The general anaesthesia was performed.
2.7 Surgical operation
The in-house made hysteroscopy apparatus was placed using the MyoSure system and a uterus expansion pressure of 100 to 120 mm Hg, and the expansion pressure was not adjusted as long as the operative vision was clear. The endometrium and capsule of hysteromyomas were cut open using scissors. The hysteromyomas were stripped off into the uterine cavity using separators and pliers, so that the type II submucosal myomas turned into type I submucosal myomas and further morcellated within the capsule. This step was repeated a few times to remove all the hysteromyomas embedded in the muscular layer. The ultrasound surveillance and monitoring was conducted by the same physician. A complete removal surgery of tumor which the tumor cannot be seen at original fibroids sites using B ultrasound imaging was thought to be a clean removal. The pathological examination confirmed all except one to be leiomyoma of the uterus; only one that failed to have a complete removal with 1-time operation was confirmed to be endometrioma (Fig. 3).
2.8 Observed parameters
The observed parameters included the operation time, success rate of the first operation, amount of bleedin, length of stay, complications, liquid loss amount (referred to the difference between uterine swelling liquid use, and the amount of uterine swelling liquid collected using collection bag coming out of the body), and menstruation improvement (Table 3).
2.9 Postoperative follow-up
Before discharge, patients were informed of the postoperative follow-up during 3 and 6 months after surgery, postoperative review of B-ultrasound in 3 months by the same doctor to check whether the original surgical site of tumor remains. And detailed records of patients with menstrual recovery to normal state of time were recorded.
2.10 Statistical analysis
All data were analyzed using SPSS 23 software (SPSS Inc, Chicago, IL).
3.1 Baseline data
In this study, we included a total of 53 women with the type II submucosal myomas. Finally, 51 women completed the surgery and all the tumors were removed at one time (Fig. 4). Of the 2 patients who failed to achieve this, one was treated with GNRH-a for pathological diagnosis of adenomyosis and then Mirena Intrauterine Ring was placed and increased symptoms were observed; 1 case did not finish the surgery because of mild water poisoning, after 1-month hysteroscopic electrosurgical excision was performed to remove remaining tumor.
3.2 One-time complete resection rate
Fifty-one of 53 patients had the hysteromyomas completely resected with 1-time operation, with the success rate of 96.226%. The average weight of the fibroids after weighed resuscitation was 31.47 ± 12.69 g Combined with intraoperative B-ultrasound images of the situation, we believe that 51 cases of patients were all one-time removal of the tumor, whereas the postoperative review of B-ultrasound in 3 months showed that beside the 3 patients lost, the remaining 49 patients showed no tumor remaining.
3.3 Operation time
The average whole operation time of 53 patients was 37.92 ± 18.57 minutes.
3.4 Bleeding amount
The average bleeding amount was 24.80 ± 12.12 mL in 51 patients with successful 1-time operation. The mean hemoglobin was 93.61 ± 9.83 g/L, whereas the average postoperative hemoglobin was 91.51 ± 9.61 g/L. There was still some difference in hemoglobin before and after operation, but the visual field was relatively clearer and the operation could be completed successfully. Thus we thought that successful surgical bleeding amount was within the acceptable range. A typical feature in the case of a large hemorrhage is that the view is not clear, leading to a negative influence on surgical operation, increased complications, and perhaps multiple operations.
3.5 Average length of stay
The average length of stay was 2.02 ± 0.14 days. One patient in 51 patients who had a successful operation was hospitalized for 3 days because of fever. The remaining 50 patients were hospitalized for 2 days.
One patient (1/53) had a transient postoperative fever with the temperature of 37.7°C; the patient was discharged after 2 days of observation. The retrospective analysis did not reveal the cause of fever, although it was reported that the transient fever was commonly found in the patients with severe anemia. One patient slight fluid overload with hyponatremia, and recovered after application of furosemidum. No uterine perforation was found in all 53 patients, although complications such as uterine perforation were found in the hysteroscopic morcellation treatment; no complication was related to the limited case number.
3.7 Postoperative follow-up
Two patients failed for the follow-up examination at 3 months postoperatively, and 3 patients failed for the examination at 6 months postoperatively. Postoperative review of B-ultrasound in 3 months showed that beside the 2 lost patients, all other 49 cases showed no tumor remains. The one who failed the complete removal with the first operation was intramuscularly injected with GNRH-a 6 times, and then the Mirena was placed. Another patient who did not have an 1-time resection received hysteroscopic electrosurgical excision to remove the remaining fibroids 1 months postoperatively
3.8 Postoperative menstrual improvement
Three months after operation, 2 cases were lost to follow-up. Of the 49 cases of successful operation, menstrual abnormalities of 32 cases disappeared and returned to normal. Six months after operation, 3 cases were lost to follow-up. Of the 48 cases of successful operation, menstrual abnormalities of 44 cases disappeared and returned to normal.
The submucosal myomas usually result in abnormal uterine bleeding and are one of the major causes for organic intrauterine lesions. The endocrine therapy is not satisfactory for most submucosal myomas, and surgery is the commonly adopted treatment. The hysteroscopic electric resection is widely accepted for submucosal myomas; it has incomparable advantages over the conventional open-abdomen mode, and therefore it is regarded as a criterion standard treatment for submucosal myomas. However, hysteroscopic electric resection treatment is difficult for type II submucosal myomas among all kinds of submucosal myomas, with a higher risk of complications and need for skilled surgeons. Therefore, the hysteroscopic electric resection for type II submucosal myomas cannot be used in a low-grade hospital. Meanwhile, the endometrial damage caused by an electrothermal injury is another concern. The cold knife treatment under hysteroscopy is a currently developed therapeutic approach.[16,17] It can maintain the anatomical and functional integrity of the myometrium without electrothermal damage. It is worthwhile to learn and master this new technology.
The MyoSure hysteroscopic tissue removal system has been recognized for treating types 0 and I submucosal myomas. However, it is not ideal for type II submucosal myomas with a lower rate of 1-time complete resection. A set of complementary hysteroscopic operating instruments was developed based on clinical experience. The low rate of 1-time complete resection for type II submucosal myomas could be improved by combining the new apparatus with the MyoSure system. Meanwhile, the advantages of the MyoSure system, including the efficiency and safety, were maintained.
More than 50% of type II submucosal fibroids were in the myometrium, and MyoSure cannot remove tumor in the muscle layer. We improved the laparoscopic surgical instruments, together with MyoSure which can be used on the basis of MyoSure under the direct look under the shear, grasping, separation of the operation. Although the success rate of 1-time surgery reached 96.226%, but we still find some limitations, a patient suspended surgery owing to lack of liquid to 1250 mL and a slight water poisoning. One hysteromyoma had an indistinct boundary to the myometrium, and hence was difficult to strip off. The operation time was then prolonged with the liquid loss of 1000 mL. Therefore, the surgery was stopped, and the lesion was confirmed to be adenomyosis. Hence, attention should be paid to pathological types of lesion before the operation. Similarly, Arnold et al reported that morcellation with the MyoSure system was unsuccessful in one woman with a calcified leiomyoma. The pathological type of the lesion could be determined by not only conventional ultrasound but also magnetic resonance imaging. Once the major part of the hysteromyoma was removed, the residual lesion with the maximum diameter of <2.0 cm could be stripped off completely into the uterine cavity using grasping forceps and removed using hysteroscopy. It not only increased the 1-time operation rate but also decreased the liquid usage, thus to minimize the fluid overload with the risk of hyponatremia.
The major proportion of time was spent on the hysteromyoma stripping. We found that the hysteromyoma located at the bottom of the uterus was easier to be stripped off compared with that located in the lower segment of the uterus; the possible reasons were as follows: it was easier to cut open the endometrium and capsule of the hysteromyoma located at the bottom of the uterus because the scissors were positioned vertically to the surface of the hysteromyoma and hence it was convenient to exert force; it was easier to separate the hysteromyoma from the adjacent tissues after the capsule was incised open; it was easier to twist the hysteromyoma clockwise or anticlockwise using grasping forceps and exert forces from inside to outside compared with from left to right or from up to down; and it was easier to control the instrument to avoid the 1-time complete stripping off of the hysteromyoma from the myometrium. The direct stripping off of the whole hysteromyoma with 1-time operation might result in the absence of mounting points and interference with the subsequent manipulation. The MyoSure system morcellated the hysteromyoma from one side to another and spared some tissue for grasping forceps to facilitate the subsequent conduction.
The 2 major reasons which may prolong the operation time were as follows: the incision on the capsule of the hysteromyoma was not large enough for the maximum diameter of the hysteromyoma, and therefore the grasping process was difficult leading to time wastage; and the fibrous tissue was not loosened by twisting the hysteromyoma, resulting in the difficulty while directly stripping off the hysteromyoma into the uterine cavity, indicating that the whole operation time and total resection time could be improved by training and experience.
MyoSure system involved mechanical morcellation without an electrothermal injury, and the hysteromyoma morcellation within the capsule can lead to minimum damage to the endometrium ensuring rapid recovery. By eliminating the risk of thermal damage to the myometrium and surrounding tissues,[21,22] the safety of future pregnancies is greatly improved. Two patients were pregnant 3 months after the operation and gave term birth; one was pregnant 5 months after the operation, but embryonic development stopped during second month of pregnancy. one was pregnant 8 months after the operation. No placenta accreta or placenta adherens was reported in the former patient. However, more cases need to be explored to validate the pregnancy success after the resection of type II submucosal myomas using the improved MyoSure hysteroscopic tissue removal system.
Although the literatures reported that MyoSure hysteroscopic tissue removal system had a fast and safe advantage in resection of the intrauterine tissue, Meulenbroeks et al reported that the TRUCLEAR system was significantly superior to MyoSure extra large (XL) in removing fibroids. When the larger fibroids are removed, the reduced durability of the MyoSure XL device may have an effect on the progression of the procedure, so if possible, the surgeon may choose the appropriate surgical instrument during surgery.
A B-ultrasound monitor was the standard equipment for difficult hysteroscopic operations. The noninvasiveness and real-time surveillance using B-ultrasound monitor can accurately estimate the residual myometrium thickness to compensate for the intraoperative visual defect.
But there is still another problem which is although the modified type of MyoSure system can improve the type II submucosal fibroids 1-time resection rate, but the cost still calls for our attention. The optical mirror and the accompanying instruments can be recycled after disinfection, but the operator required is nonrepetitive and expensive, and the price was about 9000 yuan (around $1400), which certainly increased the burden of patients to a certain extent. Thus, we need to consider whether we should use modified MyoSure system to remove type II submucosal fibroids, and patient's consent should be obtained before operation.
Besides cost problem the improved MyoSure hysteroscopic tissue removal system can improve the type II submucosal fibroids 1-time resection rate. It also maintained the advantages of the MyoSure system such as efficiency and high safety. This operation could preserve the uterus, ameliorate the symptoms of menorrhagia, and improve the life quality to a great extent. Given the limited case number in the present study, the complications, operation time, bleeding amount, postoperative menstrual improvement, and pregnancy using the improved MyoSure hysteroscopic tissue removal system need further validation using a larger number of cases.
The authors thank Dr. GAO Liwei, a surgeon from the Department of Surgery, Huzhou Hospital of Zhejiang University, for guidance on the manuscript.
. Emanuel MH, Wamsteker K. The Intra Uterine Morcellator: a new hysteroscopic operating technique to remove intrauterine polyps and myomas. J Minim Invasive Gynecol 2005;12:62–6.
. van Dongen H, Emanuel MH, Wolterbeek R, et al. Hysteroscopic morcellator for removal of intrauterine polyps and myomas: a randomized controlled pilot study among residents in training. J Minim Invasive Gynecol 2008;15:466–71.
. AlHilli MM, Nixon KE, Hopkins MR, et al. Long-term outcomes after intrauterine morcellation vs hysteroscopic resection of endometrial polyps. J Minim Invasive Gynecol 2013;20:215–21.
. Arnold A, Ketheeswaran A, Bhatti M, et al. Prospective study on the of use of the MyoSure
(R) for hysteroscopic resection of endometrial pathology. J Minim Invasive Gynecol 2015;22(6s):S45–6.
. Rajesh SK, Guyer C. Myosure
hysteroscopic morcellation for the management of submucous fibroids in an out-patient hysteroscopy
setting. J Minim Invasive Gynecol 2015;22(6s):S102–3.
. Hamerlynck TW, Dietz V, Schoot BC. Clinical implementation of the hysteroscopic morcellator for removal of intrauterine myomas and polyps. A retrospective descriptive study. Gynecol Surg 2011;8:193–6.
. Di Spiezio Sardo A, Mazzon I, Bramante S, et al. Hysteroscopic myomectomy: a comprehensive review of surgical techniques. Hum Reprod Update 2008;14:101–19.
. Hallez JP. Single-stage total hysteroscopic myomectomies: indications, techniques, and results. Fertil Steril 1995;63:703–8.
. Loffer FD. Removal of large symptomatic intrauterine growths by the hysteroscopic resectoscope. Obstet Gynecol 1990;76(5 pt 1):836–40.
. Hart R, Molnar BG, Magos A. Long term follow up of hysteroscopic myomectomy assessed by survival analysis. Br J Obstet Gynaecol 1999;106:700–5.
. Donnez J, Nisolle M, Grandjean P, et al. The place of GnRH agonists in the treatment of endometriosis and fibroids by advanced endoscopic techniques. Br J Obstet Gynaecol 1992;99(Suppl 7):31–3.
. Tiufekchieva E, Nikolov A. Hysteroresection of submucous myomas after treatment with zoladex. Akush Ginekol (Sofiia) 2006;45:19–24.
. Xia EL. Transcervical resectionof myoma. J Pract Obstet Gynecol 2005;21:387–9.
. Hamerlynck TW, Blikkendaal MD, Schoot BC, et al. An alternative approach for removal of placental remnants: hysteroscopic morcellation. J Minim Invasive Gynecol 2013;20:796–802.
. Cravello L, Agostini A, Beerli M, et al. Results of hysteroscopic myomectomy. Gynecol Obstet Fertil 2004;32:825–8.
. Homer HA, Li TC, Cooke ID. The septate uterus: a review of management and reproductive outcome. Fertil Steril 2000;73:1–4.
. Bradley LD. Complications in hysteroscopy
: prevention, treatment and legal risk. Curr Opin Obstet Gynecol 2002;14:409–15.
. Mazzon I, Favilli A, Grasso M, et al. Is cold loop hysteroscopic myomectomy a safe and effective technique for the treatment of submucous myomas with intramural development? A series of 1434 surgical procedures. J Minim Invasive Gynecol 2015;22:792–8.
. Arnold A, Ketheeswaran A, Bhatti M, et al. A prospective analysis of hysteroscopic morcellation in the management of intrauterine pathologies. J Minim Invasive Gynecol 2016;23:435–41.
. Lasmar RB, Barrozo PR, Dias R, et al. Submucous myomas: a new presurgical classification to evaluate the viability of hysteroscopic surgical treatment—preliminary report. J Minim Invasive Gynecol 2005;12:308–11.
. Propst AM, Liberman RF, Harlow BL, et al. Complications of hysteroscopic surgery: predicting patients at risk. Obstet Gynecol 2000;96:517–20.
. Jansen FW, Vredevoogd CB, van Ulzen K, et al. Complications of hysteroscopy
: a prospective, multicenter study. Obstet Gynecol 2000;96:266–70.
. Leone FP, Calabrese S, Marciante C, et al. Feasibilityand long-term efficacy of hysteroscopic myomectomy for myomas with intramural development by the use of non-electrical “cold” loops. Gynecol Surg 2012;9:155–61.
. Meulenbroeks D, Hamerlynck TW, Saglam-Kara S, et al. Hysteroscopic tissue removal systems: a randomized in vitro comparison. J Minim Invasive Gynecol 2017;24:159–64.
Keywords:Copyright © 2017 The Authors. Published by Wolters Kluwer Health, Inc. All rights reserved.
Hysteroscopy; leiomyoma; MyoSure