Submucosal Myoma Treatment for Women Who Wish to have Children in the Future Nodule Dissection Centripetal Cutting Method of TCR (Transcervical Resection).

Wear Sakurai's colposcope to confirm the opening of uterus. Nip and hold the posterior lip of the cervical duct using Tsukahara's vaginal forceps, and dilatate the cervical canal using Hegar's cervical dilators (no. 17 for 26-Fr scope and up to no. 15 for 24 Fr). The author fully extends the cervical duct to a degree where irrigation fluid can flow out from the gap between the cervical duct and the scope sheath. In cases of cervical duct dilatation without outflow, smooth operation of the scope is difficult, and surgeries with a high degree of difficulty cannot be performed ( Figs. 7 and 8 ). Even in nulliparous cases, expanding up to Hagar's no. 17 by laminaria insertion on previous day is possible. For cases without sexual experience, expansion under full-anesthesia is performed and cervical laceration may occur. 1 2 Bleeding should not be severe, and can be easily stopped by suture by Vicryl 4–0. Resectoscope (tube connector part) inflow and outflow of irrigation fluid. (Reproduced with permission from Inoue S. In: Hiramatsu Y, Konishi I, Sakuragi N, Takeda S, eds. Mastering the Essential Surgical Procedures OGS Now, No.13. Function-preserving surgery (Japanese). Tokyo: Medical View; 2013: 40–53. Copyright © Medical View.) Required instruments—Hegar dilator, placental forceps, Sakurai Vaginal Speculum, Tsukahara forceps etc. (Reproduced with permission from Inoue S. In: Hiramatsu Y, Konishi I, Sakuragi N, Takeda S, eds. Mastering the Essential Surgical Procedures OGS Now, No.13. Function-preserving surgery (Japanese). Tokyo: Medical View; 2013: 40–53. Copyright © Medical View.). Scope insertion. For efficient dissection, the insertion direction of the scope should be adjusted according to the shape of myoma. Sufficient cervix dilation is important to ensure free movement of the scope. (Reproduced with permission from Inoue S. In: Hiramatsu Y, Konishi I, Sakuragi N, Takeda S, eds. Mastering the Essential Surgical Procedures OGS Now, No.13. Function-preserving surgery (Japanese). Tokyo: Medical View; 2013: 40–53. Copyright © Medical View.) 1. Confirmation of myoma nodules and Fallopian ostia ( Figs. 9 10 11 ):(see video Roller ball hysteroscopic technique for fundal submucous myoma at: https://www.youtube.com/watch?v=jiTcrYdAwj4&t=20s . 3 10 cm type-2 fibroid hysteroscopic resection. https://www.youtube.com/watch?v=K8nmkR99GXA&t=7s . 4 Hysteroscopic resection of a huge myoma weighing 360 g is available at: https://www.youtube.com/watch?v=_kHBAzI0RAU&t=173s . 5 ) Confirmation of both sides of Fallopian ostium. (Reproduced with permission from Inoue S. In: Hiramatsu Y, Konishi I, Sakuragi N, Takeda S, eds. Mastering the Essential Surgical Procedures OGS Now, No.13. Function-preserving surgery (Japanese). Tokyo: Medical View; 2013: 40–53. Copyright © Medical View.) Resectoscope insertion. Insert the scope into the uterine cavity with the electrode stored inside the sheath. (Reproduced with permission from Inoue S. In: Hiramatsu Y, Konishi I, Sakuragi N, Takeda S, eds. Mastering the Essential Surgical Procedures OGS Now, No.13. Function-preserving surgery (Japanese). Tokyo: Medical View; 2013: 40–53. Copyright © Medical View.) Myoma on the right posterior wall with a wide base. Excision method that focuses first on dissection of myoma nodules. ( A ) Dissect the edges of the myoma in coagulation mode, ( B ) point the loop toward the myoma, move back and forth, ( C ) excise in cutting mode with the myometrium in the back, ( D ) dissection can be done efficiently with the loop in the upward direction. ( E ) Continue to excise the protrusion (f) When the protrusion has been eliminated, dissect it again. ( G ) The myometrium contracts thickly and the myoma starts to stick out ( H ) If the section has accumulated, remove with placental forceps ( I ) Dissect the last slice, and remove it with a forceps also. (Reproduced with permission from Inoue S. In: Hiramatsu Y, Konishi I, Sakuragi N, Takeda S, eds. Mastering the Essential Surgical Procedures OGS Now, No.13. Function-preserving surgery (Japanese). Tokyo: Medical View; 2013: 40–53. Copyright © Medical View.) With the electrode in the sheath, insert the scope into the uterine cavity at maximum irrigation flow. Remove any blood clots by operating the handle, confirm the uterine ostium of the fallopian tube on both sides, and confirm the number and locations of myomas. Remove the scope once, then locally inject saline-diluted pitressin to reduce bleeding from the myoma and myometrium connected to the myoma. 2. Dissection of myoma nodules ( Fig. 11 ): Reinsert the scope, and continue dissection by moving the loop electrode at 200-W coagulation mode along the myoma attachment site. 3. Excision of myoma nodules ( Figs. 11 12 13 14 ): Insert the scope upside down. When the scope is rotated 180 degrees, the electrode and the handle are turned upside down. However, the irrigation fluid tube can be rotated, so point it downward. Even if the camera cable is rotated, the top and bottom on the monitor screen will not change. When current is applied in cutting mode, always point the loop electrode toward the myoma. (Reproduced with permission from Inoue S. In: Hiramatsu Y, Konishi I, Sakuragi N, Takeda S, eds. Mastering the Essential Surgical Procedures OGS Now, No.13. Function-preserving surgery (Japanese). Tokyo: Medical View; 2013: 40–53. Copyright © Medical View.) Broad based myoma. Myoma nodules before dissection method. ( A ) If the electrode can be inserted deep into the myoma, excision in large strokes is possible. If the points indicated by the arrow can be dissection points before excision, only the myoma can be excised. ( B ) Excision efficiency of the bottom of the myoma is poor since the large strokes with the electrode are not possible. (c) As the myoma nodules continue to be dissected, the electrode can enter deep inside the myoma. Excision of the myoma can be safely performed in the direction toward the center of the uterine cavity with the myometrium in the back. (Reproduced with permission from Inoue S. In: Hiramatsu Y, Konishi I, Sakuragi N, Takeda S, eds. Mastering the Essential Surgical Procedures OGS Now, No.13. Function-preserving surgery (Japanese). Tokyo: Medical View; 2013: 40–53. Copyright © Medical View.) Successive removal of myoma slices. ( A ) The electrode is exposed deep inside of myoma. While turning on the cutting mode with the foot switch, move the scope to the front and excise the myoma. ( B ) The electrical current is stopped just before finishing excision. Grasp the excised myoma slice between the electrode and the sheath, and then pull the scope forward. ( C ) Remove the scope while holding the excised myoma slice. ( D ) Extend the electrode outside the tissue body and remove the myoma. (Reproduced with permission from Inoue S. In: Hiramatsu Y, Konishi I, Sakuragi N, Takeda S, eds. Mastering the Essential Surgical Procedures OGS Now, No.13. Function-preserving surgery (Japanese). Tokyo: Medical View; 2013: 40–53. Copyright © Medical View.) The myoma nodule can be excised even when the resectoscope is rotated 180 degrees and turning the loop electrode downward ( Fig. 12 ). However, dissection is more effective when the electrode is in the upward direction. For myomas attached to the posterior wall, proceed with the myoma dissection prior to excision, excision of only myomas can be safely performed using the electrode in an upward direction. As the myoma is excised, protrusions will disappear. Then once again, proceed with dissection ( Fig. 11f ). In myoma nodule dissection by laparotomy, the dissecting layer can be observed macroscopically. But precise dissection is possible because the image from the hysteroscope can be enlarged. If the loop electrode cannot be inserted, separate the nodule with the ball electrode. If blunt dissection is easy, do not use the electrical current. However, if there are blood vessels and funicular tissue, pass the current in coagulation mode. If myoma protrusion appears during dissecting operation, excise it with the loop electrode in cutting mode. When inserting the scope into the back, move the loop electrode in coagulation mode forward and backward in small strokes. In this way, if the loop can reach deep within the myoma, a hooking “response” on the myoma protrusion can be felt. If it is small stroke in low-voltage coagulation mode, there is no risk of perforation even if the electrode contacts the myometrium, and in cases where the bleeding point is not clearly identified, a coagulation effect can be achieved. When you can feel the loop electrode caught on the myoma, lightly pull the electrode, and switch to cutting mode to excise the myoma, using caution not to contact the myometrium in the back. If the myoma has a high-protrusion ratio, dissection may be possible by searching for the boundary of the myoma in the myometrium after shaving up to the height of the surrounding myometrium, but when excising a large myoma, sometimes you do not know “where the electrode is and what is being cut now.” If dissection is performed first, losing sight of the dissection site does not occur, and excising only the myoma is possible. This is a safe procedure. As the volume of the myoma nodule decreases, the myometrium shrinks and pushes out any remaining myomas. This is promoted by dissection operation. The myometrium which was stretched and thinned due to the myoma, shrinks as the myoma volume decreases, and becomes thicker, reducing the risk of perforation. If slices have not been removed and remain in the cavity, remove them using a placental forceps. The last remaining myoma can be removed as dissection operation continues, but it can be quickly resected by drawing it with placental forceps. Excision without perforation. ( A, B ) In deep sections, positional relationship with the myometrium is difficult to determine, and perforation while trying to excise the myoma may occur. ( C, D ) When myoma protrudes from a shallow area where the relationship with the myometrium can be determined as the myoma nodules are dissected, the myoma alone can be excised. (Reproduced with permission from Inoue S. In: Hiramatsu Y, Konishi I, Sakuragi N, Takeda S, eds. Mastering the Essential Surgical Procedures OGS Now, No.13. Function-preserving surgery (Japanese). Tokyo: Medical View; 2013: 40–53. Copyright © Medical View.) 4. Stop bleeding (coagulation/manual compression): As irrigation inner pressure increases, bleeding from minute blood vessels temporarily stop. This is useful to ensure the visual field during operation. However, as pressure decreases, bleeding will occur, so this cannot be called a hemostatic method. Cases of bleeding during TCR which are difficult to stop include (1) large intramural myomas (large contact dimensions with the myometrium, and rich vascular network around the myoma), (2) Multiple intramural myomas (poor myometrial contraction), (3) When cutting into the myometrium of the uterine side where branches of uterine artery are located, etc. In such cases, uterine contraction is important as a hemostatic mechanism. Compression on the cavity using a balloon is not recommended because it hinders uterine shrinkage. Basics of hemostasis are suture and compression. However, in TCR, the same manner as uterine bleeding at delivery/recover, compression is basic. After ergometrine and a hemostatic agent are intravenously injected and urethral catheterization, insert two/three pieces of gauze into the vagina, and press the uterus from the vagina and abdominal wall using a pelvic examination procedure (bimanual compression of the uterus Fig. 16 ). Change the gauze approximately in every 10 minutes and confirm hemostasis. Once bleeding has decreased, insert the laparoscope, and coagulate the blood vessel using the ball electrode as much as possible, and continue compression. If bleeding still does not decrease, inject prostaglandin F2α in the uterine corpus locally, and continue compression. If bleeding still does not stop, prepare for a blood transfusion, and consider suturing with the laparoscope. If the bleeding is caused by perforation, suturing is effective for hemostasis. For bleeding which was not caused by perforation, uterine artery embolization is useful. However, emergency performance is not always possible. In a case where bleeding without perforation and which did not stop even after suturing the uterine wall, the author could stop the bleeding by tying off both sides of the uterine artery. In this case, menstrual period started again. Patients who wish to have hysteroscopic myomectomy and have a strong desire to preserve their uterus, avoiding a total hysterectomy is desired as much as possible. Bimanual compression of the uterus. (Reproduced with permission from Inoue S. In: Hiramatsu Y, Konishi I, Sakuragi N, Takeda S, eds. Mastering the Essential Surgical Procedures OGS Now, No.13. Function-preserving surgery (Japanese). Tokyo: Medical View; 2013: 40–53. Copyright © Medical View.) Vasopressin is widely used to control bleeding during laparoscopic myomectomy. Although there is no evidence of bleeding control in TCR, the author has transcervically injected it in almost all cases. Almost no uterine contraction is expected. Side-effects include irregular pulse, cardiac arrest, and pulmonary edema. Increased risk of water intoxication due to antidiuretic effect is also present. For cases with asthma, use is not recommended. If PGF2α (ProstaglandinF2α [Dinoprost]) is used in the myoma with lower protrusion rate after excision of a protrusion, myoma nodules protrude due to strong contraction of the myometrium, making excision easier. Ergometrine is used for the same purpose as PGF2α, but with lower effect. It is not locally injected, but administered by IV. It can be used in cases with asthma. 5. Confirmation by ultrasound: Transvaginal injection is better than transabdominal. Even if the monitor is omitted during surgery, postoperative confirmation by ultrasound is recommended. Record any remaining myomas and fluid accumulation around the uterus. Cases of baby achievement. ( A ) TCR performed for submucosal myoma, and laparoscopic surgery for subserosal and intramuscular myomas at the same time. ( B ) Eighty days after surgery transvaginal ultrasound. (Reproduced with permission from Inoue S. In: Hiramatsu Y, Konishi I, Sakuragi N, Takeda S, eds. Mastering the Essential Surgical Procedures OGS Now, No.13. Function-preserving surgery (Japanese). Tokyo: Medical View; 2013: 40–53. Copyright © Medical View.)

Hypermenorrhea and myoma with anemia are indications. Generally, transcervical resection (TCR) can be used for submucosal myoma, as well as intramural myoma, which are large and multiple, cases where the myometrium on the serosal side is thin and cases caused inner cavity deformity and expansion, depending on operator technique and experience. Myoma dimensions and protrusion rate are the most important factors affecting operation time. Since risk of complication increases as surgery time increases, correctly evaluating one's own techniques and myoma conditions is important when determining indications. It is not unusual for myomas with a maximum diameter exceeding 10 cm to become less than 5 cm with the administration of GnRHa (gonadotropin-releasing hormone agonist). The author administered six doses of 3.75 mg of leuprorelin acetate to patients with large myomas, greatly increasing the number of cases which satisfy as indications. GnRHa definitely reduces endometrium. Usability is very high, such as to ensure the visual field and to reduce contact bleeding when inserting the scope. Malignant diseases are a contraindication of TCR. However, cases which are detected by biopsy but cannot be confirmed by other tests are not considered to be a contraindication. In cases with endometritis or salpingitis, there is a possibility of increased inflammation and peritonitis. Hydrosalpinx is not a contraindication if signs of infection are not observed. However care is needed to avoid postoperative infection. Even if the protrusion rate is high, it is not rare to have myometrium on the endometrial side. In such cases, laparoscopic resection is recommended, even when TCR is possible ( Fig. 1 ) Example of laparoscopic excision in cases where TCR is possible, and future childbirth is desired. ( A, B ) Presurgery MRI. The myometrium can be confirmed on the endometrial side. ( C, D ) After TCR MRI, the myometrium is restored. (Reproduced with permission from Inoue S. In: Hiramatsu Y, Konishi I, Sakuragi N, Takeda S, eds. Mastering the Essential Surgical Procedures OGS Now, No.13. Function-preserving surgery (Japanese). Tokyo: Medical View; 2013:40–53. Copyright © Medical View.) MRI, magnetic resonance imaging; TCR, transcervical resection. Clinical path ( Fig. 2 ). Equipment used, materials ( Fig. 3 ). Resectoscope ( Figs. 4 and 5 ), monopolar, and biopolar, 24- and 26-Fr diameters. Video system (light source and camera) possible use with laparoscope. High-frequency current generator (electric scalpel), general-purpose equipment is possible but specialized equipment is needed for bipolar. Clinical path. (Reproduced with permission from Inoue S. In: Hiramatsu Y, Konishi I, Sakuragi N, Takeda S, eds. Mastering the Essential Surgical Procedures OGS Now, No.13. Function-preserving surgery (Japanese). Tokyo: Medical View; 2013: 40–53. Copyright © Medical View.) GnRHA, gonadotropin-releasing hormone agonist; IV, intravenous; MRI, magnetic resonance imaging. Equipment used. Placement of devices and equipment (lighting is dimmed during surgery). The MRI image: ① is placed where it can be easily referenced at any time. High frequency current generator, ② Irrigation fluid bag, ③ and video system, ④ should be gathered on the left side if the surgeon is right handed. Put the ultrasound on the right side. Placement of the monitor above the patient is ideal. The electric scalpel indicator should be placed where the operator can easily see it. Discharge from Irrigation fluid drains into the pocket ⑥ in the drape ⑤ and is stored in the bucket ⑦. (Reproduced with permission from Inoue S. In: Hiramatsu Y, Konishi I, Sakuragi N, Takeda S, eds. Mastering the Essential Surgical Procedures OGS Now, No.13.Function-preserving surgery (Japanese). Tokyo: Medical View; 2013: 40–53. Copyright © Medical View.) Resectoscope cable tube. Although the camera cable can be used in common with laparoscope etc., the camera head for the hysteroscope shown in the photograph has a small diameter cable so it is lightweight and has excellent operability. (Reproduced with permission from Inoue S. In: Hiramatsu Y, Konishi I, Sakuragi N, Takeda S, eds. Mastering the Essential Surgical Procedures OGS Now, No.13. Function-preserving surgery (Japanese). Tokyo: Medical View; 2013: 40–53. Copyright © Medical View.) Resectoscope (handle part). (Reproduced with permission from Inoue S. In: Hiramatsu Y, Konishi I, Sakuragi N, Takeda S, eds. Mastering the Essential Surgical Procedures OGS Now, No.13. Function-preserving surgery (Japanese). Tokyo: Medical View; 2013: 40–53. Copyright © Medical View.). Consumable items are electrodes for excision and coagulation, and irrigation fluid. monopolar electrodes can be reused if they are not broken. Multiple cables (electric scalpel cable, camera cable, light source fiber, and irrigation fluid tube) are connected to the resectoscope, and these cables should be gathered together to either the right or the left. If the surgeon is right-handed, maintain the Tsukahara vaginal forceps in the left hand, and control the scope with the right hand, and control the foot switch with the left foot. The equipment should be located on the left side. To observe the monitor for a long time is tiring and the surgeon must look up and maintain a posture while bending his/her neck. It is easy to lose concentration. If the monitor can be moved by an extension arm, place it on the operating table, and adjust it to the height of the surgeon's line of sight. Anesthesia Choose from general anesthesia, lumbar anesthesia, and intravenous (IV) anesthesia according to difficulty and required time of the surgery. At the author's facility, there are many cases of large and multiple myoma, but the patient can be discharged on the following day. General anesthesia is chosen for the following reasons at the author's facility: Cases where cervical dilatation is difficult, response by IV anesthesia and lumbar anesthesia is not possible. Severe headache continues after early discharge from the hospital in cases of lumbar anesthesia. Obturator nerve reflexes are not suppressed by lumbar anesthesia. In an emergency, if general anesthesia is performed, immediate transfer to laparoscopic myomectomy is possible. For IV anesthesia and lumbar anesthesia performed by the surgeon, response to irregular heartbeat when using pitressin is of concern. Risk of general anesthesia by laryngeal mask is low. Bleeding: there is a possibility of hemorrhage, blood transfusion, discontinuation of surgery, and conversion to laparoscopic or laparotomy surgery when bleeding cannot be stopped. Perforation: rarely, damage to other organs may occur. Conversion to laparoscopic or laparotomy surgery requiring suture repair. Recurrence: there is the possibility of remaining myomas, increase in the number of targeted myomas, remaining/increase of myomas other than those targeted, possibility of new occurrence. Water intoxication: frequency is very low, but when prolonged surgery is expected, the risks are explained.

Understanding the three-dimensional structure of the myoma node, myometrium and endometrium are important to prevent perforation and any remaining myoma. For submucosal myomas with a low-protrusion rate and large sized, the myometrium on the serosal side is stretched and thinned. Consequently, a magnetic resonance imaging (MRI) which clearly visualizes the border of the myoma node and myometrium is essential. Take images in three directions, the sagittal, axial, and coronal planes, for reference, when considering surgical indication and intraoperative orientation. Contrast-enhanced MRI is usually not needed, but carcinosarcomas and endometrial stromal sarcomas tend to protrude into the uterine cavity, so it may be taken. For small submucosal myomas which are pedunculated or with a high-protrusion rate, transvaginal ultrasound, sonohysterogram, and diagnostic hysteroscope also can be used.