Hysteroscopic Myomectomy of Large Submucous Myomas in a 1-Step Procedure Using Multiple Slicing Sessions Technique

Objective: To evaluate the feasibility and efficacy of our technique for resectoscopic removal of large symptomatic submucous myomas. Design: Prospective study (Canadian Task Force classification II-3). Setting: A university teaching hospital and a private hospital. Patients: Forty-nine patients with submucous myomas >= 4 cm in diameter complaining of abnormal uterine bleeding. Seventeen patients were also complaining of infertility. Interventions: The intrauterine portion of submucous myomas was resected using the slicing technique. Slicing started at the site of the maximum bulge of the myoma and was continued down to the level of the endometrial surface. Each slicing session lasted for 5 to 10 minutes. After each slicing session, saline infusion was discontinued and restarted alternatively several times to induce rapid changes in the intrauterine pressure (hydromassage) to stimulate uterine contractions. The resectoscope was removed, and ovum forceps was used to extract the myoma fragments. Bimanual massage of the uterus was performed to induce extrusion of the intramural portion of the myoma into the uterine cavity. The same steps (slicing session lasting for 5-10 minutes to excise the portion of the myoma extruded into the uterine cavity, hydromassage, and uterine massage) were repeated several times until complete removal of the myoma. Measurements and Main Results: The mean diameter of the principle myomas was 51.94 +/- 5.58 mm The rate of 1-step complete resection of myomas was 91.84% (45/49). Improvement of bleeding symptoms was observed in all patients with complete resection of myomas. Nine of the 17 infertile women conceived after hysteroscopic myomectomy. One-step complete resection of myomas was more frequent in patients with myomas <6 cm (43/44 [97.73%] vs 2/5 [40%], risk ratio [RR] = 2.44, p = .002), single myomas (39/40 [97.5%] vs 6/9 [66.67%], RR = 1.46, p = .016), principle myomas with a Lasmar score < 7 (32/32 [100%] vs 13/17 [76.47%], RR = 1.31, p = .011), and myomas with less than 50% extension into the myometrium (26/26 [100%] vs 19/23 [82.61%], RR = 1.21, p = .042). The rate of 1-step complete removal of myomas was 95% (19/20) for type II myomas < 6 cm and 0% (0/3) for type II myomas 6 cm. Conclusion: Our technique of hysteroscopic myomectomy is a safe and effective management for submucous myomas up to 6 cm in diameter. (C) 2015 AAGL. All rights reserved.