Hysteroscopic Resection of Myomas and Polyps

Abstract

In 1860, Pantaleoni performed the fi rst operative hysteroscopy when he cauterized a bleeding polyp in a postmenopausal woman. A century later, modifi cations of the urologic resectoscope provided gynecologists a new visually directed method to resect intrauterine polyps and submucosal fi broids, to treat synechiae, and to obtain targeted biopsies ( Fig. 19-1). The fi rst operative hysteroscopic polypectomy and myomectomy were performed by Neuwirth in 1976, using ovum forceps and electrosurgery. 1 Gynecologists are slowly embracing operative hysteroscopy to treat myriad intrauterine conditions. The development of a continuous fl ow resectoscope permitted distention of the uterine cavity with fl uid and removal of blood and debris. Since the 1990s, improvements in optics, video recording, and intrauterine distention systems, as well as scrutiny of types and amounts of fl uid used during operative hysteroscopy have improved the safety of hysteroscopic surgery. Preoperative pain management, cervical dilating agents, paracervical blocks, and smaller-diameter hysteroscopes have increased the number of procedures performed in the offi ce or under minimal sedation. Physician awareness of the benefi ts of operative hysteroscopy and excellent outcomes has increased its use. Patient demand for minimally invasive surgery has also been infl uential. Monopolar instrumentation, bipolar equipment, and hysteroscopic morcellators that remove uterine debris (fi broid chips or polyp pieces) are now available. Hysteroscopic morcellators are the newest devices available to gynecologists. These two new modifi cations in the hysteroscope increase the speed of the procedure, remove intrauterine debris, and improve intraoperative visualization.The desire of many women to retain the uterus and return to normal activities quickly prompted development of lessinvasive technologies for treating uterine fi broids. Operative hysteroscopy fulfi lls those goals in appropriately triaged patients who have intracavitary lesions amenable to hysteroscopic intervention. GENERAL PRINCIPLESPerforming operative hysteroscopic myomectomy requires six essential components: • Determining indications and contraindications for hysteroscopic surgery • Excellent preoperative evaluation of uterine fi broids, including a detailed knowledge of the number, size, location, and depth of myometrial involvement of the uterine fi broid (Fig. 19-2) • Superb eye-hand coordination • Detailed understanding of fl uid management and fl uid management systems • Astute surgical skills and intraoperative judgment • Judgment and common sense regarding when to abandon the hysteroscopic approach PATIENT SELECTION AND COUNSELINGThe desire of many women to retain their uterus and return to normal activities quickly prompted the development of lessinvasive technologies for treating symptomatic fi broids. Fibroids are associated with abnormal uterine bleeding, bulk symptoms, and infertility. Choosing the right procedure requires a marriage between the symptoms and the procedure most like...