Abstract
Background
FIGO classification of a 100% intramural fibroid contacting the endometrium as type 3.
Objectives
Pros and cons of this modification are discussed.
Conclusion
Hysteroscopic myomectomy of type 3 fibroid is a risky procedure and should be cautiously performed by an expert hysteroscopist. More research is required to assess safety issues and feasibility of either hysteroscopic or laparoscopic myomectomy in type 3 fibroids.
Keywords: Laparoscopy, Fibroid, Infertility, Myomectomy, Submucous
Respected Madam/Sir,
The FIGO (International Federation of Gynaecology and Obstetrics) categorization of uterine fibroids defined a 100% intramural fibroid contacting the endometrium as type 3. In 2018 revisions, it considered type 3 as a submucous fibroid [1] due to potential symptoms of infertility, abnormal uterine bleeding or pregnancy complications. Nevertheless, it does not describe the suitable treatment modality. Theoretically, hysteroscopic surgery is preferable to abdominal laparoscopic or laparotomic surgery, especially for women who are committed to preserving their fertility. Due to proximity to the endometrium, hysteroscopic myomectomy (HM) exerts the least myometrial tissue damage with preservation of the protective and functioning pseudocapsule. Modifications of hysteroscopic techniques enabled complete excision of big fibroids in one session like vertical incision of the endometrium over the fibroid to allow its extrusion to the endometrial cavity, use of ecobolics or cold loop resection. Many hysteroscopists undertake HM of type 3 fibroids increasingly because of these prospective benefits of hysteroscopic approach and FIGO revisions. This approach would result in overtreatment with increased surgical risks. Contrarily, others would prefer other hormonal or surgical options for fear of possible increasing complications.
Treating type 3 fibroids as submucous fibroids without considering anatomic and clinical individual factors may result in risky probably unsuccessful invasive intervention. It should be realized that HM is the riskiest intrauterine surgery which is completely different from other hysteroscopic surgeries. First of all, it is expected to expose the patient to excessive fluid overload which is the most serious complication of prolonged hysteroscopic surgery due to the lack of an ideal distension media for hysteroscopy till date. Unlike type 1 or 2, hysteroscopic access to type 3 is technically difficult due to poor visualization with possible subsequent postoperative adhesion formation. Furthermore, fibroid resection may result in a big defect with subsequent defective myometrial healing. Visualization and sparing of pseudocapsule are usually difficult which represent an additional factor of poor healing. The most dangerous surgical step is where to stop as the whole fibroid is intramural (100%). Risk of perforation is so high unless laparoscopic or sonographic control is used. If the fibroid is seen near the serosa, a possibility of incomplete excision is high whenever the hysteroscopist stops the procedure for fear of perforation. The cutoff point of safe HM for type 3 is unclear in the literature. Residual myometrial thickness (RMT) is crucial in selection of the endoscopic approach for treating myometrial lesions. In uterine niche, RMT ≤ 3 mm is usually considered a contraindication of hysteroscopic resection and an indication of repair [2]. Alternatively, laparoscopic myomectomy (LM) would offer a safer approach despite proximity to the endometrium as the whole fibroid is intramural. Moreover, omission of a big endometrial damage and preservation of pseudocapsule are additional advantages of LM of type 3 myoma.
Obvious shortcomings include the absence of comments on the appropriate myoma size suitable for HM and the impact of proximity to serosa, or cornual ends, and RMT on the treatment tool. Moreover, for type 3 myoma management there are no guidelines available, and the best hormonal or surgical approach is not yet clarified due to the lack of international guidelines or research evidence. If 2018 revisions were made based on joint meetings with experienced laparoscopic and hysteroscopic societies, these problems might be resolved with clear stratification of the management plan of type 3 fibroids. In the era of precision medicine, regardless of the categorization scheme employed, healthcare professionals must take into account each patient’s distinct clinical presentation, symptoms and personal circumstances when deciding the best way to manage type 3 fibroids. Furthermore, significant improvements in the classification and treatment guidelines for type 3 fibroids, particularly with regard to their efficacy and efficiency in achieving pregnancy, could emerge from additional research and clinical experience.
Author Contributions
AD conventionalized the idea, wrote the manuscript from A to Z and reviewed it. DD shared the idea and reviewed the manuscript.
Funding
There is no funding information to declare.
Declarations
Conflict of interest
None.
Footnotes
Atef Darwish, MSc, MD, PhD, Professor Emeritus; Dina Darwish, MSc, MRCOG.
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
References
- 1.Munro MG, Critchley HOD, Fraser IS, FIGO Menstrual Disorders Committee. The two FIGO systems for normal and abnormal uterine bleeding symptoms and classification of causes of abnormal uterine bleeding in the reproductive years: 2018 revisions. Erratum in: Int J Gynaecol Obstet. 2019;144(2):237. PMID: 30198563 [DOI] [PubMed]
- 2.Kulshrestha V, Agarwal N, Kachhawa G. Post-caesarean niche (isthmocele) in uterine scar: an update. J Obstet Gynecol India. 2020;70(6):440–6. 10.1007/s13224-020-01370-0. [DOI] [PMC free article] [PubMed] [Google Scholar]