Long-term outcome of hysteroscopic endometrial resection with or without myomectomy in patients with menorrhagia

Publication trends and usefulness of research in hysteroscopic myomectomy for heavy menstrual bleeding: A review of the published literature

Despite the amount of research into hysteroscopic myomectomy, questions about the optimal treatment of heavy menstrual bleeding remain. This study reviewed publication trends on this topic from 2002 to 2019 and assessed the usefulness of studies. A total of 580 articles were published on PubMed in this time frame, in 15 different languages. There were meta-analyses (1.6%), systematic reviews (12%), and randomized controlled trials (4.2%). Twelve percent were published in high impact factor journals. After applying our selection criteria, the usefulness of 37 articles was assessed: one article scored high, 31 scored moderate, and five scored low. The costs of these studies were estimated at US$ 971 700.

In which cases should endometrial destruction be performed during an operative hysteroscopy? Clinical practice guidelines from the French College of Gynaecologists and Obstetricians (CNGOF)

OBJECTIVE

To provide guidelines from the French College of Obstetricians and Gynaecologists (CNGOF), based on the best evidence available, concerning the impact of endometrial destruction on bleeding and endometrial cancer risk reduction in patients candidates for operative hysteroscopy.

METHODS

Recommendations were made according to AGREE II and the GRADE® (Grading of Recommendations Assessment, Development and Evaluation) systems to determine separately the quality of evidence (QE) and in the level of recommendation.

RESULTS

In a retrospective study comparing the incidence of endometrial cancer in 4776 patients with menorrhagia treated with endometrial destruction vs 229 945 patients with a medical treatment. There was a non-significant reduced risk of developing endometrial cancer (HR, 0.45; 95% CI, 0.15-1.40; p = .17). In premenopausal women, five studies compared the incidence of endometrial cancer in patients treated with endometrial ablation/destruction (EA/D) to the incidence of endometrial cancer in a comparable population of women from national registers, all of which show reduced risk of endometrial cancer after endometrectomy. In case of menopausal metrorrhagia, the prevalence of endometrial cancer is 9%, by analogy with the results found in premenopausal patients, the combination of endometrial ablation during operative hysteroscopy seems justified. In a retrospective cohort of 177 non-menopausal patients treated with myomectomy for metrorrhagia and/or menorrhagia, a significantly better control of bleeding at 12 months was found when myomectomy was combined with endometrectomy using roller-ball (OR: 0.18 [95% Cl 0.05-0.63]; p = 0.003).

CONCLUSION

In premenopausal women with heavy menstrual bleeding, when an operative hysteroscopy is performed, it is recommended to propose an endometrial ablation/destruction in order to prevent the risk of endometrial cancer, (QE3) and to prevent recurrence of bleeding (QE2). In menopausal women, it is probably recommended to also perform an endometrial ablation/destruction in case of operative hysteroscopy in order to prevent the risk of endometrial cancer (QE1).

Likelihood of Accomplishing an In-Patient Hysteroscopic Myomectomy in a One-Step Procedure: A Systematic Review and Meta-Analysis

PURPOSE

To assess the feasibility rate of one-step hysteroscopic myomectomy according to the technique adopted.

METHODS

In July 2016, PubMed, ClinicalTrials.gov, SCOPUS, Scielo, and AJOL databases were used for searching references. Series of in-patient hysteroscopic myomectomies reporting success rate in only one-step procedure, categorization of submucous fibroids, explanation of the surgical technique, and description of patients were considered eligible for meta-analysis (retrospective, prospective randomized studies). Two authors extracted the data. Rate of myomectomies accomplished in only a surgical step and rate of intraoperative complications were extracted per protocol. A modified GRADE score was used for quality assessment. Random-effect models were already assumed. Mean rates were compared among subgroups.

RESULTS

One thousand two hundred and fifty-seven studies were screened and 241 of these were read for eligibility. Seventy-eight series were included in qualitative synthesis and 24 series were included in quantitative synthesis. Wide heterogeneity was found. In series with <50% of G2 myomas treated, the slicing technique feasibility rate was 86.5% while techniques for enucleating the deep portion of the myomas showed a feasibility rate of 92.3% (p < 0.001). In series with ≥50% of G2 myomas treated, the slicing technique feasibility rate was 70.6% while techniques for enucleating the deep portion of myomas showed a feasibility rate of 88.4% (p < 0.001). In series with ≥50% of G2 myomas treated, the slicing technique feasibility rate was 70.6% while techniques for enucleating the deep portion of myomas showed a feasibility rate of 88.4% (.

CONCLUSION

In case of submucous myomas with intramural development, the slicing technique was correlated with a lower rate of in-patient hysteroscopic myomectomies accomplished in a one-step procedure and a higher complications rate.

The prevalence of occult leiomyosarcoma at surgery for presumed uterine fibroids: a meta-analysis

There is a concern regarding the risk of occult leiomyosarcomas found at surgery for presumed benign fibroids. We sought to produce a comprehensive review of published data addressing this issue and provide high-quality prevalence estimates for clinical practice and future research. A comprehensive literature search using the PubMed/MEDLINE database and the Cochrane Library was performed. Inclusion criteria were human studies, peer-reviewed, with original data, involving cases for surgery in which fibroid-related indications were the primary reason for surgery, and histopathology was provided. Candidate studies (4864) were found; 3844 were excluded after review of the abstract. The remaining 1020 manuscripts were reviewed in their entirety, and 133 were included in the Bayesian binomial random effect meta-analysis. The estimated rate of leiomyosarcoma was 0.51 per 1000 procedures (95 % credible interval (CrI) 0.16–0.98) or approximately 1 in 2000. Restricting the meta-analysis to the 64 prospective studies resulted in a substantially lower estimate of 0.12 leiomyosarcomas per 1000 procedures (95 % CrI <0.01–0.75) or approximately 1 leiomyosarcoma per 8300 surgeries. Results suggest that the prevalence of occult leiomyosarcomas at surgery for presumed uterine fibroids is much less frequent than previously estimated. This rate should be incorporated into both clinical practice and future research.

Impact of myomas on the results of transcervical resection of the endometrium

STUDY OBJECTIVE

To investigate long-term hysterectomy rates after transcervical resection of the endometrium (TCRE) performed by experienced surgeons in the presence and absence of intracavitary myomas.

DESIGN

Multicenter case-control study (Canadian Task Force classification II-2).

PATIENTS

The study group comprised 456 women with myomas who met the inclusion criteria, and of these, 82 (17.98%) later underwent hysterectomy. The control group comprised 1438 women without myomas, and of these, 284 (19.75%) later underwent hysterectomy.

METHODS

From 2001 to 2004, standardized results were extracted from Hyskobase on the basis of a total of 1894 women aged 23 to 59 years. The women were identified as having or not having myomas, and data from both groups were statistically analyzed. Detailed information on myoma size and intramural involvement (type 0, 1, and 2) was collected.

MEASUREMENTS AND MAIN RESULTS

After TCRE, women with type 2 myomas, compared with those with type 0 myomas, were found to have a significantly higher risk of undergoing hysterectomy (p = .04), and women, including controls, with myomas >3.6 cm in greatest diameter were found to have a significantly higher risk of undergoing hysterectomy than were those with smaller myomas (p = .01). There was no statistically significant difference in risk of hysterectomy between type 0 and type 1 myomas or between type 1 and type 2 myomas. When hysterectomy rates between the myoma and control groups were compared, there was an increased risk of hysterectomy in the control group (p = .008). Multiple-step multivariate regression analysis of uterine and procedural characteristics of TCRE demonstrated that factors that were positive predictors of hysterectomy within 66 months after resection were younger age, inaccessible uterine corners, enlarged uterus, and pretreatment using gonadotropin-releasing hormone agonists.

CONCLUSION

When performing TCRE in women with intracavitary myomas, the chance of treatment success is worsened if they are of type 2 or their diameter is >3.5 cm. In addition, younger age increases the risk of hysterectomy and the need for pretreatment with gonadotropin-releasing hormone agonists, or if the uterus is enlarged or the uterine corners are difficult to access during the procedure.

AAGL practice report: practice guidelines for the diagnosis and management of submucous leiomyomas

Submucous leiomyomas or myomas are commonly encountered by gynecologists and specialists in reproductive endocrinology and infertility with patients presenting with 1 or a combination of symptoms that include heavy menstrual bleeding, infertility, and recurrent pregnancy loss. There exists a variety of interventions that include those performed under hysteroscopic, laparoscopic and laparotomic direction; an evolving spectrum of image guided procedures, and an expanding number of pharmaceutical agents, each of which has value for the appropriately selected and counseled patient. Identification of the ideal approach requires the clinician to be intimately familiar with a given patient's history, including her desires with respect to fertility, as well as an appropriately detailed evaluation of the uterus with any one or a combination of a number of imaging techniques, including hysteroscopy. This guideline has been developed following a systematic review of the evidence, to provide guidance to the clinician caring for such patients, and to assist the clinical investigator in determining potential areas of research. Where high level evidence was lacking, but where a majority of opinion or consensus could be reached, the guideline development committee provided consensus recommendations as well.