Clinical Review

UPDATE ON MINIMALLY INVASIVE SURGERY

OBG Manag. 2011 April;23(4):38-48

	Hear Dr. Garcia describe the preoperative assessment of submucosal myomas
	8 video clips selected by Dr. Garcia accompany the Update

Careful preoperative assessment and innovative tools facilitate hysteroscopic myomectomy. Can office myomectomy be far off?

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IN THIS ARTICLE

New classification system for submucosal myomas
Benefits of hysteroscopic myomectomy
Two mechanical morcellators and how they work

References

1. Day Baird D, Dunson DB, Hill MC, Cousins D, Schectman JM. High cumulative incidence of uterine leiomyoma in black and white women: ultrasound evidence. Am J Obstet Gynecol 2003;188(1):100-107.

2. Lasmar RB, Barrozo PR, Dias R, Oliveira MA. Submucous myomas: A new presurgical classification to evaluate the viability of hysteroscopic surgical treatment—Preliminary report. J Minim Invasive Gynecol. 2010;12(4):308-311.

3. Pritts EA, Parker WH, Olive DL. Fibroids and infertility: an updated systematic review of the evidence. Fertil Steril. 2009;91(4):1215-1223.

4. Shokeir T, El-Shafei M, Yousef H, Allam AF, Sadek E. Submucous myomas and their implications in the pregnancy rates of patients with otherwise unexplained primary infertility undergoing hysteroscopic myomectomy: a randomized matched control study. Fertil Steril. 2010;94(2):724-729.

5. Wamsteker K, Emanuel MH, de Kruif JH. Transcervical hysteroscopic resection of submucous fibroids for abnormal uterine bleeding: results regarding the degree of intramural extension. Obstet Gynecol. 1993;82(5):736-740.

6. Rackow BW, Taylor HS. Submucosal uterine leiomyomas have a global effect on molecular determinants of endometrial receptivity. Fertil Steril. 2010;93(6):2027-2034.

7. Stewart EA, Nowak RA. Leiomyoma-related bleeding: a classic hypothesis updated for the molecular era. Human Repro Update. 1996;2(4):295-306.

8. Laughlin SK, Stewart EA. Uterine leiomyomas. Individualizing the approach to a heterogeneous condition. Obstet Gynecol. 2011;117(2 pt 1):396-403.

9. Loffer FD. Improving results of hysteroscopic submucosal myomectomy for menorrhagia by concomitant endometrial ablation. J Minim Invasive Gynecol. 2005;12(3):254-260.

10. Emanuel MH, Wamsteker K, Hart AA, Metz G, Lammes FB. Long-term results of hysteroscopic myomectomy for abnormal uterine bleeding. Obstet Gynecol. 1999;93(5 pt 1):743-748.

11. Nathani F, Clark TJ. Uterine polypectomy in the management of abnormal uterine bleeding: a systematic review. J Minim Invasive Gynecol. 2006;13(4):260-268.

12. Munro MG. Complications of hysteroscopic and uterine resectoscopic surgery. Obstet Gynecol Clin N Am. 2010;37(3):399-425.

13. Kung RC, Vilos GA, Thomas B, Penkin P, Zaltz AP, Stabinsky SA. A new bipolar system for performing operative hysteroscopy in normal saline. J Am Assoc Gynecol Laparosc. 1999;6(3):331-336.

14. Miller CE. Training in minimally iInvasive surgery—you say you want a revolution. J Minim Invasive Gynecol. 2009;16(2):113-120.

15. Emanuel MH, Wamsteker K. The intra uterine morcellator: a new hysteroscopic moperating technique to remove intrauterine polyps and myomas. J Minim Invasive Gynecol. 2005;12(1):62-66.

16. Van Dongen H, Emanuel MH, Wolterbeek R, Trimbos JB, Jansen FW. Hysteroscopic morcellator for removal of intrauterine polyps and myomas: a randomized controlled pilot study among residents in training. J Minim Invasive Gynecol. 2008;15(4):466-471.

17. Miller CE, Glazerman L, Roy K, Lukes A. Clinical evaluation of a new hysteroscopic morcellator—retrospective case review. J Med. 2009;2(3):163-166.

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The uterine leiomyoma is the most common tumor of the female genital tract. Seventy percent of white women and 80% of black women develop one or more of these tumors by the time they reach 50 years, and the myomas are clinically apparent in 25% of patients.^1,2 When a fibroid is submucosal, it is often associated with menorrhagia, abnormal uterine bleeding, and infertility.^2-4

In this article, I describe three aspects of managing leiomyomata:

ways of classifying the tumor to better predict the blood loss, operative time and morbidity associated with removal
the indications for hysteroscopic myomectomy and polypectomy
new tools for the removal of polyps and myomas.

Preoperative assessment of submucosal myomas is essential

Lasmar RB, Barrozo PR, Dias R, Oliveira MA. Submucous myomas: a new presurgical classification to evaluate the viability of hysteroscopic surgical treatment—preliminary report. J Minim Invasive Gynecol. 2005;12(4):308–311.

Wamsteker and colleagues were the first to propose a system for classifying myoma position within the uterine cavity as a means of estimating the degree of difficulty of resectoscopic removal.⁵ The European Society for Gynaecological Endoscopy (ESGE) later adopted this system, which is now known by its acronym. According to the ESGE system, myomas that lie entirely within the uterine cavity (Type 0) are easier to remove, require less operative time, and involve less fluid deficit and blood loss than myomas that invade the myometrium to varying degrees (FIGURE 1).

FIGURE 1 ESGE classification

Submucosal myomas are classified as Type 0, Type I, or Type II, according to the degree of myometrial penetration.When more than 50% of a tumor penetrates the myometrium (Type II), the risk of excessive intraoperative fluid absorption is elevated, along with the risk of bleeding and the likelihood of electrolyte abnormalities with the use of non-electrolyte fluid media. Type II tumors also increase operative time and the likelihood that additional procedures will be needed because of incomplete resection—even in the hands of expert hysteroscopic surgeons.⁵

FIGURE 2 New classification

New classification system increases accuracy

Lasmar and colleagues devised a new system for preoperative assessment of submucosal myomas, hoping to estimate more precisely the likelihood of successful removal via resectoscopy. They call their system the New Classification (NC). Besides taking into account the degree of penetration into the myometrium, they consider the percentage of uterine wall encompassed by the myoma and the location of the myoma within the uterus (i.e., fundus, body, or lower segment) (FIGURE 2). The total score is used to categorize the tumor into Group I, II, or III to estimate the likelihood of successful removal.

In devising the system, Lasmar and colleagues used the NC and ESGE systems to analyze 55 myomectomy cases involving 57 myomas. They found that the NC more accurately predicts differences between Groups I and II in regard to completed procedures, fluid deficit, and operative time.

WHAT THIS EVIDENCE MEANS FOR PRACTICE

Preoperative hysteroscopic evaluation of submucosal myomas is essential and reliable using the New Classification system.

Hysteroscopic removal of myomas and polyps
yields multiple benefits

Shokeir T, El-Shafei M, Yousef H, Allam AF, Sadek E. Submucous myomas and their implications in the pregnancy rates of patients with otherwise unexplained primary infertility undergoing hysteroscopic myomectomy: a randomized matched control study. Fertil Steril. 2010;94(2):724–729.

Rackow BW, Jorgensen E, Taylor HS. Endometrial polyps affect uterine receptivity [published online ahead of print January 24, 2011]. Fertil Steril. doi 10.1016/j. fertnstert.2010.12.034.

Afifi K, Anand S. Nallapeta S, Gelbaya TA. Management of endometrial polyps in subfertile women: a systematic review. Eur J Obstet Gynecol Reprod Biol. 2010;151(2):117–121.

Studies evaluating the association between infertility and submucosal fibroids have been controversial because the exact mechanism has not been identified. However, new evidence suggests a molecular causal relationship, and Pritts and colleagues demonstrated improved fertility after submucosal myomectomy.^3,6

More recently, Shokeir and coworkers conducted a prospective, randomized, age-matched, controlled trial to explore the effects of hysteroscopic myomectomy on otherwise unexplained primary infertility. They enrolled 215 women who had infertility longer than 12 months and who had their fibroids assessed by means of ultrasonography and classified according to the ESGE system.

Women who underwent myomectomy were twice as likely as women in the control group to become pregnant (relative risk = 2.1; 95% confidence interval = 1.5–2.9). Women who had Type 0 and Type I myomas removed had significantly higher pregnancy rates than women in the control group (P < .001). No statistically significant difference in the pregnancy rate between groups was found for Type II myomas.