Hysteroscopic myomectomy with submucous uterine myoma

Hysteroscopic myomectomy with submucous uterine myoma

Hysteroscopic access is now considered optimal for the removal of submucous myomatous nodes. This operation serves as an alternative to laparotomy with minimal invasive effects and better results.

Indications for hysteroscopic myomectomy:

1. The need to preserve fertility.
2. Violations of the reproductive function caused by the presence of a submucosal node.
3. Pathological uterine bleeding.

Contraindications to hysteroscopic myomectomy:

1. General contraindications to any hysteroscopy.
2. The size of the uterine cavity is more than 10 cm.
3. Suspicion of endometrial cancer and leiosarcoma.
4. The combination of the submucous node with pronounced adenomyosis and the presence of myomatous nodes of other localization.

After preliminary diagnosis and classification characteristics of the submucosal node, the method of its removal, the timing of the operation, the need for preoperative preparation and the method of anesthesia are decided.

Most often, hysteroscopic myomectomy is performed under intravenous general anesthesia or epidural anesthesia, but when a large-sized site with a large interstitial component is removed, the expected long operation and the need for laparoscopic control, the operation is performed under endotracheal anesthesia.

Preoperative hormonal preparation is best performed with GnRH agonists (zoladex, decapeptil), usually 2 injections with a 4-week interval are sufficient. If this treatment is not possible because of high cost or inaccessibility, progestogen treatment is performed (nemestane 2.5 mg twice a week, norethisterone 10 mg daily or 600-800 mg daily) for 8 weeks, although it is less effective. According to the authors of the book, pre-operative hormonal preparation before miomectomy by transcervical route should be performed in the following cases:

• when the size of the submucosal node is more than 4-5 cm;
• if there is a submucosal node on a wide base, regardless of its size.

The goal of pre-operative hormonal preparation is not so much to reduce the size of the node, but rather to reduce the size of the uterus itself, while the unit is squeezed out into the uterus cavity and becomes more submucous. According to the authors, the use of agonist GnRH - Zoladex (Zeneka, UK) - reduced the size of nodes by 25-35%.

Preoperative hormone treatment leads to atrophy of the endometrium, which improves the conditions of the operation due to good visibility and reduces blood loss during surgery. Such training also allows you to restore the red blood counts to normal numbers and perform surgery under more favorable conditions. Along with the positive moments, sometimes with the treatment of GnRH agonists myoma nodes with large diameter located in the wall of the uterus become interstitial, which makes it difficult to choose the method of operation. In such cases, it is often necessary to postpone the operation for an indefinite period or to perform myomectomy with laparotomy.

Depending on the nature of the site (a sub-mucosal node on a narrow base or a submucous-interstitial node), the operation can be performed simultaneously or in two stages. Simultaneous removal is more risky. When removing the interstitial part of the node, one should always remember the depth of damage to the uterine wall, which increases the risk of bleeding and possible fluid overload of the vascular bed. If the operation is carried out simultaneously, especially when removing the node with an interstitial component, it is recommended to perform a control hysteroscopy or hydrotonography after 2-3 months to confirm the absence of remaining fragments of fibroids.

A two-stage operation is recommended for sites in which the largest part is located in the uterine wall (type II according to the EAG classification). After preoperative hormonal preparation, hysteroscopy and partial myomectomy (myolysis of the rest of the node using a laser) are performed. Then again appoint the same hormones for 8 weeks and carry out a repeated hysteroscopy. During this time, the remaining part of the knot is squeezed out into the uterus cavity, which makes it possible to easily excise it completely. When removing sub-mucosal nodes of type II, monitoring of the operation (transabdominal ultrasound or laparoscopy) is necessary.

Taylor et al. (1993) proposed the following tactics for managing patients with submucous nodes.

Patients with infertility and multiple fibroids are advised to remove the nodes on one wall of the uterus during the first operation, and the nodes located on the opposite wall in 2-3 months in order to avoid the formation of intrauterine synechia.

Tactics of management of patients with submucous myomatous nodes

The value of the submucosal component	Node size, cm
	<2.5	2.5-5	> 5
> 75%	Simultaneously	Simultaneously	Hormones + one-time
75-50%	Simultaneously	Hormones + one-time	Hormones + one-time
<50%	Hormones + one-time	Hormones + one- or two-stage	Hormones + two-stage

For women over 40, many authors recommend that myomectomy be combined with resection or ablation of the endometrium, which reduces the risk of a relapse of menorrhagia by 1/3 in the next 2 years. This issue is still debatable.

Currently, there are three approaches to hysteroscopic myomectomy:

1. Mechanical.
2. Electrosurgical.
3. Laser surgery.

The method of mechanical hysteroscopic myomectomy

Mechanical myomectomy is used for clean submucosal nodes on a narrow base, with a node size not exceeding 5-6 cm. The possibility of removing the node mechanically depends also on the site of site localization; The easiest way to remove nodes located in the bottom of the uterus.

With a large size of the node, it is advisable to carry out pre-operative hormonal preparation. To remove the node, it is necessary to ensure sufficient expansion of the cervical canal by Gegar dilators to No. 13-16 (depending on the size of the node). The authors of the book use two methods of removing submucous nodes.

1. The site is sighted with an abortion and removed by the unscrewing method, followed by hysteroscopic control.
2. Under the control of the hysteroscope, the capsule of the node or its leg is dissected by the reector, then the node is removed from the uterine cavity.

If it is impossible to remove the cut off node from the uterine cavity, which is very rare, it is permissible to leave it in the uterus; after a while (usually during the next menstruation)

If there is no resector in the medical institution, the capsule of the myomatous node or its leg can be cut with scissors inserted through the operating channel of the hysteroscope, however this operation is longer.

Doctors were convinced that the possibility of a mechanical removal of the submucosal node depends not so much on its dimensions as on the shape and mobility. Knots of elongated shape easily change the configuration and can be removed simultaneously, even if they are large (up to 10 cm).

In some cases, large-sized myomatous nodes can be removed by the method of lumpy, performing continuous visual control with a hysteroscope.

The advantages of mechanical myomectomy

1. A short duration of the operation (5-10 min).
2. No need for additional equipment and a special liquid medium.
3. The possibility to avoid complications of electrosurgical operation (fluid overload of the vascular bed, possible damage to large vessels and burns of neighboring organs).
4. The operation can be performed in any operating gynecological hospital.

However, transcervical myomectomy abortion can be performed only by an experienced gynecologist who has experience working with instruments in the uterine cavity.

The method of electrosurgical resection of the submucous node

In 1978, Neuwirth et al. Reported on the first use of a hysteroresectoscope for removal of the submucosal node. Since that time, many researchers have shown the efficacy and safety of this endoscopic operation.

To carry out electrosurgical resection of the submucosal node, the same equipment as for the ablation (resection) of the endometrium is necessary: a hysterectomy resector with cutting loops 6 to 9 mm in diameter and a ball or cylindrical electrode for coagulation of bleeding vessels.

Expansion of the uterine cavity is performed using non-electrolyte liquid media (1.5% glycine, 5% dextran, 5% glucose, polyglucin or reopolyglucinus is acceptable). After the extension of the cervical canal by Gegar dilators to No. 9-9.5, a resectoscope with a diagnostic casing is inserted into the uterine cavity, the node is identified. Then the diagnostic body is changed to the operating case with the electrode and the tissue of the node is gradually cut in the form of chips, and the loop must be constantly moved towards the surgeon.

The accumulated pieces of the node are periodically removed from the uterus by forceps or a small blunt curette.

Resection of the interstitial part of the node should not be deeper than 8-10 mm of the level of the mucosa. The interstitial part of the node itself is squeezed out into the uterine cavity as the node is removed. If such extrusion does not occur, the operation must be stopped. After this, re-resection of the remaining part of the node after 2-3 months is recommended.

Usually this operation is nekrotvotochiva, but if the deep layers of the myometrium are damaged, bleeding is possible, so you have to be careful. The electric current is regulated during the operation under the control of vision, it is 80-110 W in the cutting mode. At the end of the operation, the loop electrode is replaced by a ball electrode, the intrauterine pressure is reduced, and the bleeding vessels are coagulated in a coagulation regime at a current of 40-80 W. Many places of the remaining part of the node are produced, after which the surface of this part remains covered with numerous crater-like grooves having brown boundaries. This technique, called hysteroscopic myolysis, causes necrobiosis of the tissue of the node. The purpose of the procedure is to reduce the size of the remaining part of the myoma and worsen its blood supply. After that, the hormones are again prescribed for 8 weeks, then repeated hysteroscopy is performed to remove the remaining part of the node that has shrunk in size and squeezed out into the uterine cavity.

With multiple submucosal nodes of small size, the myolysis of each node is carried out as described above.

Thus, hysteroscopic myomectomy is a very effective operation that avoids hysterectomy, which is especially important for women of reproductive age. The choice of the method of operation depends on the following factors:

1. The species of the submucosal node, its location and magnitude.
2. Equipments with endoscopic equipment.
3. Surgical skills of the surgeon in endoscopy.

[1], [2], [3], [4]