of Obstetrics and Gynecology, Jones Institute for Reproductive Medicine, Eastern Virginia Medical School, 601 Colley Avenue, Norfolk, VA 23507, USA. Tel: +1 757 446 7444; fax: +1 757 446 8998; e-mail: tpakrashi@ gmail.com Curr Opin Obstet Gynecol 2014, 26:308–313 DOI:10.1097/GCO.0000000000000076 Volume 26 Number 4 August 2014
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Hysteroscopy and submucosal fibroids Pakrashi
KEY POINTS It is imperative to know the distance between the deepest intramural aspect of a submucous fibroid and the uterine serosal edge prior to hysteroscopic myomectomy. Technological innovation has resulted in the ability to resect partially intramural submucous uterine fibroids with varying degrees of success. The hysteroscopic morcellator has been associated with shorter mean operating time for surgeons in training compared with resectoscopy.
uterine wall is important [5]. This assessment may be performed using modalities such as transvaginal ultrasound, saline infusion sonogram or MRI [6]. This is especially important to prevent uterine perforation during hysteroscopic resection [5]. An ideal thickness is anywhere between 5 and 10 mm between the deepest margin of the fibroid and the uterine serosal edge [5,7]. The surgeon should also employ extreme caution while resecting submucous uterine fibroids close to the cornual region in order to prevent injury to the tubal ostia [5].
of misoprostol during operative hysteroscopy is to facilitate cervical dilation and prevent cervical lacerations [9]. The data regarding premenopausal versus postmenopausal patients benefiting from cervical ripening is conflicting at best. In a large metaanalysis, the benefits attributed to cervical ripening using misoprostol were evident in premenopausal patients [9]. This has been previously attributed to the possible differences in cervical consistency with observations of reduced pliability in the cervix of postmenopausal patients [10]. A systematic review by Cooper et al. [11] yields differing results in that the benefit of cervical priming using misoprostol was reduced pain when dilating the cervix beyond 5 mm. This was especially applicable to the postmenopausal patient [11]. Regarding operative hysteroscopy, a meta-analysis by Selk and Kroft [12] revealed no clinically significant difference in time for dilation or a reduction in the complications associated with the entry of the hysteroscope. Instead, they discussed the increased incidence of side-effects such as preoperative vaginal bleeding, nausea and diarrhea in women receiving misoprostol (vaginal and sublingual route of administration) compared with placebo [12]. At this time, the use of preoperative misoprostol to prime the cervix before hysteroscopic myomectomy relies on the discretion of the surgeon.
CERVICAL PRIMING USING PROSTAGLANDIN ANALOG
ANESTHESIA AND ANALGESIA
Data from a multicenter study indicate that approximately half of hysteroscopic complications arise during the entry of the hysteroscope into the uterine cavity [8]. Although there is reported use of laminaria tents to dilate the cervix prior before a hysteroscopic procedure, misoprostol – a prostaglandin analog – is commonly used in preparing the cervix prior to hysteroscopy. The rationale behind the use
Although hysteroscopic resection of submucous uterine fibroids is usually performed under general anesthesia, there have been encouraging reports of alternatives to general anesthesia in the literature. Florio et al. [13] introduced the rationale for their study by discussing contraindications to inhalational anesthesia and the risks associated with general anesthesia. In their case series, 47 patients
Leiomyoma subclassification system
SM - submucosal
O - other
3
2–5
4 1
0 6
2 5 7 Hybrid leiomyomas (impact both endometrium and serosa)
0
Pedunculated intracavitary
1
New hysteroscopic techniques for submucosal uterine fibroids Tarita Pakrashi
Purpose of review To review the preoperative preparation, intraoperative equipment and techniques to facilitate hysteroscopic resection of submucous fibroids. Recent findings The use of preoperative ultrasound can guide safe resection of submucous fibroids and should be an integral part of a preoperative workup. The data regarding misoprostol use for cervical dilation prior to hysteroscopy is somewhat conflicting and the decision to preoperatively administer misoprostol should be on a case-by-case basis. Hysteroscopic resection of submucous intrauterine fibroids can now be performed under low-dose spinal anesthesia and with the development of smaller instruments and bipolar technology, in an office-based setting without any anesthesia and, sometimes, analgesia. Although the complete removal of type 1 and 2 submucous fibroids remain a challenge, the development of newer techniques such as office preparation of partially intramural myomas and cold-loop myomectomy can result in better removal of these submucous fibroids with an intramural component. Summary Hysteroscopic resection of submucous uterine fibroids should be a simple, well tolerated and effective procedure. Innovations to the existing hysteroscopic techniques and the development of the hysteroscopic morcellator will hopefully result in a greater number of gynecologic surgeons being able to safely perform hysteroscopic resection of submucous uterine fibroids. Keywords fibroids, hysteroscopy, leiomyoma
INTRODUCTION Fibroids are benign smooth muscle cell tumors that are affected by estrogen and progesterone [1]. In the United States, there are approximately 540 000 hysterectomies being performed annually [1]. The most common indication for a hysterectomy is a leiomyoma [1]. However, in reproductive aged women desirous of fertility preservation, a myomectomy may be a more appropriate form of surgical therapy. The International Federation of Gynecology and Obstetrics leiomyoma classification system includes the Wamsteker classification for submucous uterine fibroids, in which type 0 is a pedunculated intracavitary fibroid, type 1 less than 50% intramural and type 2 submucous fibroids have an at least 50% intramural component (Fig. 1) [2,3]. Submucous fibroids may be associated with heavy menstrual bleeding, pain and infertility. Advancement of endoscopic surgical techniques has resulted in a better ability to perform hysteroscopic removal of submucous uterine fibroids. The techniques have come a long way since the hysteroscopic resection of www.co-obgyn.com
submucous uterine fibroids in five cases as reported by Neuwirth and Amin [4] in 1976. This review discusses the evolution of newer surgical techniques and instrumentation for hysteroscopic resection of submucous uterine fibroids.
PREOPERATIVE EVALUATION In addition to a detailed history and physical assessment, an evaluation of the thickness of the myometrium between any intramural portion of the submucous uterine fibroid and the serosa of the
Department of Obstetrics and Gynecology, Jones Institute for Reproductive Medicine, Eastern Virginia Medical School, Norfolk, Virginia, USA Correspondence to Tarita Pakrashi, MD, MPH, Department of Obstetrics and Gynecology, Jones Institute for Reproductive Medicine, Eastern Virginia Medical School, 601 Colley Avenue, Norfolk, VA 23507, USA. Tel: +1 757 446 7444; fax: +1 757 446 8998; e-mail: tpakrashi@ gmail.com Curr Opin Obstet Gynecol 2014, 26:308–313 DOI:10.1097/GCO.0000000000000076 Volume 26 Number 4 August 2014
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Hysteroscopy and submucosal fibroids Pakrashi
KEY POINTS It is imperative to know the distance between the deepest intramural aspect of a submucous fibroid and the uterine serosal edge prior to hysteroscopic myomectomy. Technological innovation has resulted in the ability to resect partially intramural submucous uterine fibroids with varying degrees of success. The hysteroscopic morcellator has been associated with shorter mean operating time for surgeons in training compared with resectoscopy.
uterine wall is important [5]. This assessment may be performed using modalities such as transvaginal ultrasound, saline infusion sonogram or MRI [6]. This is especially important to prevent uterine perforation during hysteroscopic resection [5]. An ideal thickness is anywhere between 5 and 10 mm between the deepest margin of the fibroid and the uterine serosal edge [5,7]. The surgeon should also employ extreme caution while resecting submucous uterine fibroids close to the cornual region in order to prevent injury to the tubal ostia [5].
of misoprostol during operative hysteroscopy is to facilitate cervical dilation and prevent cervical lacerations [9]. The data regarding premenopausal versus postmenopausal patients benefiting from cervical ripening is conflicting at best. In a large metaanalysis, the benefits attributed to cervical ripening using misoprostol were evident in premenopausal patients [9]. This has been previously attributed to the possible differences in cervical consistency with observations of reduced pliability in the cervix of postmenopausal patients [10]. A systematic review by Cooper et al. [11] yields differing results in that the benefit of cervical priming using misoprostol was reduced pain when dilating the cervix beyond 5 mm. This was especially applicable to the postmenopausal patient [11]. Regarding operative hysteroscopy, a meta-analysis by Selk and Kroft [12] revealed no clinically significant difference in time for dilation or a reduction in the complications associated with the entry of the hysteroscope. Instead, they discussed the increased incidence of side-effects such as preoperative vaginal bleeding, nausea and diarrhea in women receiving misoprostol (vaginal and sublingual route of administration) compared with placebo [12]. At this time, the use of preoperative misoprostol to prime the cervix before hysteroscopic myomectomy relies on the discretion of the surgeon.
CERVICAL PRIMING USING PROSTAGLANDIN ANALOG
ANESTHESIA AND ANALGESIA
Data from a multicenter study indicate that approximately half of hysteroscopic complications arise during the entry of the hysteroscope into the uterine cavity [8]. Although there is reported use of laminaria tents to dilate the cervix prior before a hysteroscopic procedure, misoprostol – a prostaglandin analog – is commonly used in preparing the cervix prior to hysteroscopy. The rationale behind the use
Although hysteroscopic resection of submucous uterine fibroids is usually performed under general anesthesia, there have been encouraging reports of alternatives to general anesthesia in the literature. Florio et al. [13] introduced the rationale for their study by discussing contraindications to inhalational anesthesia and the risks associated with general anesthesia. In their case series, 47 patients
Leiomyoma subclassification system
SM - submucosal
O - other
3
2–5
4 1
0 6
2 5 7 Hybrid leiomyomas (impact both endometrium and serosa)
0
Pedunculated intracavitary
1
