The challenge of FIGO type 3 leiomyomas and infertility: Exploring therapeutic alternatives amidst limited scientific certainties.

Uterine leiomyomas (ULs) are non-cancerous tumors composed of smooth muscle cells that develop within the myometrium and represent the most prevalent pathological condition affecting the female genital tract. Despite the volume of available research, many aspects of ULs remain unresolved, making it a "paradoxical disease" where the increase in available scientific literature has not been matched by an increase in solid evidence for clinical management. Fertility stands at the top of the list of clinical issues where the role of ULs is still unclear. The leiomyoma subclassification system, released by the International Federaion of Gynecology and Obstetrics (FIGO) in 2008, introduced a new and more effective way of categorizing uterine fibroids. The aim was to go beyond the traditional classification "subserosal, intramural and submucosal", facilitating a detailed examination of individual ULs impact on the female reproductive system. The "type 3 UL" is a special type of myoma, characterized by its complete myometrial development while encroaching the endometrium. It is a unique "hybrid" between a submucous and an intramural UL, that may exert a detrimental "double hit" mechanism, which is of particular interest in patients wishing pregnancy. To date, no robust evidence is available regarding the management of type 3 ULs. The aim of this narrative review is to provide a comprehensive overview of the physiopathological mechanisms that type 3 UL may exert on fertility, and to present new perspectives that may help us to better understand both the need for and the methods of treating this unique type of fibroid.

Training in Diagnostic Hysteroscopy: The "Arbor Vitae" Method.

Background and Objectives: Diagnostic hysteroscopy is the gold standard in the diagnosis of intrauterine pathology and is becoming an essential tool in the daily practice of gynecology. Training programs for physicians are necessary to ensure adequate preparation and learning curve before approaching patients. The aim of this study was to describe the "Arbor Vitae" method for training in diagnostic hysteroscopy and to test its impact on the knowledge and skills of trainees using a customized questionnaire. Materials and Methods: A three-day hysteroscopy workshop combining theory and practical "hands on "sessions with dry and wet labs has been described. The aim of the course is to teach indications, instruments, the basic principles of the technique by which the procedure should be performed, and how to recognize and manage the pathologies that can be identified by diagnostic hysteroscopy. To test this training method and its impact on the knowledge and skills of the trainees, a customized 10-question questionnaire was administered before and after the course. Results: The questionnaire was administered to 34 participants. All trainees completed the questionnaire, and no missing responses were recorded. Regarding the characteristics of the participants, 76.5% had less than 1 year of experience in performing diagnostic hysteroscopy and 55.9% reported performing fewer than 15 procedures in their career. For 9 of the 10 questions embedded in the questionnaire, there was a significant improvement in the scores between pre- and post-course, demonstrating a perceived significant improvement in theoretical/practical skills by the trainees. Conclusions: The Arbor Vitae training model is a realistic and effective way to improve the theoretical and practical skills required to perform correct diagnostic hysteroscopy. This training model has great potential for novice practitioners to achieve an adequate level of proficiency before performing diagnostic hysteroscopy on live patients.

The Technique of Vaginal Septum as Uterine Septum: A New Approach for the Hysteroscopic Treatment of Vaginal Septum.

STUDY OBJECTIVE: To evaluate the outcomes of a new hysteroscopic technique for the treatment of a longitudinal vaginal septum. DESIGN: A retrospective study. SETTING: Arbor Vitae Center for Endoscopic Gynecology, Rome, Italy. PATIENTS: Thirty women who underwent hysteroscopic treatment for a vaginal septum. INTERVENTION: All enrolled patients underwent pelvic examination, hysteroscopy, and 2-dimensional ultrasound. In case of a diagnosis of a partial or complete uterine septum, magnetic resonance imaging or 3-dimensional ultrasound were performed, and surgical procedures were performed after diagnostic laparoscopy was used to better visualize the uterine fundus. All patients were treated with the technique using vaginal septum as uterine septum or the same methodology applied for a uterine septum. MEASUREMENTS AND MAIN RESULTS: The procedure was successfully accomplished in all patients, and longitudinal vaginal septa were totally resected. There were no perioperative complications, and in only 1 case, vaginal bleeding occurred because of an erroneous identification of the excision line that was easily remedied with coagulation by resectoscope. Dyspareunia has improved or completely disappeared in all patients. CONCLUSION: The technique of vaginal septum as uterine septum for the resectoscope of a longitudinal vaginal septum appears to be safe and effective with good outcomes, even in terms of dyspareunia.

Risk Factors for the Completion of the Cold Loop Hysteroscopic Myomectomy in a One-Step Procedure: A Post Hoc Analysis.

INTRODUCTION: The aim of the study was to analyze which variables influenced the completion of a cold loop hysteroscopic myomectomy in a one-step procedure in a large cohort of patients. MATERIALS AND METHODS: A retrospective cohort study of 1434 cold loop resectoscopic myomectomies consecutively performed. The study population was divided into two groups according to the number of procedures needed to accomplish the treatment. Variables influencing the completion of hysteroscopic myomectomy in a one-step procedure were investigated. RESULTS: A total of 1434 resections were performed and 1690 myomas in total were removed. The procedure was accomplished in a one-step procedure in 1017 patients (83.7%), whereas 198 women (16.3%) needed a multiple-step procedure. The multivariate analysis showed that the size, the number of myomas, and the age of patients were significantly correlated with the risk of a multiple-step procedure. No correlation was revealed with the grading of myomas, parity, and the use of presurgical GnRH-agonist therapy. CONCLUSIONS: In case of multiple fibroids, the intramural development of submucous myomas did not influence the completion of cold loop hysteroscopic myomectomy in a one-step procedure. The size of myomas and the age of patients were significantly correlated with the need to complete the myomectomy in a multiple-step procedure.

Intraoperative Effect of Preoperative Gonadotropin-Releasing Hormone Analogue Administration in Women Undergoing Cold Loop Hysteroscopic Myomectomy: A Randomized Controlled Trial.

STUDY OBJECTIVE: To evaluate the intraoperative effects of gonadotropin-releasing hormone (GnRH) analogue pretreatment in patients undergoing cold loop hysteroscopic myomectomy. DESIGN: Randomized controlled trial (Canadian Task Force classification I). SETTING: Arbor Vitae Center for Endoscopic Gynecology, Rome, Italy. PATIENTS: A total of 99 patients were randomized and subsequently allocated to the GnRH analogue group or to the nonpharmacologic treatment control group. Fifteen patients were lost after allocation, and 42 patients per group underwent hysteroscopic myomectomy. INTERVENTIONS: Cold loop hysteroscopic myomectomy. MEASUREMENTS AND MAIN RESULTS: The control group accomplished the treatment in a 1-step procedure more frequently than the GnRH analogue group (92.85% and 73.8% of cases, respectively; p = .040). The completion of the treatment was more unlikely in case of G2 myomas (p = .006), whereas no differences were recorded for G1 and G0 myomas. The multivariate analysis showed a significant correlation between the multiple-step treatment and the use of GnRH analogue (odds ratio, 5.365; 95% confidence interval [CI], 1.018-28.284; p = .048), grading (odds ratio, 4.503; 95% CI, 1.049-19.329; p = .043), and size of myomas (odds ratio, 1.128; 95% CI, 1.026-1.239; p = .013). CONCLUSIONS: Preoperative GnRH analogue administration did not facilitate the completion of cold loop hysteroscopic myomectomy in a single surgical procedure in G2 myomas and was correlated with a longer duration of the surgery. No significant benefits were found for G0 and G1 myomas. (ClinicalTrials.gov: NCT01873378.).

Antibiotics Prophylaxis for Operative Hysteroscopy.

OBJECTIVE: To evaluate the incidence of infectious complications and effect of prophylactic antibiotic administration during operative hysteroscopic procedures. METHODS: A multicentric randomized controlled trial was conducted between January 2012 and December 2013. Women (n = 180) affected by endometrial hyperplasia, myomas, or endometrial polyps undergoing operative hysteroscopy were randomized to receive cefazolin 2 g intravenously 30 minutes prior to the procedure (n = 91) and no treatment (n = 89). RESULTS: No statistical difference in terms of postoperative fever (2.4% vs 2.3%, P = .99), endometritis (0% vs 0%), pain (6.0% vs 10.4%, P = .40), cervicitis-vaginitis (0% vs 0%), pelvic abscess (0% vs 0%), pelvic inflammatory disease (0% vs 0%), and bleeding (0% vs 0%) was noticed. No statistical difference in terms of side effects attributable to antibiotic prophylaxis such as allergy (0% vs 4.8%, P = .12), nausea (10.7% vs 17.4%, P = .27), vomiting (3.6% vs 4.6%, P = .99), diarrhea (4.8% vs 5.4%, P = .99), cephalea (9.5% vs 3.5%, P = .13), dizziness (4.8% vs 2.3%, P = .44), and meteorism (5.4% vs 3.4%, P = .99) was noticed. CONCLUSION: The results of the current study support the recommendation not to prescribe routine antibiotic prophylaxis prior to operative hysteroscopy.

Resectoscopic myomectomy.

Hysteroscopic myomectomy currently is the "gold standard" procedure for treating submucous myoma and represents an effective and safe solution to abnormal uterine bleeding and infertility myoma-related. Several studied have shown that, in the case of submucous myomas, resectoscopic myomectomy has several advantages compared with the traditional surgical treatment of myomectomy by laparotomy, in terms of reduced myometrial trauma, shorter hospitalization times and decreased risk of postoperative adhesion formation. The aim of this paper was to describe the alternative techniques, currently available, of resectoscopic myomectomy. The choice of the procedure mostly depends on the intramural extension of the myoma, as well as on personal experience and available equipment.

Predicting success of single step hysteroscopic myomectomy: A single centre large cohort study of single myomas.

INTRODUCTION: Submucous myomas represent one of the main indications of operative hysteroscopy. Hysteroscopic resection of submucous fibroids should be a simple, well-tolerated and effective procedure and ideally accomplished in in only one surgical step. METHODS: Retrospective cohort single Centre study of 1244 women undergoing hysteroscopic myomectomy. Data analysis included patients' and the myomas characteristics. A multiple logistic regression was carried out in order to assess which variables were able to determine a multiple step procedure. RESULTS: 1090 myomas (87.62%) were completely resected in a single-step procedure (SS group) whereas a multiple-step procedure (MS group) was needed for the removal of 154 fibroids (12.38%). The mean size of myomas resected in the SS group was 22.83 ± 9.36 mm whereas fibroids of the MS group measured 29.67 ± 10.76 mm. The overall feasibility of hysteroscopic myomectomy in one surgical procedure was 88.28%. All hysteroscopic myomectomies of G0 fibroids were completed in a single step. The chance of success to accomplish the treatment in a single-step for G1 and G2 myomas were 88.59% and 82.55%, respectively. The multivariate analysis revealed an inverse correlation between age and multiple step procedures and size of myomas were all directly correlated to multiple step procedures. CONCLUSION: The grading, the size of the myomas and the age of patients play a crucial role in completing the hysteroscopic myomectomy in a single step. Only the diameter greater than 3 cm in G2 myomas is correlated to a higher risk of a multiple procedure.

Is Cold Loop Hysteroscopic Myomectomy a Safe and Effective Technique for the Treatment of Submucous Myomas With Intramural Development? A Series of 1434 Surgical Procedures.

STUDY OBJECTIVE: To assess the safety and efficacy of cold loop hysteroscopic myomectomy in a large series of cases. DESIGN: Retrospective study (Canadian Task Force Classification III). SETTING: Arbor Vitae Center for Endoscopic Gynecology, Rome, Italy. PATIENTS: A total of 1215 patients with 1 or more G1-G2 submucous myomas. INTERVENTION: Cold loop hysteroscopic myomectomy. MEASUREMENT AND MAIN RESULTS: A total of 1690 myomas were removed. A minimum of 1 to a maximum of 5 fibroids for each surgical procedure were totally removed. Out of 1215 patients, 1017 (83.7%) were treated with a single surgical procedure. Twelve intraoperative complications occurred (0.84%). No cases of uterine perforation with the thermal loop or clinical intravasation syndrome were reported. CONCLUSION: Cold loop hysteroscopic myomectomy seems to represent a safe and effective procedure for the removal of submucous myomas with intramural development, while at the same time respecting the anatomic and functional integrity of the myometrium. The use of a cold loop in resectoscopic myomectomy is associated with a low rate of minor intraoperative complications and an absence of major complications. This could be of primary relevance with a view to fertility and future pregnancies.

Pain during diagnostic hysteroscopy: what is the role of the cervical canal? A pilot study.

OBJECTIVE: To evaluate whether a correlation exists between the pain perceived during diagnostic anesthesia-free hysteroscopy and the characteristics of the cervical canal. STUDY DESIGN: Prospective observational pilot study of 255 women undergoing diagnostic hysteroscopy. Data analysis included characteristics of the patient and the cervical canal, and the pain experience during the procedure, assessed by visual analog score (VAS). A multiple logistic regression was then carried out in order to exclude confounding factors. RESULTS: The degree of pain during hysteroscopy was equal to a median VAS score of 2 (range 0-10). Bivariate analysis between patients with VAS>3 and patients with VAS≤3 demonstrated a significant correlation between pain and the presence of synechiae in the cervical canal (P=0.022), the patient's age (P=0.003) and parity (P=0.001). Multivariate analysis revealed that the presence of cervical synechiae (P=0.0001) [OR=4.99 (95% CI 2.13-11.70)] and parity (P=0.014) [OR=0.42 (95% CI 0.21-0.83)] were significantly correlated with pain. There was no significant correlation with the different angles of the cervical canal. CONCLUSION: Cervical synechiae appear as a major factor influencing pain during hysteroscopy. While parity acts as a protective factor, the angle of the cervical canal does not seem to play an important role for pain during diagnostic hysteroscopy.

Pain in diagnostic hysteroscopy: a multivariate analysis after a randomized, controlled trial.

OBJECTIVE: To study which variables are able to influence women's experience of pain during diagnostic hysteroscopy. DESIGN: Multivariate analysis (phase II) after a randomized, controlled trial (phase I). SETTING: Endoscopic gynecologic center. PATIENT(S): In phase I, 392 patients were analyzed. Group A: 197 women with carbon dioxide (CO2); group B: 195 women with normal saline. In phase II, 392 patients were assigned to two different groups according to their pain experience as measured by a visual analogue scale (VAS): group VAS>3 (170 patients); group VAS≤3 (222 patients). INTERVENTION(S): Free-anesthesia diagnostic hysteroscopy performed using CO2 or normal saline as distension media. MAIN OUTCOME MEASURE(S): Procedure time, VAS score, image quality, and side effects during and after diagnostic hysteroscopy. RESULT(S): In phase I the median pain score in group A was 2, whereas in group B it was 3. In phase II the duration of the procedure, nulliparity, and the use of normal saline were significantly correlated with VAS>3. A higher presence of cervical synechiae was observed in the group VAS>3. The multivariate analysis revealed an inverse correlation between parity and a VAS>3, whereas the use of normal saline, the presence of synechiae in the cervical canal, and the duration of the hysteroscopy were all directly correlated to a VAS score>3. CONCLUSION(S): Pain in hysteroscopy is significantly related to the presence of cervical synechiae, to the duration of the procedure, and to the use of normal saline; conversely, parity seems to have a protective role. CLINICAL TRIAL REGISTRATION NUMBER: NCT01873391.

Does cold loop hysteroscopic myomectomy reduce intrauterine adhesions? A retrospective study.

OBJECTIVE: To estimate the prevalence and the characteristics of intrauterine adhesions after cold loop resectoscopic myomectomy. DESIGN: Retrospective study. SETTING: Endoscopic gynecologic center. PATIENT(S): 688 women with one or more G1-G2 myomas. INTERVENTION(S): Cold loop resectoscopic myomectomy and diagnostic hysteroscopy in all patients 2 months after surgery. MAIN OUTCOME MEASURE(S): Integrity of the uterine cavity and prevalence of intrauterine synechiae. RESULT(S): A total of 806 myomas were removed, ranging from a minimum of one to a maximum of five fibroids removed for each surgical procedure. Complications were reported in eight cases (1.16%). No hemorrhage, intravasation clinical syndrome, or perforation with the thermal loop were registered. Synechiae were found in 29 patients (4.23%): in 2 patients a new surgical hysteroscopic treatment was required to remove fibrous synechiae, and in 27 patients light adhesions were removed with the tip of the instrument in outpatient hysteroscopy. Neither intrauterine device nor anti-adherence mixtures were used at the end of surgery. CONCLUSION(S): The cold loop hysteroscopic myomectomy is a safe and effective procedure that seems to be associated with a lower rate of intrauterine adhesions in comparison with the reported literature. The issue appears to be of notable importance for fertility patients.

Should the myometrial free margin still be considered a limiting factor for hysteroscopic resection of submucous fibroids? A possible answer to an old question.

OBJECTIVE: To evaluate the feasibility of the hysteroscopic resection of type II submucous fibroids regardless of the myometrial free margin separating them from the serosa and to report the dynamic changes the margin undergoes after the various phases of resection. DESIGN: A prospective observational study. SETTING: A tertiary-level university hospital. PATIENT(S): Thirteen women with single type II submucous fibroids of ≤ 5 cm in diameter regardless of the myometrial free margin. INTERVENTION(S): Hysteroscopic myomectomy and ultrasound evaluation of myometrial free margin before and after each phase of the procedure. MAIN OUTCOME MEASURE(S): The possibility of a complete one-step resection, the incidence of intraoperative or postoperative complications, and the analysis of the dynamic changes occurring in myometrial free margin. RESULT(S): Complete resection was performed successfully in all patients. No complications were registered. The myometrial free margin decreased on the distension of the uterine cavity and then increased progressively and significantly after the various phases of resection. CONCLUSION(S): In selected cases and in experienced hands, hysteroscopic myomectomy of type II submucous fibroids may be performed successfully and safely regardless of the myometrial free margin. Myometrial free margin increases progressively with each step of the procedure probably leading to an increasing margin of safety.