Hysteroscopic Myomectomy

A hysteroscopic myomectomy removes a fibroid (leiomyoma) that bulges into the inside of the uterus, working entirely through the vagina and cervix with no cut on the skin. Fibroids in this location (submucous fibroids) are often small but cause heavy menstrual bleeding, which can lead to anemia, and they can also get in the way of a pregnancy. They are grouped by how much of the fibroid is inside the cavity: type 0 is entirely inside, type I is mostly inside, and type II is mostly in the uterine wall. Removing the fibroid this way spares the uterus, avoids an abdominal incision, and is often done as an outpatient case. The classic tool is the resectoscope, a scope much like the urologic resectoscope used for the prostate. A wire loop electrode shaves the fibroid away in strips under direct vision while fluid keeps the uterus filled and the view clear. Monopolar resectoscopes need an electrolyte-free fluid such as glycine or sorbitol; bipolar resectoscopes can use saline. Some surgeons use a mechanical tissue-removal device instead (such as MyoSure), which cuts and suctions the tissue through its own scope with no electrical current. All removed tissue goes to pathology, because a cancer of the uterine muscle (leiomyosarcoma) is occasionally found. The main risks are perforation of the uterus, bleeding, and absorption of too much fluid into the bloodstream, which can cause fluid overload and, with electrolyte-free fluids, a dangerous drop in blood sodium. For this reason, fluid in and fluid out is measured throughout the case, and the surgeon stops if the deficit gets too high. Gas embolism is another risk, which is why tubing is primed and fluid, not carbon dioxide, is used for operative work. Some patients are given medicine for a few months beforehand to shrink the fibroid and correct anemia.