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A new technique for and additional experience with hysteroscopic resection of submucous fibroids
CURRENT INVESTIGATION
This section offers prompt first announcement of new observations or discoveries. Articles should be limited to 1,500 words and six references. Illustrations or additional references require a proportionate reduction in total words.
A new technique for and additional experience with hysteroscopic resection of submucous fibroids ROBERT S. 1'-JEU\A/IRTH,
~f.D.
New York, New York New instrumentation and a new technique are described which simpHfy the hysteroscopic removal of the pedunculated submucous fibroid and make possible the panial removal of the sessile variety. Experience with the method is presented including the foHow-up of four patients. (AM. J. OS STET. GYNECOL. 131: 91, 1978.)
experience with hysteroscopic excision of submucous fibroids was described. Case selection was carefully limited to pedunculated tumors as the pedicle could be isolated for control of bleeding whether the tumor was excised intact or morcellated for removal. The sessile type of tumor was avoided because of the greater potential for heavy bleeding and thermal injury to the bladder or intestines if eiectrosurgery was used. In addition, there was concern that partial removal of a leiomyoma would not result in correction of the menorrhagia, which usually causes these patients to seek medical attention. Since publication of the aforementioned article, an instrument and technique have been developed which simplify the removal of pedunculated tumors and make feasible the partial resection of sessile submucous fibroids. The system was first tried in specimens and IN A PREVIOUS REPORT, 1
then in a limited clinical trial. This article will describe the equipment, the technique, and some of the patient experience to date.
From the Departments of Obstetrics and Gynecology, St. Luke's H05pital Center and The College of Physicians and Surgeons, Columbia University.
The design that was finally chosen is basically a urologic resectoscope* (Fig. 1), modified only to adapt to the higher pressures necessary in 32 per cent dextran 70 hysteroscopy. The insuiated externai sheath has a diameter of 8 mm. which requires slightly more cervical diiatation than for routine diagnostic hysteroscopy. The standard hysteroscope, a foroblique fiberoptic telescope, fits into the working element within the operating sheath. A cutting loop moves to-and-fro beyond the telescope within the insulated sheath controlled by a leaf spring, and can be viewed constantly. The loop is connected to the electrosurgical unit by an active cord plugged into the base of the working element. Hyskont is delivered to a Luer lock connection on the side of the cannula.
Reprint requests: Dr. RobertS. Neuwirth, Director of Obstetrics-Gynecology, St. Luke's Hospital Center, Am.sterd!!m Ave. at! 14th St., New York, New York 10025.
*Supplied by American Cystoscope Makers. Inc., Stamford, Conn. tThirty-two per cent dextran 70 in 10 per cent dextrose in water, Pharmacia Laboratories, Piscataway, New .Jersey.
0002·9378/78/01131-0091$00.40/0
©
1978 The C. V. Mosby Co.
91
May I, 1978 Am. J. Obstet. Gynecol.
92 Neuwirth
Fig. 1. Modified resectoscope.
20 mi. volume, which exceeds considerably the average uterine volume. The stem containing the ball valve protrudes through the cervix into the vagina, where it can be grasped for deflation, or removal.
Fig. 2. Shavings of leiomyoma following resection.
The electrosurgical generator is a transistorized unit set at 60 to 120 watts of cutting current. Studies of the function of the instrument in uterine specimens demonstrated the control and movement of the cutting loop to be satisfactory within the uterine cavity. The depth of burn during the cutting maneuver was found to be not greater than 2 mm. When the current is applied the instrument will cut easily through a leiomyoma to produce a shaving of the tissue (Fig. 2). The cauterized base of the cut accomplishes the bulk of necessary hemostatis. The center of the slivt::r of myoma is not affected by the burn and a pathologic diagnosis can be made from this tissue (Fig. 3). To cope with postoperative oozing or delayed bleeding following the resection, a silicone rubber uterine balloon stent* was made to produce tamponade of the raw surfaces. The conical balloon can be inflated with air or sterile saline. It has a ball valve to control entry and exit of the inflating fluid. It can inflate readily to a *Heyer-Schulte Corporation, Goleta, California.
Technique All the patients have complained primarily of menorrhagia, have been ovulatory as determined by basal body temperature, and have had evident fibroids or findings suggestive of myomata. They all underwent hysterography and/or hysteroscopy prior to undergoing the resection of the myoma. The risks of uncontrollable hemorrhage requiring emergency laparotomy having been explained, the patients were scheduled for operative hysteroscopy, laparoscopy, and possible laparotomy. A cross-match and an abdominal-perineal preparation are done. The procedure is carried out using general anesthesia and a modified dorsal lithotomy position so that concomitant laparoscopy and hysteroscopy can be performed. Hysteroscopy is used initially to map out the location of the tumors in the cavity (Fig. 4). Liparoscopy is performed to keep the fundus in view during the resection and mobilize it away from the intestines. The resection is performed under direct view by either pushing the activated loop steadily away from the objective lens or, preferably, placing the loop on the far side of the tumor and drawing it toward the objective lens until the slice is completed (Fig. 5). Several pieces of tumor may be cut off before it is necessary to remove the hysteroscope and retrieve the pieces with an ovum forceps. Occasionally, a piece of tissue or blood clot may float against the lens, forcing the surgeon to remove it before proceeding further. The tumor is progressively shaved down to the level of the wall of the cavity. Once completed the cavity is washed out with 5 per cent dextrose in water and re-examined to check for bleeding and adequacy of resection (Fig. 6). If necessary a blunt curette can be used to fed out the cavity to confirm complete resection. The silicone rubber balloon uterine
Volume 131 Number I
Hysteroscopic resection of submucous fibroids
93
Fig. 5. Photomicrograph of fragment of leiomyoma.
Fig. 4. Close-up of submucous myoma on left side of uterine isthmus with cutting loop beyond.
Fig. 5. Cutting loop nearing completion of first cut of myoma.
stent is inserted with a uterine dressing forceps and inflated until the cavity is filled or the bleeding stops. The procedure is ended with withdrawai of the laparoscope. The patient is treated with prophylactic antibiotics for five days. If future fertility is important, I. 25 mg. of Pre marin* are administered twice daily for one month and a Lippes loop, size B or C, is inserted after removal of the balloon stent, before discharge from the hospital.
Foiiow-up examination at six weeks has revealed no complications. The intrauterine device, when present, was removed at this visit and the patients have been followed, particularly with regard to bleeding and, when pertinent, basal body temperature.
*Conjugated equine estrogens, Ayerst Laboratories, New York, New York.
Caae material Fljlur patients with sessile submucous fibroids have und~rgone resection to date. Patients are not accepted if th~ uterine cavity is sounded at more than 9 em. The follow -up ranges from nine to 18 months. To date
May 1, 1978
94 Neuwirth
Am. J. Obstet. Gynecol.
area at the site of the resection. Repeat examination at one year showed the early formation of another submucous fibroid in a different iocation from the first. which is at present asymptomatic. The mucosa appeared normai over the site of the previous resection.
Comment
Fig. 6. The partial resection of the myoma is almost complete. The cutting loop rests against the transected remainder of the fibroid, which lies embedded in the wall of the isthmus.
none of the patients required transfusion during the operation. The iongest procedure iasted one hour and no patient has required laparotomy. Laparoscopic observations were unremarkable and no thermal effects on the uterine serosa have been seen. The hospital stay was three days and patients returned to usual activities one week following the procedure, although coitus was interdicted for six weeks. The menorrhagia and anemia were corrected in all of the patients. There has been no postoperative hemorrhage or infection to date. Repeat office hysteroscopy of one patient, three months after operation, showed a thin epithelialized
Hysteroscopy as a diagnostic and therapeutic modality in gynecology is still finding its place vis-a-vis hysterography and curettage. In a previous report on symptomatic pedunculated submucous fibroids and now with the sessile variety, it has been demonstrated that operative techniques can be designed to be performed under hysteroscopic controls, which are safe and therapeutically useful. The method described is an alternative to either abdominal myomectomy or hysterectomy. For the present, hysteroscopic resection or removal of fi broids under laparoscopic control must be considered dinicai investigation from which much can be learned beyond clinical effectiveness. Nevertheless, the satisfactory experience thus far derived from these procedures indicates that this type of management can be applied to selected cases by experienced endoscopists. Indeed, hysteroscopic excision or resection of submucous fibroids may serve as a therapeutic trial which, if a failure, can be followed by standard and time-tested surgical approaches. The author would like to thank Mr. Robert Quint of American Cystoscope Makers, Inc., for suggestions and for the modification of the resectoscope. REFERENCE l. Neuwirth, R. S., and Amin, H. K.: Excision of submucous
fibroids with hysteroscopic control, AM. i26: 95, 1976.
GYNECOL.
J.
OBSTET.
This section offers prompt first announcement of new observations or discoveries. Articles should be limited to 1,500 words and six references. Illustrations or additional references require a proportionate reduction in total words.
A new technique for and additional experience with hysteroscopic resection of submucous fibroids ROBERT S. 1'-JEU\A/IRTH,
~f.D.
New York, New York New instrumentation and a new technique are described which simpHfy the hysteroscopic removal of the pedunculated submucous fibroid and make possible the panial removal of the sessile variety. Experience with the method is presented including the foHow-up of four patients. (AM. J. OS STET. GYNECOL. 131: 91, 1978.)
experience with hysteroscopic excision of submucous fibroids was described. Case selection was carefully limited to pedunculated tumors as the pedicle could be isolated for control of bleeding whether the tumor was excised intact or morcellated for removal. The sessile type of tumor was avoided because of the greater potential for heavy bleeding and thermal injury to the bladder or intestines if eiectrosurgery was used. In addition, there was concern that partial removal of a leiomyoma would not result in correction of the menorrhagia, which usually causes these patients to seek medical attention. Since publication of the aforementioned article, an instrument and technique have been developed which simplify the removal of pedunculated tumors and make feasible the partial resection of sessile submucous fibroids. The system was first tried in specimens and IN A PREVIOUS REPORT, 1
then in a limited clinical trial. This article will describe the equipment, the technique, and some of the patient experience to date.
From the Departments of Obstetrics and Gynecology, St. Luke's H05pital Center and The College of Physicians and Surgeons, Columbia University.
The design that was finally chosen is basically a urologic resectoscope* (Fig. 1), modified only to adapt to the higher pressures necessary in 32 per cent dextran 70 hysteroscopy. The insuiated externai sheath has a diameter of 8 mm. which requires slightly more cervical diiatation than for routine diagnostic hysteroscopy. The standard hysteroscope, a foroblique fiberoptic telescope, fits into the working element within the operating sheath. A cutting loop moves to-and-fro beyond the telescope within the insulated sheath controlled by a leaf spring, and can be viewed constantly. The loop is connected to the electrosurgical unit by an active cord plugged into the base of the working element. Hyskont is delivered to a Luer lock connection on the side of the cannula.
Reprint requests: Dr. RobertS. Neuwirth, Director of Obstetrics-Gynecology, St. Luke's Hospital Center, Am.sterd!!m Ave. at! 14th St., New York, New York 10025.
*Supplied by American Cystoscope Makers. Inc., Stamford, Conn. tThirty-two per cent dextran 70 in 10 per cent dextrose in water, Pharmacia Laboratories, Piscataway, New .Jersey.
0002·9378/78/01131-0091$00.40/0
©
1978 The C. V. Mosby Co.
91
May I, 1978 Am. J. Obstet. Gynecol.
92 Neuwirth
Fig. 1. Modified resectoscope.
20 mi. volume, which exceeds considerably the average uterine volume. The stem containing the ball valve protrudes through the cervix into the vagina, where it can be grasped for deflation, or removal.
Fig. 2. Shavings of leiomyoma following resection.
The electrosurgical generator is a transistorized unit set at 60 to 120 watts of cutting current. Studies of the function of the instrument in uterine specimens demonstrated the control and movement of the cutting loop to be satisfactory within the uterine cavity. The depth of burn during the cutting maneuver was found to be not greater than 2 mm. When the current is applied the instrument will cut easily through a leiomyoma to produce a shaving of the tissue (Fig. 2). The cauterized base of the cut accomplishes the bulk of necessary hemostatis. The center of the slivt::r of myoma is not affected by the burn and a pathologic diagnosis can be made from this tissue (Fig. 3). To cope with postoperative oozing or delayed bleeding following the resection, a silicone rubber uterine balloon stent* was made to produce tamponade of the raw surfaces. The conical balloon can be inflated with air or sterile saline. It has a ball valve to control entry and exit of the inflating fluid. It can inflate readily to a *Heyer-Schulte Corporation, Goleta, California.
Technique All the patients have complained primarily of menorrhagia, have been ovulatory as determined by basal body temperature, and have had evident fibroids or findings suggestive of myomata. They all underwent hysterography and/or hysteroscopy prior to undergoing the resection of the myoma. The risks of uncontrollable hemorrhage requiring emergency laparotomy having been explained, the patients were scheduled for operative hysteroscopy, laparoscopy, and possible laparotomy. A cross-match and an abdominal-perineal preparation are done. The procedure is carried out using general anesthesia and a modified dorsal lithotomy position so that concomitant laparoscopy and hysteroscopy can be performed. Hysteroscopy is used initially to map out the location of the tumors in the cavity (Fig. 4). Liparoscopy is performed to keep the fundus in view during the resection and mobilize it away from the intestines. The resection is performed under direct view by either pushing the activated loop steadily away from the objective lens or, preferably, placing the loop on the far side of the tumor and drawing it toward the objective lens until the slice is completed (Fig. 5). Several pieces of tumor may be cut off before it is necessary to remove the hysteroscope and retrieve the pieces with an ovum forceps. Occasionally, a piece of tissue or blood clot may float against the lens, forcing the surgeon to remove it before proceeding further. The tumor is progressively shaved down to the level of the wall of the cavity. Once completed the cavity is washed out with 5 per cent dextrose in water and re-examined to check for bleeding and adequacy of resection (Fig. 6). If necessary a blunt curette can be used to fed out the cavity to confirm complete resection. The silicone rubber balloon uterine
Volume 131 Number I
Hysteroscopic resection of submucous fibroids
93
Fig. 5. Photomicrograph of fragment of leiomyoma.
Fig. 4. Close-up of submucous myoma on left side of uterine isthmus with cutting loop beyond.
Fig. 5. Cutting loop nearing completion of first cut of myoma.
stent is inserted with a uterine dressing forceps and inflated until the cavity is filled or the bleeding stops. The procedure is ended with withdrawai of the laparoscope. The patient is treated with prophylactic antibiotics for five days. If future fertility is important, I. 25 mg. of Pre marin* are administered twice daily for one month and a Lippes loop, size B or C, is inserted after removal of the balloon stent, before discharge from the hospital.
Foiiow-up examination at six weeks has revealed no complications. The intrauterine device, when present, was removed at this visit and the patients have been followed, particularly with regard to bleeding and, when pertinent, basal body temperature.
*Conjugated equine estrogens, Ayerst Laboratories, New York, New York.
Caae material Fljlur patients with sessile submucous fibroids have und~rgone resection to date. Patients are not accepted if th~ uterine cavity is sounded at more than 9 em. The follow -up ranges from nine to 18 months. To date
May 1, 1978
94 Neuwirth
Am. J. Obstet. Gynecol.
area at the site of the resection. Repeat examination at one year showed the early formation of another submucous fibroid in a different iocation from the first. which is at present asymptomatic. The mucosa appeared normai over the site of the previous resection.
Comment
Fig. 6. The partial resection of the myoma is almost complete. The cutting loop rests against the transected remainder of the fibroid, which lies embedded in the wall of the isthmus.
none of the patients required transfusion during the operation. The iongest procedure iasted one hour and no patient has required laparotomy. Laparoscopic observations were unremarkable and no thermal effects on the uterine serosa have been seen. The hospital stay was three days and patients returned to usual activities one week following the procedure, although coitus was interdicted for six weeks. The menorrhagia and anemia were corrected in all of the patients. There has been no postoperative hemorrhage or infection to date. Repeat office hysteroscopy of one patient, three months after operation, showed a thin epithelialized
Hysteroscopy as a diagnostic and therapeutic modality in gynecology is still finding its place vis-a-vis hysterography and curettage. In a previous report on symptomatic pedunculated submucous fibroids and now with the sessile variety, it has been demonstrated that operative techniques can be designed to be performed under hysteroscopic controls, which are safe and therapeutically useful. The method described is an alternative to either abdominal myomectomy or hysterectomy. For the present, hysteroscopic resection or removal of fi broids under laparoscopic control must be considered dinicai investigation from which much can be learned beyond clinical effectiveness. Nevertheless, the satisfactory experience thus far derived from these procedures indicates that this type of management can be applied to selected cases by experienced endoscopists. Indeed, hysteroscopic excision or resection of submucous fibroids may serve as a therapeutic trial which, if a failure, can be followed by standard and time-tested surgical approaches. The author would like to thank Mr. Robert Quint of American Cystoscope Makers, Inc., for suggestions and for the modification of the resectoscope. REFERENCE l. Neuwirth, R. S., and Amin, H. K.: Excision of submucous
fibroids with hysteroscopic control, AM. i26: 95, 1976.
GYNECOL.
J.
OBSTET.