To help document and evaluate the results of hysteroscopically directed myoma surgery, a classification system was developed that is based on the proportion of the myoma that is in the uterine cavity. In patients with myomas that are entirely intracavitary (type 0), excision is feasible and in many instances relatively easy, depending in part on the diameter; whereas in larger type II lesions an abdominal approach with laparoscopy or laparotomy is frequently necessary. Small type 0 leiomyomas may be removed following transection of the stalk with scissors or an electrode attached to a uterine resectoscope. For larger type 0 lesions, or for type I myomas, mechanical or electrosurgical morcellation with a resectoscope is necessary before removal. For a limited number of type II myomas, careful dissection into the avascular plane interposed between the tumor and the myometrial pseudocapsule may be attempted, provided that satisfactory ultrasonography or MRI demonstrated an adequate margin of myometrium between the deepest aspect of the lesion and the uterine serosa. It may be preferable to undertake such procedures with laparoscopic monitoring to verify that bowel is not adjacent to the zone of dissection. Patients should be counseled that for some type I and many type II myomas, more than one procedure might be required to complete excision (178,187). The use of intrauterine prostaglandin F2α was described to facilitate extrusion of type II myomas (188).
Endometrial Ablation Heavy menstrual bleeding that does not respond to oral medical therapy may be managed by EA using coagulation, resection, or vaporization, provided the patient is willing to forgo future fertility (51). Alternatively, or if future fertility is desired, a levonorgestrel-releasing intrauterine contraceptive device can provide virtually equal clinical outcomes (189,190). Ablation may be performed with the laser, radiofrequency electrosurgical desiccation, resection, or vaporization using a uterine resectoscope, or by any of a number of nonresectoscopic techniques, including those employing thermal balloons, cryotherapy, heated free ﬂuid, or microwave or bipolar radiofrequency systems (151,152,187,191–195). Many of these endometrial ablation devices can be used in an office setting using local anesthetic protocols.
Endometrial resection is an EA technique performed with an electrosurgical loop electrode to shave the endometrium and superficial myometrium (109,142,143,150,196,197). Vaporization utilizes specially designed electrodes that are attached to standard resectoscopes but which are capable of destroying large volumes of tissue without morcellation (187). Ablation is achieved using ball or barrel-shaped electrodes that coagulate the endometrial surface (51,152). Complications of these procedures include ﬂuid overload, electrolyte imbalances (if nonelectrolytic or even isosmotic media are used), uterine perforation, bleeding, and intestinal and urinary tract injury (198,199). The risk of uterine perforation may be reduced by using a combination of resection or vaporization and electrosurgical ablation; the latter is most suitable for the thinner areas of the myometrium in the cornu (177). The preoperative use of GnRH analogues or danazol may reduce operating time. GnRH may reduce bleeding and the amount of ﬂuid absorbed into the systemic circulation (186).