Extreme Hysteroscopic Myomectomy for Delivering Fibroids

Study Objective

Review a minimally invasive hysteroscopic approach to large submucosal delivering fibroids with a video demonstration.

Design

Case series.

Setting

Tertiary referral center.

Patients or Participants

Two patients with significant fibroid burden experiencing delivery of submucosal fibroids after an inciting event.

Interventions

Hysteroscopic myomectomy with resectoscope.

Measurements and Main Results

The first patient was a 30 yo G1P0010 who presented to the emergency room with pelvic pain, recent spontaneous abortion at 12w5d, and vaginal discharge. Evaluation was notable for 12cm degenerated submucosal fibroid with superimposed infection consistent with pyomyoma. She failed a course of conservative treatment with IV antibiotics and underwent urgent myomectomy with vaginal debulking of delivering pyomyoma and hysteroscopic myomectomy with the resectoscope utilizing dilute vasopressin and temporary cervical cerclage to maintain fluid pressure. She underwent Lupron administration and interval myomectomy at 6 weeks with repeat hysteroscopic resection of the remaining 3.5cm myoma with 95% success. The second patient was a 46 yo G7P1142 who presented to clinic with leukorrhea, delivery of fibroid at home, and pelvic pain 6 months after uterine artery embolization. Preoperative imaging demonstrated 15cm uterus and a conglomeration of five 4-6cm FIGO type 0-2 fibroids. She underwent hysteroscopic myomectomy of the two most inferior fibroids with plans for postoperative Lupron and additional staged myomectomy. Benefits of the hysteroscopic approach include easy accessibility, avoidance of abdominal incisions, and utilizing the already dilated cervix to a surgical advantage. Disadvantages include requiring a multi-stage procedure for completion.

Conclusion

Hysteroscopic myomectomy can be utilized in cases of delivering fibroids in the setting of extreme submucosal fibroid burden, this offers a less invasive alternative to myomectomy but may require staged procedures. Preoperative imaging and examination are key to planning and can change rapidly. Pregnancy and uterine artery embolization can incite fibroid degeneration with delivery of submucosal fibroids, and rarely subsequent infection.