Understanding the ISGE Guidelines for Hysteroscopic Myomectomy
- Dr. Reena Sherene
- 4 days ago
- 5 min read
What Is Hysteroscopic Myomectomy?
Hysteroscopic myomectomy is a surgical procedure that removes fibroids (myomas) from the uterine cavity using a hysteroscope—a thin, lighted tube inserted through the vagina and cervix. Unlike abdominal surgery, this approach avoids external incisions and allows direct visualization of the uterine cavity.
Fibroids that grow inside the uterine lining, called submucosal fibroids, often cause heavy menstrual bleeding, infertility, or recurrent pregnancy loss. Removing these fibroids can relieve symptoms and improve fertility.
Patient Selection According to ISGE
The ISGE guidelines emphasize careful patient selection to maximize benefits and minimize risks. Key criteria include:
Fibroid type and size: Submucosal fibroids classified as FIGO type 0, 1, or 2 are suitable for hysteroscopic removal. Fibroids larger than 4 cm or with significant intramural extension may require alternative approaches.
Symptom severity: Patients with abnormal uterine bleeding, infertility, or recurrent pregnancy loss linked to fibroids are ideal candidates.
Uterine anatomy: A normal uterine cavity without significant distortion or adhesions supports successful hysteroscopic surgery.
Patient health status: Patients should be fit for surgery, with no contraindications such as active pelvic infection or severe coagulopathy.
By following these criteria, surgeons can select patients who will benefit most from hysteroscopic myomectomy.
Preoperative Assessment and Preparation
Before surgery, the ISGE guidelines recommend thorough evaluation to plan the procedure effectively:
Imaging: Transvaginal ultrasound is the first-line tool to assess fibroid size, location, and type. Sonohysterography or MRI may be used for detailed mapping.
Endometrial preparation: In some cases, preoperative treatment with gonadotropin-releasing hormone (GnRH) analogs can reduce fibroid size and improve visualization.
Informed consent: Patients should understand the procedure, potential risks, benefits, and alternatives.
Anesthesia planning: General or regional anesthesia is preferred for patient comfort and surgical precision.
Proper preparation helps reduce complications and improves surgical outcomes.
Surgical Technique Highlights
The ISGE guidelines outline best practices for performing hysteroscopic myomectomy:
Equipment: Use a resectoscope with a bipolar or monopolar energy source, depending on surgeon preference and availability.
Distension medium: Normal saline is recommended with bipolar systems; glycine or sorbitol-mannitol solutions may be used with monopolar systems.
Stepwise resection: Remove fibroids in layers, starting with the protruding portion and progressing to the intramural part.
Hemostasis: Achieve bleeding control with careful coagulation and minimize fluid overload by monitoring distension medium absorption.
Avoid uterine perforation: Maintain clear visualization and gentle instrument manipulation.
Surgeons should be trained and experienced in hysteroscopic techniques to ensure safety.
Image caption: Eye-level view of hysteroscopic instrument inside the uterine cavity during myomectomy.
What are the 14 ISGE Recommendations?
Recommendation 1: The preoperative evaluation should start with detailed history and physical examination
Recommendation 2: Ultrasonographic examination should be offered to all patients with uterine LMs while MUSA terms, definitions and measurements are recommended to be used for the description of scanning and sonographic findings
Recommendation 3: For planning HM, evaluation of the uterus with SIS or combined assessment by TVUS and diagnostic hysteroscopy is recommended MRI evaluation is appropriate when ultrasound-based assessment faces its limitations
Recommendation 4: Proper informed consent has to be given to the patient explaining alternative therapeutic strategies, the potential risks of HM, eventual need for a second intervention, and the likelihood of LM recurrence
Recommendation 5: STEP W Classification to be used to predict complex HM
Recommendation 6: Preop treatment with GnRH analog not routinely required
Recommendation 7: For type 0 LMs, in addition to resectoscopy (slicing technique), morcellation is recommended, being faster and having a shorter learning curve with respect to resectoscopy
Recommendation 8: For type 1–2 LMs, slicing technique is recommended
Recommendation 9: No recommendation can be advanced concerning cold and thermal loop myomectomy for type 1-2 LM
Recommendation 10: Monopolar compared to bipolar type Menstrual symptom relief and reproductive outcome
Recommendation 11: The use of vaginal misoprostol prior to HM is not routinely recommended in order to reduce cervical trauma and perforation
Recommendation 12: Fluid deficit in saline bipolar: 1000ml
1000-2500ml : caution, stop if signs of embolism
>2500ml: terminate immediately
Recommendation 13: fluid deficit lower threshold: 750 mL
Elderly, comorbidities
Recommendation 14: routine Hyaluronic gel application after HM
Managing Complications
The guidelines provide strategies to prevent and manage common complications:
Fluid overload: Monitor fluid input and output carefully. Stop the procedure if fluid deficit exceeds safe limits.
Bleeding: Use coagulation and tamponade techniques. Severe bleeding may require conversion to laparotomy.
Uterine perforation: Recognize promptly and manage conservatively or surgically depending on severity.
Infection: Maintain sterile technique and consider prophylactic antibiotics in high-risk cases.
Early recognition and management of complications improve patient safety.
Postoperative Care and Follow-Up
After surgery, the ISGE recommends:
Observation: Monitor vital signs and fluid balance for several hours.
Pain management: Use nonsteroidal anti-inflammatory drugs or acetaminophen as needed.
Discharge instructions: Advise patients on signs of infection or bleeding and when to seek medical help.
Follow-up imaging: Ultrasound or hysteroscopy may be performed to assess uterine healing and detect residual fibroids.
Fertility counseling: Discuss timing for attempting conception if relevant.
Proper postoperative care supports recovery and long-term success.
Benefits of Following ISGE Guidelines
Adhering to these guidelines helps:
Improve surgical outcomes with higher rates of complete fibroid removal.
Reduce complications such as fluid overload and uterine injury.
Enhance patient satisfaction through clear communication and care.
Support fertility preservation and symptom relief.
Clinicians can use the ISGE framework to standardize care and improve quality.
ISGE Recommendations for Hysteroscopic Myomectomy
Indications for Hysteroscopic Myomectomy
Submucosal fibroids causing heavy menstrual bleeding or infertility.
Patients with symptomatic fibroids who desire to preserve fertility.
Women with fibroids that distort the endometrial cavity.
Preoperative Assessment
Comprehensive history and physical examination.
Ultrasound or MRI to evaluate fibroid location and size.
Assessment of uterine cavity using saline infusion sonography (SIS) or hysterosalpingography (HSG).
Technique
Use of appropriate hysteroscopic instruments for myomectomy.
Consideration of the size and number of fibroids for technique selection.
Utilization of energy sources (e.g., electrosurgery, laser) for fibroid resection.
Postoperative Care
Monitoring for complications such as bleeding or infection.
Follow-up evaluations to assess recovery and symptom relief.
Guidance on resuming normal activities and fertility considerations.
Complications
Potential for uterine perforation.
Risk of intrauterine adhesions (Asherman’s syndrome).
Bleeding and infection post-surgery.
Conclusion
Hysteroscopic myomectomy is a valuable procedure for managing symptomatic submucosal fibroids, particularly in women seeking to maintain fertility. Adherence to the recommendations by ISGE can optimize outcomes and minimize complications.
Hysteroscopic myomectomy has become a preferred surgical technique for treating submucosal fibroids, offering a minimally invasive option with faster recovery and fewer complications. The International Society for Gynecologic Endoscopy (ISGE) has developed comprehensive guidelines to help gynecologists perform this procedure safely and effectively. These guidelines provide clear recommendations on patient selection, surgical technique, and postoperative care, aiming to improve outcomes and reduce risks.
This article explores the key points of the ISGE guidelines on hysteroscopic myomectomy, breaking down the recommendations into practical insights for clinicians and patients alike.
Final Thoughts
The ISGE guidelines on hysteroscopic myomectomy offer a clear, evidence-based roadmap for treating submucosal fibroids safely and effectively. By selecting appropriate patients, preparing thoroughly, following meticulous surgical techniques, and managing complications proactively, surgeons can achieve excellent results.
For patients, understanding these guidelines can help set realistic expectations and encourage informed discussions with their healthcare providers. If you or someone you know is considering hysteroscopic myomectomy, ask your doctor how these recommendations apply to your care.
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