This study was approved by the Institutional Ethics Committee of Alexandria Maternity University hospital and written informed consent was obtained from all participants.
Patients with type II submucous myoma who were treated at Alexandria Maternity University hospital and Agial Specialized Center from October 2016 to December 2019 were assigned to complete history taking, clinical examination, and imaging study.
Transvaginal ultrasound was done and verification of the type of the submucous myoma using 3D transvaginal ultrasound and/or saline sonohysterography was done. Routine lab investigations were done for all cases included complete blood count, urine analysis, prothrombin activity, hepatitis viral markers, liver enzymes, and renal function. The patient allocation in either groups was done using an online randomizer (random.org) to select either laparoscopy or hysteroscopy approach. The inclusion criteria include any case with single submucous myoma type I or type II of any size although our maximum diameter of myoma in our study group did not exceed 6 cms in diameter. The distance between the edge of the myoma and the serosal surface (myometrium above the myoma) was >5mm. Informed consent was taken from every patient before recruitment and all cases of hysteroscopy group were counselled about the possible need for more than one session of hysteroscopy to complete the myomectomy. All our patients wished to maintain their fertility and therefore preservation of the uterus was decided. The exclusion criteria included severe heart, liver, or kidney dysfunction; multiple myomas; a cervical neoplasm, broad ligament myoma, severe uncorrected anemia less than 9 gm/dl.
Laparoscopy group: Laparoscopic myomectomy (LM) was done in the group (1). After inducing general anesthesia, a conventional puncture was performed to induce pneumoperitoneum with a carbon dioxide pressure of 12 to 14 mmHg. Four ports were established in the abdomen for placement of the surgical equipment. Injection of 10 ml of diluted epinephrine hydrochloride containing 20 mcg was done in the capsule of the myoma. The capsule over the tumor was incised using monopolar hook, traction and countertraction was done using grasping forceps to separate the tumor from its bed. We used selective cauterization of the bleeding vessels in the myometrium or bed of the myoma. Figure 
The endometrium and muscle layer were then sutured using one or two layered separate intracorporeal sutures using vicryl 1/0 whenever indicated to confirm strict hemostasis and to ensure sound healing. Finally, all ports were sutured using subcuticular sutures.
Hysteroscopy group (2): Hysteroscopic myomectomy (HM) was done as follows: Under general anesthesia, the patient was placed in lithotomy position for exploration of the uterine cavity after dilatation of the cervical canal. The resectoscope was placed in the uterine cavity to observe the relationship among the position and size of the myoma and intima of the uterine cavity. A loop monopolar electrode was used to remove the myoma into ships and removed from the uterine cavity Figures [2, 3]. During this procedure, inflation and deflation of the uterus using the distension media (Glycine 1.5% solution) was done to encourage the remaining part of the myoma to bulge into the uterine cavity and remove it also in the same manner. The procedure was interrupted only if the deficit of glycine reached 1200ml. The patient was assigned for another session to remove the rest of the submucous myoma after 1-2 months. Intrauterine device was inserted in 12 cases out of 37 (32.4%) as the endometrium showed signs suggesting endometritis and the raw area was large to prevent intrauterine adhesions.
The postoperative observation of the hematocrit was ordered twice 6 hours postoperative and the second test was 6 days after the procedure to assess the blood loss during the surgery and early postoperative period. A follow up transvaginal ultrasound was done after 3 months to assess the endometrial thickness during late follicular phase and the thickness of the myometrium in the site of previous myoma.