FORT LAUDERDALE, FLA. — Outcomes of operative hysteroscopy for uterine leiomyomas can be optimized using tips and techniques presented at a meeting on hysterectomy sponsored by the Cleveland Clinic.
▸ Large fibroids. If a patient has larger fibroids or the case is long or involves a new resident, use a bipolar resection device instead of a unipolar instrument, recommended Dr. Linda Bradley, director of the center for menstrual disorders, fibroids, and hysteroscopic services at the clinic.
“You will have more time to do the procedure. You just continue to shave, shave, shave, always working toward yourself. … Sometimes it's a lot of work,” she said.
New technology targets the tedium of large fibroid resections. For example, perforated roller devices “are good for removal of huge myomas,” Dr. Bradley said. “You step on the pedal and within 10 minutes you can get about half of the volume out.” A hysteroscopic morcellator is another option. This device uses no electricity but quickly removes tissue as it cuts. A third option is a conventional resectoscope. “This will suck 85%–90% of the chips right into the scope. But you have to go a little slower and make smaller bites of the tissue. I still like my conventional hysteroscope, but you can see how this would be less frustrating,” she said.
▸ The “snowstorm.” With traditional hysteroscopy, free-floating tissue pieces in the saline can obscure the view.
“Sometimes at the end you get what we call the 'snowstorm,'” Dr. Bradley said. The pieces can be pulled out with polyp forceps or removed one by one with the loop.
“I have a rule of thumb. If I go three times through and do not catch any, I go back to work. Be careful not to perforate while you are doing this.”
▸ Pressure. Inflation and deflation during hysteroscopy aid visualization, Dr. Bradley said. “When pressure is at 100, everything is really flat. Lower the pressure to 50–80 and a fibroid might pop out of its capsule.” If the visual field gets very bloody, you can turn the pressure back up, she added. “It's a very dynamic process.”
▸ Complications. Reinspect the endometrial cavity a few minutes after removal of the hysteroscope, Dr. Bradley said. Postoperative hysteroscopic complications are infrequent, but malodorous discharge and persistent fever, nausea, vomiting, constipation, or abdominal pain can occur. Instruct patients to call if symptoms are not improving, she added, especially if the pain worsens or there is a new onset of fever.
▸ Contraindications. Contraindications to operative hysteroscopy include fibroids that are completely intramural or subserosal.
“These are much more difficult to remove hysteroscopically,” Dr. Bradley said. Contraindications also include myomas that are larger than 3 cm and/or situated more than 50% within the myometrium.
“Not everything can be done with hysteroscopy,” she said. “You may want to do a laparoscopy or open procedure [in these cases].”
▸ Saline infusion sonography. Hysteroscopy is a complementary procedure to saline infusion sonography, Dr. Bradley said. “Ultrasound can show a large intracavity fibroid, and we can measure and know how deep it goes.”
“Remember volume,” she said. A 1-cm fibroid on ultrasound is approximately 0.5 cm
“A 1-cm [fibroid] you can remove within a few moments. A 5-cm [fibroid] might be a two-stage procedure.”
▸ D&C. Myomas are often missed on a routine dilatation and curettage (D&C). They can be in the submucosal region, for example. If a deep intramural lesion is observed, Dr. Bradley advised waiting a few minutes. In some cases, uterine contractions will expel the myoma into view, in a way similar to the expulsion of a placenta.
Dr. Bradley disclosed that she is a consultant to Gynecare, a researcher for Smith & Nephew, and a consultant for Gyrus/ACMI.
A velvetlike secretory endometrium covers a submucosal fibroid.
A large polyp is shown attached to a submucosal fibroid. Photos courtesy Dr. Linda Bradley