UOG Journal Club: September 2011 Preoperative assessment of submucous fibroids by three-dimensional saline contrast sonohysterography D. Mavrelos, J. Naftalin, W. Hoo, J. Ben-Nagi, T. Holland, D. Jurkovic Volume 38, Issue 3, Date: September 2011, pages 350–354 Journal Club slides prepared by Ligita Jokubkiene (UOG Editor for Trainees)

Submucous fibroids can be a cause of: Heavy and irregular menstrual bleeding Early pregnancy loss Subfertility Clevenger-Hoeft M et al., Obstet Gynecol 1999 Pritts EA, Obstet Gynecol Surv 2001

Type 0: fibroid polyp Type 1: <50% confined to the myometrium or protrusion ratio >50% Type 2: ≥50% confined to the myometrium or protrusion ratio ≤50% Classification is widely used in clinical practice but not very accurate in predicting the success of hysteroscopic resection What are the other factors that are important in determining the success of hysteroscopic surgery? Wamsteker K et al. Obstet Gynecol 1993

Submucous fibroids can be assessed by: Diagnostic hysteroscopy This can visualize only the part of the fibroid that is visible within the uterine cavity Three-dimensional saline contrast sonohystero-graphy (3D-SCSH) This can help to determine the proportion of the fibroid that is confined to the myometrium Ultrasonography This allows accurate measurement of fibroid size Saline contrast sonohysterography This facilitates detection of submucous fibroids and improves diagnostic accuracy Leone FP et al., Fertil Steril 2003 Lee C et al., UOG 2006 Salim R et al., Hum Reprod 2005

Transcervical resection of fibroid (TCRF) introduced into clinical practice Not all submucous fibroids can be successfully removed at hysteroscopic surgery A critical aspect of the procedure is careful selection of patients to avoid treatment failure Emanuel MH et al., Obstet Gynecol 1999

Preoperative assessment of submucous fibroids by three-dimensional saline contrast sonohysterography D. Mavrelos et al, UOG, 2011 To identify variables that can be used to predict successful complete submucous fibroid hysteroscopic resection Objective:

Prospective observational study of 61 symptomatic women, 2006–2008 Inclusion criteria: Heavy and/or irregular periods AND Submucous fibroid diagnosed by two-dimensional transvaginal ultrasound Exclusion criteria: Use of hormonal contraception Previous operation for fibroids 3D saline contrast sonohysterography with 5–10 mL sterile saline solution

Widest diameter of the fibroid, plane perpendicular to the endometrium Methodology Measurements taken: Section of fibroid protruding into the uterine cavity (A) Intramural component (B) Distance between lowermost part of the fibroid and internal cervical os (C) Calculated: Protrusion ratio (A/(A+B))x100 Fibroid diameter A+B Widest diameter of the fibroid, plane perpendicular to the endometrium

Additionally recorded variables: Number of submucous fibroids Fibroids classified according to European Society of Hysteroscopy Location of the fibroid – anterior/ posterior/fundal

Multivariate logistic regression analysis Univariate analysis Comparison of demographic and ultrasound variables between women with complete and incomplete fibroid resection Multivariate logistic regression analysis Completeness of resection as response variable Training set 60% of cases 27 with complete resection 12 with incomplete resection Testing set 40% of cases 22 with complete resection 6 with incomplete resection

Comparison of variables: complete vs incomplete fibroid resection Parameter P-value Age 0.435 Nulliparous 0.141 Multiple fibroids 0.281 Protrusion ratio 0.001 * † Diameter of fibroid 0.001 † Size of intramural component 0.001 0.472 Distance from fibroid to internal os Fundal location 0.559 *Larger in cases with complete resection †Smaller in cases with complete resection Results of univariate analysis. Women with complete (n = 49) vs incomplete resection (n = 18) (n = 61 women, 67 fibroids)

Predicting complete resection of submucous fibroid: multivariate logistic regression model Variables in the model: OR (95% CI) P-value Parity 0.002 (0.000–0.035) 0.035 Size of intramural component (mm) 0.511 (0.277–0.943) 0.032 Fibroid diameter (mm) 0.843 (0.655–1.000) 0.050 Training set (n = 39)

Analysis of single variables Size of intramural component using a testing set ROC AUC Cut-off value Sensitivity Specificity Degree of protrusion 0.777 43 % 86% 67% Fibroid diameter 0.867 38 mm 86% 83% Size of intramural component 0.833 10 mm 59% 100% Testing set (n = 28)

AUC Cut-off value Sensitivity Specificity Prediction of complete hysteroscopic submucous fibroid resection using logistic regression model Training set n = 39 Sensitivity Testing set n = 28 1 – Specificity ROC curves AUC Cut-off value Sensitivity Specificity Training set 0.975 36% 96% 92% Testing set 0.864 9% 86% 83%

Complete submucous fibroid resection can be predicted by Larger protrusion ratio of submucous fibroid into the uterine cavity Smaller fibroid diameter Smaller size of intramural fibroid component Parity Unsuccessful fibroid resection is more common in cases with Smaller protrusion ratio of submucous fibroid into the uterine cavity Larger fibroid diameter Larger size of intramural fibroid component

Conclusions Larger submucous fibroid protrusion ratio, smaller fibroid diameter and smaller size of intramural component are associated with successful fibroid resection Logistic regression model, including: 1. parity, 2. fibroid diameter, 3. size of intramural component can be used to calculate individual probability of complete hysteroscopic resection of submucous fibroid D. Mavrelos et al, UOG, 2011