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OBJECTIVE: The aim of this study was to assess postoperative pregnancy outcomes in patients with different types of submucous myomas after hysteroscopic resection. MATERIALS AND METHODS: This retrospective unicentric study used data from the electronic medical records system of the hospital. All patients (n = 77) who underwent hysteroscopy for submucous myomas between November 2010 and December 2018 were included. Patients were divided into three groups according to the myoma classification (G0, G1, and G2). Medical files were reviewed and phone questionnaires were conducted to evaluate demographic characteristics, clinical features, surgical treatment, and pregnancy outcomes. RESULTS: The median age of the patients was 32 (30.0, 34.0) years. The myoma diameter was 2.9 (2.0, 3.8) cm. The operation duration was 50.0 (30.0, 75.0) min. There were 15 patients in Group G0, 20 patients in Group G1, and 37 patients in Group G2. Follow-up data were available for 65 of the 77 patients. The total pregnancy rate was 58 (89.2%) of 65. The live birth rate was 41 (70.7%) of 58. There was no significant difference in pregnancy rate (G0 100% vs. G1 76.5% vs. G2 91.2%; p = 0.097) or in live birth rates among the three groups (G0 78.6% vs. G1 53.8% vs. G2 74.2%; p = 0.325). CONCLUSION: There was no difference in pregnancy outcome among the three types of submucosal myomas. Our results support the idea that hysteroscopic myomectomy is an effective option for submucous myomas with good long-term pregnancy outcomes.

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OBJECTIVES: To compare hysteroscopic morcellation with bipolar resection for the removal of submucous type 0 and 1 myomas, in terms of procedure time (primary outcome), adverse events, tissue availability, short term effectiveness and postoperative adhesion formation (secondary outcomes). STUDY DESIGN: The study was performed from May 2011 to May 2018 in the Catharina hospital (Eindhoven, the Netherlands) and the Ghent University hospital (Ghent, Belgium). Women with type 0 and 1 submucous myomas up to 3 cm were randomized to hysteroscopic morcellation with the TruClearTM 8.0 Tissue Removal System or to bipolar resection with a rigid 8.5-mm resectoscope. Skewed time variables were log-transformed and analyzed with the Student t-test. Multiple linear regression analysis was performed to assess the effect of myoma diameter on operating time. RESULTS: Forty-five and 38 women were included in the hysteroscopic morcellation and resection group, respectively. The median operating time was significantly shorter for hysteroscopic morcellation compared with resection (9.2 min [interquartile range 5.6-14.4] versus 13.4 min [interquartile range 8.6-17.5], P = .04). In the morcellation group, operating time, corrected for the myoma diameter, was reduced by 26 % (95 % CI 5-43%; P = .02). The median setup time was significantly longer in the morcellation group (5.2 min [interquartile range 4.2-6.9] versus 3.8 min [interquartile range 3.3-5.3], P = .006). The median total procedure time was not significantly different between the two techniques (14.4 min [interquartile range 11.4-19.2] versus 17.3 [interquartile range 12.7-23.8], P = .18). Two procedures of the morcellation group were converted to bipolar resection because of the myoma hardness. Complete resection was found in 89 % of the morcellation group and 95 % of the resection group. Adverse events occurred in 3 patients of the morcellation group, namely a fluid deficit > 2500 mL with the need of potassium suppletion, an asystolic vasovagal response after conversion to resection and postoperative fever requiring antibiotics. Tissue was available for pathology analysis in all cases. Routine second-look hysteroscopy performed in one center showed no intrauterine adhesions. CONCLUSION: Overall, there is no difference in total procedure time between hysteroscopic morcellation using the TruClearTM system compared to bipolar resection for the removal of smaller type 0 and 1 submucous myomas. Although hysteroscopic morcellation is faster, its setup time is longer. Calcified myomas can be challenging and fluid deficit remains a limiting factor.

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OBJECTIVE: To evaluate the feasibility and safety of leaving the submucous myoma (SM) in the uterine cavity after office hysteroscopic enucleation. STUDY DESIGN: Prospective multicenter study including patients who had a single SM diagnosed by transvaginal ultrasounds with surgical indication. Office hysteroscopic enucleation of the SM was performed using a 5 mm continuous flow office hysteroscope with a 2.9 mm rod lens optical system and a 5 Fr operative channel. After the SM was released preserving the pseudo capsule using cold instruments, it was left into the uterine cavity. The primary endpoint was the proportion of patients without evidence of the myoma at the transvaginal ultrasound performed after 90 days from surgery. RESULTS: Between January 1st, 2018, and March 31st, 2020, a total of 204 patients were enrolled. Most patients were nulliparous and reported abnormal uterine bleeding as the leading symptom. 76.5 % of enucleated myomas had a diameter ranging between 1.5 and 2.5 cm, and 81.4 % of SMs were of G0 or G1. Hysteroscopic procedures had a mean duration of 23.2 ± 10.5 min. The operative time was associated with the SM grade and size. All hysteroscopic procedures were completed. A vasovagal reaction was observed in 3 women (1.5 %), and minimal post-operative bleeding was reported after 7 procedures (3.4 %). None reported pelvic pain or vaginal discharges/bleeding during follow-up. The average patient satisfaction from surgery was 4.59 (5-points Likert scale). The level of patient satisfaction was not associated with the grade and the size of the myoma. In 192 (94.12 %; 98 %CI: 89.03-96.93 %) out of 204 patients, the SM was absent at the transvaginal ultrasound performed at the follow-up end. A higher prevalence of G2 SMs and lower prevalence of G1 SMs were observed among patients with evidence of the myoma after 90 days from the surgery. CONCLUSION: Office hysteroscopic myomectomy with SM enucleation without mass extraction appears safe, well-tolerated, and effective in at least 89 % of patients. G2 SMs may be the factor associated with the procedure's failure.

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OBJECTIVE: This study aimed to analyze the results of hysterosonography performed prior to in vitro fertilization (IVF) and to correlate anomalous findings with hysteroscopy. METHODS: Findings from 197 hysterosonograms of patients examined in an assisted reproduction clinic between January 2012 and August 2014 were included. Enrollment criteria: patients in preparation for IVF not recently submitted to uterine examination through hysterosalpingography or hysteroscopy referred to hysterosonography. Uterine cavity evaluation was considered anomalous when one or more of the following were found: polyps, submucous myomas, uterine synechiae, Müllerian duct anomalies. Individuals with cavity abnormalities that might interfere with IVF results were referred to hysteroscopy. RESULTS: Normal test results were seen in 170/197 of the cases (86.3%). Eighteen of the 197 cases (9.1%) were suspected for polyps, two (1%) for submucous myoma, six (3.5%) for synechiae, and one (0.5%) for Müllerian duct anomalies. Sixteen of the patients diagnosed with abnormalities underwent hysteroscopy to confirm or treat the suspected pathology. In only two cases there was no agreement between tests: one patient suspected for synechiae and another for polyps were not confirmed; another individual suspected for polyps was found to have focal endometrial thickening in hysteroscopy. The positive predictive value (PPV) in our study was 93.7%. CONCLUSION: In most cases, the diagnoses obtained by hysterosonography showed normal uterine cavities. The most common anomalous findings were polyps, followed by synechiae, submucous myoma, and Müllerian duct anomalies. Hysterosonography is a good option for evaluating the uterus and offers a high positive predictive value, while hysteroscopy stands as the gold standard.

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Resectoscopic surgery is routinely performed to remove endometrial polyps and uterine myomas. A search of Medline, PubMed, and the Cochrane Library was conducted through November 2016 for studies written in English, regardless of sample size or study type. The studies were then filtered by selecting those evaluating resectoscopic surgery. An analysis of peer-reviewed, published literature was performed to examine the clinical application of this treatment modality on patients requiring polypectomy and myomectomy. Different surgical techniques were also compared: hysteroscopy with scissors, forceps, or a cold loop; resectoscopy with radiofrequency energy; and mechanical resection. The literature finds that operative time during resectoscopic surgery is significantly longer than with mechanical resection. Resectoscopic myomectomy, however, may be necessary for removal of larger or more deeply embedded myomas. Ultimately, both techniques result in symptom resolution and a low recurrence rate.

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STUDY OBJECTIVE: To examine demographics and outcome measures of women having undergone vaginal excision of myomas through the Dührssen (longitudinal median cervical) incision. DESIGN: Prospective case series (Canadian Task Force classification II-3). SETTING: A London teaching hospital. PATIENTS: Nineteen patients with either a submucous myoma (type 1) located near the cervix or a pedunculated intracavity myoma (type 0), excised via the Dührssen incision. INTERVENTIONS: Dührssen (median longitudinal) incision on the anterior or posterior cervical lip. MEASUREMENTS AND MAIN RESULTS: Duration of procedures, intraoperative complications, estimated blood loss, length of stay, percent of patients discharged in 24 hours, and readmission rates were studied. Between 2009 and 2016, 19 women had their myomas (submucous type 1, n = 17; pedunculated intracavity type 0, n = 2) removed vaginally with the Dührssen incision. The median age at time of procedure was 46 years (range, 43-55), and the most common indication was menorrhagia, which occurred in 90% of cases. The median myoma size was 7 cm (range, 6-9), whereas the median duration of surgery was 60 minutes (range, 40-120). Anterior cervical incisions were performed in 60% of cases, and 20% of the patients received gonadotropins for medical debulking of the myomas before surgery. One patient sustained a bladder injury that occurred when making the anterior cervical incision. The median length of stay was 8 hours (range, 6-36) and the median estimated blood loss was 90 mL (range, 50-150). The median duration of follow-up was 4 years (range, .5-6), and no patients had symptoms that were attributable to the procedure. CONCLUSION: This is a useful technique that complements a minimally invasive surgeon's repertoire and is a viable alternative when hysteroscopic myomectomy is deemed unsuitable because of location and size of the myomas.

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STUDY OBJECTIVE: To demonstrate a laparoscopic myomectomy technique for the removal of multiple submucous myomas. DESIGN: A step-by-step demonstration of the surgical procedure (Canadian Task Force classification III-C). SETTING: In cases of multiple submucous myomas, hysteroscopic resection of myomas might not be a viable option, especially in cases requiring fertility preservation. It may cause significant damage to the endometrial surface, leading to the formation of endometrial synechiae [1]. The procedure is technically challenging and requires prolonged operating time owing to impaired visibility and the need for repeated specimen removal. This can lead to complications, such as fluid overload and, rarely, air embolism [2]. Thus, laparoscopic myomectomy may be a better option in such cases [1]. INTERVENTIONS: A 30-year-old nulligravida presented with a 3-year history of heavy menstrual bleeding and dysmenorrhea. She had received no symptom relief with hormonal medications and magnetic resonance-guided focused ultrasound. On examination, she was anemic, and her uterus was enlarged to 16-weeks gravid size. Ultrasonography revealed an intramural fundal myoma of 6 × 4.2 cm and numerous submucous myomas of 1 to 3.2 cm. During hysteroscopy, multiple submucous myomas of varying sizes ranging from type 0 to type 1 were seen. On laparoscopy, an incision was made on the uterine fundus with an ultrasonic device after injecting vasopressin (20 U in 200 mL dilution), and the fundal myoma was enucleated. The incision was then extended to open the endometrial cavity for the removal of the submucous myomas. Most of the myomas were removed with mechanical force, along with the minimal use of ultrasonic energy. A total of 46 myomas were removed, and the myometrium was closed in 2 layers. The duration of the surgery was 210 minutes, and estimated blood loss was 850 mL. The patient did not require blood transfusion, but was advised to take hematinics. At a 6-month follow-up, the patient reported significant improvement in her symptoms. A repeat hysteroscopy revealed moderate synechiae in the midline and 2 small submucous myomas near the internal os. The synechiae were incised with hysteroscopic scissors, and the submucous myomas were resected with a bipolar resectoscope. The patient was advised to attempt conception after 2 months. CONCLUSION: Laparoscopic myomectomy is an alternative to hysteroscopic resection for multiple submucous myomas. A repeat hysteroscopy is useful for identifying any residual myomas and synechiae.

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A new International Federation of Gynecology and Obstetrics classification for myomas was recently described. Type 0, 1 and 2 are the submucosal fibroids. Submucous myomas represent one of the main indications for operative hysteroscopy. Hysteroscopic resection of submucous fibroids should be a simple, well-tolerated procedure and ideally finished in a single surgical step. Hysteroscopic myomectomy is an effective procedure. Fertility outcome and menorrhagia are improved by this procedure. However, for menorrhagia, a recurrence can occur mainly during the first year following the surgery. For bleeding outcome, a success rate from 70 to 99% has been reported by different studies. The success rate seems to decline as the follow- up period increases. For fertility outcome, submucosal fibroids have negative impact on pregnancy rates. The size of the fibroids plays a crucial role in completing the hysteroscopic myomectomy in a single step. A diameter greater than 3 cm in type 2 myomas results in a higher risk of a multiple procedure.

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The aim of this single-center, prospective, randomized, parallel-group study was to compare Dienogest and Danazol as endometrial preparation in patients who have to undergo hysteroscopic surgery for submucous myomas. We enrolled 80 consecutive eligible patients, in reproductive age, affected by submucous myomas. Pre- and posttreatment characterization of endometrium was performed by hysteroscopic visual observation and histologic confirmation. The enrolled patients were randomly assigned to two groups: 40 were treated with 2 mg of Dienogest/die, 40 with 100 mg of Danazol/die, both orally for 5 weeks, starting on day 1 of menstruation. Posttreatment comparison of endometrial patterns showed a significant more marked effect of Dienogest, respect to Danazol, in atrophying endometrium ("normotrophic non-responders" versus "hypotrophic"-"atrophic", p = 0.028). Intraoperative data showed no significant difference between the two groups for cervical dilatation time (p = 0.326), while in the Dienogest group, we found a significant reduction of operative time (p = 0.001), infusion volume (p = 0.001), and severity of bleeding (p = 0.042). Moreover, Dienogest caused less side effects (p = 0.008). According to our data analysis, Dienogest, respect to Danazol, is more effective for the preparation of the endometrium in patients who have to undergo hysteroscopic surgery for submucous myomas, and causes less side effects.

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Fibroids or (leio)myomas are benign tumours that very commonly derive from smooth muscle cells of the myometrium. They are the most common indication for a hysterectomy. However, in women desirous of preservation of their uterus or of their fertility, a myomectomy may be a more appropriate form of surgical therapy. The submucous variant is often associated with heavy menstrual bleeding or subfertility. It can be removed with hysteroscopic surgery. Refinements of hysteroscopic surgical techniques have resulted in a better ability to remove submucous myomas. The state of the art of such hysteroscopical techniques and instrumentation to treat submucous myomas and what has been proven is discussed.

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STUDY OBJECTIVE: To evaluate the effect of radiofrequency volumetric thermal ablation (RFVTA) on menstrual bleeding in patients with intramural myomas. DESIGN: Retrospective analysis of a recently completed prospective trial of laparoscopic ultrasound-guided RFVTA in which 135 subjects had objectively measured heavy menstrual bleeding (≥160 to ≤500 mL) and confirmed submucosal, intramural, and subserosal myomas. We analyzed the pretreatment monthly menstrual blood loss as well as the response to treatment based on the types of myomas, specifically those subjects with only intramural myomas versus those with only submucosal myomas or those with both (Canadian Task Force classification II-2). SETTING: Outpatient hospital and private surgery centers. PATIENTS: One hundred thirty-five premenopausal symptomatic women (mean age: 42.4 ± 4.5 years) with uterine myomas and heavy menstrual bleeding confirmed by alkaline hematin analysis. INTERVENTIONS: Laparoscopic ultrasound-guided RFVTA. MEASUREMENTS AND MAIN RESULTS: Menstrual blood loss (MBL) at baseline and at 12 months after the procedure was quantified in 122 subjects with intramural myomas (including those that abut the endometrium, those that are within the myometrium, and those that extend from the serosa into the myometrium) and/or submucous myomas. Although 91.8% (112/122) of these subjects had 1 or more intramural myomas, submucous myomas were present in fewer than half of the subjects ([48.4%]). We identified 10 subjects who had submucous but no intramural myomas. This group had a significant (-45.1%) posttreatment decrease in monthly bleeding (95% confidence interval [CI], -78.0% to -12.2%; p = .013). In this same study, there were 63 subjects with intramural myomas and no submucosal myomas, and their posttreatment decrease in MBL of -31.8% was also clinically and statistically significant (95% CI, -41.4% to -22.2%; p<.001). Of those 63 subjects was a subset with intramural myomas (n = 27) without myomas abutting the endometrium or submucous myomas; this third set also resulted in a clinically and statistically significant reduction in MBL (-25.0% and -65.22 mL; 95% CI, -38.8% to -11.2%; p = .001). CONCLUSION: Although it has been known that the treatment of submucous myomas results in a reduction of MBL, this is the first study to show that radiofrequency ablative therapy for intramural myomas without a submucosal component will also result in a significant reduction in menstrual blood loss.

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