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Hysteroscopic myomectomy for submucosal type 2 fibroids with cold enucleation technique and complete fibroid extraction using a double-lumen intracervical cannula
VIDEO
Hysteroscopic myomectomy for submucosal type 2 fibroids with cold enucleation technique and complete fibroid extraction using a double-lumen intracervical cannula Walter Osorio, M.D., Natalia Posada, M.D., John Cano, M.D., Sergio Tamayo, M.D., and Juan Giraldo, M.D. InSer, Instituto de Fertilidad Humana, Medellín, Colombia
Objective: To introduce a new double-lumen intracervical cannula designed to allow a single-step hysteroscopic myomectomy with nonfragmented complete fibroid extraction after cold enucleation of submucosal type 2 fibroids, avoiding complications related to the use of energy and hypo-osmolar solutions. Design: Video article depicting the use of a new double-lumen intracervical cannula for single-step hysteroscopic cold myomectomy, according to our institutional care guidelines and after obtaining the patient’s informed consent. (The publication of this video has been authorized by the Institutional Ethics Committee of CES University in Medellín, Colombia.) Setting(s): Private infertility clinic. Patient(s): A 45-year-old woman with abnormal uterine bleeding consisting of polymenorrhea and hypermenorrhea, nonresponsive to medical treatment, caused by three type 2 (FIGO leiomyoma subclassification system) submucosal fibroids of 17, 15, and 13 mm with more than 80% of intramyometrial component. Intervention(s): Hysteroscopic enucleation of three submucosal fibroids performed by blunt dissection using the 30 Bettocchi hysteroscope’s bevel under continuous observation of the avascular subcapsular plane of the fibroids. Once full enucleation was attained, cervical dilatation to 12 mm with Hegar plugs was performed followed by intracervical placement of a newly designed double-lumen intracervical cannula that allows the concomitant introduction of the Bettocchi diagnostic hysteroscope and a 5-mm laparoscopic tenaculum into the uterine cavity for complete nonfragmented fibroid extraction under direct visualization. Main Outcome Measure(s): Complete and unfragmented fibroid extraction in a single intervention, absence of surgical complications, and postoperative course. Result(s): Ambulatory hysteroscopic myomectomy of three submucosal type 2 fibroids was successfully performed by blunt enucleation and complete nonfragmented fibroid extraction using the double-lumen intracervical cannula. The total operative time was 32 minutes, and the total amount of distension media (normal saline) used was 800 mL with a liquid balance of 50 mL. No surgical or anesthesia-related complications occurred. In the postsurgical evaluation, the patient classified her pain as minimal, giving it a score of 1 on a pain scale of 1 to 5 (in which 1 is the lowest and 5 the highest pain perception). When asked about the level of satisfaction with the surgical procedure, the patient reported the highest degree of satisfaction with a score of 5 on a satisfaction scale of 1 to 5 (in which 1 is the lowest and 5 the highest satisfaction). The patient reported having postsurgical regular menstrual cycles every 28 days and 3 bleeding days without hypermenorrhea. Conclusion(s): An efficient hysteroscopic myomectomy of submucosal type 2 fibroids with deep intramyometrial component can be performed with complete and nonfragmented fibroid extraction in a single intervention by using a newly designed double-lumen intracervical cannula. This technique allows the completion of the surgery without the need of a resectoscope, electrosurgery, or hypo-osmolar uterine distension media, thus avoiding potential complications such as thermal-induced myometrial injury and hyponatremia; a second surgical intervention will not be required because the fibroid enucleation is complete. The procedure can be
Received June 15, 2020; revised September 1, 2020; accepted September 8, 2020. nula Bil n de Miomas Uterinos Submucosos’’ (double lumen intracervical cannula). N.P. has nothing to W.O. has a patent for the ‘‘Ca umen para la Extraccio nula Bilu n de Miomas Uterinos Sub men para la Extraccio disclose. J.C. has nothing to disclose. S.T. has nothing to disclose. J.G. has a patent for the ‘‘Ca mucosos’’ (double lumen intracervical cannula). Reprint requests: Juan Giraldo, M.D., InSer, Instituto de Fertilidad Humana, Cll 12 # 39-60 Medellín, Antioquia, Colombia 050021 (E-mail: juangiraldo@inser. com.co). Fertility and Sterility® Vol. -, No. -, - 2020 0015-0282 Copyright ©2020 The Authors. Published by Elsevier Inc. on behalf of the American Society for Reproductive Medicine. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). https://doi.org/10.1016/j.fertnstert.2020.09.028 VOL. - NO. - / - 2020
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performed with the use of a diagnostic hysteroscope that is widely available in gynecologic practices. (Acknowledgment: The authors thank Dr. David Olive for the invaluable help and guidance with this surgical Use your smartphone technique and video article.) (Fertil SterilÒ 2020;-:-–-. Ó2020 by American Society for to scan this QR code Reproductive Medicine.) and connect to the Key Words: Hysteroscopy, leiomyoma, uterine fibroid, uterine myomectomy Discuss: You can discuss this article with its authors and other readers at https://www. fertstertdialog.com/posts/30825
NOW AVAILABLE ON YOUTUBE
2.
https://youtu.be/iMEglDXakTY
SUGGESTED READING 1.
2
Zepiridis LI, Grimbizis GF, Tarlatzis BC. Infertility and uterine fibroids. Best Pract Res Clin Obstet Gynaecol 2016;34:66–73.
3. 4.
video for this article now.*
* Download a free QR code scanner by searching for “QR scanner” in your smartphone’s app store or app marketplace.
Practice Committee of the American Society for Reproductive Medicine. Removal of myomas in asymptomatic patients to improve fertility and/or reduce miscarriage rate: a guideline. Fertil Steril 2017;108:416–25. Connor M. New technologies and innovations in hysteroscopy. Best Pract Res Clin Obstet Gynaecol 2015;29:951–65. Pritts EA, Parker WH, Olive DL. Fibroids and infertility: an updated systematic review of the evidence. Fertil Steril 2009;91:1215–23.
VOL. - NO. - / - 2020
Hysteroscopic myomectomy for submucosal type 2 fibroids with cold enucleation technique and complete fibroid extraction using a double-lumen intracervical cannula Walter Osorio, M.D., Natalia Posada, M.D., John Cano, M.D., Sergio Tamayo, M.D., and Juan Giraldo, M.D. InSer, Instituto de Fertilidad Humana, Medellín, Colombia
Objective: To introduce a new double-lumen intracervical cannula designed to allow a single-step hysteroscopic myomectomy with nonfragmented complete fibroid extraction after cold enucleation of submucosal type 2 fibroids, avoiding complications related to the use of energy and hypo-osmolar solutions. Design: Video article depicting the use of a new double-lumen intracervical cannula for single-step hysteroscopic cold myomectomy, according to our institutional care guidelines and after obtaining the patient’s informed consent. (The publication of this video has been authorized by the Institutional Ethics Committee of CES University in Medellín, Colombia.) Setting(s): Private infertility clinic. Patient(s): A 45-year-old woman with abnormal uterine bleeding consisting of polymenorrhea and hypermenorrhea, nonresponsive to medical treatment, caused by three type 2 (FIGO leiomyoma subclassification system) submucosal fibroids of 17, 15, and 13 mm with more than 80% of intramyometrial component. Intervention(s): Hysteroscopic enucleation of three submucosal fibroids performed by blunt dissection using the 30 Bettocchi hysteroscope’s bevel under continuous observation of the avascular subcapsular plane of the fibroids. Once full enucleation was attained, cervical dilatation to 12 mm with Hegar plugs was performed followed by intracervical placement of a newly designed double-lumen intracervical cannula that allows the concomitant introduction of the Bettocchi diagnostic hysteroscope and a 5-mm laparoscopic tenaculum into the uterine cavity for complete nonfragmented fibroid extraction under direct visualization. Main Outcome Measure(s): Complete and unfragmented fibroid extraction in a single intervention, absence of surgical complications, and postoperative course. Result(s): Ambulatory hysteroscopic myomectomy of three submucosal type 2 fibroids was successfully performed by blunt enucleation and complete nonfragmented fibroid extraction using the double-lumen intracervical cannula. The total operative time was 32 minutes, and the total amount of distension media (normal saline) used was 800 mL with a liquid balance of 50 mL. No surgical or anesthesia-related complications occurred. In the postsurgical evaluation, the patient classified her pain as minimal, giving it a score of 1 on a pain scale of 1 to 5 (in which 1 is the lowest and 5 the highest pain perception). When asked about the level of satisfaction with the surgical procedure, the patient reported the highest degree of satisfaction with a score of 5 on a satisfaction scale of 1 to 5 (in which 1 is the lowest and 5 the highest satisfaction). The patient reported having postsurgical regular menstrual cycles every 28 days and 3 bleeding days without hypermenorrhea. Conclusion(s): An efficient hysteroscopic myomectomy of submucosal type 2 fibroids with deep intramyometrial component can be performed with complete and nonfragmented fibroid extraction in a single intervention by using a newly designed double-lumen intracervical cannula. This technique allows the completion of the surgery without the need of a resectoscope, electrosurgery, or hypo-osmolar uterine distension media, thus avoiding potential complications such as thermal-induced myometrial injury and hyponatremia; a second surgical intervention will not be required because the fibroid enucleation is complete. The procedure can be
Received June 15, 2020; revised September 1, 2020; accepted September 8, 2020. nula Bil n de Miomas Uterinos Submucosos’’ (double lumen intracervical cannula). N.P. has nothing to W.O. has a patent for the ‘‘Ca umen para la Extraccio nula Bilu n de Miomas Uterinos Sub men para la Extraccio disclose. J.C. has nothing to disclose. S.T. has nothing to disclose. J.G. has a patent for the ‘‘Ca mucosos’’ (double lumen intracervical cannula). Reprint requests: Juan Giraldo, M.D., InSer, Instituto de Fertilidad Humana, Cll 12 # 39-60 Medellín, Antioquia, Colombia 050021 (E-mail: juangiraldo@inser. com.co). Fertility and Sterility® Vol. -, No. -, - 2020 0015-0282 Copyright ©2020 The Authors. Published by Elsevier Inc. on behalf of the American Society for Reproductive Medicine. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). https://doi.org/10.1016/j.fertnstert.2020.09.028 VOL. - NO. - / - 2020
1
VIDEO
performed with the use of a diagnostic hysteroscope that is widely available in gynecologic practices. (Acknowledgment: The authors thank Dr. David Olive for the invaluable help and guidance with this surgical Use your smartphone technique and video article.) (Fertil SterilÒ 2020;-:-–-. Ó2020 by American Society for to scan this QR code Reproductive Medicine.) and connect to the Key Words: Hysteroscopy, leiomyoma, uterine fibroid, uterine myomectomy Discuss: You can discuss this article with its authors and other readers at https://www. fertstertdialog.com/posts/30825
NOW AVAILABLE ON YOUTUBE
2.
https://youtu.be/iMEglDXakTY
SUGGESTED READING 1.
2
Zepiridis LI, Grimbizis GF, Tarlatzis BC. Infertility and uterine fibroids. Best Pract Res Clin Obstet Gynaecol 2016;34:66–73.
3. 4.
video for this article now.*
* Download a free QR code scanner by searching for “QR scanner” in your smartphone’s app store or app marketplace.
Practice Committee of the American Society for Reproductive Medicine. Removal of myomas in asymptomatic patients to improve fertility and/or reduce miscarriage rate: a guideline. Fertil Steril 2017;108:416–25. Connor M. New technologies and innovations in hysteroscopy. Best Pract Res Clin Obstet Gynaecol 2015;29:951–65. Pritts EA, Parker WH, Olive DL. Fibroids and infertility: an updated systematic review of the evidence. Fertil Steril 2009;91:1215–23.
VOL. - NO. - / - 2020