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Hysteroscopic myomectomy
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Mar 2014. | This topic last updated: May 6, 2013.

INTRODUCTION — Uterine leiomyomas (fibroids) are the most common pelvic tumor in women [1,2]. Abnormal uterine bleeding, the most common symptom associated with fibroids, is most frequent in women with tumors that abut the endometrium, including submucosal and some intramural fibroids [3-5]. This is likely due to distortion of the uterine cavity and an increase in the bleeding surface of the endometrium [6]. Submucosal tumors, which derive from myometrial cells just below the endometrium, account for approximately 15 to 20 percent of fibroids.

Historically, hysterotomy or hysterectomy was performed to remove submucosal leiomyomas. This has been largely replaced by hysteroscopic myomectomy, a minimally invasive surgical procedure that effectively and safely removes these lesions [4,7].

Hysteroscopic myomectomy is reviewed here. General principles of hysteroscopy and abdominal approaches to myomectomy are discussed separately. (See "Overview of hysteroscopy" and "Prolapsed uterine leiomyoma (fibroid)" and "Abdominal myomectomy".)

PATIENT SELECTION — Hysteroscopic myomectomy is performed for intracavitary fibroids, ie, submucosal and some intramural leiomyomas for which most of the fibroid protrudes into the uterine cavity. Appropriate candidates for hysteroscopic myomectomy are women with the following characteristics:

  • Symptomatic uterine fibroid(s)
  • It is feasible to remove the fibroid(s) hysteroscopically
  • An abdominal approach is not required to remove additional fibroids in other locations (eg, intramural or subserosal) or treat other pathology

For women who are candidates for hysteroscopic myomectomy, this procedure is preferred over an abdominal approach, particularly laparotomy, for the following reasons:

  • Outpatient procedure
  • Minimal recovery time
  • Decreased perioperative morbidity
  • Minimal or no scarring of myometrium

Indications — The most common indications for hysteroscopic myomectomy in the setting of intracavitary fibroids are:

  • Abnormal uterine bleeding
  • Recurrent pregnancy loss
  • Infertility

The effects of leiomyomas on reproductive function are discussed in detail separately. (See "Reproductive issues in women with uterine leiomyomas (fibroids)", section on 'Infertility and miscarriage'.)

Infrequent indications for hysteroscopic myomectomy include:

  • Dysmenorrhea
  • Leukorrhea
  • Necrotic leiomyoma following uterine fibroid embolization
  • Histologic evaluation of intracavitary lesions with uncertain findings on pelvic imaging

Hysteroscopic myomectomy is also performed in selected patients with intracavitary fibroids who have conditions that are more commonly attributed to etiologies other than fibroids. In these women, hysteroscopic myomectomy is performed when other therapies have failed or it is reasonable to attribute symptoms to an intracavitary fibroid. Such conditions include: dysmenorrhea, leukorrhea, or a history of preterm delivery, postpartum hemorrhage [8], or a puerperal infection arising in or exacerbated by a submucosal fibroid [9].

Contraindications — Hysteroscopic myomectomy is contraindicated in women in whom hysteroscopic surgery is contraindicated (eg, active pelvic infection, intrauterine pregnancy, cervical or uterine cancer). Medical comorbidities (eg, coronary heart disease, bleeding diathesis) are also potential contraindications to hysteroscopic surgery. However, since this is a minimally invasive procedure, it is contraindicated in few women. (See "Overview of the principles of medical consultation and perioperative medicine".)

Leiomyoma characteristics — Women who are appropriate candidates for hysteroscopic myomectomy must conform to appropriate indications and contraindications, but also must have fibroid characteristics that are amenable to this technique. Hysteroscopic myomectomy removes fibroids that have an intracavitary component (figure 1). Removal of fibroids that penetrate into the myometrium, are large, or are sessile takes longer, has the potential for increased perioperative complications, and may result in incomplete fibroid resection. In addition, for women with additional fibroids that are intramural or subserosal or who have other uterine pathology (eg, adenomyosis), hysteroscopic myomectomy may not provide symptomatic relief.

Myometrial penetration — For women with symptomatic fibroids, we suggest hysteroscopic myomectomy only for fibroids that are completely within the endometrial cavity or extend less than 50 percent into the myometrium. Removal of fibroids with deeper myometrial involvement requires advanced hysteroscopic skills or myomectomy using laparotomy or laparoscopy.

The most commonly used classification system for the extent of myometrial involvement of a fibroid was described by the European Society of Hysteroscopy (ESH) [10]:

  • Type 0 - completely within the endometrial cavity
  • Type I - extend less than 50 percent into the myometrium
  • Type II - extend 50 percent or more within the myometrium

Observational studies support the ability of the ESH system to predict complete fibroid resection; reported rates of complete resection rates by type were: type 0 (96 to 97 percent), type I (86 to 90 percent), and type II (61 to 83 percent) [10,11]. In addition, depth of myometrial penetration appears to correlate with the volume of distension fluid absorbed. This was illustrated in a series of 339 hysteroscopic myomectomies that reported that the volume of fluid absorbed during the procedure increased significantly with the degree of myometrial penetration (type 0: 450 mL; type I 957 mL; type II 1682 mL) [12].

However, the ESH system considers only the degree of penetration of the submucous myoma in the myometrium. Another classification system was proposed in 2005, which uses transvaginal ultrasound (TVUS) or magnetic resonance imaging (MRI) to assess the degree of penetration in the myometrium, as well as other fibroid characteristics: size, distance of the base along the uterine wall, and portion of the cavity in which the fibroid is located [13]. Further studies are needed to validate this classification system.

Leiomyoma size — Hysteroscopic resection of large fibroids may involve increased perioperative complications and/or require more than one procedure for symptomatic relief. The definition of large is not well established. Only one prospective study of 122 women examined the effect of fibroid size; the risk of subsequent fibroid-related surgery within four years was significantly lower in women with fibroids that were ≤3 cm versus 4 cm or more (10 versus 60 percent) [14]. Increasing size of fibroid requires exquisite hysteroscopic skill, complete understanding of fluid management, ability to quickly remove myoma chip fragments that might preclude surgical visualization, and techniques to decrease risk of uterine perforation when chip fragments are removed.

There are no high quality data regarding the size and/or number of intramural or subserosal fibroids that preclude using a hysteroscopic approach. Physician skills ultimately determine the maximal size or number of fibroids that can be removed. For leiomyomas that are multiple or are >3 cm, it is prudent to include in the informed consent the possibility of a two-stage procedure.

Presence of other leiomyomas or adenomyosis — Many women have intracavitary fibroids in combination with fibroids in other locations (eg, intramural, subserosal). As the volume of additional fibroids increases, the surgeon must decide whether isolated removal of the intracavitary fibroid(s) will provide adequate treatment or if a laparoscopic or abdominal approach to myomectomy or a hysterectomy is preferable. Other factors that influence the choice of surgical approach include: desire for future fertility and presence of other pathology.

The greater the volume of additional fibroids, the greater the likelihood that symptomatic relief will be provided only by a laparoscopic or abdominal approach to myomectomy and the less likely that isolated removal of intracavitary fibroids will provide symptomatic relief.

Patients with fibroids that are both intracavitary and in other locations who have bulk symptoms (abdominal pain, pressure, or distension; urinary urgency, frequency, or retention; or constipation) are not likely to benefit from hysteroscopic resection alone.

On the other hand, women without bulk symptoms and normal or slightly enlarged uterine size who have heavy uterine bleeding or conditions that appear to derive specifically from the presence of an intracavitary lesion, such as recurrent pregnancy loss or fibroid-associated leukorrhea, may benefit from the isolated removal of an intracavitary myoma, even if other leiomyomas are present.

Women with abnormal uterine bleeding or dysmenorrhea who have both adenomyosis and intracavitary fibroids are also likely to have persistent symptoms after hysteroscopic myomectomy. These women may require a medical therapy alone or in combination with hysteroscopic myomectomy, or a hysterectomy. (See "Uterine adenomyosis".)

For women with symptoms of abnormal uterine bleeding or dysmenorrhea who have an intracavitary fibroid in combination with diffuse adenomyosis, a hysteroscopic myomectomy is unlikely to provide complete symptomatic relief. However, patients with focal adenomyosis and normal uterine size should be offered hysteroscopic myomectomy; such patients should be counseled preoperatively regarding the limited evidence regarding outcome of this procedure among women with these two uterine pathologies.

PREOPERATIVE EVALUATION AND PREPARATION — Preoperative evaluation and preparation are generally the same as for other hysteroscopic procedures. Issues specific to hysteroscopic myomectomy are presented here. (See "Overview of hysteroscopy", section on 'Preoperative evaluation and preparation'.)

Informed consent — Women with symptomatic intracavitary fibroids should be counseled about other medical, interventional radiologic, and surgical options for treatment. (See "Chronic menorrhagia or anovulatory uterine bleeding", section on 'Medical therapy' and "Overview of treatment of uterine leiomyomas (fibroids)".) Women should be counseled about potential complications of the procedure and about the likelihood of recurrence of fibroids or symptoms (see 'Complications' below and 'Recurrence of leiomyomas or bleeding symptoms' below). Women with intracavitary myomas that are multiple, broad-based, large (>3 cm), and/or penetrate into the myometrium should be advised that a second procedure may be necessary to fully remove all myomas (see 'Two-step procedures' below). This discussion should be documented on the surgical consent form and in the medical record.

History — A thorough history is important to determine which fibroid-related symptoms are present (eg, heavy uterine bleeding, bulk symptoms) and whether these symptoms affect the patient's quality of life.

Evaluation of the uterus — Evaluation of the uterus and cervix for fibroids (both submucosal and at other locations) or other pathology (eg, adenomyosis, endometrial polyp) with pelvic imaging or diagnostic hysteroscopy are essential prior to hysteroscopic myomectomy. Knowledge of these fibroid characteristics prior to surgery helps to select appropriate patients, as well as to prepare for or prevent blood loss (eg, measurement of preoperative hematocrit, preoperative endometrial preparation) and to ensure that the appropriate instruments and surgical expertise are available (see 'Leiomyoma characteristics' above and 'Preoperative medications' below).

We suggest saline infusion sonography (SIS) where available, since it is a single modality that can evaluate the relationship of a leiomyoma to both the endometrial cavity and the myometrium. An alternative is to use a combination of office-based diagnostic hysteroscopy and TVUS. Hysteroscopy can define the extent to which a fibroid protrudes into the uterine cavity and TVUS can define the depth of myometrial penetration. It is useful for the surgeon to view the TVUS images to establish whether a hysteroscopic approach is feasible. MRI defines leiomyoma position well, but is prohibitively expensive to use routinely for this indication. Hysterosalpingography and computed tomography have limited use in delineating fibroid location. The use of pelvic imaging for diagnosis of leiomyomas is discussed in detail separately. (See "Epidemiology, clinical manifestations, diagnosis, and natural history of uterine leiomyomas (fibroids)", section on 'Diagnosis'.)

In addition, any woman with abnormal uterine bleeding at risk for endometrial hyperplasia or cancer should undergo evaluation of the endometrium prior to hysteroscopic myomectomy (table 1). (See "Evaluation of the endometrium for malignant or premalignant disease".)

Preoperative medications

Prophylactic antibiotics — Antibiotics are not indicated during hysteroscopy for prevention of surgical site infection or endocarditis. (See "Antimicrobial prophylaxis for bacterial endocarditis" and "Overview of preoperative evaluation and preparation for gynecologic surgery", section on 'Antibiotic prophylaxis'.)

GnRH agonists — Gonadotropin releasing hormone agonists (GnRHa) decrease the size of large fibroids; however, after use of these agents, it is more difficult to dissect fibroids from the surrounding capsule. While many surgeons use these agents, particularly for large fibroids (>3 cm) [1], we prefer not to use GnRHa, since there are no high quality data that they make complete resection possible for large fibroids, or reduce intraoperative blood loss or distention fluid absorption [12,15-18]. In addition, they result in vasomotor symptoms and may lead to cervical stenosis (an antiestrogenic effect) or profuse vaginal hemorrhage (due to GnRHa-induced estrogen flare) [19,20]. The exception to this is for temporary cessation of menses in patients with severe anemia that may preclude surgery, or in whom intravenous iron therapy is contraindicated.

Danazol, another antiestrogenic agent, is not recommended since a randomized trial found that it did not reduce operative duration or fluid deficit and the adverse effects are poorly tolerated [15].

Vasopressin — Vasopressin intracervical injection is an option for decreasing blood loss during hysteroscopic myomectomy. Injection of vasopressin into the cervical stroma was found to decrease blood loss and absorption of distension fluid during hysteroscopic myomectomy or endometrial resection in one randomized trial [21]. Although generally well tolerated, vasopressin injection must be performed with caution (by aspirating and confirming the absence of blood prior to each injection), since intravascular injection or absorption has been associated with profound hypertension, bradycardia, and intraoperative mortality [22]. There are few data that evaluate the risks versus benefits of the use of vasopressin for hysteroscopic myomectomy.

We routinely use vasopressin prior to hysteroscopic myomectomy; we mix 20 units in 100 mL of normal saline, and inject into the cervical stroma in 5 mL aliquots at the 12, 3, 6, and 9 o'clock positions around the cervix. It can be given every 30 to 45 minutes, if bleeding is encountered or the procedure is prolonged. An additional benefit of vasopressin is that it facilitates cervical dilation [23]. (See "Overview of hysteroscopy", section on 'Cervical stenosis'.)

Cervical preparation — Cervical dilation can be facilitated with use of preoperative misoprostol or laminaria. This is discussed in detail separately. (See "Overview of hysteroscopy", section on 'Cervical preparation and dilation'.)

Anesthesia — Hysteroscopic myomectomy is performed under general or regional anesthesia. In addition, a paracervical block is sometimes performed to provide postoperative analgesia. (See "Overview of hysteroscopy", section on 'Anesthesia'.)

INSTRUMENTATION — Advances in operative technology have greatly improved the performance of hysteroscopic myomectomy since it was first performed in 1976 by Neuwirth and Amin [24]. Surgical innovations have improved visualization and decreased risk of fluid-related complications.

Resection — The wire loop with a monopolar or bipolar resectoscope is the most commonly used instrument for hysteroscopic myomectomy (picture 1). Most gynecologists are familiar with this technique and the equipment is cost-effective and widely available. If a monopolar device is used, a non-electrolytic solution is used (eg, 1.5 percent glycine). If a bipolar device is used, the fluid medium is isotonic saline or Ringer's lactate solution [25]. (See "Hysteroscopy: Managing fluid and gas distending media", section on 'Fluid media'.) As an adjunct to this technique, hysteroscopic scissors can be used for small pedunculated fibroids or fragments that remain attached to the uterine wall and are not easily removed with the loop.

New technologies, such as vaporization electrodes and hysteroscopic morcellators, have been introduced. The goal of these techniques is to make resection of fibroids easier. However, these devices are expensive and additional training is required. Vaporization electrodes (eg, VaporTrode®, Force FX™) operate at a higher power density (120 to 220 watts versus 60 to 120 watts with a monopolar resectoscope) and vaporize the tissue. This eliminates accumulation of tissue fragments that can occlude the view; however, it also prohibits evaluation of the tissue for pathology. In addition, vaporization may lead to the formation of bubbles in the distension fluid, thereby interfering with visualization.

The vaporization technique should be avoided at the cornua and isthmus, since these anatomic regions are thinner and at increased risk of perforation, bowel burns, and intraperitoneal injuries. With the higher power settings used, two dispersive pads should be placed to ground the patient [26].

Another option for this procedure is a hysteroscopic morcellator (Intra Uterine Morcellator), which has a rotary blade for resection and suction tubing to remove tissue fragments. Comparative studies have reported that myomectomy duration was 8 to 26 minutes shorter with the Intra Uterine Morcellator versus a resectoscope [27,28]. The disadvantage for the hysteroscopic morcellators is that they cannot cauterize bleeding vessels. The hysteroscopic morcellator is also not designed to treat deeper myomas, and thus, is limited to women with hysteroscopic type 0 leiomyomas. Since myomas that appear to be type 0 upon preoperative evaluation may "sink" deeper into the myometrium during surgery and may not be retrieved with a morcellating device, the optimal situation is for a surgeon to have access to both the wire loop and morcellator.

Tissue removal and fluid control — Use of a hysteroscope with a continuous flow operative sheath helps to clear blood from the uterine cavity and thus improves visualization. In addition, some operative sheaths aspirate pieces of tissue from the uterine cavity to remove debris or retrieve specimens for pathologic evaluation (eg, Chip E-Vac, hysteroscopic morcellator). This allows removal of large debris while maintaining clear visualization.

Hysteroscopic myomectomy may be associated with a risk of excessive absorption of distending fluid. Continuous fluid monitoring is necessary throughout the procedure. Automated fluid pump and monitoring systems are preferable to manual techniques [29]. (See "Hysteroscopy: Managing fluid and gas distending media", section on 'Inflow and monitoring'.)

PROCEDURE — Positioning, sterile preparation, and cervical dilation are performed in the standard fashion for hysteroscopy. (See "Overview of hysteroscopy", section on 'Procedure'.) Close attention to the distension fluid deficit is critical to avoid complications of excessive fluid absorption. (See "Hysteroscopy: Managing fluid and gas distending media".)

Wire loop technique — This section will describe the wire loop resectoscope technique, which is the most commonly used for hysteroscopic myomectomy. This technique works well for most Intracavitary leiomyomas, those that protrude entirely or more than 50 percent of their mass into the uterine cavity (type 0 or 1) (see 'Myometrial penetration' above).

  • Insert the resectoscope through the cervix.
  • After distension with fluid, inspect the uterine cavity. Note the size and location of the fibroids and whether they are sessile or pedunculated.
  • We set a monopolar resectoscope to a cutting current of 60 to 120 watts; fibroids that are calcified may require a current up to 120 watts. Bipolar technology uses the default setting for both cutting and hemostasis. The wire loop should easily pass through the tissue. If it does not, the power setting is increased to prevent tissue adherence to the wire loop.
  • Begin incising at the most cephalad surface of the myoma (figure 2) (picture 2). For a pedunculated fibroid, the loop electrode can be used to cut directly through the base.
  • Bring the resectoscope loop towards the surgeon using the spring mechanism of the loop alone or by moving the entire resectoscope towards the surgeon. To avoid injury, it is important to keep the loop in view at all times and activate the loop only when moving it towards the operator.
  • Repeat this motion until the fibroid has been resected to the level of the surrounding endometrium.

Tissue obtained should be sent for pathologic evaluation. The surgically disrupted area will become covered with newly proliferated endometrium postoperatively.

During hysteroscopic wire loop resection, the edges of the fibroid tend to fall inward as the middle is resected, thus increasing the panoramic view. It is more efficient to continue resection until fibroid fragments, or "chips," preclude further visualization. At that point, carefully remove the chips (picture 3). This can be accomplished using the inactivated wire loop or blindly with a polyp/myoma forceps or suction curette; another option is to remove the inner sheath of the resectoscope to facilitate the egress of tissue chips. As noted in a preceding section, some surgical systems evacuate chips (Chip E-Vac, hysteroscopic morcellator) (see 'Tissue removal and fluid control' above).

Occasionally, as the fibroid is cut, the previously round myoma becomes more irregularly shaped, and can be grasped bluntly and avulsed with polyp/myoma forceps. If this is done, hysteroscopic reinspection is imperative to ensure complete resection and hemostasis. Excessive traction blindly with the avulsing technique should be avoided to decrease the risk of uterine eversion, perforation, or injury to surrounding intraabdominal viscera.

In the event of heavy perioperative bleeding, the endometrium should be reinspected with the hysteroscope. Small areas of bleeding can be desiccated with the resectoscope using coagulating current. When using a monopolar system, set the coagulating current at 60 to 80 watts. With bipolar technology, the coagulating current is set to the default setting. Additional measures are described below (see 'Excessive perioperative bleeding' below).

Techniques for challenging resections — When a leiomyoma is large (>3 cm), sessile, or penetrates into the myometrium, advanced hysteroscopy skills are necessary to differentiate the fibroid from the myometrium and apply techniques to achieve complete fibroid resection [30]. Excessive resection of the myometrium will increase blood loss, fluid absorption, and myometrial scar tissue, and potentially result in uterine perforation.

Distinguishing myoma versus myometrium — To distinguish the border between the leiomyoma and surrounding myometrium, a surgeon should recognize differences in texture and appearance between the two types of tissue. The fibroid is firm, with a whorled appearance, while the myometrium is soft and the muscular fascicles are apparent.

Enucleating a myoma — Techniques for enucleating the fibroid from its pseudocapsule include placing the wire loop electrode strategically behind the myoma to elevate and separate the myoma (picture 4). Initially, the inactive electrode is used to elevate the leiomyoma out of the pseudocapsule, followed by using the activated electrode to incise the myoma and facilitate its retrieval. Another technique is to use the inactive loop to partially enucleate the fibroid with mechanical dissection and then deflate the uterine cavity to cause further protrusion of the myoma (see 'Use of uterine contractions' below). The wire loop technique, described in a preceding section, is then resumed to achieve complete resection (see 'Wire loop technique' above).

Use of uterine contractions — Deflation of the uterine cavity refers to removing the operative hysteroscope and waiting for several minutes to permit myometrial contractions to cause extrusion of the myoma. When the hysteroscope is replaced, the surgeon will commonly see more of the myoma extruding into the cavity. Facilitation of uterine contractions with administration of a prostaglandin has been proposed [31-33]; a series of 13 patients reported successful use of carboprost (125 mcg in 5 mL of saline, injected intracervically) for this purpose [33]. However, profound diarrhea and difficult uterine distention may be associated with carboprost.

Uterine massage via bimanual examination or other techniques has also been described to help to extrude the remaining portion of a fibroid [34,35].

Sonographic guidance — Use of intraoperative pelvic ultrasonography to delimit the endometrial, myometrial, and serosal boundaries can be useful, in our experience. The only study to evaluate this approach was a retrospective cohort study of 126 patients that reported that complete fibroid resection was more likely with sonographic versus laparoscopic guidance [36].

Two-step procedures — A two-step procedure is occasionally necessary for fibroids that are multiple, large, broad-based, or penetrate deeply within the myometrium [37]. The most common reason for this is that the initial procedure was halted when the maximal fluid absorption was reached. Such patients should be seen for a follow-up visit two to four months after the initial procedure to assess whether fibroid-related symptoms persist. If so, evaluation of the uterine cavity is repeated: the size, number, and location of the leiomyoma(s). With this information, the surgeon can offer appropriate management, whether hysteroscopic myomectomy or another treatment.

CONCOMITANT PROCEDURES

Endometrial polypectomy — Removal of a coexisting endometrial polyp is standard practice at the time of hysteroscopic myomectomy. There are no data regarding the outcomes of such concurrent procedures. In our experience, removing both types of lesions during the same procedure does not increase operative duration or complications. (See "Endometrial polyps".)

Endometrial ablation — In women who have abnormal uterine bleeding and do not plan a subsequent pregnancy, some surgeons perform a concomitant myomectomy and endometrial ablation or resection. It is uncertain whether this procedure is more effective at improving uterine bleeding symptoms than myomectomy alone.

This topic is discussed in detail separately. (See "An overview of endometrial ablation", section on 'Concomitant procedures'.)

Hysteroscopic sterilization — Women who desire hysteroscopic sterilization and who have symptomatic intracavitary fibroids will need hysteroscopic myomectomy. Hysteroscopic sterilization and myomectomy can be done concurrently, however, bleeding, debris, and/or endometrial edema from the myomectomy may also obscure the ostia. Patients interested in concomitant hysteroscopic sterilization and myomectomy should be scheduled for the procedure within one week after menses to decrease the difficulty in visualizing tubal ostia. There are no data regarding combining these two procedures. (See "Hysteroscopic sterilization", section on 'Contraindications'.)

FOLLOW-UP — Most patients experience postoperative cramping or light bleeding and some complain of vaginal discomfort. Acetaminophen or nonsteroidal antiinflammatory drugs are usually adequate for postoperative pain control, if necessary. The patient may resume most normal activities within 24 hours and should follow standard postoperative instructions for gynecologic procedures. (See "Patient information: Care after gynecologic surgery (Beyond the Basics)".)

We see patients for a follow-up visit four to six weeks postoperatively to assess for further complications and review pathology results.

COMPLICATIONS — Series of 200 or more hysteroscopic myomectomy procedures report a complication rate of 0.8 to 2.6 percent [38,39]. In a retrospective series of 235 procedures, the complication rate was lower for procedures involving single versus multiple fibroids (1.4 versus 6.7 percent) [38].

Few large studies of hysteroscopic complications report specific complications for hysteroscopic myomectomy. General complications of hysteroscopy are discussed in detail separately. (See "Overview of hysteroscopy", section on 'Complications'.)

Uterine perforation — Extensive resection increases the risk of uterine perforation, but this complication is uncommon [16]. There are no data to suggest that laparoscopic guidance decreases the frequency of uterine perforation. Uterine perforation associated with hysteroscopy can be diagnosed by direct visualization of the defect, or suspected if visualization is obscured by blood. If electrosurgical energy, morcellation, or suction curettage were utilized during the procedure and perforation is suspected, the potential for visceral injury (eg, bowel, bladder) is increased. In such patients, immediate abdominal exploration should be performed. (See "Uterine perforation during gynecologic procedures", section on 'Criteria for surgical management'.)

Excessive fluid absorption — Extensive endometrial or myometrial resection increases the risk of absorption of distension fluid, potentially resulting in hyponatremia or volume overload. A common reason for termination of a technically difficult procedure is excessive absorption of distension fluid [11].

Diagnosis and management of excessive fluid absorption are discussed in detail separately. (See "Hysteroscopy: Managing fluid and gas distending media" and "Hyponatremia following transurethral resection or hysteroscopy".)

Excessive perioperative bleeding — Excessive bleeding was reported in 4 of 235 women in a retrospective series [38]; 4 of 94 women required perioperative blood transfusion in another series [40].

If a patient has persistent bleeding, a size 16 French Foley catheter with a 30 mL balloon can be inserted into the uterine cavity and distended with 30 mL of sterile water. Over four to six hours, the catheter balloon is gradually deflated until empty and then removed while the bleeding is monitored. With the balloon removed, if bleeding is minimal, the patient can be discharged from the surgical unit. In one series of 216 resectoscope procedures, four women (1.9 percent) developed postoperative uterine bleeding and were successfully treated with this procedure [21]. (See "Overview of hysteroscopy", section on 'Hemorrhage'.)

If the patient continues to bleed briskly with the Foley bulb in place, the initial step is to administer intracervical vasopressin (see 'Vasopressin' above). If excessive bleeding persists, the patient is examined using a speculum and hysteroscope to assess for a cervical laceration or uterine perforation; if present, appropriate measures are taken to control bleeding (see 'Uterine perforation' above). If bleeding is significantly reduced, the patient is monitored in the operating room for 20 minutes to make sure that the bleeding does not recur. If bleeding persists after injection of vasopressin, the patient should be evaluated for anemia and coagulopathy, and treated if appropriate. (See "Management of hemorrhage in gynecologic surgery", section on 'Medical stabilization'.)

Intrauterine adhesions — Formation of intrauterine adhesions can interfere with fertility or menstruation. In studies in which women had a second look hysteroscopy after the initial hysteroscopic myomectomy report, the rates of this complication varied widely, from 0 to 46 percent [15,38,41]. The rate appears to be higher if more than one fibroid is resected (in one study, 31 percent for single versus 46 percent for multiple fibroids) [15]. Evaluation and treatment for intrauterine adhesions are discussed in detail separately. (See "Intrauterine adhesions".)

Infection — Infection is uncommon; it was reported in 2 of 128 women in one series [16].

OUTCOME — Outcomes after hysteroscopic surgery have been difficult to compare due to the lack of consistency across studies regarding the type of myoma treated, menopausal status, objective measurement of blood loss, complication rates, duration of follow-up, and rates of subsequent reoperation or pregnancy [42]. However, many studies and surgeons report high patient satisfaction, resolution of abnormal uterine bleeding, and a low rate of complications [38].

Complete myoma resection — Complete resection of a fibroid depends upon the extent of myometrial penetration, as noted in a preceding section (see 'Leiomyoma characteristics' above). The rate of incomplete myoma resection ranges from 5 to 17 percent in retrospective series [11,38].

Incomplete myoma resection does not commit a patient to reoperation. In a series of 41 women with incomplete hysteroscopic resection of fibroids, only 44 percent underwent further fibroid-related surgery within three years [11]. In addition, in another series, at three-month follow-up, saline infusion sonohysterography revealed that incompletely resected fibroids had regressed in 21 of 38 patients [43].

Recurrence of leiomyomas or bleeding symptoms — The recurrence rate of fibroids and/or abnormal uterine bleeding was approximately 20 percent in most studies in which women were followed for three or more years after hysteroscopic myomectomy [14,40,44].

Across all studies, 3 to 21 percent of women underwent subsequent surgery for fibroid-related complaints. In one study, the risk was highest in women with fibroids >3 cm or when two or more fibroids were present [14].

Reproductive outcomes

Infertility and recurrent pregnancy loss — Women with cavity-distorting fibroids who undergo myomectomy are more likely to conceive a pregnancy; however, the effect on the risk of miscarriage is uncertain.

In addition, observational studies have reported that the presence of intracavitary leiomyomas decreases pregnancy rates in women undergoing in vitro fertilization. Thus, many IVF units advise women with these lesions to undergo myomectomy.

The effects of leiomyomas on reproductive function are discussed in detail separately. (See "Reproductive issues in women with uterine leiomyomas (fibroids)", section on 'Infertility and miscarriage'.)

Obstetric issues — It is not known whether hysteroscopic myomectomy affects placentation in subsequent pregnancies. In addition, there have been no case reports of uterine rupture after hysteroscopic myomectomy [45,46].

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SUMMARY AND RECOMMENDATIONS

  • Hysteroscopic myomectomy is performed for intracavitary fibroids, ie, submucosal and some intramural leiomyomas for which most of the fibroid protrudes into the uterine cavity. (See 'Patient selection' above.)
  • The most common indications for hysteroscopic myomectomy are abnormal uterine bleeding, recurrent pregnancy loss, and infertility. Hysteroscopic myomectomy is contraindicated in women in whom hysteroscopic surgery is contraindicated (eg, active pelvic infection, intrauterine pregnancy). (See 'Indications' above and 'Contraindications' above.)
  • For women planning hysteroscopic myomectomy, we suggest preoperative evaluation of the uterus with saline infusion sonography (SIS). Use of both diagnostic hysteroscopy and transvaginal sonography is a reasonable option where SIS is not available. (See 'Evaluation of the uterus' above.)
  • The following recommendations are for women with fibroid-associated symptoms who desire surgical treatment:

  • We suggest not performing hysteroscopic myomectomy in women with intracavitary fibroids that extend 50 percent or more into the myometrium (Grade 2C). Removal of fibroids with deep myometrial involvement requires advanced hysteroscopic skills or myomectomy using laparotomy or laparoscopy. (See 'Myometrial penetration' above.)
  • For women with intracavitary fibroids in combination with three or more intramural or subserosal fibroids with a total volume of >3 cm who have fibroid-associated bulk symptoms (abdominal or pelvic pressure or pain, urinary symptoms, constipation), we suggest myomectomy using laparotomy or laparoscopy rather than hysteroscopy (Grade 2C). Isolated removal of intracavitary fibroids is reasonable in some women, such as those with menstrual aberrations only, recurrent miscarriage or fibroid-associated leukorrhea. (See 'Presence of other leiomyomas or adenomyosis' above.)

  • We suggest against use of gonadotropin releasing hormone agonists prior to hysteroscopic myomectomy (Grade 2C). Use of these agents is reasonable in women with large fibroids (>3 cm) who are willing to tolerate the vasomotor symptoms and by surgeons who find an operative benefit. (See 'GnRH agonists' above.)
  • Potential complications of hysteroscopic myomectomy include: uterine perforation, excessive absorption of distension fluid with resultant hyponatremia or volume overload, excessive perioperative bleeding, intrauterine adhesions, and infection. (See 'Complications' above.)
  • Following hysteroscopic myomectomy, the recurrence rate of fibroids and/or abnormal uterine bleeding is approximately 20 percent. (See 'Recurrence of leiomyomas or bleeding symptoms' above.)
  • Women with cavity-distorting fibroids who undergo myomectomy are more likely to conceive a pregnancy; however, the effect on the risk of miscarriage is uncertain. (See "Reproductive issues in women with uterine leiomyomas (fibroids)", section on 'Infertility and miscarriage'.)

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