1. Hysteroscopic myomectomy

2. Hysteroscopic myomectomy is performed for intracavitary fibroids, ie, submucosal and some intramural leiomyomas for which most of the fibroid protrudes into the uterine cavity

3. PATIENT SELECTION Symptomatic uterine fibroid(s) ●It is feasible to remove the fibroid(s) hysteroscopically ●An abdominal approach is not required to remove additional fibroids in other locations (eg, intramural or subserosal) or treat other pathology

4. ●Outpatient procedure ●Minimal recovery time ●Decreased perioperative morbidity ●Minimal or no scarring of myometrium

5. Indications ●Abnormal uterine bleeding ●Recurrent pregnancy loss ●Infertility

6. Infrequent indications for hysteroscopic myomectomy include ●Dysmenorrhea ●Leukorrhea ●Necrotic leiomyoma following uterine fibroid embolization ●Histologic evaluation of intracavitary lesions with uncertain findings on pelvic imaging

7. Contraindications women in whom hysteroscopic surgery is contraindicated (eg, active pelvic infection, intrauterine pregnancy, cervical or uterine cancer). Medical comorbidities (eg, coronary heart disease, bleeding diathesis) are also potential contraindications to hysteroscopic surgery.

8. Removal of fibroids that penetrate into the myometrium, are large, or are sessile takes longer, has the potential for increased perioperative complications, and may result in incomplete fibroid resection. women with additional fibroids that are intramural or subserosal or who have other uterine pathology (eg, adenomyosis), hysteroscopic myomectomy may not provide symptomatic relief.

9. classification system for the extent of myometrial involvement of a fibroid ●Type 0 - completely within the endometrial cavity ●Type I - extend less than 50 percent into the myometrium ●Type II - extend 50 percent or more within the myometrium

10. suggest hysteroscopic myomectomy only for fibroids that are completely within the endometrial cavity or extend less than 50 percent into the myometrium Removal of fibroids with deeper myometrial involvement requires advanced hysteroscopic skills or myomectomy using laparotomy or laparoscopy

11. Leiomyoma size large fibroids may involve increased perioperative complications and/or require more than one procedure for symptomatic relief Increasing size of fibroid requires exquisite hysteroscopic skill, complete understanding of fluid management, ability to quickly remove myoma chip fragments that might preclude surgical visualization, and techniques to decrease risk of uterine perforation when chip fragments are removed.

12. Leiomyoma size There are no high quality data regarding the size and/or number of intramural or subserosal fibroids that preclude using a hysteroscopic approach. Physician skills ultimately determine the maximal size or number of fibroids that can be removed. For leiomyomas that are multiple or are >3 cm, it is prudent to include in the informed consent the possibility of a two-stage procedure

13. Presence of other leiomyomas or adenomyosis desire for future fertility and presence of other pathology Patients with fibroids that are both intracavitary and in other locations who have bulk symptoms (abdominal pain, pressure, or distension; urinary urgency, frequency, or retention; or constipation) are not likely to benefit from hysteroscopic resection alone

14. Evaluation of the uterus saline infusion sonography (SIS) :evaluate the relationship of a leiomyoma to both the endometrial cavity and the myometrium. An alternative is to use a combination of office-based diagnostic hysteroscopy and TVUS. Hysteroscopy can define the extent to which a fibroid protrudes into the uterine cavity and TVUS can define the depth of myometrial penetration.. MRI defines leiomyoma position :expensive Hysterosalpingography and computed tomography have limited use in delineating fibroid location

15. In addition, any woman with abnormal uterine bleeding at risk for endometrial hyperplasia or cancer should undergo evaluation of the endometrium prior to hysteroscopic myomectomy

16. GnRH agonists decrease the size of large fibroids there are no high quality data that they make complete resection possible for large fibroids, or reduce intraoperative blood loss or distention fluid absorption Cases in which we make an exception and use a GNRHa to suppress menses are patients with severe anemia that may preclude surgery or in whom intravenous iron therapy is contraindicated.

17. Cervical preparation preoperative misoprostol or laminariamisoprostol 200 to 400 mcg of vaginal misoprostol 12 to 24 hours prior to hysteroscopymisoprostol laminaria inserted in the office on the day prior to the procedure

18. vasopressin vasopressin injection must be performed with caution (by aspirating and confirming the absence of blood prior to each injection) intravascular injection or absorption has been associated with profound hypertension, bradycardia, and intraoperative mortality

19. vasopressin prior to hysteroscopic myomectomy; mix 20 units in 100 mL of normal saline, and inject into the cervical stroma in 5 mL aliquots at the 12, 3, 6, and 9 o'clock positions around the cervix. vasopressin It can be given every 30 to 45 minutes, if bleeding is encountered or the procedure is prolonged. An additional benefit of vasopressin is that it facilitates cervical dilation

20. Resection wire loop with a monopolar or bipolar resectoscope monopolar device : a non-electrolytic solution (eg, 1.5 percent glycine). bipolar device is used, the fluid medium is isotonic saline or Ringer's lactate solution

21. New technologies such as vaporization electrodes and hysteroscopic morcellators expensive and additional training

22. risk of excessive absorption of distending fluid Continuous fluid monitoring is necessary throughout the procedure. Automated fluid pump and monitoring systems are preferable to manual techniques

23. Hysteroscopic myomectomy: Wire loop technique

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25. Enucleating a myoma wire loop electrode strategically behind the myoma to elevate and separate the myoma Initially, the inactive electrode is used to elevate the leiomyoma out of the pseudocapsule, followed by using the activated electrode to incise the myoma and facilitate its retrieval. Another technique is to use the inactive loop to partially enucleate the fibroid with mechanical dissection and then deflate the uterine cavity to cause further protrusion of the myoma

26. Hysteroscopic myomectomy: Leiomyoma pseudocapsule

27. Use of uterine contractions Deflation of the uterine cavity refers to removing the operative hysteroscope and waiting for several minutes to permit myometrial contractions to cause extrusion of the myoma. When the hysteroscope is replaced, the surgeon will commonly see more of the myoma extruding into the cavity. Facilitation of uterine contractions with administration of a prostaglandin has been proposed a series of 13 patients reported successful use of carboprost (125 mcg in 5 mL of saline, injected intracervically) for this purpose

28. Uterine massage via bimanual examination or other techniques has also been described to help to extrude the remaining portion of a fibroid

29. two-step procedure fibroids that are multiple, large, broad-based, or penetrate deeply within the myometrium initial procedure was halted when the maximal fluid absorption was reached. Such patients should be seen for a follow-up visit two to four months after the initial procedure to assess whether fibroid-related symptoms persist. If so, evaluation of the uterine cavity is repeated: the size, number, and location of the leiomyoma(s). With this information, the surgeon can offer appropriate management, whether hysteroscopic myomectomy or another treatment.

30. CONCOMITANT PROCEDURES Endometrial polypectomy Endometrial ablation Hysteroscopic sterilization

31. COMPLICATIONS Uterine perforation Excessive fluid absorption Excessive perioperative bleeding Intrauterine adhesions Infection