Incidence of Intrauterine Adhesions Following Hysteroscopic Myomectomy in Patients Seeking Fertility

Elsevier

Available online 27 May 2023

Journal of Minimally Invasive GynecologyAuthor links open overlay panel, , , , , AbstractStudy Objective

To study the incidence of intrauterine adhesions following hysteroscopic myomectomy. Previous studies report a range of incidence for intrauterine adhesions following hysteroscopic myomectomy.

Design

Retrospective review study.

Setting

Academic community hospital in the Boston metropolitan area.

Patients

Patients undergoing hysteroscopic myomectomy at our institution from January 2019 to February 2022. Patients were excluded if they do not have plans for future fertility or had a new diagnosis of cancer.

Interventions

All patients underwent hysteroscopic myomectomy using bipolar resectoscope without post-operative medical or barrier treatment. All procedures were performed by 1 of 4 fellowship-trained high-volume gynecologic surgeons with resident and fellow assistance. Incidence of post-operative intrauterine adhesions was assessed and treated using second-look office hysteroscopy.

Measurements and Main Results

A total of 44 patients without pre-operative intrauterine adhesions underwent hysteroscopic myomectomy during our study period, and 4 (9.1%) patients developed new intrauterine adhesions. Among 9 patients who was found to have pre-operative intrauterine adhesions and underwent concurrent hysteroscopic myomectomy and lysis of adhesions, we found a recurrence of intrauterine adhesions in 5 (55.6%) patients. We found the number, size and deepest type of myoma removed was not correlated to an increased risk of new intrauterine adhesions formation. Additionally, removing myomas on opposing walls during the same operation did not increase the incidence of new intrauterine adhesions.

Conclusion

Formation of intrauterine adhesions following hysteroscopic myomectomy is a well-documented consequence. Our reported incidence of 9.1% of new intrauterine adhesions that is not affected by the number, size, deepest type of myoma resected and resection of myomas on opposing uterine walls contributes to the current literature. Additionally, our finding of 55.6% of recurrent intrauterine adhesions in patients undergoing both hysteroscopic myomectomy and lysis of adhesions highlight a high-risk population requiring additional study.

Section snippetsINTRODUCTION

Hysteroscopic myomectomy is a minimally invasive treatment for submucosal myoma. Uterine myoma has been categorized by the International Federation of Gynecology and Obstetrics (FIGO) based on the myoma's relationship to the uterine serosa and mucosal surfaces (1). FIGO types 0 – 2 myomas are routinely resected using hysteroscopy, and type 3 myomas can be removed in certain instances by skilled surgeons. Risks of hysteroscopic myomectomy include intrauterine adhesions (IUA), or bands of scar

MATERIALS AND METHODS

This is a retrospective review of patients undergoing hysteroscopic myomectomy at our institution from January 2019 to February 2022. All reproductive aged patients, aged 18 – 50, who underwent hysteroscopic myomectomy were identified using CPT code 58561. Patients were excluded if they did not have a second-look hysteroscopy, did not have plans for future fertility or had a new diagnosis of cancer. Our data was obtained from patient chart review via EPIC electronic medical records (EMR). Data

RESULTS

A total of 44 patients without pre-operative IUA underwent hysteroscopic myomectomy using the bipolar loop resectoscope and underwent a second-look hysteroscopy. An additional 9 patients who had pre-operative IUA are also included in the cohort. The demographic information can be found in Table 1.

The mean age of patients without pre-operative IUA undergoing hysteroscopic myomectomy was 37.5. Most patients were white (50.0%) and nulliparous. The most common indication for myomectomy was

DISCUSSION

New IUA formation is a possible consequence of hysteroscopic myomectomy, which may hinder a patient's ability to achieve pregnancy. In our cohort, all patients who underwent hysteroscopic myomectomy were seeking fertility. Most of the patients were white, nulliparous and underwent hysteroscopic myomectomy for infertility indications. We found an incidence of new IUA following hysteroscopic myomectomy of 9.1%. Our incidence of 9.1% is much lower than the reported incidence of new IUA following

CONCLUSION

Formation of IUA following hysteroscopic myomectomy is a well-documented consequence, which may affect a patient's ability to achieve pregnancy. Previously outlined risk factors for formation of IUA following hysteroscopic myomectomy include number of myoma and location of myoma resected, which we did not find in our cohort. Our reported incidence of 9.1% without any post-operative barrier treatment contributes to the growing literature to help counsel patients on the risk of IUA following

References1

Munro MG, Critchley HOD, Broder MS, Fraser IS, for the FIGO Working Group on Menstrual Disorders. FIGO classification system (PALM-COEIN) for causes of abnormal uterine bleeding in nongravid women of reproductive age. International Journal of Gynecology & Obstetrics 2011;113(1):3–13.

2

Taskin O, Sadik S, Onoglu A, Gokdeniz R, Erturan E, Burak F, et al. Role of endometrial suppression on the frequency of intrauterine adhesions after resectoscopic surgery. J Am Assoc Gynecol Laparosc 2000;7(3):351–4.

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© 2023 Published by Elsevier Inc. on behalf of AAGL.

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