Feasibility of a new two-step procedure for office hysteroscopic resection of submucous myomas: results of a pilot study Sergio Haimovich a, *, Gemma Mancebo a , Francesc Alameda b , Silvia Agramunt a , Josep M. Sole ´ -Sedeno a , Jose ´ Luis Herna ´ ndez a , Ramo ´n Carreras a a Service of Obstetrics and Gynecology, Hospital Universitari Parc de Salut Mar, Auniversitat Auto `noma de Barcelona, Barcelona, Spain b Service of Pathology, Hospital Universitari Parc de Salut Mar, Auniversitat Auto `noma de Barcelona, Barcelona, Spain 1. Introduction Myomas of the uterus are the most common benign tumors of the female genital tract. Uterine myomas are estimated to occur in 25–40% of women of reproductive age and account for up to 5% of gynecological consultations [1–5]. Submucous myomas are found in 5–10% of cases and, although a cause-effect relationship has not been demonstrated, removal of these tumors is accompanied by a substantial improvement of menstrual disturbances and infertility [6–9]. The classification system developed in 1993 by Wamsteker et al. [10], which was adopted by the European Society for Gynecological Endoscopy (ESGE), considers the degree of penetra- tion of the submucous myoma in the myometrium. The separation into three grades according to the size of the myoma and the proportion of the myoma protruding into the uterine cavity (G0 with total intracavitary development, G1 with mostly (>50%) intracavitary development and G2 with >50% intramural devel- opment) has been shown to be efficient at discriminating the complexity of hysteroscopic myomectomies [11–14]. Recently, Bettocchi et al. [15] described a new hysteroscopic technique for the office preparation of partially intramural myomas to facilitate the subsequent scheduled resectoscopic myomectomy. The procedure consists of an incision of the endometrial mucosa and the pseudsocapsule covering the myoma aimed at facilitating protrusion of the intramural portion of the myoma into the uterine cavity as a preliminary step for in-patient resectoscopic surgery after 2 menstrual cycles. At follow-up hysteroscopy, the conversion of myomas with partially intramural development into totally or prevalently intracavitary ones was observed in 55 out of 59 patients (93.2%). The present pilot study was conducted to assess the feasibility of a modification of the technique described by Bettocchi et al. [15] for the treatment of submucous myomas with intramural development (G1 or G2), in which the two steps are performed in the office setting. European Journal of Obstetrics & Gynecology and Reproductive Biology 168 (2013) 191–194 A R T I C L E I N F O Article history: Received 21 October 2012 Received in revised form 25 November 2012 Accepted 9 January 2013 Keywords: Hysteroscopy/methods Ambulatory surgical procedures Myoma/pathology Myoma/surgery Uterine neoplasms/surgery Uterine neoplasms/pathology Pilot projects A B S T R A C T Objective: To assess the feasibility of a new two-step technique for office hysteroscopic resection of submucous myomas. Study design: Between January 2010 and December 2011, all consecutive patients of reproductive age with symptomatic lesions sonographically diagnosed as single mainly intracavitary (G1 or G2) myoma 4.0 cm were eligible to participate in a prospective study. They underwent a two-step hysteroscopic procedure, which included preparation of partially intramural myomas with incision of the endometrial mucosa and the pseudocapsule covering the myoma in the first step, and excision of the myoma by means of diode laser four weeks later. All procedures were performed on an outpatient basis and without anesthesia. Results: A total of 43 women (mean age 36.7 years) were included. The two-step myomectomy technique was successfully performed in 34 (79.1%) patients. All myomas 18 mm were successfully enucleated as compared with 85% of 19–30 mm, and 0% of 30 mm (P < 0.001). Also, myomas located in the anterior/posterior walls and those located in the fundus/lateral walls were enucleated in 87.9% and 50% of cases, respectively (P = 0.020). Success of surgery was not influenced by the initial type of myoma. Conclusion: The new two-step hysteroscopic myomectomy carried out as an outpatient procedure and without anesthesia is feasible for the excision of symptomatic submucous fibroids. ß 2013 Elsevier Ireland Ltd. All rights reserved. * Corresponding author at: Service of Obstetrics and Gynecology, Hospital Universitari Parc de Salut Mar, Passeig Marı ´tim 25-29, E-08003 Barcelona, Spain. Tel.: +34 669899333; fax: +34 93 4665388. E-mail address: sergio@haimovich.net (S. Haimovich). Contents lists available at SciVerse ScienceDirect European Journal of Obstetrics & Gynecology and Reproductive Biology jou r nal h o mep ag e: w ww .elsevier .co m /loc ate/ejo g rb 0301-2115/$ – see front matter ß 2013 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ejogrb.2013.01.002