“Thinking out of the box in hysteroscopy”

During the last 30 years the predominant surgery technique for submucous myomas has been the resectoscopy. This technique consists in cutting slices of the myoma and the taking out from the uterus the small chips until the uterus was empty. Surgery takes place in theater under anesthesia using a bipolar or the still most frequent used device; the monopolar resectoscope. Monopolar energy requires the use of glicine as distension media with the associated risks of it. The resectoscopy technique surgical time depends on the myomas size, and it can be quiet long as show in the graph published by Emmanuel (Fig 1). Emanuel′s study

What do we ask from a surgical technique?

1. Safe: no adverse events for the patient, no complications
2. Short surgical time – rapid: more time more complications and more cost
3. Efficiency: must solve the problem

During the 80′s Jacques Hamou introduced the concept of diagnostic hysteroscopy (Fig 2), first we see and then in a second step in surgery room we treat.

Fig 2. Contact microcolpohysteroscope with a double ocular. The 30° Foroblique, 4-mm-OD telescope is encased in a 5-mm-OD sheath. France 1979

At the 90′s a new concept came in to hysteroscopy, “see and treat”. Thanks to the development of thinner instruments associated to small surgical instruments and new sources of energy adapted to the small hysteroscope, we were able to see, achieve a diagnostic, and in the same step, to treat. There were limitations and not all the pathologies could be solved, especially submucous myomas of more than 20mm or with an important intramural component (deep myomas).

Understanding the physiology of the myoma was crucial to improve the results. Myomas do not have a capsule but they do have a pseudocapsule (Fig 3-4), Andrea Tinelli published many works on this anatomical entity that become the breakout in hysteroscopy myomas surgery.Tinelli′s on Pseudocapsule

                        Fig 3. Myoma′s pseudocapsule 

        Fig 4.  Pseudocapsule

In 2009, Stefano Bettocchi, published the OPPIuM Technique for big and deep submucous myomas. For me it was a “thinking out of the box” technique. Based on the pseudocapsule, he simply made a crown cut around the myoma reaching the pseudocapsule and this way liberating the myoma and facilitating the migration from the wall into the endometrial cavity (Bettocchi′s OPPIuM ). Then the patient was sent to a resectoscopy to finish the myomectomy.

Based on Bettocchi′s work, we have decided to try to enucleate the myoma as it is done in a laparoscopic myomectomy or even in a laparotomic open myomectomy. To reach the pseudocapsule, perform a dissection, with diode laser, of this cleavage plane until a complete enucleation of the myoma is achieved. And it worked. The first time we enucleated a 20mm myoma, the small white ball fell into the endometrial cavity, but since we work with a 4.3mm optic we couldn’t take it out. There was a problem, something we did not think about before. What we did was to perform a biopsy for histological study and just left it inside. We followed up the patient and perform an ultrasound 2 month after, the myoma wasn’t there, just disappeared.

The results encourage us to keep up developing this enucleation technique and we first published our results in 2013, 43 deep myomas enucleated and many were left in the cavity with the same results (Haimovich′s 2 steps technique).

This “thinking out of the box” was hard to believe so we continue following up and in 2015 we published the first 61 cases of myomas left in the cavity, always with an histological sample taken before. The success rate was of 100%, even for myomas of more than 30mm, after 2 month no myoma was found in the cavity. No complications, only one patients complained about a mild pain that was solved with analgesics (Haimovich′s Leaving the mass in the cavity).

I believe that it is another breakout in the hysteroscopy surgery of the myomas. Analyzing the technique in terms of safety, surgical time and efficiency:

1. Safety: it is done with conscious patients with a small diameter optic and using saline solution as distension media. All the risks associated to resectoscopy disappear. The technique respects the pseudocapsule, no damage to the myometrium, no scar in the myometrium, no adhesions post procedure.
2. Short surgical time: a G0 myoma, of even more than 30mm, by taking a sample and cutting the pedicle, surgery is finished. With diode laser, that cuts and coagulates at the same times, it takes between 4 and 10 minutes to finish the myomectomy. The deep myomas require sometimes 2 surgical steps in office, of 15 to 30 minutes.
3. Efficiency: No size limitation in G0, and 85% success rate in deep myomas until 30mm. 

This “leaving the mass” inside technique is actually performed by 4 university hospitals in Spain with the same success results.

Some may think about the risk of leaving tissue inside the cavity in terms of malignancy. Resectoscopy by cutting slices of the myoma spreads a lot of tissue, small pieces and there is not even one case published about cancer dissemination by the tubes after a submucous myoma resection. A biopsy is almost never performed before the resectoscopy. The risk of malignancy in non-menopausal women and with myomas so small is extremely infrequent. The AAGL guidelines on the management of submucous myomas says regarding malignancy in submucous myomas “There are no data specific to submucous leiomyomas. Nevertheless, considering the prevalence of myomas, the specter of potential malignancy should only rarely be a factor in treatment decisions for premenopausal women.“ (AAGL Guidelines on Submucous Myomas ).

Do not be afraid to be “out of the box”, the fact that “always has been this way” or “that is was I was taught” it does not mean that we cannot do it better. Surgery is dynamic and we must progress with it.

All the newest developments on hysteroscopy will be shown in the next  Global Congress on Hysteroscopy which will be held in Barcelona next May 2017.