To the Editor:
Ivan Mazzon et al. recently published an interesting paper focusing on “the prevalence and the characteristics of intrauterine adhesions after cold loop resectoscopic myomectomy” for G1 and G2 submucous myomas (1).
Although retrospective, the large number of operated patients (688) and removed myomas (806) make this study robust and relevant. The authors interestingly concluded that “cold loop resectoscopic myomectomy of G1-G2 myomas is effective and safe, with a prevalence of postsurgical intrauterine adhesions that appears to be lower than those reported in the literature. The technique we have described could thus contribute to improving fertility, making it especially noteworthy for patients who desire pregnancy.”
After initial monopolar slicing of the endocavitary portion of the myoma, a cold mechanical, “non-electrical” loop was inserted into the cleavage plane between myoma and myometrium, and repeatedly applied along the surface of the myoma to disconnect by blunt dissection the connective fibers anchoring the myoma to the myometrium. After the detachment, the intramural part of the myoma became an endocavitary neoformation and was safely removed by slicing, without damaging the surrounding myometrium.”
As a result, intrauterine adhesions two months after resectoscopic surgery were found in 29/688 patients (4.23%): light in 27 cases, removed with the tip of the hysteroscope during the outpatient hysteroscopy but in one case, in which the use of microscissors was needed; fibrous synechiae in two cases, treated by resectoscopy.
In the last decade, my group and I extensively focused on this topic by standardizing the classification of submucous myomas by 2D and 3D saline contrast sonohysterography (2, 3), by reporting the dynamic changes of the myometrial free margin during 2D saline infusion (4), and, particularly, by assessing “the feasibility and the short- and long-term efficacy of hysteroscopic myomectomy for submucous myomas with intramural development [grade 1 (G1) and grade 2 (G2)] by using non-electrical “cold” loops and to verify the role of preoperative variables on surgical outcomes” (5).
In this prospective paper, based on 169 consecutive procedures in 159 patients, we concluded, similarly to Mazzon et al., as follows: “hysteroscopic myomectomy by non-electrical “cold” loops is an effective and efficient treatment for submucous myomas with intramural development. Myoma mean diameter is the only significant preoperative variable for perioperative outcome, while myoma grading loses its role as a prognostic factor.” Beside these relevant results related to intra-operative outcomes (operative time, fluid deficit, complications and complete removal at first procedure), we further observed the similar very low rate of intrauterine adhesions of 2.6% (4/156), removed by office hysteroscopy, and a pregnancy rate of 45% (9/20).
Surgeon skills might be a remarkable bias in this series. However, both these two papers clearly evidenced the reproducibility of the technique, being the 688 procedures performed by four different surgeons (1), and the short learning curve, showing the first 50 cases the same intra-operative outcome of the following.
In sum, I do absolutely agree with the conclusions by Mazzon et al., thus strengthening the take home message of using this cold loops hysteroscopic technique to remove submucous myomas with intramural development (G1 and G2) particularly in childbearing patients, providing “to preserve the integrity of the myometrium and avoid thermic damage to tissue close to the myoma.”
Francesco Paolo Giuseppe Leone, M.D.
Department of Obstetrics and Gynecology, Clinical Sciences Institute L. Sacco, University of Milan, Italy.
1.Mazzon I, Favilli A, Cocco P, Grasso M, Horvath S, Bini V, Di Renzo GC, Gerli S. Does cold loop hysteroscopic myomectomy reduce intrauterine adhesions? A retrospective study. Fertil Steril. 2014 Jan;101(1):294-8.
2.Leone FP, Lanzani C, Ferrazzi E. Use of strict sonohystero- graphic methods for preoperative assessment of submucous myomas. Fertil Steril (2003) 79(4):998-1002.
3.Leone FP, Bignardi T, Marciante C, Ferrazzi E. (2007) Sonohysterography in the preoperative grading of submucous fibroids: considerations on three-dimensional methodology. Ultrasound Obstet Gynecol 29:717-8.
4.Leone FP. Should the myometrial free margin still be considered a limiting factor for hysteroscopic resection of submucous fibroids? A possible answer to an old question. Fertil Steril. 2012 Jan;97(1):e1-2; author reply e3.
5.Leone FP, Calabrese S, Marciante C, Cetin I, Ferrazzi E. Feasibility and long-term efficacy of hysteroscopic myomectomy for myomas with intramural development by the use of non-electrical “cold” loops. Gynecol Surg (2012) 9:155-61.
The authors respond:
We would like to thank Leone et al. for the positive comments on our study, “Does cold loop hysteroscopic myomectomy reduce intrauterine adhesions? A retrospective study” (1). The excellent outcomes reported by Leone et al. (2) in terms of safety, efficacy and pregnancy rate (45%) confirm that cold loop hysteroscopic technique could improve fertility in patients seeking pregnancy, preserving the integrity of the myometrium and avoiding a thermal damage to the healthy tissue close to the myoma. Indeed, the adhesions rate reported in the cited study is not significantly different from our results (p=0.46), confirming the low synechiae rate achievable with our technique.
These results and the short learning curve reported by Leone et al. (2) demonstrate the reproducibility of the technique by the surgeon independently.
In the same report (2), the authors affirm that the “perioperative outcomes were significantly different when comparing myoma mean diameter <3.0 vs. ≥3.0 cm (75th percentile). Myoma mean diameter is the only significant preoperative variable for perioperative outcome, while myoma grading loses its role as a prognostic factor." We strongly agree with Leone et al. regarding the relative importance of the grading of the myoma, since the dynamic changes of the myometrial free margin have been widely demonstrated (3).
In our report, we did not analyse the perioperative outcome in the same manner; therefore, we were not able to assess which variable could influence it. Nevertheless, all patients concluded the treatment with a single procedure. Furthermore we demonstrated that the prevalence of the intrauterine adhesions was correlated neither to the GnRH agonist therapy, nor to the number, the size, or the grading of myomas.
Unlike previous studies, we never resorted to "auto-cross-linked hyaluronic acid gel" (4) or "poly- ethylene oxide-sodium carboxymethylcellulose gel" (5), and, nevertheless, the adhesions rate we observed after cold loop hysteroscopic myomectomy was significantly lower than in series where medical devices have been used.
In conclusion, we believe that the technique itself, the cold loop resectoscopic myomectomy, is important to reduce the prevalence of intrauterine adhesions, and this is of notable importance for fertility patients.
Ivan Mazzon, M.D., Arbor Vitae Centre, Rome, Italy
Alessandro Favilli, M.D., Sandro Gerli, M.D, Department of Obstetrics and Gynecology, University of Perugia, Perugia, Italy
1. Mazzon I, Favilli A, Cocco P, Grasso M, Horvath S, Bini V, Di Renzo GC, Gerli S. Does cold loop hysteroscopic myomectomy reduce intrauterine adhesions? A retrospective study. Fertil Steril. 2014;101:294-8.
2. Leone FP, Calabrese S, Marciante C, Cetin I, Ferrazzi E. Feasibility and long-term efficacy of hysteroscopic myomectomy for myomas with intramural development by the use of non-electrical “cold” loops. Gynecol Surg (2012) 9:155–61.
3. Casadio P1, Youssef AM, Spagnolo E, Rizzo MA, Talamo MR, De Angelis D, Marra E, Ghi T, Savelli L, Farina A, Pelusi G, Mazzon I. Should the myometrial free margin still be considered a limiting factor for hysteroscopic resection of submucous fibroids? A possible answer to an old question. Fertil Steril. 2011;95:1764-8.e1.
4. Guida M, Acunzo G, Di Spiezio Sardo A, Bifulco G, Piccoli R, et al. Effective- ness of auto-crosslinked hyaluronic acid gel in the prevention of intrauterine adhesions after hysteroscopic surgery: a prospective, randomized, controlled study. Hum Reprod 2004;19:1461–4.
5. Di Spiezio Sardo A, Spinelli M, Bramante S, Scognamiglio M, Greco E, Guida M, et al. Efficacy of a polyethylene oxide-sodium carboxymethylcellu- lose gel in prevention of intrauterine adhesions after hysteroscopic surgery. J Minim Invasive Gynecol 2011;18:462–9.