Myomas and Office Hysteroscopy...what is new?

The biggest challenge in Hysteroscopy surgery but especially in office Hysteroscopy has been and still is the submucous myoma. Represents between 5% and 10% of all myomas but are the most problematic due to their repercussion on fertility and on heavy bleeding.

During the last 25 years the only solution was surgery under anesthesia and resectoscopy, sometimes requiring even two surgery sessions. In each session the goal was to slice chips of the myoma until all the mass was out. Because of the use of monopolar energy, glycine was the distension medium used. Many centers are using a bipolar resectoscope, avoiding the use of glycine and the potential complications of it.

But in the last decade Office Hysteroscopy entered into the myomectomy field. At the beginning applied only for small myomas. The technique was limited by 3 factors, time of procedure, myomas type and myomas size. Most studies published during the 90's and the first years of this decade, included only myomas that were mostly inside the cavity (G0 and G1 according to the ESGE classification) and less than 20mm. The technique was to cut the fibroid into small pieces and then pull the pieces out. To cut a myoma of more than 20mm took to much time and the patients usually starts to feel discomfort after 15 to 30' of procedure. Another problem was to deal with the intramural portion of the fibroid, how to enucleate it.

Stefano Bettocchi published in 2009 his OPPIuM technique, office preparation of partially intramural myoma. Deep fibroids with a diameter of more than 15mm were included. First step was an office Hysteroscopy were using bipolar energy (versapoint) he made a crown cut around the myoma releasing it from the mucosa and pseudocapsule. The natural behavior of the myoma was to migrate into the endometrial cavity, converting a G2 to a G1 or even G0. The second step was a resectoscopy in surgery room under anesthesia. With this technique Bettocchi achieved a 93% success rate. (fig.1)PubMed OPPIuM

         Fig. 1 Bettocchi′s OPPIuM  technique

What came after was to think about performing the complete procedure in an office setting. In 2013 we published the first study on the feasibility of a new two-step procedure for office hysteroscopic enucleation of deep submucous myomas (G1-G2). It was based on Bettocchi's OPPIuM technique but both steps were performed in office settings and we used diode laser as energy source to perform the cutting of the mucosa and the pseudocapsule.(Fig.2-3) With this technique we achieved a success rate of 100% on myomas till 19mm and 85% for fibroids between 19 and 30mm. The limitation was the size; in some cases the myoma did not have read enough room in the cavity so it could not migrate totally. So, to be more exactly, the limiting factor was the relation between content and container, it does not depend only on the size of the fibroid, the way a 20mm fibroid is small for a multiparius uterus but big for a nulliparous one. This enucleation technique respects the myomas pseudocapsule without damaging the myometrium, no scars and quickly endometrial healing. (video) PubMed of the technique

                           Fig. 2 The cutting plane of Mucosa and Pseudocapsule

Fig.3  Natural migration of the myoma into the cavity after cutting mucosa and pseudocapsule 

laser enucleation of a G1 myoma

Laser Office Hysteroscopy Total Enucleation of a Myoma 

Other devices that could be used for myomectomy in office are the morcellator and the mini-resectoscope. These also are limited by the myoma type and size. The morcellator has a diameter of 6.3mm and needs a 7mm dilatation and at least local anesthesia, results are limited for G2 myomas and there is not much medical evidence in office setting a fact that the mini-resectoscope shares with the morcellator.

During the last 2 years we have been using techniques to reduce the myomas volume and improving the relation container-content. First comes the Ulipristal Acetate, 3 month treatment with 5mg per day reduces an average of 49% of the myoma's volume in 80% of the patients, given before surgery increases the probability of success. The second technique is myoma's tissue vaporization with diode laser, based on prostate fibroadenoma vaporization, by reducing the fibroid size migration into the endometrial cavity and enucleation is achieved.

Office Hysteroscopy Laser Vaporization of a myoma 

It looks like that everything is still open and in the near future we are going to read about new devices/techniques that will improve the existing results of the myomectomy by hysteroscopy in office setting.

I want to finish with a question, after we succeed to perform a total enucleaction of a 30mm myoma and it is free inside the uterine cavity, it is impossible extract it with a small hysteroscope. What can we do with the myoma?

The answer will come in my next text.