Uterine Fibroids Associated With Infertility
Uterine Fibroids Associated With Infertility
Hysteroscopic myomectomy is the preferred surgical modality whenever possible. It is appropriate for submucous myomas that are up to 4–5 cm in size. Hysteroscopic resection can be performed on type 0, 1 or 2 myomas (Figure 1), although type 2 fibroids often require multiple procedures for complete resection. Complications of hysteroscopic myomectomy include uterine perforation, fluid overload, bleeding and intracavitary adhesion formation. Many fibroids with a significant intramural component (some type 2s, hybrid myomas; Figure 1) as well as any with no intracavitary involvement (types 3–8) require abdominal removal, whether via laparotomy, traditional laparoscopy or robotic-assisted laparoscopy. An additional classification, created by Lasmar et al., that is specific to hysteroscopic myomectomy exists. This system (STEPW), has been shown to be a better predictor of successful hysteroscopic fibroid removal and surgical complications than the ESGE/FIGO system (Table 1 & Figure 1).
There are several techniques available for hysteroscopic myomectomy. These include electrocautery resection, morcellation, laser ablation and vaporization. Electrocautery resection can be performed with monopolar energy, which requires a nonconductive distension media, such as glycine, or bipolar energy (can be used with saline). This method of resection can be used in any case where hysteroscopic myomectomy is appropriate; however, it may be more time consuming and requires more advanced cervical dilation than other techniques. Laser ablation is appropriate for myomas measuring 2 cm or less in diameter. The disadvantages of this technique are operative time, the prohibitive cost of the equipment and the inability to evaluate a tissue specimen. Studies of electrode vaporization have shown shorter operative times than resectoscopic surgery. However, the risks of this procedure include the lack of ability to evaluate the pathologic specimen in its entirety and the potential for significantly high CO2 blood levels resulting from the many gas bubbles produced. In 2005, the FDA approved the first hysteroscopic morcellator, the TRUCLEAR™ Hysteroscopic Morcellator (Smith & Nephew, Andover, MA, USA). Shortly thereafter, in 2009, a second device, the MyoSure® Tissue Removal System (Hologic, Bedford, MA, USA) was approved. Both of these devices function via mechanical energy generated by a motor with suction applied for specimen collection. Studies to date have shown that hysteroscopic morcellation is often faster than traditional electrocautery resection, with reductions in operating room time from 38% to 72%, depending on the type of lesion being removed. This is largely because no additional time is required for removal of portions of surgical specimen. As this is a newer technique, research regarding the potential for fluid overload is less extensive at this point. The main disadvantage of hysteroscopic morcellation is that it is not appropriate for myomas with greater than 50% extension into the uterine wall. Laser ablation, morcellation and vaporization are felt to be less traumatic techniques and in theory could improve fertility, although further study is needed to confirm this.
Hysteroscopy
Hysteroscopic myomectomy is the preferred surgical modality whenever possible. It is appropriate for submucous myomas that are up to 4–5 cm in size. Hysteroscopic resection can be performed on type 0, 1 or 2 myomas (Figure 1), although type 2 fibroids often require multiple procedures for complete resection. Complications of hysteroscopic myomectomy include uterine perforation, fluid overload, bleeding and intracavitary adhesion formation. Many fibroids with a significant intramural component (some type 2s, hybrid myomas; Figure 1) as well as any with no intracavitary involvement (types 3–8) require abdominal removal, whether via laparotomy, traditional laparoscopy or robotic-assisted laparoscopy. An additional classification, created by Lasmar et al., that is specific to hysteroscopic myomectomy exists. This system (STEPW), has been shown to be a better predictor of successful hysteroscopic fibroid removal and surgical complications than the ESGE/FIGO system (Table 1 & Figure 1).
There are several techniques available for hysteroscopic myomectomy. These include electrocautery resection, morcellation, laser ablation and vaporization. Electrocautery resection can be performed with monopolar energy, which requires a nonconductive distension media, such as glycine, or bipolar energy (can be used with saline). This method of resection can be used in any case where hysteroscopic myomectomy is appropriate; however, it may be more time consuming and requires more advanced cervical dilation than other techniques. Laser ablation is appropriate for myomas measuring 2 cm or less in diameter. The disadvantages of this technique are operative time, the prohibitive cost of the equipment and the inability to evaluate a tissue specimen. Studies of electrode vaporization have shown shorter operative times than resectoscopic surgery. However, the risks of this procedure include the lack of ability to evaluate the pathologic specimen in its entirety and the potential for significantly high CO2 blood levels resulting from the many gas bubbles produced. In 2005, the FDA approved the first hysteroscopic morcellator, the TRUCLEAR™ Hysteroscopic Morcellator (Smith & Nephew, Andover, MA, USA). Shortly thereafter, in 2009, a second device, the MyoSure® Tissue Removal System (Hologic, Bedford, MA, USA) was approved. Both of these devices function via mechanical energy generated by a motor with suction applied for specimen collection. Studies to date have shown that hysteroscopic morcellation is often faster than traditional electrocautery resection, with reductions in operating room time from 38% to 72%, depending on the type of lesion being removed. This is largely because no additional time is required for removal of portions of surgical specimen. As this is a newer technique, research regarding the potential for fluid overload is less extensive at this point. The main disadvantage of hysteroscopic morcellation is that it is not appropriate for myomas with greater than 50% extension into the uterine wall. Laser ablation, morcellation and vaporization are felt to be less traumatic techniques and in theory could improve fertility, although further study is needed to confirm this.
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