hyseroscopy myoma resection

Hysteroscopic Myomectomy

Trans-Cervical Resection of

Myoma (TCRM)

A. Prof. Dr Aisha Mohamed El-Bareg MBBS, DGO, MMedSci (ART), ABOG, (MD), PhD (UK)

Consultant Obstetrician & Gynecologist / subspecialty

in Endoscopic Surgery and Reproductiv medicine

Al-Amal Hospital for Obs&Gyn. Infertility Treatments

and Genetic Research

Faculty of Medicine , Misurata University /Libya

Uterine myomas are benign encapsulated

tumors that originate from the muscle tissue

of the uterus.

Depending upon their location, they can be

classified as :

Subserosal

Intramural

Submucousal.

Cervical, broad ligament myoma

Fibroid, Myoma, Liomyoma

Fibroid, Myoma, Liomyoma

Most frequent benign tumour in gyn practice.

Occurs in 20-30% of women of reproductive

age and frequently increases toward the end of

the reproductive period.

Estrogen increases its growth.

Hysterectomy and laparotomic myomectomy

used to be the tt of choice in women with HMB

and infertility.

Most common reason for hysterectomy.

Burden of Myomas for patients

Pain, Cramping, pressure symptoms

Heavy menstrual bleeding

Anemia

Reproductive complications:

Infertility

Miscarriages

Preterm labor

Malpresentations

Uterine fibroid may be asymptomatic.

Evaluation and classification of

fibroid Submucous fibroids account for 5.5% -16.6% of

all uterine fibroids.

A common structural cause of AUB, pelvis pain,

infertility, and other symptoms.

In women with infertility, an effort should be

made to adequately evaluate and classify

fibroids, particularly those impinging on the

endometrial cavity

Diagnosis -Submucosal Fibroids

Diagnosis:

1. TVS

2. SIS

3. MRI

4. Hysteroscopy

appear as white spherical

masses covered by

network of thin fragile

vessles.

Treatment considerations

Treatment of uterine fibroids can be complex

because:

Fibroids can be located in any part of the uterus

Multiple fibroids can reside in one uterus.

Fibroid can be different sizes.

Fibroid disease varies in severity (some uteri

are replete with tumors).

Fibroids have variable growth rates: some

grow, others are stable, some shrink

spontaneously.

There is no universally accepted classification

system.

Symptoms vary: some studies focused only

on bleeding outcome, other outcomes are

important- pain, fertility, re-intervention.

Treatment considerations

Treatment options

Watchful waiting.

Pain medications.

Hormone therapy.

GnRH agonist/antagoist .

Progesterone-blocking agents (Mefipristone).

Aromatase-blocking agents (Letrozole).

Progestin only pill.

Oral contraceptive pills.

Intrauterine device (Mirena)

Minimally invasive options:

Uterine artery embolization

MRI-guided focused USS

Hysteroscopic/laparoscopic

resection

Treatment options

• In women with otherwise unexplained infertility,

submucosal fibroids should be removed in

order to improve conception and pregnancy

rates.

• There is fair evidence to recommend against

myomectomy in women with intramural fibroids

(hysteroscopically confirmed intact

endometrium) and otherwise unexplained

infertility, regardless of the size of the fibroids.

Surgical Management

Hysteroscopic myomectomy

TransCervical Resection of Myoma

(TCRM)

In the past, a diagnosis of submucous myoma

was usually followed by a recommendation for

hysterectomy.

Dilation and curettage (D&C). a blind

procedure guided by tactile feedback, may be

used as a diagnostic procedure to obtain

tissue for pathologic examination, a

temporizing measure for heavy uterine

bleeding.

Hysteroscopic myomectomy-TCRM

Today, hysteroscopic surgery offers an accurate

diagnostic, assessment and therapeutic

alternatives.

Goal of hysteroscopic myomectomy is

removal of the entire fibroid without

compromising the surrounding myometrium or

endometrium. This will result in alleviation of

the patient’s symptoms without weakening the

myometrium or creating intracavitary

synechia. Removal of the entire myoma will

also decrease the risk of regrowth of the

lesion.

Hysteroscopic Myomectomy- TCRM

Pre-operative assessment:

Fibroid size and location within the uterine

cavity.

Thickness of residual myometrium to the serosa.

Degree of protrusion to the cavity.

A combination of TVS and Hysteroscopy are the

modalities of choice.

Endometrial biopsy is also indicated.

Classification/ European Society Of Hysteroscopy

)0(G0 GRADE

limited to uterine

cavity.

Pedunculated

)1(G1 GRADE

Partial intramural

>50%

endocavitary.

Angle of

protrusion<90o

)2(G2 GRADE

Predominantly

intamural <50%

endocavitary

Angle of protrusion

>90o

Submucosal fibroids are managed hystero-

scopically. The fibroid size should be < 5 cm,

although larger fibroids have been managed

hysteroscopically, but repeat procedures are

often necessary.

Preferred due to:

Higher efficacy

Reduction in surgical morbidity

Absence of abdominal scar


Pre-procedural Preparation

1. Use of suppressive medical therapy:

GnRH agonist is commonly used.

Reduction of myoma volume by 40%

Amenorrhea to built up hemoglobin.

Facilitation of procedure, risk of bleeding.

Reduced systemic absorption of the distending

media

Complete resection of large myomas in one

setting.

Factors For GnRH analogues

Parameters disfavoring Infavour pre-tt

•Anaemia none or mild pronounced

•Type of myoma G0 or GI G2

•Diameter <2cm > 4cm

•Residual distance 10 mm <8 mm

to serosa.

•No. of Myoma Single Multiple

•Location. Anterior, post fundus, close to

or lateral tubal ostium

•Ability of the surgeon highly skilled skilled


Various dosing regimens of GnRH a exist.

Depot Luprolide Acetate 7.5 mg IM 6 weeks

preoperatively.

The second injection is given 4 weeks later

and the surgery is scheduled 2–4 weeks after

the second injection.

Longer treatment for up to 3 months can be

tried to maximize the intracavity portion of a

type II myoma prior to surgery.


2. Cervical preparation

Misoprostol – PGE1 analogue

200-400 mcg PO/PV, 12-24 hrs before surgery

Intracervical vasopressin

4 U in 80ml : use 10 ml to inject at 4:00, 8:00 of

the cervix at the time of hysteroscopy.

Significant reduction in force of cx. Dilation.

Decrease risk for absorption syndrome,

bleeding.

Cutting- using

electrosurgical loop

Vaporization-

electrosurgical vaporizer

ball

Morcellation –

Mechanical mincing


A 26 Fr resectoscope with working elements is

inserted :

Cutting electrodes resectoscope

Cutting loop utilizing a radiofrequency energy

which either Monopolar or bipolar energy.

Straight loop for fundus, angled one for wall.

Often leave surgeons battling tissue “chips.”

Thin strips of resected tissue, or chips, are

created and need to be periodically removed

from the uterine cavity to enhance visualization

using forceps or grasper.


Vaporizing electrodes resectoscope

Roller ball utilizing a radiofrequency energy

device.

Monopolar or bipolar energy.

Vaporizes the myoma so obviating the need for

frequent chip removal but precluding pathologic

examination of the specimen.


.

Morcellation • First generation-TRUCLEAR system.

• Second generation- MyoSure system (2009).

• Use a suction-based, mechanical energy,

rotating tubular cutter system rather than the

HF electrical energy.

• Faster and easier to learn.

• No chips in the uterine cavity.

• Chips are retrieved from suction and can be

sent for H/P.


Myosure Truclear

Comparison of Device Characteristics of TRUCLEAR™

Hysteroscopic Morcellator and MyoSure® Tissue Removal

System

The loop is first placed behind the fibroid to be

resected. The foot pedal is then used to

activate the energy and the loop is drawn back

into the resectoscope while shaving.

After initiating the current, the loop must be

kept moving while activated to prevent

extensive thermal necrosis with a subsequent

risk of perforation.

Technique of TCRM

A power setting of 60 W of pure cutting current

is often employed.

Technique of TCRM

The technique for removing a submucous

fibroid depends largely on its location and

protrution within the endometrial cavity.

The type 0

Option of first transecting the base of the stalk

or shaving the fibroid, removing it in pieces

through the cervix.

For larger fibroid, it is often symmetrically

shaved off with the resectoscope loop unitl the

base is reached.

The exposed base can then be

coagulated. The free floating fibroid can

be retrieved blindly with a polyp forceps or

grasped under visualization with the

optical tenaculum.

Technique of TCRM

Type 1 & 2

• The intracavitary portion of the fibroid is first

shaved to the level of the endometrium.

• Small myomas will often fall into the uterine

cavity after this initial unroofing, making their

removal easy.

• Larger myoma. After shaving till the level of

endometrium, with the effect of uteime muscle

contractility, the remainder of the fibroid may

protrude into the cavity permitting its safe

resection again.

Technique of TCRM

• The patient should be aware that more

than one surgical attempt may be

necessary for large myoma.

Technique of myoma

vaporization

For type 0: spring-tip electrode is used to

resect the base which then coagulated; the

free fibroid is then retrieved for HP exam.

For type 1,2: As the electrode is moved over

the protruding fibroid, instantaneous tissue

vaporization and desiccation flushing the

fibroid with the endometrium

Bipolar current of 130 W is used.

Postoperative follow-up

GnRH can be continued for 2-3 months if

myoma was not completely resected.

Intraoperative antibiotics.

Follow-up diagnostic

hysteroscopy is generally

performed 2-3 months after

surgery may show residual

myomas. Review HP result: the risk of liomyosarcoma is

low (<0.5%)

Complications of TCRM

Associated with a higher incidence of

complications

Difficult procedure, takes longer time

Perforation, bleeding, infections

Complications of distension media

Risk of synechia

Conclusion

Hysteroscopic myomectomy is a highly

effective and minimally invasive means of

treating symptomatic submucous leiomyomas.

Unfortunately, this treatment modality is

underutilized by today’s gynecologists.

This is likely due to inadequate exposure to

hysteroscopy during residency training as well

as the misconception that the skills necessary

to perform hysteroscopic procedures are

difficult to acquire.

Endometrial polyp

Localized endometrial hyperplasia:

single/multiple; sessile/ pedunculated

Causes:- AUB/ Infertility/ Endometritis

Diagnosis: USG/SIS/Hysteroscopy.

Hysteroscopic polypectomy

Several hysteroscopic systems to resect

endometrial polyps are currently available

Monopolar loop cautery

Bipolar systems

Microscissors or graspers,

Hysteroscopic morcellators

Of these, the monopolar loop is more

commonly available and of lower cost.

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hyseroscopy myoma resection

Health & Medicine