Long-term results of hysteroscopic myomectomy in 235 patients

Abstract

Objective

To assess the efficacy of transcervical resection of submucous fibroids according to type and size.

Materials and methods

Retrospective follow-up of 235 women with submucous fibroids at outpatient hysteroscopy who underwent a hysteroscopic transcervical resection. The main indications were the abnormal uterine bleeding and fertility problems. Thirty-seven percent of patients had an associated endometrial ablation and 32% had a polyp resection. Fifty-one percent of women were menopausal. In cases of incomplete resection a repeat procedure was offered.

Results

Intra-operative complications were rare (2.6%) and there was no major complication. Eighty-four percent of cases were followed-up. The median follow-up was 40 months (range 18–66 months). The procedure was classed as a success in 94.4% of patients. Among the cases that were classed as a failure, four patients had a repeated hysteroscopic procedure, three patients had a subsequent hysterectomy and four patients presented with abnormal uterine bleeding at follow-up.

Conclusion

The hysteroscopic transcervical resection of submucous fibroids is a safe and highly effective long-term therapy for carefully selected women presenting with abnormal uterine bleeding and fertility problems. It produces satisfactory long-term results with few complications.

Introduction

Fibroids (leiomyoma) are benign tumours consisting of smooth muscle and varying degrees of connective tissue. They are a frequent pathology occurring in up to 40% of women over the age of 35.

Prior to fibroid resection an evaluation of the uterine cavity by ultrasonography and diagnostic hysteroscopy permit an accurate classification of fibroids with regard to size, number and locations, which allows selection for transcervical resection in appropriate cases. Submucous fibroids are classified according to the European Society of Gynecologic Endoscopic Classification: type 0 (pedunculated submucous fibroid without intramural extension), type I (sessile and with an intramural part of less than 50%) and type II (with an intramural part of 50% or more).

This classification is of clinical significance because both symptoms and treatment vary according to the location of fibroids.

Cancer arising in a fibroid is very uncommon, but needs to be excluded prior of surgery.

Depending on their location, size and number, fibroids may be symptomatic or asymptomatic. Although most fibroids are asymptomatic, patients may present with abnormal uterine bleeding, pressure on the bowel or bladder, pain, infertility, or with a palpable abdominal-pelvic mass.

Intramural fibroids which are the most common, are most often asymptomatic.

Usually no intervention is needed in asymptomatic women with fibroids. In symptomatic women a pre-surgical assessment of fibroids is essential. The surgical approach will be dependent on the anatomical site of the fibroids, their size and number and whether the patient wishes to preserve her fertility or her uterine integrity.

Although submucosal fibroids are less frequently encountered, they are more likely symptomatic. They may be associated with menorrhagia, infertility and dysmenorrhea. Medical therapy is often ineffective and surgery will often be required.

The surgical options are: hysterectomy and myomectomy. Myomectomy may be accomplished by performing a laparotomy or with less invasive surgical techniques such as vaginal myomectomy, laparoscopy and hysteroscopy, whereby fertility may be preserved.

During the last decades hysteroscopic removal of submucous fibroids has been developed and recommended [1], [2], [3], [4].

The objective of this study is to assess the safety and effectiveness of hysteroscopic transcervical resection of submucous fibroids.