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Uterine fibroids that are completely or partially inside the cavity of the uterus (submucous myomas) can often be removed through the cervix by using an instrument called a resectoscope. A resectoscope is a special kind of hysteroscope that uses a loop powered by high-frequency electrical energy to cut through the fibroid. Since the instrument goes through the cervix, no incision is necessary. This is usually done as an outpatient, and recovery typically requires a day or two until most normal activity can be resumed.
Selection of patients for whom hysteroscopic removal of fibroids is appropriate is one of the most important factors in obtaining good results. Factors to consider are the size and number of fibroids, location, the percentage that is in the cavity and percentage that is in the wall (intramural) or the uterus, the possibility that other intramural or subserous myomas would remain, and the desire for future pregnancy are some of the factors that must be considered.
Fibroids that are entirely inside the uterine cavity are the easiest to resect, and a very experienced gynecologist may be able to resect these up to 5 cm. (2 inches) in diameter. Most submucous fibroids are partially in the wall of the uterus. The illustration above shows a fibroid that is about 2/3 in the cavity and 1/3 in the wall. During the process of resecting this the uterus often contracts, squeezing out the portion that is in the wall, and allowing more complete removal.
The photo below shows a large fibroid that is over 50% in the wall, as determined by MRI. This is the most difficult type of fibroid to remove hysteroscopically, especially if it is toward the top of the uterus.
The loop is used to resect the fibroid, bite by bite, (photo on the left) until it is level with the surface. In this case a special medication was used to help the uterus contract so virtually all of the fibroid could be squeezed into the cavity, allowing me to completely remove it. The right photo shows the “shell” of where the myoma was. This will cover over with endometrium (the lining of the uterus). When we look at this area in several months with office hysteroscopy we won’t even be able to see where the fibroid used to be.
Comment: This last example pushes the limits of hysteroscopic myomectomy. This woman ended up with a normal uterine cavity, with no adhesions (scar tissue). When this type of procedure is considered in a woman wanting to become pregnant, much experience is needed to determine whether hysteroscopic treatment will leave a normal cavity or will cause permanent scarring and infertility. Hysteroscopic removal of all but the simplest submucous fibroids should only be done by a gynecologist with extensive experience in hysteroscopic surgery. I will have more about hysteroscpic myomectomy in time to come.