Uterine fibroids (leiomyomas): Hysteroscopic myomectomy

INTRODUCTION — Uterine fibroids (leiomyomas) are the most common pelvic tumor in females [1,2]. Abnormal uterine bleeding, the most common symptom associated with fibroids, is most frequent in patients with tumors that abut the endometrium (lining of the uterine cavity), 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 leiomyomas, 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 "Uterine fibroids (leiomyomas): Prolapsed fibroids" and "Uterine fibroids (leiomyomas): Open abdominal myomectomy procedure".)

PATIENT SELECTION — Hysteroscopic myomectomy is performed to remove intracavitary fibroids, a term that refers to (1) submucosal leiomyomas and (2) some intramural leiomyomas for which most of the fibroid protrudes into the uterine cavity. It is a minimally invasive procedure that is the procedure of choice for appropriate candidates. The ability to remove intracavitary fibroids depends on the surgeon's experience and skill, surgical device used, and size and depth of the leiomyoma.

Appropriate candidates for hysteroscopic myomectomy are patients with the following characteristics:

●Symptomatic uterine fibroid(s).

●It is feasible to remove the fibroid(s) hysteroscopically. This is particularly the case if the fibroids can be removed by hysteroscopy alone, so an open abdominal or laparoscopic approach is not required to remove additional fibroids in other locations (eg, intramural or subserosal) or treat other pathology.

For patients who are candidates for hysteroscopic myomectomy, this procedure is preferred to an abdominal approach (ie, laparotomy, minimally invasive laparoscopic, robotic) for the following reasons:

●Outpatient procedure

●Minimal recovery time

●Minimal need for opioids or prolonged pain medication

●Minimal postoperative restrictions with ability to quickly return to activities (eg, work, sports, intercourse)

●Decreased perioperative morbidity

●Decreased febrile morbidity

●Minimal or no scarring of myometrium (a scarred myometrium may require the patient to have a cesarean delivery for future childbirth)

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

●Abnormal uterine bleeding (both in reproductive-age and postmenopausal patients)

●Recurrent pregnancy loss

●Infertility

The effects of leiomyomas on reproductive function are discussed in detail separately. (See "Uterine fibroids (leiomyomas): Treatment overview", section on 'Impact of fibroids on fertility'.)

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 patients, 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

●Necrotic leiomyoma following uterine fibroid embolization, magnetic resonance imaging (MRI)-focused ultrasound, or radiofrequency fibroid ablation

●Histologic evaluation of intracavitary lesions with uncertain findings on pelvic imaging

●History of preterm delivery

●Postpartum hemorrhage [8]

●Puerperal infection arising in or exacerbated by a submucosal fibroid [9]

●Postmenopausal bleeding

●Residual fibroid stalk or tissue following vaginal myomectomy

Contraindications — Hysteroscopic myomectomy is contraindicated in patients in whom hysteroscopic surgery is contraindicated (eg, active pelvic infection, pyometra, intrauterine pregnancy, known 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, medical comorbidities are rarely a contraindication. (See "Overview of the principles of medical consultation and perioperative medicine".)

Leiomyoma characteristics — Patients 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 patients with additional fibroids that are intramural or subserosal or who have other uterine pathology (eg, adenomyosis), hysteroscopic myomectomy may not provide symptomatic relief.

Classification systems — The most commonly used classification system for the extent of myometrial involvement of a fibroid was described by the European Society of Hysteroscopy (ESH (figure 2)) [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, and 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 or 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.

Another classification system, the STEP-W submucosal fibroid classification system takes into account additional features of the fibroid utilizing transvaginal ultrasound or MRI to assess five myoma characteristics (table 1) [14]. Two- and three-dimensional saline infusion sonography (SIS) is widely accepted to improve the visualization of the endometrium and myometrial interface. The STEP-W classification considers size, topography, extension of the fibroid base, depth of fibroid penetration, and the lateral wall involvement. Each factor is assigned a point value. A low score of 0 to 4 (low complexity) is associated with safety and successful removal of the fibroid in one hysteroscopic setting. A score of 5 or 6 is considered high complexity, and may require a two-stage hysteroscopic procedure. A score of 7 to 9 is considered not amenable to treatment hysteroscopically.

The International Federation of Gynecology and Obstetrics also has a classification system for uterine leiomyomas (figure 3).

Myometrial penetration — For patients 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.

Leiomyoma size and number — 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 patients examined the effect of fibroid size; the risk of subsequent fibroid-related surgery within four years was significantly lower in patients with fibroids that were ≤3 cm versus 4 cm or more (10 versus 60 percent) [15]. 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.

Clinician skills ultimately determine the maximal size or number of fibroids that can be removed. For leiomyomas that are multiple or are >3 cm or deep in myometrium, it is prudent to include in the informed consent the possibility of a two-stage procedure (ie, two hysteroscopy procedures).

Presence of other leiomyomas or uterine pathology — Many patients 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 [16].

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, patients 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. This approach may be particularly useful in perimenopausal patients by providing symptom relief through the menopause transition.

Patients with abnormal uterine bleeding or dysmenorrhea may have adenomyosis in addition to intracavitary fibroids. For patients with diffuse adenomyosis, a hysteroscopic myomectomy is unlikely to provide complete symptomatic relief. However, patients with focal adenomyosis and normal uterine size can be offered hysteroscopic myomectomy. Such patients should be counseled preoperatively regarding the limited evidence regarding outcome of this procedure among patients with these two uterine pathologies. These patients can also benefit from medical therapy or insertion of a levonorgestrel-containing intrauterine device in combination with hysteroscopic myomectomy. (See "Uterine adenomyosis".)

The differential diagnosis for an intrauterine mass also includes adenomyoma, endometrial polyp, calcified retained products of conception, smooth muscle tumor of uncertain malignant potential, leiomyosarcoma, or endometrial stromal tumor. (See "Uterine fibroids (leiomyomas): Differentiating fibroids from uterine sarcomas".)

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 — Patients with symptomatic intracavitary fibroids should be counseled about other medical, interventional radiologic, and surgical options for treatment. (See "Abnormal uterine bleeding in nonpregnant reproductive-age patients: Management" and "Uterine fibroids (leiomyomas): Treatment overview".)

Patients 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.)

Patients 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 whether fibroid-related symptoms are present (eg, heavy uterine bleeding, bulk symptoms) and whether these symptoms affect the patient's quality of life. (See "Uterine fibroids (leiomyomas): Epidemiology, clinical features, diagnosis, and natural history", section on 'Clinical features'.)

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 and/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 minimize fluid deficit and to ensure that the appropriate instruments and surgical expertise are available. (See 'Leiomyoma characteristics' above and 'Perioperative medications' below.)

We suggest three-dimensional 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 transvaginal ultrasound (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. Magnetic resonance imaging (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 "Uterine fibroids (leiomyomas): Epidemiology, clinical features, diagnosis, and natural history", section on 'Diagnostic evaluation'.)

For patients with enlarged uterine size (ie, 14 to 16 weeks or larger on pelvic examination), SIS may be impractical. Maintenance of uterine distension is difficult and limits the ability to interpret images of the endometrium and myometrium. MRI may be more useful to evaluate patients for a type 0, I, or II leiomyoma as described in the International Federation of Gynecology and Obstetrics and European Society of Hysteroscopy classification systems. Additionally, MRI is also used in the STEP-W classification system.

In addition, any patient with abnormal uterine bleeding at risk for endometrial hyperplasia or cancer should undergo evaluation of the endometrium with endometrial sampling prior to hysteroscopic myomectomy (table 2). (See "Overview of the evaluation of the endometrium for malignant or premalignant disease".)

Laboratory testing — Routine preoperative evaluation should be performed. For hysteroscopic myomectomy, some institutions routinely order a hematocrit. For reproductive-age patients, pregnancy testing is required. (See "Preoperative medical evaluation of the healthy adult patient".)

Patients with uterine leiomyomas and abnormal uterine bleeding may be anemic. The blood loss during hysteroscopic myomectomy does not typically exceed 100 mL. However, if anemia is a concern, measure should be taken to treat this prior to surgery and/or to prevent bleeding during surgery. (See "Techniques to reduce blood loss during abdominal or laparoscopic myomectomy", section on 'Preoperative measures' and 'Agents to decrease bleeding' below.)

PERIOPERATIVE MEDICATIONS

Agents to decrease bleeding

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 [12,17-20]. 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) [21,22]. Cases in which we make an exception and use a GNRHa to suppress menses include: patients with severe anemia that may preclude surgery, those in whom intravenous iron therapy is contraindicated, or those who refuse blood products.

Danazol, an antiestrogenic agent, is not recommended since a randomized trial found that it did not reduce operative duration or excessive absorption of distension fluid and the adverse effects are poorly tolerated [17].

Vasopressin — Vasopressin intracervical injection is an option to prevent excessive 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 [23]. 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 [24]. 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 10 units in 100 mL of normal saline and inject into the cervical stroma in 5 mL aliquots at the 10, 2, 5, and 8 o'clock positions around the ectocervix; the 3 and 9 o'clock positions are avoided to decrease the potential for inadvertent injection into the cervical branches of the uterine arteries. This dose can be repeated 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 and promotes myometrial contractions, facilitating complete removal of the uterine fibroid [25]. (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'.)

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

Thromboprophylaxis — Thromboprophylaxis is generally not required for hysteroscopic procedures. (See "Prevention of venous thromboembolic disease in adult nonorthopedic surgical patients".)

INSTRUMENTATION — Advances in operative technology have greatly improved the performance of hysteroscopic myomectomy since it was first performed in 1976 by Neuwirth and Amin [26]. Surgical innovations have improved visualization and decreased risk of fluid-related complications.

Distension fluid control — Fluid is instilled to distend the uterus and allow visualization. General principles of fluid control and avoidance of excessive absorption are the same for hysteroscopic myomectomy as for other procedures. Risk factors for increased absorption of fluid includes operating time, depth of myometrial incision, and size of the lesion. Continuous fluid monitoring is necessary throughout the procedure to avoid complications (eg, hyponatremia, pulmonary, cardiac, or laryngeal edema) or the need to abort the procedure. Hypotonic solutions (ie, glycine) are used when a resectoscope with monopolar electrical wire loop technique is employed. Bipolar resectoscopes are used with isotonic fluids. Tissue extraction (morcellation) and vaporization devices are used with saline. (See "Hysteroscopy: Managing fluid and gas distending media".)

Automated fluid pumps with audible alerts and monitoring systems are preferable to manual techniques [27]. Use of a hysteroscope with a continuous flow operative sheath helps to clear blood from the uterine cavity and thus improves visualization. Some hysteroscopic tissue extraction and vaporization devices require use of a proprietary fluid monitoring system.

Leiomyoma resection — The wire loop with a monopolar or bipolar resectoscope has traditionally been the technique used for hysteroscopic myomectomy (picture 1). Hysteroscopic morcellation and vaporization devices have also been introduced.

Most gynecologists are familiar with the wire loop 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, sorbitol 3 percent, or mannitol is used). If a bipolar device is used, the fluid medium is isotonic saline or Ringer's lactate solution [28]. 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. (See "Hysteroscopy: Managing fluid and gas distending media", section on 'Fluid media'.)

The goals of newer techniques, such as morcellation (also referred to as tissue retrieval) or vaporization, is to make resection of fibroids technically easier [29,30], produce fewer tissue fragments, require fewer insertions of the hysteroscope, and use saline as the distention medium. Fewer insertions of the hysteroscope is helpful for patients with marked cervical stenosis, a retroverted/retroflexed uterus, or a small uterine cavity associated with menopause. Any of these factors may increase the risk of uterine perforation, particularly with repeat insertions of the hysteroscope. The use of saline avoids use of hypotonic solutions (ie, glycine), that may result in hyponatremia. In addition, because resection is performed mechanically or with limited bipolar radiofrequency (Symphion), there is minimal risk of damage to the endometrium. These devices are designed to enter only to a shallow depth and therefore are not likely to cause an incision that penetrates the full thickness of the uterine wall. As with any intrauterine instrument, it is possible for uterine perforation to occur if the entire device is pushed through the wall of the myometrium.

Visual dilation and curettage can be performed with a hysteroscopic tissue retrieval system. The hysteroscopic morcellator cutting aperture is aligned next to or abutting the endometrium. Under direct hysteroscopic visualization, the endometrium can be sampling with a to and fro maneuver with the hysteroscope, duplicating the same technique used with a curette.

However, the disposable morcellator or tissue retrieval system is more expensive than a wire loop and may require a propriety fluid management system, which also adds to the expense.

Comparative studies have reported that myomectomy duration was 8 to 26 minutes shorter with the intrauterine morcellator versus a resectoscope [29-31]. Of note, some of these studies were performed in an office setting. In addition, a review of events reported to the US Food and Drug Administration Manufacturer and User Device Experience (MAUDE) database from 2005 to 2014 included 119 adverse events, including death (2 cases), bowel damage (12), hysterectomy (6), uterine perforation requiring no other treatment (29), and pelvic infection (4) [32]. The limitation of these data is that the total number of procedures performed during this time period is unknown.

The disadvantage for two of the current hysteroscopic morcellators is that they cannot cauterize bleeding vessels. Only one system, Symphion, utilizes a built-in spot coagulation to control bleeding to maintain continuous visualization. The hysteroscopic morcellator is also not designed to treat deeper myomas, and thus, is limited to use in patients with hysteroscopic type 0 or type I leiomyomas. Since myomas that appear to be type 0 or I 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 and surgical skills to utilize both the wire loop and morcellator if needed.

Tissue removal — Use of the wire loop or tissue extraction (morcellator) techniques yield tissue fragments (referred to as chips) that need to be removed.

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.

There are several options to remove tissue fragments with conventional resectoscopy. Options include grasping as many myoma fragments under direct visualization with the wire loop and removing tissue fragments, chip by chip. This is safe, but time-consuming. Other techniques include blind insertion of uterine polyp forceps or myoma graspers, suction curettage, or slow removal of the hysteroscope through the dilated cervix allowing the tissue fragments to tumble out. Overall these techniques require multiple insertions of the hysteroscope.

With hysteroscopic tissue retrieval or morcellation devices, tissue fragments are retrieved throughout the procedure with the device in place, and thus fewer insertions are required. This may result is a shorter operative duration and decreased risk of cervical trauma.

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".)

The most important limiting factor in completing operative hysteroscopic myomectomy is fluid deficit. Guidelines advise in otherwise healthy patients that the procedure be concluded when a deficit of 2500 mL of saline is reached. If monopolar energy is used, the clinician should halt the procedure at 1000 mL of 1.5% glycine and check electrolytes. If normal, then the entire procedure should be halted at 1500 mL 1.5% glycine deficit.

Informed consent for a two-staged procedure should be discussed with the patient when large fibroids (>3 cm) are anticipated. Additionally, there is greater absorption of fluid when fibroids are type I or type II due to opening myometrial blood vessels, which increase the risk of intravasation. With patient-informed consent, the author discusses two-stage procedures in patients with multiple leiomyomas, especially those who are considering pregnancy and whose fibroids are on opposing walls. Theoretically, this would decrease the risk of postoperative intrauterine adhesions. Additionally, those with >2 fibroids that are 3 cm or greater, and those with type I and type II fibroids, are informed of increased risk of incomplete procedure due to fluid intravasation.

As surgical acumen increases, the rapidity of hysteroscopic resection often improves, and surgeons can deftly remove increased amount of fibroid tissue. The upper limit size of the leiomyoma resected will depend on the surgeon's expertise and how quickly surgery can be performed before reaching maximal fluid absorption. Removal of fibroids with deeper myometrial involvement and greater than 3 cm in diameter requires advanced hysteroscopic skills. Defining what constitutes a "large" leiomyoma was described by comparing outcomes and need for additional surgery within four years of initial treatment. In one prospective study of 122 subjects, patients with fibroids 3 cm or less were able to avoid additional fibroid surgery 90 percent of the time compared with patients with fibroids 4 cm or greater, who required additional surgery 60 percent of the time [15].

In the event of an incomplete procedure, the decision to proceed with additional attempts at hysteroscopic resection should depend upon the resolution of menstrual abnormalities, desire for future pregnancy, or if in vitro fertilization is anticipated. Some patients with an incomplete procedure may spontaneously pass residual leiomyomas and have complete resolution of clinical symptoms. Others will persist with menstrual aberrations or develop chronic leukorrhea. If a second procedure is anticipated, the author recommends reevaluating the size, number, and location of the fibroid with saline infusion sonogram to objectively plan the next surgical procedure.

Expert hysteroscopic experience is required for removal of type I fibroids greater than 5 to 6 cm and 4 to 5 cm if a type II fibroid is encountered. Several techniques have been described to approach resectoscopic retrieval of type I and type II fibroids. The main objective is to separate the fibroid from the pseudocapsule and then, with intermittent uterine decompression, slice the protruding fibroid and intramural component. It may require a two-step intervention if the maximal fluid deficit is reached. Patients with type II leiomyomas may have a volumetrically significant component of the leiomyoma retained within the myometrium. While protrusion of the leiomyoma may occur with partial resection, it may occur less effectively when there is a large intramural component remaining. Fibroid protrusion may be hindered by resistance of the contralateral wall. Attempts of a second-stage hysteroscopic resection may be incomplete. If a second-stage procedure is considered, then repeat evaluation with saline infusion sonohysterography or magnetic resonance imaging (MRI) is recommended to objectively confirm the size and location of the remaining fibroid.

Two additional techniques have been described to increase the likelihood of complete removal of the leiomyoma. While it lacks evidence-based trials, the author employs the technique of hydromassage. It involves rapid change in the intrauterine pressure using an automatic fluid management system. Stopping and starting the fluid as well as periodically removing the hysteroscope from the endometrial cavity increases myometrial contractions and facilitates migration of the intramural component into the uterine cavity [33]. Another technique called "manual massage" is performed by placing a finger into the uterus (similar to obstetric maneuvers such as Crede) and massaging the endocavity to help expel the fibroid into the uterine cavity [34].

The learning curve for operative resectoscopy may be longer than with hysteroscopic tissue retrieval systems. Deeper lesions (type I and type II leiomyomas) may more often benefit from resection technology [35]. However, with increased surgical volume, use of simulators, observing skilled hysteroscopists, and increased complexity of removing type I and type II leiomyomas, surgical acumen is improved and facilitates greater retrieval of larger leiomyomas with both devices.

Some clinicians advocate the release of the fibroid pseudocapsule, with the anticipation that deeply imbedded leiomyomas will become fully intracavitary, thereby facilitating complete hysteroscopic resection at a follow-up procedure. If this is a preferred technique, the author would confirm this with SIS or office hysteroscopy before rescheduling the patient [11,12,36-39].

Anesthesia — Hysteroscopic myomectomy is performed under general or regional anesthesia or intravenous sedation.

Preoperatively, a paracervical block, acetaminophen, and/or intravenous ketorolac may also be utilized to help with postoperative analgesia. (See "Overview of hysteroscopy", section on 'Pain management'.)

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, I, or II). (See 'Myometrial penetration' above.)

●Insert the resectoscope through the cervix under direct visualization.

●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 4 and 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.

●Perform intermittent uterine decompression (by lowering the fluid management system pressure) to facilitate fibroid removal and prevent a false-negative view of the fibroid (ie, a fibroid can "sink" into the myometrium and no longer be visualized when pressure is held continuously), which would prevent complete extraction.

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' 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. Care must be taken to avoid uterine perforation. If this is done, hysteroscopic reinspection is imperative to ensure complete resection and hemostasis. Excessive traction should be avoided to decrease the risk of uterine eversion, perforation, or injury to surrounding intraabdominal viscera. To minimize the risk of uterine perforation, the tissue fragments can be removed with the wire loop under direct visualization.

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. Additionally, reinjection of a dilute solution of vasopressin, as described above, is recommended. Further measures for management of excessive bleeding are described elsewhere. (See 'Excessive bleeding' below.)

Tissue extraction device — A hysteroscopic tissue extraction device (also referred to as a tissue retrieval system; Intra Uterine Morcellator, Truclear, and Myosure), utilizes a rotary blade for resection and suction tubing to remove tissue fragments. The Symphion system utilizes a bladeless resection technology with radiofrequency energy and has a proprietary self-contained recirculating fluid management fluid and internal uterine pressure monitoring system.

There are no data or guidelines regarding the risk of dissemination of potentially malignant tissue with hysteroscopic tissue extraction devices, as with laparoscopic morcellation of uterine leiomyomas. The risk of this is likely lower, since the uterus is mostly contained, although tissue and fluid may extrude from the fallopian tubes. This has been raised as a concern when hysteroscopy is used in the evaluation of abnormal uterine bleeding. In addition, the traditional wire loop technique also disrupts the tissue into small fragments. (See "Overview of the evaluation of the endometrium for malignant or premalignant disease", section on 'Risk of tumor dissemination'.)

This section will describe the techniques utilized for use of hysteroscopic tissue extraction devices. This technique can be used for most type 0 (completely within the endometrial cavity) and some type I leiomyomas (extend less than 50 percent into the myometrium), endometrial polyps, or retained products of conception [40].

The procedure is as follows:

●Saline is used as the distention medium. A fluid monitoring pump is utilized.

●The hysteroscope is inserted through the cervix into the uterine cavity under direct visualization. The uterine cavity is examined and confirms that a hysteroscopically removable lesion is present. Once this is confirmed, the disposable morcellator device can be opened and inserted through the working channel of the hysteroscope.

●The hysteroscopic aperture is aligned so that the aperture touches the surface of the lesion. Activate the foot pedal. It is important to keep the morcellator aperture closely approximated to the lesion to facilitate complete removal.

●The hysteroscope's working channel is at the distal tip equipped with a tissue removal device with a distal window that captures intracavitary pathology and resects it through a reciprocating or rotating cutting edge with simultaneous aspiration retrieval.

●Intermittently decompress the uterine cavity by lowering the intrauterine pressure on the fluid monitoring system. This will decrease the likelihood of a "negative hysteroscopic view," make it easier to remove fundal lesions and help enucleate type 0 leiomyomas.

There are several available hysteroscopic morcellator devices; the manufacturer instructions should be followed.

Vaporization technique — Vaporization electrodes (eg, VaporTrode, Force FX, and Gyne-Pro Perforated roller electrode) can be used with a monopolar or bipolar hysteroscope, 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. Clinically, these devices are useful to desiccate the fibroid, making it smaller, and then exchange the vaporization electrode for a wire loop to complete the procedure. In so doing, histologic retrieval is possible. 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 [41].

Radiofrequency ablation — Ultrasound-guided radiofrequency ablation (RFA) of fibroids is a technique that can be accomplished using a hysteroscopic (eg, Sonata) or, more commonly, laparoscopic approach; the technique and its outcomes are described in detail elsewhere. (See "Uterine fibroids (leiomyomas): Laparoscopic myomectomy and other laparoscopic treatments", section on 'Radiofrequency fibroid ablation'.)

By integrating ultrasonography and a needle array, one advantage of RFA is the potential to treat fibroids that may not be amenable to treatment with other forms of hysteroscopic resection (ie, intramural fibroids with significant myometrial involvement) [42] (see 'Myometrial penetration' above). This technique is not used to treat submucous pedunculated fibroids (which are easily amenable to resection) or subserous pedunculated fibroids (to prevent thermal injury to nearby structures). In one prospective study of 147 patients, hysteroscopic RFA was associated with a reduction in menstrual bleeding in 95 percent of patients; no adverse effects were reported, and only one patient required reintervention through 12 months of follow-up [43].

Safety and effectiveness regarding fertility and fecundity after hysteroscopic RFA have not been established.

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 [44]. Excessive resection of the myometrium will increase blood loss, fluid absorption, and myometrial scar tissue, and potentially result in uterine perforation.

Difficult-to-reach myomas — It is very helpful to have the patient's buttocks at the end of the operating table. Additionally, the cervix should be grasped tightly with a single-toothed tenaculum. An extra-long operative hysteroscope may be utilized if available. Ergonomics is important during surgery and each surgeon should determine whether the sitting position or standing position facilitates difficult-to-reach fibroids. Use of Trendelenburg position should never be utilized during hysteroscopy in order to decrease the risk of air embolism.

Patients with obesity — Patients with obesity may require use of a larger open-sided speculum, an extra-long heavy weighted speculum, or an extra-long operative hysteroscope in order to traverse a long vagina to gain access to the uterine cavity.

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 pink muscular fascicles are apparent.

In addition, adenomyomas must be differentiated from leiomyomas. Adenomyosis is defined as the presence of ectopic stroma and glandular tissue in the myometrium and thickened junctional zone on imaging. The diagnosis is made histologically with biopsy. MRI of the pelvis, two-dimensional and three-dimensional transvaginal ultrasound, and, on occasion, hysteroscopy can be used to identify adenomyosis. During operative hysteroscopy, glandlike openings may be seen and appear as multiple small pits in the endometrium, best identified during the early proliferative phase. The endometrium may appear irregular with superficial gland openings; irregular and spongy texture of the subendometrium is noted, and, unlike a leiomyoma, no pseudocapsule is identified and the tissue appears spongy and soft. Additionally, visually altered vascularity and intramural cystic hemorrhage (appears with a dark blue hue) can be noted. Most adenomyosis occurs on the posterior wall. When a hysteroscopic loop is used, the surgeon can obtain an endomyometrial biopsy by extending the wire loop and obtaining a long strip of myometrium. This tissue would include the endometrium and superficial myometrium, thereby facilitating a histologic diagnosis of superficial adenomyosis. While the hysteroscopic findings above are suggestive of adenomyosis, a pathognomonic feature for adenomyosis in hysteroscopy is elusive [45,46].

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 [47-49]; a series of 13 patients reported successful use of carboprost (125 mcg in 5 mL of saline, injected intracervically) for this purpose [49]. However, as profound diarrhea and difficult uterine distention may occur with carboprost, we do not use this in our practice.

Uterine massage via bimanual examination or other techniques have also been described to help to extrude the remaining portion of a fibroid [34,50].

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 [51].

Two-step procedures — A two-step procedure is occasionally necessary for fibroids that are multiple, large, broad-based, or penetrate deeply within the myometrium [52]. 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 patients 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 "Overview of endometrial ablation", section on 'Concomitant procedures'.)

FOLLOW-UP — Most patients experience postoperative cramping or light bleeding, and some complain of vaginal discomfort. Acetaminophen or nonsteroidal anti-inflammatory 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 education: 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 [53,54]. 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) [53].

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 [18]. 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 becomes suddenly difficult (because uterine distension cannot be achieved or visualization is obscured by blood) or if rapid loss of uterine pressure and marked fluid loss occur. Uterine perforation usually results in excessive bleeding, and the evaluation for uterine perforation is discussed as part of the management of bleeding below. (See 'Prevention or management of bleeding' below.)

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.

The evaluation and management of uterine perforation is discussed in detail separately. (See "Uterine perforation during gynecologic procedures".)

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, hysteroscopy, or other procedures involving electrolyte-free irrigation".)

Excessive bleeding — Excessive bleeding was reported in 4 of 235 patients who underwent hysteroscopic myomectomy in a retrospective series [53]; 4 of 94 patients required perioperative blood transfusion in another series [55].

Bleeding is usually minimal and averages 5 to 100 mL, in our experience. When there is excessive bleeding encountered, it is often associated with preoperative factors, such as patients who present with heavy bleeding or performing the procedure at the time of menstruation. The most common reason for excessive bleeding is uterine perforation when the uterus is sounded and is seen immediately at the beginning of the procedure. Perforation may also occur during resection. Heavy bleeding may also occur if the resection involves deep myometrial blood vessels. Cervical laceration from the cervical tenaculum can also lead to increased bleeding. If this occurs, placement of a figure-of-eight suture may be all that is required. Transfusion is rarely indicated, and the risk is generally related to the degree of preoperative anemia encountered.

Prevention or management of bleeding — Heavy intraoperative bleeding can be prevented or managed with several approaches.

For prevention, a preoperative intracervical injection of vasopressin may be used. In some cases, gonadotropin-releasing hormone agonists are used preoperatively to reduce leiomyoma size, thus reducing bleeding. (See 'Agents to decrease bleeding' above.)

For management intraoperatively, measures to assess and control bleeding include:

●Assess hemodynamic status – The hemodynamic status at the time of onset of bleeding should be assessed and checked again at regular intervals throughout the perioperative period. The volume of blood loss that results in hemodynamic changes depends upon the patient's age and health status.

●Evaluate for uterine perforation – Signs of a uterine perforation include:

•Rapid increase in the fluid deficit, especially when prior absorption was minimal

•Visualization of bowel loops or bowel contents

•Hemodynamic changes (this may occur due to visceral or vascular injury)

To assess for perforation, the hysteroscope should be inserted and the intrauterine pressure increased briefly to 100 to 125 mmHg to visualize the endometrial cavity and inspect for a perforation. There should be a high suspicion of perforation if the uterine cavity cannot be adequately distended and visualization is poor, particularly if distension and visualization were achieved easily prior to the onset of bleeding. Evaluation and management of uterine perforation is discussed in detail separately. (See "Uterine perforation during gynecologic procedures".)

●Evaluate for cervical laceration – To evaluate for a cervical laceration, remove the hysteroscope and visualize the cervix. A single-tooth tenaculum is placed on the anterior lip of the cervix as the mechanical dilation of the cervix at the beginning of the procedure. If the tenaculum pulled off and/or if the tenaculum had to be replaced multiple times, it is important to look for cervical laceration. Cervical laceration is an uncommon complication; in our experience, this occurs in approximately 1 percent of procedures. Factors that are associated with an increased risk of cervical laceration include difficult cervical dilation (eg, due to cervical stenosis), a cervix that is flush with the vaginal vault, a small loop electrosurgical excision procedure (LEEP) was required due to marked cervical stenosis (a mini-shallow LEEP was performed at the time of hysteroscopy to resect the stenotic external os), or postmenopausal or postpartum status. If a cervical laceration is noted, it is repaired with a figure-of-eight or running and locked suture. A very curved suture (eg, a UR-6 needle) is ideal for cervical repairs.

●Apply intrauterine pressure – Intrauterine pressure may be applied using a bladder (Foley) catheter balloon place inside the uterine cavity.

Care should be taken to evaluate the uterine size and compliance to estimate the amount of fluid that should be instilled into the balloon. Excessive inflation may result in postoperative pain or uterine rupture. For this reason, the Bakri balloon should not be used for intrauterine tamponade in cases of heavy bleeding that occurs during hysteroscopic surgery. The Bakri balloon is too large and may cause uterine rupture if inflated too much; it is intended only for obstetric hemorrhage.

The uterine cavity normally sounds to 8 cm and holds approximately 8 mL of fluid. Preoperative bimanual examination, hysteroscopic visualization of the uterine cavity, and gentle sounding of the cavity will aid in determining the uterine size.

Overall uterine size can be evaluated with bimanual examination, but in some cases the overall size may not correspond to the size of the cavity. There are several factors to consider: Does the patient have a 10 cm exophytic pedunculated fibroid that is attached to a normal size uterus? If so, the uterine cavity will be normal size, yet on bimanual examination, the uterine size is large. Does the patient have multiple intramural fibroids that make the uterus enlarged? Does the patient have a 10 cm intracavitary fibroid that grossly enlarges the uterus? Hysteroscopic visualization of the endometrium is useful in determining the volume of the cavity and presence of myomas within the cavity.

The ability to instill fluid for hysteroscopy gives a sense of the uterine distensibility. A surgeon may note that higher intrauterine pressure is required to maintain uterine distention when the uterus has multiple uterine fibroids. Factors that decrease compliance, in our experience, include gonadotropin-releasing hormone agonists, tamoxifen, prior endometrial ablation, multiple intramural fibroids greater than 4 cm, and adenomyosis.

The bladder catheter is inserted through the cervix and into the uterine cavity. We use a size 16 French catheter with a 3 to 30 mL balloon. Inflate the balloon with sterile water until mild resistance is encountered. There is a subtle tactile feeling when it becomes more difficult to distend the balloon; recognizing this feeling is achieved with experience with intrauterine procedures. The amount of fluid instilled into the balloon should be recorded in the operative note. If the patient complains of lower pelvic pain after emerging from anesthesia, the balloon should be deflated until tolerated by the patient.

After inflation, the catheter bag should be monitored for volume of blood drainage. In our practice, we generally leave the intrauterine catheter in place four to eight hours; however, surgeons must individualize the care of each patient. To remove the catheter, it should be deflated over several hours and blood loss monitored. The balloon can be reinflated if increased bleeding occurs. With the balloon removed, if bleeding is minimal, the patient can be discharged from the surgical unit.

In terms of efficacy, in one series of 216 resectoscope procedures, four patients (1.9 percent) developed postoperative uterine bleeding and were successfully treated with this procedure [23].

●Vasopressin – If the patient continues to bleed briskly with the intrauterine balloon in place, we administer an intracervical injection of vasopressin (eg, 10 units in 100 mL of normal saline, injected into the cervical stroma in 5 mL aliquots at the 10, 2, 5, and 8 o'clock positions around the ectocervix). This dose can be repeated every 30 to 45 minutes, if bleeding increases. (See 'Vasopressin' above.)

●Evaluate for anemia and coagulopathy – If the estimated blood loss is ≥500 mL and/or 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'.)

If the patient is hemodynamically unstable or massive bleeding occurs, the hysteroscopic procedure should be terminated and a laparoscopy or laparotomy may be required for further evaluation and management. This may include evaluation for uterine perforation with vascular or visceral injury or surgical approaches to controlling bleeding. (See "Management of hemorrhage in gynecologic surgery", section on 'Management of intraoperative bleeding'.)

Intrauterine adhesions — Formation of intrauterine adhesions can interfere with fertility or menstruation. In studies in which patients had a second-look hysteroscopy after the initial hysteroscopic myomectomy report, the rates of this complication varied widely, from 0 to 46 percent [17,53,56]. 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) [17]. Evaluation and treatment for intrauterine adhesions are discussed in detail separately. (See "Intrauterine adhesions: Clinical manifestation and diagnosis".)

Infection — Infection is uncommon; it was reported in 2 of 128 subjects in one series [18].

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 [57]. However, many studies and surgeons report high patient satisfaction, resolution of abnormal uterine bleeding, and a low rate of complications [53].

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 [11,53].

Incomplete myoma resection does not commit a patient to reoperation. In a series of 41 patients 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 [58].

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 patients were followed for three or more years after hysteroscopic electrosurgical myomectomy [15,55,59]. A subsequent study of 320 patients treated with hysteroscopic morcellation reported a three-year recurrence rate of approximately 1 percent [60].

Across all studies, 3 to 21 percent of patients underwent subsequent surgery for fibroid-related complaints. In one study, the risk was highest in those with fibroids >3 cm or when two or more fibroids were present [15].

Reproductive outcomes

Infertility and recurrent pregnancy loss — Patients 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 patients undergoing in vitro fertilization (IVF). Thus, many IVF units advise patients with these lesions to undergo myomectomy.

The effects of leiomyomas on reproductive function are discussed in detail separately. (See "Uterine fibroids (leiomyomas): Treatment overview", section on 'Impact of fibroids on fertility'.)

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 [61,62].

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Gynecologic surgery" and "Society guideline links: Uterine fibroids (leiomyomas)".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Beyond the Basics topics (see "Patient education: Uterine fibroids (Beyond the Basics)")

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 patients in whom hysteroscopic surgery is contraindicated (eg, active pelvic infection, intrauterine pregnancy). (See 'Indications' above and 'Contraindications' above.)

●For patients 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 patients with fibroid-associated symptoms who desire surgical treatment:

•We suggest not performing hysteroscopic myomectomy in patients 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 patients 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 patients, such as those with menstrual aberrations only, recurrent miscarriage, or fibroid-associated leukorrhea. (See 'Presence of other leiomyomas or uterine pathology' above.)

●We suggest against use of gonadotropin-releasing hormone agonists prior to hysteroscopic myomectomy (Grade 2C). Use of these agents is reasonable in patients 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.)

●Patients 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 outcomes' above.)