Modified hysteroscopic myomectomy of large submucous fibroids.
OBJECTIVE
To compare the efficacy, feasibility, operative time and possible complications of a modified technique of hysteroscopic removal of large submucus myomata versus traditional morcellation technique, and to assess the efficacy of preoperative sonohysterography (SHG).


METHODS
A prospective comparative study.


METHODS
Gynecologic Endoscopy Unit, Assiut University Hospital, Assiut, Egypt.


METHODS
One hundred forty-two women of childbearing age with a clinical and transvaginal sonographic diagnosis of large solitary submucous myomata (>3 cm in diameter) with or without an intramural element.


METHODS
The patients were divided into two groups. In group A (65 patients), a modified resectoscopic technique was used where the base of the myoma was excised followed by ring forceps extraction after misoprostol priming. In group B (77 patients), the myoma was cut using traditional resectoscopic morcellation.


METHODS
For each patient, operating time, intra- and postoperative complications and feasibility of the procedure were recorded. The accuracy of preoperative SHG in localizing submucous myoma and detecting intramural extension was assessed by diagnostic hysteroscopy.


RESULTS
Transvaginal SHG showed good agreement with hysteroscopy in localizing submucous myomata and detecting intramural extension (k = 0.83). The operating time was significantly shorter in group A (15.6 +/- 3.02 min) than in group B (28.9 +/- 4.3 min). The procedure was completed in 60 (92%) and 51 patients (66%), whereas a second session was required in 2 (3%) and 20 patients (25.9%) in both groups respectively. Glycine volume was highly significantly less in group A (2.3 +/- 0.86 vs. 6.3+/- 1.7 liters, p = 0.001). Intraoperative complications were encountered in 9 (13.8%) and 22 patients (28.5%) in both groups respectively (p = 0.03). Cervical laceration was diagnosed in 3 cases (4.6%) in group A. Postoperative visual disturbances were diagnosed in 4 cases (5%) in group B.


CONCLUSIONS
Hysteroscopic resection of large submucous myomata with minimal intramural encroachment is feasible using a modified technique. It shows a minimal complication rate and fluid deficit and a shorter operative time than the standard morcellation technique. If the excised myoma is extracted as one mass, this carries a minimal risk of cervical lacerations and possible cervical incompetence in a subsequent pregnancy. Transvaginal SHG is a reliable diagnostic aid to assess submucous myomata.
Department of Obstetrics and Gynecology, Assiut University Hospital, Assiut, Egypt. a_darwish@mailcity.com
Atef
A
Darwish
D000328:Adult; D005260:Female; D006801:Humans; D015907:Hysteroscopy / Q000379:methods*; D007431:Intraoperative Complications / Q000453:epidemiology; D007889:Leiomyoma / Q000000981:diagnostic imaging / Q000601:surgery*; D011183:Postoperative Complications / Q000453:epidemiology; D011446:Prospective Studies; D013997:Time Factors; D014463:Ultrasonography; D014594:Uterine Neoplasms / Q000000981:diagnostic imaging / Q000601:surgery*