Resectoscopic Surgery Part I: Overcoming Obstacles and Mastering the Basics

Abstract

The introduction of the continuous flow gynecologic resectoscope (CFGR) in 1989 revolutionized minimally invasive gynecologic surgery (MIGS) by introducing such intrauterine procedures as hysteroscopic myomectomy, polypectomy, and endometrial ablation. However, with the subsequent introduction of global endometrial ablation (GEA) devices and hysteroscopic morcellators (HMs), the CFGR has fallen into relative disuse—a regrettable situation since it remains ideally suited for accomplishing many procedures that are otherwise not achievable with these newer technologies. Procedures which involve greater precision and control—endomyometrial resection (EMR), hysteroscopic metroplasty, the correction of isthmoceles, the resection of intramural myomas, and the management of late-onset endometrial ablation failure—are only possible with the CFGR. In addition, the CFGR permits a variety of functions that would otherwise require several different disposable platforms. Despite the benefits of the gynecologic resectoscope, there are clear impediments to its use including a scarcity of educational resources and trained experts, medico-legal concerns, institutional obstacles to organizing an operative team, and the need to develop and maintain an adequate caseload. In Part I of this three-part series, the author will review why the CFGR remains a relevant and indispensable tool for the minimally invasive gynecologic surgeon, the composition of an operating room team, and the instrumentation and skills necessary to accomplish basic resectoscopic surgery. In Part II, we will describe how ultrasound guidance can be used to assist the execution of more challenging intermediate-level cases. Finally, in Part III, we will discuss the most demanding cases for the resectoscopic surgeon—the treatment of post-ablation failures and the removal of intramural leiomyomas—which are clinical scenarios that require ultrasound guidance and well-honed resectoscopic surgical skills.

Use of Diode Laser in Hysteroscopy for the Management of Intrauterine Pathology: A Systematic Review

“…In 1981, Milton Goldrath introduced what can be considered the inaugural hysteroscopic endometrial ablation, utilizing an Nd:YAG laser [61]. Since this pioneering procedure, laser vaporization has gained global acceptance.…”

Therapeutic options for the management of abnormal uterine bleeding

“…The process of destroying the endometrial layer (endometrial ablation) to treat the symptom of HMB dates to the late 19th century, with published techniques reported through the 20th century and subject to extensive review. [14][15][16] In the latter part of the 20th century, several techniques were developed that used laser and, more often, radiofrequency electrical energy via a modified urological resectoscope to ablate, vaporize, or resect the endometrial tissue; hence the term resectoscopic endometrial ablation or REA.…”

Surgical management of uterine fibroids

“…Endometrial ablation is associated with up to 90% satisfactory improvement of uterine bleeding, and low rate of complications (1–2%) including uterine perforation and bleeding. Failure and re-operation rates range between 29 and 40% and are higher in cases of large intramural or submucosal fibroids, age older than 45 years, higher parity, history of dysmenorrhea or concomitant adenomyosis [17]. When the main symptom is heavy menstrual bleeding, consideration should be given to concomitant endometrial ablation at the time of transcervical resection of myoma when preservation of fertility is not desired.…”