Submucous leiomyomas are the most problematic type of fibroid and have been associated with abnormal uterine bleeding, infertility, and other clinical issues. Treatment has been shown to be effective in improving fertility and success rates with assisted reproduction.
Newer hysteroscopic surgical techniques and morcellation technology allow us to remove not only polyps, but selected submucous myomas, in a fashion that is not only minimally invasive but that also raises few if any concerns about spreading or upstaging an unsuspected leiomyosarcoma. In this respect, the controversy over laparoscopic power morcellation does not extend to hysteroscopic morcellation.
Joseph S. Sanfilippo
Such a distinction was made during opening remarks at a meeting in June 2014 of the Obstetrics & Gynecology Devices Panel of the Food and Drug Administration’s Medical Devices Advisory Committee, which was charged with addressing such concerns.
Dr. Aron Yustein, deputy director of clinical affairs and chief medical officer of the FDA’s Office of Surveillance and Biometrics, explained that the panel would not address hysteroscopic morcellators "as we do not believe that when used [as intended], they pose the same risk" as that of laparoscopic morcellation in terms of potentially disseminating and upstaging an undetected uterine malignancy.
In hysteroscopic morcellation, tissue is contained and delivered through the morcellation system into a trap, or collecting pouch. This allows for complete capture and histopathologic assessment of all fragments extracted from the uterine cavity.
Numerous equipment options are currently available to gynecologic surgeons for hysteroscopically-guided myomectomy: Newer systems such as the Gynecare VersaPoint (Ethicon Endo-Surgery), and the Symphion system (Boston Scientific) facilitate bipolar electrosurgical resection. MyoSure (Hologic) and TRUCLEAR (Smith & Nephew), on the other hand, are hysteroscopic morcellators; they both use mechanical energy rather than high-frequency electrical energy to simultaneously cut and aspirate tissue.
Common to each of these options are advanced, automated fluid management systems that continuously measure distending media input and output, intrauterine distension pressure, and fluid deficit volume throughout the procedure. Such monitoring is critical to preventing excess fluid absorption and its associated complications. The new fluid management systems allow excellent visualization of the intrauterine cavity.
Benefit of Treatment
Leiomyomas, synonymously known as myomas, are among the uterine bleeding abnormalities included in a new classification system introduced in 2011 by the International Federation of Gynecology and Obstetrics. The system classifies the causes of abnormal uterine bleeding in reproductive-aged women; it is known by the acronym PALM-COEIN, for polyp, adenomyosis, leiomyoma, malignancy and hyperplasia, coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, and not yet classified.
In a practice bulletin published in 2012, the American College of Obstetricians and Gynecologists endorsed the nomenclature system and provided guidelines for evaluating reproductive-aged patients with abnormal uterine bleeding (Obstet. Gynecol. 2012;120:197-206).
The diagnosis and management of submucous leiomyomas is particularly important in cases of infertility, as these types of myomas (compared with intramural or subserosal) appear to have the greatest impact on pregnancy and implantation rates.
In general, uterine myomas are found in 5%-10% of women with infertility. In 1%-3% of infertility patients, myomas are the only abnormal findings. As described in a literature review, it is believed that myomas may interfere with sperm transport or access, and with implantation. Endometrial cavity deformity, cornual ostia obstruction, altered uterine contractility, and altered endometrial development may each play a role (Obstet. Gynecol. Clin. North Am. 2006;33:145-52).
Studies evaluating the impact of myomectomy on fertility outcomes provide evidence that submucous myomas should be removed before assisted reproductive technology/in vitro fertilization. According to the AAGL’s practice guidelines on the diagnosis and management of submucous leiomyomas, it "seems clear from high-quality studies that pregnancy rates are higher after myomectomy than no or ‘placebo’ procedures" (J. Minim. Invasive Gynecol. 2012;19:152-71).
The most widely used system for categorizing submucous myomas, developed by the European Society of Gynecological Endoscopy (ESGE), breaks them into three subtypes according to how much of the lesion’s diameter is contained within the myometrium: Type 0 myomas are entirely within the endometrial cavity, while type I have less than 50% myometrial extension, and type II are 50% or more within the myometrium.
It is the ESGE type 0 submucous myomas that are appropriate for resectoscopic surgery.
(Another system known as the STEPW classification system adds other categories, taking into account factors such as topography, extension of the base, and penetration. This system is becoming more recognized and may be useful in the future for evaluating patients for resectoscopic surgery and predicting outcomes, but it is not being used as often as the ESGE classification system.)
As the AAGL guidelines state, diagnosis is generally achieved with one or a combination of hysteroscopic and radiological techniques that may include transvaginal ultrasonography, saline infusion sonohysterography, and magnetic resonance imaging.