Video Description
Deep subendometrial fibroids represent a technical challenge for complete hysteroscopic removal. Such fibroids include deep type II submucosal fibroids, type III fibroids (intramyometrial abutting the endometrium), and hybrid stage II-V fibroids (intramyometrial extending in both directions, submucosa and subserosa) according to FIGO classification.
This video demonstrates a case of a 34 year old female who had failed several embryo transfers with good quality blastocysts. After comprehensive testing for her recurrent implantation failure, the sole finding was a 2.3cm posterior wall, upper cavity, sub-endometrial fibroid 3mm from the serosa.The video presented captures the hysteroscopic removal of this 2.3cm intramural posterior wall fibroid in the upper cavity abutting and subtly elevating the posterior endometrium.
The clip demonstrates the complete and safe removal of this technically challenging myoma, while offering some surgical tips. Following her myomectomy, the patient conceived after a subsequent embryo transfer and had a full-term caesarean delivery.
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Affiliations
Astra Fertility Group, William Osler Health System – Etobicoke General Hospital
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Video Transcript: Hysteroscopic Resection of Deep Sub-Endometrial Fibroid (FIGO stage III bordering on hybrid stage II)
Deep sub-endometrial fibroids represent a technical challenge for complete hysteroscopic removal. Such fibroid groups include deep type II submucosal fibroids, type III fibroids and hybrid stage II to IV fibroids according to FIGO classification.
The following video demonstrates a case of a 34 year old female who had failed several embryo transfers with good quality blastocysts. After comprehensive testing for her recurrent implantation failure, the sole finding was a 2.3 centimetre posterior wall upper cavity sub-endometrial fibroid that was three to four millimetres from the serosa.
The following video presented captured the hysteroscopic removal of this 2.3 centimetre intramural posterior wall fibroid seen abutting and slightly elevating the endometrium. The clip will reveal the complete and safe removal of this positionally challenging myoma and offer some surgical tips.
Following the myomectomy the patient conceived after a subsequent embryo transfer and had a full-term caesarean delivery.
For this case, the patient had deep sedation in the operating room. The cervix was dilated to a number ten Hegar and the resectoscope was positioned into the endometrial cavity. Glycine 1.5% was used as a dissention medium and a nine millimetre monopolar resectoscope was used with a wire loop at the cutting mode of 80 watts.
On inspection of the endometrial cavity, initially the fibroid was hardly visible above the endometrial surface. Identification of these types of fibroids is usually made by the previous knowledge of the location and the optional concomitant use of ultrasound. And also by careful inspection of the endometrium for any change of vascular pattern or subtle elevations.
After the first pass through the surface of the endometrium over the suspected area you can clearly start to see the myoma. Now we have identified just the tip of the iceberg. Following this, we proceeded by resecting the myoma piece by piece as usual until the myoma was completely removed from its underlying bed.
The difficulty associated with this case is that we are working below the endometrial surface and chipping at the fibroid and working our way down to almost the serosa. Obvious risks related to this include perforation.
The careful use of visual and tactile clues received from both the screen and from the manual feel of dragging the loop against the fibroid edge are of paramount importance for complete removal with the avoidance of perforation of the uterine serosa.
Here we can see the loop being pulled against the edge of the myoma, and as we are doing so, we want to be able to see the remaining fibroid mass moving with the loop, ensuring that the tip of the wire is not touching anything but fibroid tissue.
When one is resecting, one should not be touching or applying pressure on either the myometrium or the underlying serosa.
Towards the end of the resection, we can now see that the myoma has now been completely removed from its underlying myometrial bed. Sometimes minor inadvertent resection of the myometrium can occur, at least in the first initial passes through the fibroid when we’re trying to find the current plane.
At our centre, six to eight weeks follow hysteroscopic myomectomies we perform an ultrasound and offer hysteroscopy to ensure the normal myometrial thickness, complete healing of the endometrium and to rule out any intrauterine adhesions before proceeding with fertility treatment and assistance.