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Hysteroscopic myomectomy is a therapeutic option for the treatment of submucous fibroids with uterine preservation [1]. However, transcervical resection of fibroids with deep intramural extension is performed only in selected patients [2]. A major concern is that complete hysteroscopic resection might result in uterine perforation or fluid overload.To avoid these problems, laparoscopic rather than hysteroscopic myomectomy was performed in 18 women who complained of persistent menorrhea probably due to submucous fibroids. Inclusion criteria were fibroids larger than 4 cm in diameter and an intramural extension greater than 50%. Informed consent forms were filled out by study participants.Patient characteristics and operative results are summarized in Table 1. No major complications such as ureter, bladder, or bowel injury occurred in any of the patients, and no patient required laparotomy or a blood transfusion during or after surgery. On histologic examination, the resected tissue was leiomyomatous in all patients. Three women incurred perforation of the uterine cavity during the procedure, but a hysteroscopic examination showed no intrauterine adhesion 4 weeks postoperatively. At the 6-month visit, excessive menstrual bleeding was controlled in 17 women (95.0%).With the 1-step hysteroscopic myomectomy [3,4], a second operation is sometimes required and uterine perforation can occur [3]. In the latter case, a surgical intervention via laparotomy or laparoscopy is required to correct the uterine defect. Therefore, it was suggested that the procedure not be performed when the intramural part of the fibroid is larger than 4 cm in diameter and the myometrial thickness at the implantation site is thinner than 5 mm [4].The intrauterine location of the submucous fibroid is also a major factor when deciding whether the operation can be performed hysteroscopically. When a large sessile fundal fibroid exists, it is sometimes inaccessible to the resectoscope owing to the design of the instrument. In this situation, transabdominal myomectomy, rather than hysteroscopy, is the definite manner to remove the fibroid.On the basis of the results obtained in the present study, in the presence of a submucous fibroid larger than 4 cm and with an intramural extension greater than 50%, laparoscopic rather than hysteroscopic myomectomy can be performed for the sake of safety and, if needed, for the concomitant removal of fibroids of a nonsubmucous type. However, this particular approach should be performed only by surgeons skilled in laparoscopic suturing. ⁎ Corresponding author. 5, Variable Value Age (years) 38.5 (33.8-44.3) a BMI (kg/m 2 ) 22.5 (20.3-23.6) Parity no. (%) Nulliparous 1 (5.6) Multiparous 17 (94.4) Wall where fibroid originated no. (%) Anterior 8 (44.4) Posterior 7 (38.9) Fundus 3 (16.7) Diameter of fibroid (cm) 5.0 (5.0-6.0) Fibroid weight (g) 60 (50-70) Fibroids removed no. 1 (1.0-2.3) Operating time (min) 62.5 (58.8-73.0) Blood loss (mL) 100 (50-150) Postoperative stay (days) 3 (2-3) BMI = body mass index. a Values ar...

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