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T he treatment of intrauterine masses, such as endometrial polyps and leiomyomas, has undergone a tech- nological revolution in the past few decades. Gynecologists may now choose from a variety of unipolar and bipolar resectoscopes as well as an assortment of both mechanical and bipolar hysteroscopic mor- cellators. We present a comparison of these technologies to better practitioners understanding of the strengths and limitations of these devices. Should We Abandon the Gynecologic Resectoscope in Favor of Hysteroscopic Morcellators? MORRIS WORTMAN, MD, FACOG DIRECTOR CENTER FOR MENSTRUAL DISORDERS ROCHESTER, NEW YORK CLINICAL ASSOCIATE PROFESSOR DEPARTMENT OF OBSTETRICS & GYNECOLOGY UNIVERSITY OF ROCHESTER MEDICAL CENTER ROCHESTER, NEW YORK - 1 - ABSTRACT Gynecology SURGICAL TECHNOLOGY INTERNATIONAL Volume 30

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Page 1: #846-Wortman Galley - 01 Gynecology SURGICAL ......results. Uterine perforation occurred in only two (1.3%) subjects—a complica - tion rate that rivals any modern method . Five of

TThe treatment of intrauterine masses, such as endometrial polyps and leiomyomas, has undergone a tech-

nological revolution in the past few decades. Gynecologists may now choose from a variety of unipolar

and bipolar resectoscopes as well as an assortment of both mechanical and bipolar hysteroscopic mor-

cellators. We present a comparison of these technologies to better practitioners understanding of the

strengths and limitations of these devices.

Should We Abandon the GynecologicResectoscope in Favor of Hysteroscopic

Morcellators?MORRIS WORTMAN, MD, FACOG

DIRECTORCENTER FOR MENSTRUAL DISORDERS

ROCHESTER, NEW YORK

CLINICAL ASSOCIATE PROFESSORDEPARTMENT OF OBSTETRICS & GYNECOLOGYUNIVERSITY OF ROCHESTER MEDICAL CENTER

ROCHESTER, NEW YORK

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#846-Wortman Galley - 01

ABSTRACT

GynecologySURGICAL TECHNOLOGY INTERNATIONAL Volume 30

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History of Resectoscopy andOther Tissue Removal Techniques

The treatment of symptomaticintrauterine masses has been a well-known challenge for gynecologists formany centuries. Until nearly 150 yearsago, techniques were limited to the blindintroduction of a variety of instrumentsincluding curettes, grasping forceps, liga-tures, and snares. In 1869, an Englishphysician, Commander Pantaleoni,1 firstused a rudimentary endoscope—a “lightbox” invented by Antonin Jean Des-ormeaux (Fig. 1)—to examine andchemically cauterize an endometrialpolyp in a 60-year-old woman with post-menopausal bleeding.

In the decades that followed “blindtechniques” became the primaryapproach to intrauterine pathology. Asrecently as 1990, Goldrath 2 describedthe removal of submucous myomas in151 patients using an assortment ofgrasping forceps. His approach involvedpreoperative cervical dilation with lami-naria tents followed—the next day—bythe blind introduction of a variety ofcommon gynecologic instruments. Gol-drath’s results were, by today’s standards,admirable—myomas were successfullyremoved in 92% of subjects while hys-terectomy and abdominal myomectomywere avoided in all but four subjects.Goldrath only utilized hysteroscopy priorto, and immediately following, the pro-cedure to confirm the diagnosis and theresults. Uterine perforation occurred inonly two (1.3%) subjects—a complica-tion rate that rivals any modern method.

Five of the subjects reported by Goldrathunderwent removal of leiomyomas thatweighed more than 100 grams—thelargest weighed 180 grams.

A new era of intrauterine surgery,performed under direction vision, beganin 1976 when Neuwirth and Amin3

reported the use of a urologic resecto-scope to perform the first “hysteroscop-ic” removal of a submucous myoma onfive patients. In 1983, Neuwirth4

described his results on a larger series of28 women who underwent resectoscopicmyomectomy and was able to avoid hys-terectomy in 75% of his subjects.

In 1989, the FDA approved the con-tinuous flow gynecologic resectoscopeenabling a variety of operative techniquesincluding hysteroscopic myomectomyand polypectomy, as well as endometrialablation. However, reports of severe, andoccasionally fatal, complications damp-ened early enthusiasm for resectoscopicsurgery. In 1993, Baggish et al.5 reportedfour cases of acute glycine and sorbitoltoxicity during operative hysteroscopyresulting in two deaths. Propst et al.6noted that the risk of excess fluid absorp-tion in women undergoing myomectomywas 4.7%, a more than 10-fold increasecompared to women without myomas. Itis worth noting, however, that thesereports antedate the use of fluid manage-ment systems7 and bipolar resectoscopy 8

and occurred prior to the adoption ofpractice guidelines for managing hystero-scopic distention media.9 Since theserefinements, the frequency of these com-plications have doubtlessly diminished.

However, despite the reduction influid-related complications, early resec-

toscopic surgery by inexperienced physi-cians was all-too-often associated withuterine perforation and visceral thermalinjuries. These difficulties were inappro-priately attributed to unipolar electro-surgery10 rather than their truesource—surgical naïveté and disorienta-tion. Nonetheless, professional concernswere addressed by instrument manufac-turers who responded by introducingbipolar resectoscopes.11

Notwithstanding, these improve-ments in hysteroscopic myomectomiesand polypectomies remained technicallydifficult for many practitioners. Gynecol-ogists were often challenged to maintainvisual orientation through a blood-soaked operative field filled with accu-mulated tissue “strips”—the removal ofwhich was both time-consuming andnecessary to maintain visual references.These impediments often led to a loss ofspatial orientation and resulted in uterineperforation and visceral injuries. Instru-ment manufacturers found an importantopportunity to solve this issue by con-verting much of the same technologythat was already being employed forarthroscopic shaving.

In 2005, Emanuel and Wamsteker12

reported the use a mechanical hystero-scopic morcellator for the removal ofendometrial polyps and leiomyomas in aseries of 55 women. Morcellation pro-vides two important advantages com-pared to resectoscopic techniques. First,it obviates the theoretic risks of electro-surgery and low viscosity anionic disten-tion media. Second, and mostimportantly, it addresses the time-con-suming challenge of tissue retrieval dur-ing myomectomy and polypectomy.

The past 12 years have seen a prolifer-ation of hysteroscopic tissue removal sys-tems that are marketed for a range ofprocedures including adhesiolysis, direct-ed biopsies, myomectomy, polypectomy,the removal of retained products of con-ception, and even the treatment of uter-ine septae. These systems typicallyconsist of a 0o operative hysteroscope, adisposable co-located mechanical mor-cellation device, and a proprietary fluid-management system for the delivery ofphysiologic saline under adequate pres-sure and flow.

The first of these systems—TRU-CLEAR™ (Smith and Nephew Inc.,Andover, Massachusetts)—receivedFood and Drug Administration (FDA)approval in 2005. The second,MyoSure™ (Hologic Inc., Bedford,

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HISTORY OF RESECTOSCOPY AND OTHERTISSUE REMOVAL TECHNIQUES

Figure 1. Desormeaux scope.

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Massachusetts) became available in 2009.The MyoSure™ hysteroscope is availablein two sizes—6.25 mm and 7.2 mm—with 3 and 4 mm working channelrespectively. TRUCLEAR™ also offers achoice of two hysteroscope diameters—the TRUCLEAR™ 5.0 featuring a 5.6mm hysteroscope and a 3 mm operatingchannel, while the TRUCLEAR™ 8.0comes with a 9.0 mm outer sheath and a4 mm operating channel.

A third system, the Symphion™ Tis-sue Removal System™ (Boston Scientif-ic Corporation, Marlborough,Massachusetts) became available in 2013and includes in single 6.3 mm O. D. 0o

hysteroscope equipped with two fluidchannels and a 3.7 mm working channel.This system attempts to address some ofthe shortcomings of the existing mechan-ical systems by introducing bipolar cut-ting, on-demand tissue coagulation, adedicated uterine pressure control sys-tem, and a closed-loop molecular filtra-tion system. The closed-loop systemobviates the possibility of fluid overloadwith normal saline distention fluid.

Hysteroscopic Morcellators (HMs)versus the Gynecologic Resectoscope

With the introduction of HMs, gyne-cologists now have a choice in managingintrauterine pathology using the oldergynecologic resectoscope or the newerhysteroscopic morcellator. A side-side-byside analysis examining the advantagesand disadvantages of each modality iswarranted (Figs. 2a and b).

Hysteroscopic morcellators Hysteroscopic morcellators (HMs)

are easily mastered and are swiftlyreplacing the traditional gynecologicresectoscope. The appeal of HMs lie inthe fact that they can be inserted into the

uterine cavity and brought into contactwith the target tissue—myoma orpolyp—without the repetitive insertion,cutting, removal, and re-insertion(ICRRI) cycle required of the resecto-scope to clear chips and strips of tissuethat accumulate within the uterine cavity.All of this occurs using normal saline fordistention, which eliminates most of theconcerns regarding fluid management.Some physicians prefer the mechanicalmorcellation of intrauterine pathology inplace of electrosurgical tissue cuttingbelieving that the former obviates thecomplications associated with the gyne-cologic resectoscope. However, mechan-ical morcellators are not exempt fromcausing uterine perforation and injury topelvic viscera.13

But the disadvantages of hysteroscopic

morcellators (HMs) are striking. HMsrequire the use of a relatively cumber-some “offset” operative hysteroscopeequipped with a suboptimal 0o lens, andthey are available only in a limited rangeof diameters compared to either a unipo-lar or bipolar resectoscopes. An impor-tant drawback of HMs is the expense oftheir disposables—$1,000 to $1,400 perdevice. Moreover, since mechanicaldevices easily dull during the resection ofdense myomas, it is common for multi-ple devices to be required during thecourse of a single procedure. This repre-sents a marked cost increase comparedto disposable loops which are available at$150 to $400 per case. Another hiddencost of hysteroscopic morcellators is thattheir use is strictly confined to theremoval of intrauterine masses. For

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GynecologySURGICAL TECHNOLOGY INTERNATIONAL Volume 30

HYSTEROSCOPIC MORCELLATORS (HMS) VS.THE GYNECOLOGIC RESECTOSCOPE

Figure 2a. Gynecologic resectoscope 2b. Hysteroscopic morcellator.

a b

Table IAdvantages and Disadvantages of the Hysteroscopic

Morcellator (HM)

Advantages1. Distention medium is normal saline 2. One may choose to avoid electrosurgical energy and possible burns3. Obviates the need for insertion and reinsertion cycle for chip removal4. Suitable for “see-and-treat” hysteroscopy 5. Rapid learning curve

Disadvantages1. Available in 1 or 2 diameters depending on the manufacturer2. Mechanical systems dull and may need replacements during a single proce-

dure3. Tissue removal is slowed by dense or calcified tissue4. Function poorly at the fundus and uterine cornua5. Mechanical systems are associated with intrauterine pressure loss6. Expensive7. Devices are not suited to ancillary procedures such as endometrial ablation

or resection8. Devices are not suitable for the small postmenopausal uterus9. Devices are not suitable for the very stenotic cervix10. 0 0 optic is suboptimal for examining and operating within the uterine cavity11. The instruments have a small operating window and limit rate of tissue

removal12. Disruption of the histologic specimen

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ancillary procedures, such as endometri-al ablation or resection, an entirely sepa-rate apparatus, such as a globalendometrial ablation (GEA) device, isrequired to adequately manage suchcases. This is a significant issue given thefrequent requirement for concomitantprocedures. A summary of the advan-tages and disadvantages of HMs are listedin Table I.

The gynecologic resectoscopeThe gynecologic resectoscope, by

comparison, is a relatively simple pieceof equipment available in both unipolarand bipolar variants and in a wide varietyof diameters (Figs. 3a and b) fitted withinexpensive disposable loops. Its viewing

angle—12 or 30o–is far more appropri-ate to operating within the uterine cavi-ty, allowing the surgeon to more easilymaintain orientation.

The range of resectoscopes, loopsizes, and configurations allows them toaddress a wide variety of intrauterinepathology. For example, very small-diameter resectoscopes are ideal formanaging endometrial polyps in womenwell beyond their sixth decade of life—apopulation in which severe cervicalstenosis is common. At the other end ofthe spectrum, the 28 Fr resectoscopewith its 9 mm electrosurgical loop, pro-vides efficient cutting—up to 5grams/minute in our experience—andallows the removal of dense fibroids

greater than 100 grams. Loop electrodesare available in many configurations from90–180o and are well-suited for remov-ing the base of myomas or polyps any-where within the uterine cavity (Figs. 4aand b). In contrast, hysteroscopic mor-cellators are limited by their side-cuttingwindows which are ideally designed foroperating in the lower 2/3 of the uterus(Fig. 5a), but achieve only limited accessto fundally-attached myomas and polyps(Fig. 5b). Finally, electrosurgical loopsprovide excellent cutting with tissue ofvarying density as well as on-demandcoagulation, and they do not dull.

The resectoscope, unlike the HM,easily lends itself to multiple concomi-tant procedures—myomectomy,polypectomy, endometrial ablation,endomyometrial resection—without theneed for instrument changes. This isimportant in our menstrual disorderspractice since a quarter of our patientswho undergo endomyometrial resectionfor managing abnormal uterine bleedingalso require the concurrent removal of asubmucous or intramural myoma (Figs.6a–c). Relying on hysteroscopic morcel-lators in these scenarios would requirean entirely separate device to accomplishendometrial ablation or EMR. In ourpractice, the resectoscope is oftenemployed, with the adjuvant use of ultra-sound guidance, to remove intramuralleiomyomas (Figs. 7a–d), an impossiblefeat for the hysteroscopic morcellator.

The disadvantages of resectoscopycannot to be dismissed, however. Poortraining is associated with a greater inci-dence of fluid and electrolyte distur-bances, incomplete procedures,hemorrhage, uterine perforation, as wellas visceral and vascular injuries. Masteryof this instrument requires a commit-ment to proper supervision and a signifi-cantly longer and steeper learning curve.The repetitive ICRRI cycle, particularlyin the hands of a novice, may contribute

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Should We Abandon the Gynecologic Resectoscope in Favor of Hysteroscopic Morcellators?WORTMAN

3a. Array of commercially available gynecologic resectoscopes.

a b

Table IIAdvantages and Disadvantages of the Gynecologic

Resectoscope

Advantages1. Available in unipolar and bipolar2. Many scope diameters: 13, 15, 21, 24 26, 28 Fr (4.3, 5, 7, 8, 8.7, 9.3 mm)

(Figure 3)3. Many loop sizes and configurations4. Disposables are far less expensive5. Electrodes don’t dull6. Simultaneous availability of electrosurgical hemostasis7. Highly effective even with the densest myomas8. Can be used to treat intramural leiomyomas (Figure 7A-D)9. Superior ability to remove fundally attached tissue (Figure 4A) using a vari-

ety of loop configurations. 10. Resectoscopes can be used for polyps, fibroids, septums and EMR11. Larger diameter resectoscopes are far more efficient with large myomas

(Figure 2)12. Resultant specimen is easily oriented13. Small diameter resectoscopes are better suited to the small postmenopausal

uterus

Disadvantages1. Frequent insertion and reinsertion to perform resection of large myomas or

polyps2. Visualization can be challenging during insertion and reinsertion3. Insertion, cutting, retrieval and reinsertion (ICRRI) cycles present a signifi-

cant problem with cervical stenosis

3b. Corresponding electrosurgical loops.

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to poor visualization and disorientation.Moreover, in anticipation of this cycle,the cervix should be adequately preppedwith laminaria insertion, particularly ifthere is reason to suspect cervical steno-sis. In fact, the combination of a largemyoma (greater than 4 cm) and a stenot-ic cervix may preclude successful resec-toscopic surgery entirely. A summary ofthe advantages and disadvantages of thegynecologic resectoscope can be found inTable II.

Discussion

As we welcome new technology intoour specialty, we need to appreciateboth their contribution and limitations.Hysteroscopic morcellators, which areeasily mastered, allow gynecologists toperform polypectomy and myomectomywith relative safety. Their use for theremoval of retained products of concep-tion or for the management of Asher-man’s syndrome lacks evidence and isunlikely to replace already well-estab-

lished techniques using far less expen-sive equipment.

Because HMs eliminate the ICRRIcycle, their use requires a shorter learn-ing curve to develop proficiency—mak-ing them ideal for low volumepractices. But, this convenience comesat a cost, not just financial but in theprice we pay by abdicating our resecto-scopic skills and reinforcing our depen-dence on these expensive and disposabledevices. As we have shown, morcella-tion is best-suited to the removal of rel-atively small endometrial polyps andleiomyomas in the lower 2/3 of theuterine cavity. Another shortcoming ofthese devices is that they require a mea-sure of cervical dilatability and, there-fore, are ill-suited for the removal ofpolyps in many elderly women, particu-lar those with a small, flush, andpyknotic uterine cervix. Well-con-trolled clinical trials comparing the hys-teroscopic morcellator and theresectoscope have not been accom-plished. From the author’s experience,HMs offer substantial safety, but areinefficient compared to a standard

resectoscope, in the removal of dense orcalcified myomas or those that aregreater 4 cm. Finally, the skills learnedusing hysteroscopic morcellation do notlend themselves to the wide array ofprocedures that can be accomplishedwith a standard resectoscope.

The gynecologic resectoscope, on theother hand, requires commitment to aslow and methodical learning process.The advantages are many—chief amongthem is the ease with which a resecto-scope can be adapted to managing a widevariety of intrauterine pathology, as wellas concomitant procedures such asendomyometrial resection. With theincorporation of ultrasound guidance,the resectoscope can also be utilized toremove many intramural leiomyomas,14as well as large submucous fibroids inexcess of 7 cm and up to 150 g. Therange of gynecologic resectoscopes—from 13–28 Fr—has allowed us to man-age intrauterine pathology in uteriranging from 40-400 cc. Gynecologistswho wish to learn resectoscopy areencouraged to attend post-graduatecourses and obtain one-on-one supervi-

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GynecologySURGICAL TECHNOLOGY INTERNATIONAL Volume 30

4a. Resectoscopic removal of fundally-attached submucous leiomyoma 4b. Resectoscopic removal of left lateral wall submucous leiomyoma.

a b

5a. Hysteroscopic morcellation of left lateral wall submucous leiomyoma. 5b. Hysteroscopic morcellation of fundally attached submucous leiomyoma.

a b

DISCUSSION

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sion with an experienced surgeon. Sincepatients do not present themselves inorder of increasing complexity, it isimportant to exercise wide discretionduring the patient selection process.The author recommends the insertionof small laminaria japonica the after-noon prior to surgery as this will easethe repetitive ICRRI cycle. For thosethat wish to advance their skills, the useof sonographic guidance is strongly rec-ommended. Our practice’s incorpora-tion of ultrasound guidance has reducedour perforation rate to 1 in 700 cases. Aclear advantage of resectoscopic surgeryis the ease with which concomitantendometrial ablation or endomyometri-al resection can be performed withoutthe use of additional equipment.

Conclusions

The development of resectoscopicskills will require a coordinated effort

by professional organizations, such asthe American College of Obstetricsand Gynecology and the AmericanAssociation of Gynecologic Laparo-scopists, as well as many others. Inaddition, major medical institutions,as well as residency training pro-grams, will need to develop teachingmodules. Unfortunately, many accom-plished resectoscopic surgeons haveretired while others are in the twi-light of their career. There have beentoo many examples within our spe-cialty that demonstrate the difficultyof resurrecting lost skills as we havebecome highly dependent on innova-tive and expensive technology. Timeis running out.

Author’s Disclosures

Dr. Wortman has no conflicts ofinterest to disclose.

References

1. Pantaleoni D. On endoscopic examination ofthe cavity of the womb. Med Press Circ1969.8:26–7.2. Goldrath MH. Vaginal removal of thepedunculated submucous myoma. Historicalobservation and development of a new proce-dure. J Reprod Med 1990;35:921–4.3. Neuwirth RS, Amin HK. Excision of sub-mucous fibroids with hysteroscopic control.Am J Obstet Gynecol 1976;126:95–9.4. Neuwirth RS. Hysteroscopic management ofsymptomatic submucous fibroids. ObstetGynecol 1983;62:509–11.5. Baggish MS, Brill AJ, Rosensweig BA, et al.Fatal acute glycine and sorbitol toxicity duringoperative hysteroscopy. J Gynecol Surg1993;9:137–43.6. Propst AM, Liberman RF, Harlow BL, et al.Complications of hysteroscopy surgery: Pre-dicting patients at risk. Obstet Gynecol2000;96:517–2.7. Corson SL. Hysteroscopic fluid manage-ment. J Am Assoc Gynecol Laparosc 1997;4:542.8. Isaacson K, Nardella P. Development anduse of a bipolar resectoscope in endometrialelectrosurgery. J Am Assoc Gynecol Laparosc1997;4:385–91.9. Loffer FD, Bradley LD, Brill AI, et al. Hys-teroscopic Fluid Monitoring Guidelines. J AmAssoc Gynecol Laparosc 2000;7:438.10. Munro MG. Capacitive Coupling: A Com-parison of Measurements in Four UterineResectoscopes. J Am Assoc Gynecol Laparosc2004;11:379–87.11. Loeffer FD. Preliminary experience withthe VersaPoint bipolar resectoscope using avaporizing electrode in a saline distentionmedium. J Am Assoc Gynecol Laparosc2000;7:498–502.12. Emanuel MH, Wamsteker K. The IntraUterine Morcellator: a new hysteroscopicoperating technique to remove intrauterinepolyps and myomas. J Minim Invasive Gynecol2005;12:62–6. 13. Haber K, Hawkins E, Levie M, et al. Hys-teroscopic morcellation: review of the manu-facturer and user facility device experience(MAUDE) database. J Minim Invasive Gynecol2015;22:110–4.14. Wortman M. Sonographically guided hys-teroscopic myomectomy (SGHM): minimiz-ing the risks and maximizing efficiency. SurgTechnol Int 2013;23:181–9.

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a cb

6a–c. Specimens demonstrating large quantities of tissue in women undergoing resectoscopic myomectomy and concomitant endomyometrial resection.

7c. Posterior wall intramural leiomyoma invagi-nates the endometrial cavity.

7a. Panoramic view of uterus with apparently nor-mal endometrial cavity.

a b

c d

REFERENCES

STI

CONCLUSION AUTHORS’ DISCLOSURES

7b. Resection of posterior endomyometrium depict-ing the unroofing of an intramural leiomyoma.

7d. Panoramic view of the uterus following com-plete removal of the entire endomyometrium alongwith posterior wall intramural leiomyoma.