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Excision of submucus fibroids with hysteroscopic control
Excision of submucus fibroids with hysteroscopic control ROBERT HUSSEIN
S. K.
NEUWIRTH, AMIN,
M.D. M.D.
New York, New Yo’ork
Hyterascopy offers a neu~ option in the diagnosisand management of submucwjbroids. The hysteroscopic excision of su6mucusjibroid.s infive casesis described. The j.n-obkms and potentials of this approach are discussed.
SUBMUCUS FIBROID isoneofthemoreserious forms of leiomyomas of the uterus causing menorrhagia and secondary anemia, recurrent abortion, or infertility. The symptomatology usually requires operation which classicallyhasbeen abdominal hysterotomy and myomectomy, or hysterectomy. Occasionally, a pedunculated submucus myoma, presenting at the cervix or in the vagina, is excised transvaginally through the dilated cervix or via vaginal hysterotomy.’ Norment and associates’reported a modification of the hysteroscopeto accomplish hysteroscopic resection of submucusfibroids but did not report their experiences. The transcervical route for removal of submucus fibroids would be preferable, particularly in the younger patient who desiresto preserve reproductive function, becauseof the avoidance of laparotomy and hysterotomy. The inability to visualize the endometrial cavity has heretofore been the major obstacle to transcervical removal of thesefibroids. The tumors can he difficult to manipulate blindly for removal through the cervix. Moreover, there has been no means of visualization of the baseof the tumor for appraisal of the risk of bleeding, and t.here has not been a sure method, short of hysterectomy, for its control should hemorrhage occur. Thus, without visual control, the hazards of a blind operation outweigh any possible
advantage to transcervical removal. Hysteroscopy has provided a meansof visual appraisal of the endometrial cavity and, therefore, introduces the possibility of safe excision of thesetumors3 In this report, the removal of submucus fibroids transcervically with hysteroscopic control in five patients isdescribed. Although the number is small,these casesserve to illustrate the potential as well as the limitations of this application of hysteroscopy.
THE
land d-8 All procedures were done in the operating room with general anesthesia. A standard hysteroscope of the Storz or ACMI type wasused. Thirty-two per cent dextran 70 wasusedfor distending the uterine cavity in four casesand 5 per cent dextrose in water wasusedin one case.A regular light source of 150 watts wa?used. For photography, a 500 watt light source, a photohysteroscope, and an Olympus SLR 35 mm. camera, or a Beaulieu 16 mm. motion picture camera, with Ektachrome ASA 160 film, were used. care raports CaseNo. 1. Mrs. C. Q., a 26-year-old-woman, gravida 4, para 1, abortuses 3, presented with secondary infertility of three years’ duration, dysmenorrhea, and a uterine filling defect on hysterography. Hysteroscopy confirmed the presenceof a pendunculated fibroid. Its pedicle wascut with scissorsand, although the tumor was believed to be free in the uterine cavity, it could not be extricated through the cervix becauseof difficulty in grasping it with an ovum forceps, the only available accessoryinstrument. The fibroid wassubsequently removed via an abdominal hysterotomy. The postoperative course was uneventful, and the patient was discharged on the seventh postoperative day. This patient then becamepregnant and wasdelivered of her infant by cesareansection 11 months after myomectomy. CaseNo. 4. Mrs. J. E., a 32-year-& woman, who had never been pregnant, underwent dilatation and curet-
From the Woman% Hospital Division, St. Luke’s Hospital Center, and the Department of Obstetrics-Gynecology, College of Physicians U Surgeons, Cohm&iaUniversity. Financial assistance in tkc publlblication photographs was provided b Pharmucia Inc., 800 Cwtennial Ave., Piscataway, 08854. Received for publication AcceptedJanwlly
Januav
of the color Laboratories, New Jersey
5, 1976.
17, 1976.
Reprint requests: Dr. Robert S. New&h, Department of Obstetrics and Gynecology-Woman’s Hospital, St. Luke’s Hospital Center, 114th St. and Amsterdam Ave., New York, Nezo York 10025.
95
tage for heavy periods and anemia. The uterus was normal in size and measured 3% inches. Exploration of the uterine cavity, with both ovum forceps and curet, revealed only slight irregularity on the posteriol uterine wall. The curettings showed proliferative endometrium. Uterine bleeding recurred, and a hysterogram 10 months later suggested two submucosal fibroids. Hysteroscopy confirmed the presence of two pedunculated submucus fibroids. With laparoscopic and hysteroscopic control, the fibroids were morcellated by diathermic cutting, and their bases were cauterized. Postoperatively, the patient was given antibiotics and estrogens prophylactically. Recover) was uneventful with discharge on the third postoperative day. Menses have since been normal, and the anemia was corrected. The hysterogram returned to normal. Case No. 3. Mrs. M. K., a 44-year-old woman, who had never been pregnant. r\‘as given hormonal therapy for progressive polymenorrhea, menorrhagia, and anemia. The uterus was normal, and a Papanicolaou smear and endometrial biopsy were negative for malignancy. Despite the therapeutic trial, menses continued to be heavy. At hysteroscopy, a broad-based, pedunculated. submucus fibroid, measuring 2 by 2 by 5 cm. was discovered (Figs. 1 and 2). With hysteroscopic control, morcellation by diathermic cutting was attempted but was discontinued because the instrument was too small to morcellate the tumor satisfactorily. The fibroid was then removed by grasping it with an ovum forceps, placed alongside the hysteroscope. so that the tumor was held under visual control and twisted off (Fig. 3). The pedicle was then visualized, and bleeding was controlled with light cautery. Postoperatively, the patient did well; she was treated with prophylactic estrogens and antibiotics and was discharged on the second postoperative day. The rnenstrual periods and blood parameters have returned to normal. Case No. 4. Mrs. F. W., a 64-year-old, obese, hypertensive, and diabetic woman, presented with postmenopausal bleeding. Atrophic changes of the vulva and vagina and a large cervical polyp were found on examination. A Papanicolaou smear was negative. Dilatation and curettage and cervical polypectomy were performed. The uterine cavity \ras described as irregular, and the histology was benign. Light vaginal bleeding persisted, and a second Papanicolaou smear was negative. Six months later, a pedunculated submucus fibroid, 3 by 3 by 5 cm., was discovered at hysteroscopy. The cervix was dilated to 12 mm. which permitted the fibroid to be grasped with ovum forceps and then twisted off the pedicle. Bleeding ensued, and, though its source could be visualized, attempts at controlling it with cautery were not successful, although the uterine cavity was intact on hysteroscopic examination. One-inch iodoform gauze packing was used to control the bleeding. Packing was removed 12 hours later; the patient’s recovery was uneventful, and
there has been no recurrence of bleeding to datr. I‘he pathology revealed a benign leiomyoma. Case No. 5. A 32-year-old womau, gra\ida 3. para 1, abortuses 2, was referred with progressive tnenorrhagia of one year’s duration. An infertility work-up had been done, including ovulatory temperature charts. A hysterogram showed two filling tlcfec ts. There was associated anemia for which the patient was receiving iron. The Papanicolaou smear ~\a\ (Ilass 1. The uterus l+as of‘ normal size. Hysteroscopic examination in the office c,onfirmed the presence of two submucus fibroids which wcr< beliel,ed to be amenable to hysteroscopic resrcriotl (Fig. 4). The patient was admitted and prepared fol hysteroscopy. laparoscopy, anti possible laparotont!.. At hysteroscopy, one submucus fibroid was grasped with an ovutn forceps and twisted off. The large1 fibroid IVES morcellated with a cutting loop and removed piecemeal (Fig. 5). The estimated blood loss was less than 100 ml. Postoperatively., the patient was treated with estrogen, antibiotics, and iron. She teas discharged after 48 hours. Two months law, the Xlernia
W1S
COrrKtCd,
a hystel-osalpiligograrn pathology confirmed leiomyomas.
lnC!nSes
rCtl~rIled
t(J W~lmd.
was uuremarkahle. the diagnosis of’
and
.I‘hr uter-int
Comment Hjsteroscopy can assist in the management of abnormal vaginal bleeding associated with submucus fibroids in two ways. First, it permits precise evaluation of the enclometrial cavity, thus confirming the presence of the fibroid. It also enables appraisal for the best approach to removal, including possible transcervical resection of the tumors. The second advantage of hysteroscopy has been illustrated by the cases presented. that is, the possibilitl of excision of the submucus fibroid by the transcervical route, with hysteroscopic control. Although the experience to date consists of’only five cases and, therefore, is preliminary, there is no doubt that excision is feasible in selected cases, saving the patient pain and expenditure in hospital costs, as well as time lost from normal activities. Long-range beneficial effects include control of bleeding and anemia. It is too early to determine if there will be any improvement in probletns of infertility and/or abortion. Several technical points are worthy of comment. The resection has certain features in common with transurethral prostatectomy in that the larger tumors must be morcellated partially or totally for removal. AS illustrated in our first case, the problems are not only- to resect the tumor but also to remove it through the cervix. Instruments are being designed to accomplish this type of manipulation more easily. As the space in the endometrial cavity around the fibroid is usually
-
‘Is,’
Fig. i I
;
I.
“1
u,.
2. View of pedicle of submucus fibroid (Case 3). 3. Submucus fibroid following removal (Case 3). 4. View of both submucus myomas from the c.ervix
Fig. Fig. 5). Fig. 5. Submucus
myomas
following
removal
(CAW
.i).
(Case
Volllme 126 Number
Hysferoscopic excision of submucus fibroids
99
1
small, the surgical excision may be tedious. The surgeon not only should be highly skilled in endoscopy and eiectrosurgery but also should have had considerable experience with hysteroscopy before attempting resection. We have found that resection of these tumors is feasible if the hysteroscope is employed very flexibly. If the tumor is small, the hysteroscope should be removed, and the tumor can be grasped with an ovum forceps and twisted off. Following removal, the hysteroscope is reinserted to evaluate the site for completeness of removal and to control bleeding with cautery, if necessary. For large tumors, resection with a cutting loop or a rectoscope is feasible. Alternatively, a slender scissors or biopsy instrument ma!; be inserted alongside the hysteroscope to manipulate the tumor mechanically with visual control. Such manipulation is only possible with high-viscosity liquids, such as 32 per cent dextran 70, because distending fluid losses through the cervix are great. In addition, bleeding during manipulation may become brisk and is more easily controlled by intermiuent cauterization in the high-viscosity medium. As for selection of the type of tumor to be resected, we have thus far limited ourselves to the pedunculated variety with a distinct stalk. The sessile type which may
be partially embedded in the myometrium may ,tlso be amenable to this approach. but the risk of bleeding will probably be higher. Electrocautery in such cases will have to be carried out carefully and under Iaparoscopic control to ensure that the intestines are separarec! trorn the uterus. For the present, such tumors have not been approached. In summary, this experience has demonstrated that hysteroscopy can be used to select certain sulnnucus fibroids and perform transcervical resection ef‘tectiv+ and safely. The follow-up to date has been satisfactory in that there was no recurrence of the abnormal vaginal bleeding with concomitant correction of the associated anemia. The effect of this approach on subsequent reproductive performance remains to be learned. The reduction in time lost from work and the avoidance of the pain and complications of laparototny arc the major advantages of this approach. However, the method requires specialized skills and equipmcn~. is tedious, and carries potential hazards of serious bleeding and visceral burns from cauterv; therefore. it should be approached with caution. These risks must also be explained to the patient, and the procedures must be carried out in the operating room with general anesthesia so that emergency laparotornv can be performed if necessary.
REFERENCES
1. McCall, M., and Bolton, K.: Martius’ Gynecological Operations, Boston, 1956, Little, Brown & Company. 2. Norment, W. B., Sikes, C. H., Berry, F. X.. and Bird. I.: Surg. Clin. North Am.. p. 1377. 1957.
3. Neuwirth, R. S.: Hvsteroscopy. Philadelphia. Saunders Company.
1975. W. 8.
S. K.
NEUWIRTH, AMIN,
M.D. M.D.
New York, New Yo’ork
Hyterascopy offers a neu~ option in the diagnosisand management of submucwjbroids. The hysteroscopic excision of su6mucusjibroid.s infive casesis described. The j.n-obkms and potentials of this approach are discussed.
SUBMUCUS FIBROID isoneofthemoreserious forms of leiomyomas of the uterus causing menorrhagia and secondary anemia, recurrent abortion, or infertility. The symptomatology usually requires operation which classicallyhasbeen abdominal hysterotomy and myomectomy, or hysterectomy. Occasionally, a pedunculated submucus myoma, presenting at the cervix or in the vagina, is excised transvaginally through the dilated cervix or via vaginal hysterotomy.’ Norment and associates’reported a modification of the hysteroscopeto accomplish hysteroscopic resection of submucusfibroids but did not report their experiences. The transcervical route for removal of submucus fibroids would be preferable, particularly in the younger patient who desiresto preserve reproductive function, becauseof the avoidance of laparotomy and hysterotomy. The inability to visualize the endometrial cavity has heretofore been the major obstacle to transcervical removal of thesefibroids. The tumors can he difficult to manipulate blindly for removal through the cervix. Moreover, there has been no means of visualization of the baseof the tumor for appraisal of the risk of bleeding, and t.here has not been a sure method, short of hysterectomy, for its control should hemorrhage occur. Thus, without visual control, the hazards of a blind operation outweigh any possible
advantage to transcervical removal. Hysteroscopy has provided a meansof visual appraisal of the endometrial cavity and, therefore, introduces the possibility of safe excision of thesetumors3 In this report, the removal of submucus fibroids transcervically with hysteroscopic control in five patients isdescribed. Although the number is small,these casesserve to illustrate the potential as well as the limitations of this application of hysteroscopy.
THE
land d-8 All procedures were done in the operating room with general anesthesia. A standard hysteroscope of the Storz or ACMI type wasused. Thirty-two per cent dextran 70 wasusedfor distending the uterine cavity in four casesand 5 per cent dextrose in water wasusedin one case.A regular light source of 150 watts wa?used. For photography, a 500 watt light source, a photohysteroscope, and an Olympus SLR 35 mm. camera, or a Beaulieu 16 mm. motion picture camera, with Ektachrome ASA 160 film, were used. care raports CaseNo. 1. Mrs. C. Q., a 26-year-old-woman, gravida 4, para 1, abortuses 3, presented with secondary infertility of three years’ duration, dysmenorrhea, and a uterine filling defect on hysterography. Hysteroscopy confirmed the presenceof a pendunculated fibroid. Its pedicle wascut with scissorsand, although the tumor was believed to be free in the uterine cavity, it could not be extricated through the cervix becauseof difficulty in grasping it with an ovum forceps, the only available accessoryinstrument. The fibroid wassubsequently removed via an abdominal hysterotomy. The postoperative course was uneventful, and the patient was discharged on the seventh postoperative day. This patient then becamepregnant and wasdelivered of her infant by cesareansection 11 months after myomectomy. CaseNo. 4. Mrs. J. E., a 32-year-& woman, who had never been pregnant, underwent dilatation and curet-
From the Woman% Hospital Division, St. Luke’s Hospital Center, and the Department of Obstetrics-Gynecology, College of Physicians U Surgeons, Cohm&iaUniversity. Financial assistance in tkc publlblication photographs was provided b Pharmucia Inc., 800 Cwtennial Ave., Piscataway, 08854. Received for publication AcceptedJanwlly
Januav
of the color Laboratories, New Jersey
5, 1976.
17, 1976.
Reprint requests: Dr. Robert S. New&h, Department of Obstetrics and Gynecology-Woman’s Hospital, St. Luke’s Hospital Center, 114th St. and Amsterdam Ave., New York, Nezo York 10025.
95
tage for heavy periods and anemia. The uterus was normal in size and measured 3% inches. Exploration of the uterine cavity, with both ovum forceps and curet, revealed only slight irregularity on the posteriol uterine wall. The curettings showed proliferative endometrium. Uterine bleeding recurred, and a hysterogram 10 months later suggested two submucosal fibroids. Hysteroscopy confirmed the presence of two pedunculated submucus fibroids. With laparoscopic and hysteroscopic control, the fibroids were morcellated by diathermic cutting, and their bases were cauterized. Postoperatively, the patient was given antibiotics and estrogens prophylactically. Recover) was uneventful with discharge on the third postoperative day. Menses have since been normal, and the anemia was corrected. The hysterogram returned to normal. Case No. 3. Mrs. M. K., a 44-year-old woman, who had never been pregnant. r\‘as given hormonal therapy for progressive polymenorrhea, menorrhagia, and anemia. The uterus was normal, and a Papanicolaou smear and endometrial biopsy were negative for malignancy. Despite the therapeutic trial, menses continued to be heavy. At hysteroscopy, a broad-based, pedunculated. submucus fibroid, measuring 2 by 2 by 5 cm. was discovered (Figs. 1 and 2). With hysteroscopic control, morcellation by diathermic cutting was attempted but was discontinued because the instrument was too small to morcellate the tumor satisfactorily. The fibroid was then removed by grasping it with an ovum forceps, placed alongside the hysteroscope. so that the tumor was held under visual control and twisted off (Fig. 3). The pedicle was then visualized, and bleeding was controlled with light cautery. Postoperatively, the patient did well; she was treated with prophylactic estrogens and antibiotics and was discharged on the second postoperative day. The rnenstrual periods and blood parameters have returned to normal. Case No. 4. Mrs. F. W., a 64-year-old, obese, hypertensive, and diabetic woman, presented with postmenopausal bleeding. Atrophic changes of the vulva and vagina and a large cervical polyp were found on examination. A Papanicolaou smear was negative. Dilatation and curettage and cervical polypectomy were performed. The uterine cavity \ras described as irregular, and the histology was benign. Light vaginal bleeding persisted, and a second Papanicolaou smear was negative. Six months later, a pedunculated submucus fibroid, 3 by 3 by 5 cm., was discovered at hysteroscopy. The cervix was dilated to 12 mm. which permitted the fibroid to be grasped with ovum forceps and then twisted off the pedicle. Bleeding ensued, and, though its source could be visualized, attempts at controlling it with cautery were not successful, although the uterine cavity was intact on hysteroscopic examination. One-inch iodoform gauze packing was used to control the bleeding. Packing was removed 12 hours later; the patient’s recovery was uneventful, and
there has been no recurrence of bleeding to datr. I‘he pathology revealed a benign leiomyoma. Case No. 5. A 32-year-old womau, gra\ida 3. para 1, abortuses 2, was referred with progressive tnenorrhagia of one year’s duration. An infertility work-up had been done, including ovulatory temperature charts. A hysterogram showed two filling tlcfec ts. There was associated anemia for which the patient was receiving iron. The Papanicolaou smear ~\a\ (Ilass 1. The uterus l+as of‘ normal size. Hysteroscopic examination in the office c,onfirmed the presence of two submucus fibroids which wcr< beliel,ed to be amenable to hysteroscopic resrcriotl (Fig. 4). The patient was admitted and prepared fol hysteroscopy. laparoscopy, anti possible laparotont!.. At hysteroscopy, one submucus fibroid was grasped with an ovutn forceps and twisted off. The large1 fibroid IVES morcellated with a cutting loop and removed piecemeal (Fig. 5). The estimated blood loss was less than 100 ml. Postoperatively., the patient was treated with estrogen, antibiotics, and iron. She teas discharged after 48 hours. Two months law, the Xlernia
W1S
COrrKtCd,
a hystel-osalpiligograrn pathology confirmed leiomyomas.
lnC!nSes
rCtl~rIled
t(J W~lmd.
was uuremarkahle. the diagnosis of’
and
.I‘hr uter-int
Comment Hjsteroscopy can assist in the management of abnormal vaginal bleeding associated with submucus fibroids in two ways. First, it permits precise evaluation of the enclometrial cavity, thus confirming the presence of the fibroid. It also enables appraisal for the best approach to removal, including possible transcervical resection of the tumors. The second advantage of hysteroscopy has been illustrated by the cases presented. that is, the possibilitl of excision of the submucus fibroid by the transcervical route, with hysteroscopic control. Although the experience to date consists of’only five cases and, therefore, is preliminary, there is no doubt that excision is feasible in selected cases, saving the patient pain and expenditure in hospital costs, as well as time lost from normal activities. Long-range beneficial effects include control of bleeding and anemia. It is too early to determine if there will be any improvement in probletns of infertility and/or abortion. Several technical points are worthy of comment. The resection has certain features in common with transurethral prostatectomy in that the larger tumors must be morcellated partially or totally for removal. AS illustrated in our first case, the problems are not only- to resect the tumor but also to remove it through the cervix. Instruments are being designed to accomplish this type of manipulation more easily. As the space in the endometrial cavity around the fibroid is usually
-
‘Is,’
Fig. i I
;
I.
“1
u,.
2. View of pedicle of submucus fibroid (Case 3). 3. Submucus fibroid following removal (Case 3). 4. View of both submucus myomas from the c.ervix
Fig. Fig. 5). Fig. 5. Submucus
myomas
following
removal
(CAW
.i).
(Case
Volllme 126 Number
Hysferoscopic excision of submucus fibroids
99
1
small, the surgical excision may be tedious. The surgeon not only should be highly skilled in endoscopy and eiectrosurgery but also should have had considerable experience with hysteroscopy before attempting resection. We have found that resection of these tumors is feasible if the hysteroscope is employed very flexibly. If the tumor is small, the hysteroscope should be removed, and the tumor can be grasped with an ovum forceps and twisted off. Following removal, the hysteroscope is reinserted to evaluate the site for completeness of removal and to control bleeding with cautery, if necessary. For large tumors, resection with a cutting loop or a rectoscope is feasible. Alternatively, a slender scissors or biopsy instrument ma!; be inserted alongside the hysteroscope to manipulate the tumor mechanically with visual control. Such manipulation is only possible with high-viscosity liquids, such as 32 per cent dextran 70, because distending fluid losses through the cervix are great. In addition, bleeding during manipulation may become brisk and is more easily controlled by intermiuent cauterization in the high-viscosity medium. As for selection of the type of tumor to be resected, we have thus far limited ourselves to the pedunculated variety with a distinct stalk. The sessile type which may
be partially embedded in the myometrium may ,tlso be amenable to this approach. but the risk of bleeding will probably be higher. Electrocautery in such cases will have to be carried out carefully and under Iaparoscopic control to ensure that the intestines are separarec! trorn the uterus. For the present, such tumors have not been approached. In summary, this experience has demonstrated that hysteroscopy can be used to select certain sulnnucus fibroids and perform transcervical resection ef‘tectiv+ and safely. The follow-up to date has been satisfactory in that there was no recurrence of the abnormal vaginal bleeding with concomitant correction of the associated anemia. The effect of this approach on subsequent reproductive performance remains to be learned. The reduction in time lost from work and the avoidance of the pain and complications of laparototny arc the major advantages of this approach. However, the method requires specialized skills and equipmcn~. is tedious, and carries potential hazards of serious bleeding and visceral burns from cauterv; therefore. it should be approached with caution. These risks must also be explained to the patient, and the procedures must be carried out in the operating room with general anesthesia so that emergency laparotornv can be performed if necessary.
REFERENCES
1. McCall, M., and Bolton, K.: Martius’ Gynecological Operations, Boston, 1956, Little, Brown & Company. 2. Norment, W. B., Sikes, C. H., Berry, F. X.. and Bird. I.: Surg. Clin. North Am.. p. 1377. 1957.
3. Neuwirth, R. S.: Hvsteroscopy. Philadelphia. Saunders Company.
1975. W. 8.