European Journal of Obstetrics & Gynecology and Reproductive Biology
Hysteroscopic treatment of symptomatic submucous fibroids using a bipolar intrauterine system: a feasibility study
Introduction
The introduction of more sophisticated imaging techniques such as transvaginal ultrasound scanning and hysteroscopy has led to increased recognition of intrauterine structural pathology, e.g. endometrial polyps and submucous fibroids, in association with abnormal uterine bleeding [1], [2], [3]. Medical treatments are often ineffective in the presence of intracavity fibroids [4] and so many women seek a surgical solution to their symptoms [5]. This has traditionally involved either a hysterectomy or open myomectomy, which are major gynaecological procedures associated with significant morbidity [4], [6]. Over the last two decades, less radical minimally invasive surgical removal of intrauterine fibroids has been developed [7] and recommended [8] utilising operative monopolar continuous flow resectopes [9] or laser [10] for use under direct hysteroscopic vision.
Recent advances in endoscopic technology have lead to the production of miniature operative hysteroscopes, which avoid the need for cervical dilatation and provide superior image quality. Furthermore, fine electrodes using bipolar electrical circuits have been developed for use with normal saline [11], [12], [13]. This potentially provides improved safety because of the inherent safety features of bipolar diathermy without loss of electrosurgical cutting properties [11], [12]. Moreover, the intense heat generated at the small diameter active electrode allows tissue to be rapidly vaporised with almost no blood loss similar to the effect produced by more expensive laser fibres. “Chips” of fibroid material are not produced, improving visualisation further and potentially shortening the length of procedures. This in conjunction with the osmolarily neutral normal saline fluid irrigation medium reduces risks from fluid overload.
We conducted a literature search of the general bibliographic databases, MEDLINE and EMBASE using the medical subject headings (MeSH) endoscopy, hysteroscopy, leiomyoma [surgery], uterine neoplasm [surgery], electrosurgery and the textword Versapoint. This identified two studies of hysteroscopic treatment of fibroids using bipolar diathermy [14], [15]. They were both small uncontrolled case series without follow-up, which described the practicability of treating submucous fibroids with a bipolar intrauterine system. Efficacy in terms of symptom response and costs were not reported. We, therefore, wanted to determine the feasibility (safety, potential efficacy and cost effectiveness) of such a system in the treatment of symptomatic submucous fibroids.
Section snippets
Materials and methods
We designed this study to determine the feasibility of a bipolar intrauterine system in the treatment of symptomatic submucous fibroids in terms of safety, clinical efficacy and associated costs. Women referred to our Rapid Access Ambulatory Diagnostic hysteroscopy service because of abnormal uterine bleeding symptoms between January 1999 and June 2000 (18 months) and diagnosed with a submucous fibroid were identified from a comprehensive, prospective electronic database of all such
Baseline and operative data
A total of 37 symptomatic women were diagnosed with submucous fibroids. The fibroid treatment as outlined above was completed successfully in all cases and there were no serious complications. The response rate to the 6-month outcome questionnaire was 36/37 (97%). Patient baseline characteristics and operative data are shown in Table 1 for these respondents. The submucous fibroids were retrieved from 24/36 (67%) women and all were histologically benign. There was additional endometrial
Discussion
This study shows that endoscopic treatment of submucous fibroids with a bipolar intrauterine system is feasible, in terms of safety, and it appears to have potential efficacy in relieving symptoms of abnormal uterine bleeding. Furthermore, it may be a more cost-effective treatment than the open and endoscopic surgical procedures currently available for this condition [4], [9], [10]. These results, however, should be viewed in the context of a feasibility assessment. Because of the small sample
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