Video Description
This video demonstrates a technique for injection of vasopressin into the uterus to mitigate blood loss during hysteroscopic myomectomy.
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University of Saskatchewan
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Summary:
- Fibroids that grow inside the uterus can cause symptoms like pain, bleeding, and cramping. A type of surgery called hysteroscopic myomectomy lets surgeons remove them without any incisions.
- Vasopressin, an injectable medication, helps reduce bleeding in the area near the fibroid during your procedure. This can make hysteroscopic myomectomy safer.
- If you have heart disease or chronic health issues, vasopressin may not be right for you. Ask your doctor about alternatives for more information.
- Most patients recover from hysteroscopic myomectomy quickly, and return to normal activities within a week.
Intraoperative Vasopressin Injection During Hysteroscopic Myomectomy
Fibroids are non-cancerous growths made of smooth muscle tissue that develop in or on your uterus. They’re very common—up to 70% of all people with a uterus will be diagnosed with at least one before the age of 50. In many cases, they don’t cause any symptoms at all.
For others, fibroids can cause debilitating symptoms like heavy bleeding, cramping, pelvic pressure, and bloating. If they interfere with your life, your provider might suggest having them surgically removed so you can get relief.
Hysteroscopic myomectomy is a minimally-invasive surgical technique for removing submucosal fibroids that grow inside your uterus. Your surgeon may use an injectable medication called vasopressin to reduce bleeding in the area during this procedure.
Vasopressin can help control bleeding, which makes it easier to see the surgical field and helps you recover faster. Learn about this medication in this guide from CanSAGE.
What is Hysteroscopic Myomectomy
Hysteroscopic myomectomy is an effective way to remove submucosal fibroids without cutting or damaging the uterus. Instead of making an incision in your belly, your surgeon will access and remove the fibroid through your cervix.
In most cases, you’ll be given an anesthetic to sedate you or put you to sleep before having this procedure. Once you’re resting comfortably, your surgeon will:
- Insert a hysteroscope (a thin tube with a camera and light) into your uterus through the cervix.
- Gently expand your uterus by flooding it with sterile fluid (typically saline).
- Use a special instrument to remove the fibroid in small pieces.
- Send all removed tissue to the lab to confirm the fibroid is benign.
Since this technique avoids major incisions, it’s a great option for people experiencing heavy bleeding, infertility, or pain. But even without a large incision, controlling bleeding during the procedure is still important. That’s where vasopressin comes in.
What Is Vasopressin?
Vasopressin is a type of hormone that helps your body regulate blood pressure and balance fluids in your bloodstream. It also causes constriction of blood vessels, which can help to reduce bleeding. In hysteroscopic myomectomy, your surgeon injects a diluted form into the lining of your uterus (myometrium) near the fibroid before or during your surgery.
How Vasopressin Helps During Hysteroscopic Myomectomy
One of the main challenges in fibroid removal is bleeding. Excessive bleeding inside the uterus makes it harder for your surgeon to work. It may also extend your recovery time or increase your risk for complications afterward.
Vasopressin helps by:
- Controlling bleeding in and around the surgical site.
- Making it easier for your surgeon to see the area they’re working on.
- Shortening the length of your surgery and the total time you’re asleep.
- Improving your surgeon’s ability to completely remove the entire fibroid.
Usually, vasopressin is injected into the cervix or uterus after you’re asleep, but before the fibroid is removed. It can also be used to treat a sudden increase in bleeding at any other point in the procedure.
Are There Any Risks Associated With Vasopressin?
Vasopressin is safe and effective for most patients when used correctly. Most of the side effects are rare and go away on their own with no treatment.
Common side effects include:
- Mild cramping from uterine contractions
- Changes in blood pressure (this is usually temporary)
- Slow heart rate (bradycardia) in very rare cases
If you’re concerned about side effects like these, or have other chronic cardiovascular conditions like heart disease, let your doctor know before your surgery.
Who Should Avoid Vasopressin?
Most patients tolerate vasopressin very well, and don’t have any issues. If you have a heart condition, a bleeding disorder, or a history of low blood pressure, vasopressin might not be the right choice. Ask your surgeon for more info if you have questions about the medication.
How Your Surgeon Keeps You Safe
Research helps us understand how to use vasopressin safely during fibroid removal surgeries. If your provider turns to this medication, it’s because they believe the benefits it provides outweigh any risks.
They’ll also:
- Dilute the vasopressin to a safe concentration.
- Check the injection site to avoid injecting directly into a blood vessel.
- Use a very small amount (usually 4-5 mL of diluted solution).
Steps like these help minimize your risk for complications and prevent uncomfortable side effects, like low blood pressure.
Is Vasopressin Always Used?
Not always. Every surgery is unique, so your surgeon looks at specific factors before deciding whether to use vasopressin.
These may include:
- The size and location of the fibroid
- Your overall health and medical history
- Whether they expect significant bleeding
Some patients won’t need vasopressin at all, while others might benefit from a preoperative or intraoperative injection to reduce bleeding. Your doctor can answer any questions you have about this medication and whether it’s part of your surgical plan.
Are There Alternatives to Vasopressin?
While vasopressin is a safe and reliable option for most patients, other options do exist for managing bleeding during fibroid removal:
- Tranexamic acid helps blood clot, which can reduce bleeding during or after surgery.
- Uterine artery embolization cuts off blood flow to fibroids, causing them to shrink.
- Electrosurgical tools let your surgeon cauterize blood vessels as they go.
- Local anesthetic with epinephrine can facilitate blood vessel constriction.
Sometimes, your surgeon will use a combination of options—like vasopressin and cauterization—to reduce any bleeding.
What to Expect From Your Surgery
Your surgeon will order blood work and other tests to confirm that you’re healthy enough for surgery in advance. They may also ask you to:
- Stop blood-thinning medications, like aspirin, a few days before surgery.
- Fast for around 8 hours before your surgery.
- Take medications to soften the cervix for easier access (not always used).
If you’re feeling anxious about having surgery, talk to your provider. They can help you develop strategies for managing these feelings.
Recovering From Hysteroscopic Myomectomy
Most patients recover from this procedure quickly and experience very few symptoms. Mild cramping or bleeding is common, and you may experience an increase in discharge for a day or two. This is your body’s way of clearing out any remaining saline or tissue—it’s normal!
To help you recover faster:
- Drink plenty of fluids and try to get enough sleep.
- Avoid any heavy lifting or intense activities for about a week.
- Tell your doctor about any excessive bleeding, fever, or intense pain.
- Schedule a follow-up appointment with your surgeon.
Tylenol (acetaminophen), ibuprofen, and Aleve (naproxen) can help you manage mild to moderate pain after your surgery. Your doctor or pharmacist can confirm whether these medications are safe for you to take and help you use them correctly.
Get Informed About Vasopressin Injections With CanSAGE
Hysteroscopic myomectomy is a safe and effective way to remove fibroids without the need for incisions and scarring. Vasopressin makes the procedure even safer by reducing blood loss, improving surgical precision, and lowering the risk of complications.
If you’re scheduled for hysteroscopic myomectomy, talk to your doctor about whether they intend to use vasopressin and what that means for your case. Preparing for the procedure and working with an experienced surgeon can help you recover quickly and successfully in less time—and get relief from fibroid symptoms.
Want to learn more about treating and managing fibroids? Explore our full library of resources at CanSAGE.
Video Transcript: Intraoperative Vasopressin Injection During Hysteroscopic Myomectomy
The objective of this video is to review techniques to help troubleshoot difficult hysteroscopic myoma resections and demonstrate the use of intraoperative hysteroscopic vasopressin injection to secure hemostasis at the time of myomectomy via a hysteroscopic intrauterine tissue removal device. The case presented is that of a 40-year-old woman with heavy and irregular menstrual bleeding. Transvaginal ultrasound revealed a 3cm to 4cm submucosal fibroid. She has consented for hysteroscopy and myomectomy.
A 6.25mm outer sheath, 0-degree hysteroscope was introduced through the cervix after dilatation. Examining the uterine cavity reveals a large 4cm anterior fibroid, grade 0, as the stalk can be visualized. The myoma encompasses close to the entirety of the uterine cavity. The decision is made to go ahead with the procedure as booked.
The hysteroscopic intrauterine tissue removal device is positioned, and resection of the anterior fibroid is started. The device uses normal saline as a distension medium due to its many advantages over high viscosity medium. The main disadvantage to using normal saline is that the blood is not immiscible. Viewing from far away leads to a cloudy field, as even small amounts of blood mix with the isotonic fluid. In contrast, high viscosity distending media allows blood to appear to drip, as the blood is immiscible in such media.
A method to improve visualization while using normal saline is the flow-by technique. Here you can see that the operative field has become obstructed with blood and tissue. To improve visualization, the flow-by technique is illustrated. The hysteroscope is brought close to the pathology to let high-flow normal saline pass by the tissue and clear the field. The flow-by technique allows for the operative field to be cleared and for resection to continue on the anterior fibroid. The device is moved side-by-side systematically to resect the myoma.
Hysteroscopic myomectomy is the ideal procedure for patients with symptomatic submucosal fibroids. It is safe, cost-effective and has high patient satisfaction. However, it is an operative challenge to achieve complete resection while avoiding complications, including cervical injury, uterine perforation, excessive fluid absorption and bleeding. In order to reduce intraoperative blood loss and improve visual clarity, Vasopressin may be used. There are reports that injection of dilute Vasopressin into myomas preoperatively can reduce bleeding as well as systemic fluid absorption. Vasopressin acts by constricting the smooth muscle in the myometrium and the walls of the capillaries, small arterioles and venules.
As you can see, the majority of the fibroid appears to be removed. Only the base of the stalk remains. In efforts to resect the base, brisk bleeding is encountered. The flow-by technique is attempted. The scope is brought close to the bleeding to let high-flow saline clear the field. However, the bleeding is too brisk. The decision is made to inject Vasopressin into the myometrium in an attempt to obtain hemostasis. The hysteroscopic intrauterine tissue removal device is removed from the operative hysteroscope, and the [unclear] needle is introduced, placed into the myometrium, aspirated, and Vasopressin is injected.
Cardiovascular complications following intramyometrial injection have been reported in isolated cases. To prevent this, low-dose dilute Vasopressin is used, and the surgeon first aspirates to ensure the needle has not inadvertently been placed intravascularly. In this case, the solution is 20 units of Vasopressin diluted in 50ml of normal saline. 4 to 5ml is used. A change in the uterine cavity contour due to the increased myometrial contractility is seen after the injection of the Vasopressin. Almost immediately, hemostasis is achieved.
The uterine cavity is partially de-insufflated to allow further visualization of the base of the fibroid on the anterior wall. This decrease in pressure allows a previously unseen posterior wall fibroid to become visible. It appears to be a submucosal, grade 1. This fibroid is resected with the hysteroscopic tissue removal device. Resection of the base of the anterior wall fibroid is also completed. A normal uterine cavity is restored. The specimen is sent to pathology, and the final report came back as a fibroid with cystic degeneration.
In conclusion, the flow-by technique works well to clear an operative field that has become obstructed with tissue or blood and can help enable complete resection. Direct infiltration of Vasopressin into the base of a myoma during hysteroscopic myomectomy has a rapid onset of action to assist with hemostasis, enabling visualization to perform a complete resection, even when used intraoperatively after bleeding occurs.