Operative hysteroscopy
Submucosal Myomas and Hysteroscopic Myomectomy
Occurs in 20-50% women (especially in perimenopausal age)
Symptomatology:
- a.u.b. (abnormal menstrual and intermenstrual uterine bleeding)
- Sense of weight and pelvic pain
- Volumetric increase at subsequent controls
- Compression symptoms (feeling of weight)
- Sterility or abortive
Myomas of hysteroscopic relevance are only submucosal ones that are divided into:
- G0 myoma: completely endocavitary myoma
- G1 and G2 myoma with more or less than 50% intrauterine development.
When is it necessary to operate on a submucosal myoma?
- Always if a woman wishes to become pregnant (the presence of a myoma can cause sterility or miscarriages)
- Always if it is symptomatic (i.e. if it causes continuous, heavy menstruation, bleeding outside menstruation)
Before operating on a submucosal myoma, it is essential to determine its size, location, number, intramural development, distance from the external surface of the uterus
Pre-surgical diagnosis and evaluation is done with:
A) Outpatient hysteroscopy, which allows evaluation:
- The intracavitary portion of the myoma
- Its location
- The characteristics of the endometrium
- Any associated intracavitary pathologies
B) Transvaginal ultrasound or sonohysterography allows the evaluation of
- The actual size of the myoma and the location especially if it is intramural
- The 'myometrial free margin', i.e. the thickness of the myometrium above the myoma
- The presence of other associated pathology (subserous myomas, ovarian cysts
The operating technique must have the following objectives
- Total removal of myoma
- Respect for uterine anatomical integrity
It recognises the following phases
- G0 myoma: resection of the myoma until its complete removal
- G1 and G2 myomas: resection of the endocavitary part with thermal loops and of the intramural part with cold loops, a complex operation depending on whether the development is partially or predominantly intramural and which requires proven operator skill and the use of various types of loops with different functions
- Complete removal of the myoma in no more than two stages. Any other solution proposed or implemented carries the risk of not resolving the symptoms.
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