Surgical Techniques

Hysteroscopic myomectomy using a mechanical approach

OBG Manag. 2015 February;27(2):25-28,30-31

References

1. Perez-Medina T, Font EC, eds. Diagnostic and Operative Hysteroscopy. Tunbridge Wells, Kent, UK: Anshan Publishing; 2007:13.

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7. Emanuel MH, Wamsteker K. The intra uterine morcellator: a new hysteroscopic operating technique to remove intrauterine polyps and myomas. J Minim Invasive Gynecol. 2005;12(1):62–66.

8. Emanuel MH, Hart A, Wamsteker K, Lammes F. An analysis of fluid loss during transcervical resection of submucous myomas. Fertil Steril. 1997;68(5):881–886.

9. Taskin O, Sadik S, Onoglu A, et al. Role of endometrial suppression on the frequency of intrauterine adhesions after resectoscopic surgery. J Am Assoc Gynecol Laparosc. 2000;7(3):351.

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Preoperative evaluation
A complete history is vital to document which fibroid-related symptoms are present and how they affect quality of life.

Preoperative imaging also is imperative—using either 2D or 3D saline infusion sonography or a combination of diagnostic hysteroscopy and transvaginal ultrasound—to select patients for hysteroscopy, anticipate blood loss, and ensure that the proper instrumentation is available at the time of surgery. Magnetic resonance imaging, computed tomography, and hysterosalpingography are either prohibitively expensive or of limited value in the initial preoperative assessment of uterine fibroids.

Any woman who has AUB and a risk for endometrial hyperplasia or cancer should undergo endometrial assessment as well.

Use of preoperative medications
In most cases, prophylactic administration of antibiotics is not warranted to prevent infection or endocarditis.

Although some clinicians give gonadotropin-releasing hormone (GnRH) agonists to reduce the size of large fibroids, the drug complicates dissection of the fibroid from the surrounding capsule. For this reason, and because we lack data demonstrating that GnRH agonists decrease blood loss and limit absorption of distension media, I do not administer them to patients.^8–12 Moreover, this drug can cause vasomotor symptoms, cervical stenosis, and vaginal hemorrhage (related to estrogen flare).

GnRH agonists may be of value to stimulate transient amenorrhea for several months preoperatively in order to correct iron-deficiency anemia. Intravenous iron also can be administered during this interval.

The risk of bleeding in hysteroscopic myomectomy is 2% to 3%.¹ When the mechanical approach is used, rather than resectoscopy, continuous flow coupled with suctioning of the chips during the procedure keeps the image clear. Post-procedure contraction of the uterus stops most bleeding. Intrauterine pressure of the pump can be increased to help tamponade any oozing.

Misoprostol. Cervical stenosis is not uncommon in menopausal women. It can also pose a challenge in nulliparous women. Attempting hysteroscopy in the setting of cervical stenosis increases the risk of cervical laceration, creation of a false passage, and uterine perforation. For this reason, I prescribe oral or vaginal misoprostol 200 to 400 µg nightly for 1 to 2 days before the procedure.

Vasopressin can reduce blood loss during hysteroscopic myomectomy when it is injected into the cervical stroma preoperatively. It also reduces absorption of distension fluid and facilitates cervical dilation.

However, vasopressin must be injected with extreme care, with aspiration to confirm the absence of blood prior to each injection, as intravascular injection can lead to bradycardia, profound hypertension, and even death.¹³ Always notify the anesthesiologist prior to injection when vasopressin will be administered.

I routinely use vasopressin before hysteroscopic myomectomy (0.5 mg in 20 cc of saline or 20 U in 100 cc), injecting 5 cc of the solution at 3, 6, 9, and 12 o’clock positions.

Anesthesia during hysteroscopic myomectomy typically is “monitored anesthesia care,” or MAC, which consists of local anesthesia with sedation and analgesia. The need for regional or general anesthesia is rare. Consider adding a pericervical block or intravenous ketorolac (Toradol) to provide postoperative analgesia.

Surgical technique
Strict attention to fluid management is required throughout the procedure, preferably in accordance with AAGL guidelines on the management of hysteroscopic distending media.¹⁴ With the mechanical approach, because the distension fluid is isotonic (normal saline), it does not increase the risk of hyponatremia but can cause pulmonary edema or congestive heart failure. Intravasation usually is the result of excessive operative time, treatment of deeper myometrial fibroids (Type I or II), or high intrauterine pressure. I operate using intrauterine pressure in the range of 75 to 125 mm Hg.

The steps involved in the mechanical hysteroscopy approach are:

Insert the hysteroscope into the uterus under direct visualization. In general, the greater the number of insertions, the greater the risk of uterine perforation. Preoperative cervical ripening helps facilitate insertion (see “Misoprostol” above).
Distend the uterus with saline and inspect the uterine cavity, noting again the size and location of the fibroids and whether they are sessile or pedunculated.
Locate the fibroid or other pathology to be removed, and place the morcellator window against it to begin cutting. Use the tip of the morcellator to elevate the fibroid for easier cutting. Enucleation is accomplished largely by varying the intrauterine pressure, which permits uterine decompression and myometrial contraction and renders the fibroid capsule more visible. If necessary, the hysteroscope can be withdrawn to stimulate myometrial contraction, which also helps to delineate the fibroid capsule.
Reinspect the uterus to rule out perforation and remove any additional intrauterine pathology with a targeted view.
Once all designated fibroids have been removed, withdraw the morcellator and hysteroscope from the uterus.
Inspect the endocervical landscape to rule out injury and other pathology.

Best practices for hysteroscopic myomectomy

Careful preoperative evaluation is important, preferably using diagnostic hysteroscopy or saline infusion sonography, to choose the optimal route of myomectomy and plan the surgical approach.
During the myomectomy, pay close attention to fluid management and adhere strictly to predetermined limits.
Complete removal of the fibroid is essential to relieve symptoms and avert the need for additional procedures.

Postoperative care
A nonsteroidal anti-inflammatory drug or limited use of narcotics usually is sufficient to relieve any postoperative cramping or vaginal discomfort.

Advise the patient to notify you in the event of increasing pain, foul-smelling vaginal discharge, or fever.

Also counsel her that she can return to most normal activities within 24 to 48 hours. Sexual activity is permissible 1 week after surgery. Early and frequent ambulation is important.

Schedule a follow-up visit 4 to 6 weeks after the procedure.

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