Postoperative evaluation of the uterus after hysteroscopic versus Laparoscopic myomectomy of type 1 and type 2 submucous myomas

Myomectomy of submucous broids is usually performed using hysteroscopic approach. The reproductive performance of women after removal of submucous myomas is much better in type 0 more than type 1 and 2. This conict result might be due to harmful effect of hysteroscopy on the endometrium and inadequate healing. The objective of the cohort study was to evaluate the uterus after myomectomy using 2 surgical approaches. Both hysteroscopic and laparoscopic myomectomy were used. Methods: A total of 74 patients with submucous broids were recruited and were randomly divided equally into 2 groups. Group (1) included those in whom laparoscopic myomectomy was done while in group (2) the hysteroscopic myomectomy was used. The hysteroscopic myomectomy was done using the standard techniques using the resectoscope with wire loop. The laparoscopic method was also done using the standard techniques. Results: The duration of surgery was longer in group one and signicant decrease in hemoglobin level in group one. Postoperative hysteroscopic evaluation of the uterus showed better endometrial thickness, interface and normal myometrium denoting normal uterine cavity in group (one) when compared with group (two). The complication rate was comparable in both groups. Conclusion: Surgical treatment of type 1 and 2 submucous broid is feasible by both hysteroscopic and laparoscopic approaches. The laparoscopic approach had better postoperative endometrium and myometrium, fewer days of postoperative uterine bleeding and better functioning endometrium.


Introduction
Submucous myoma (SM) is one of the commonest indications of myomectomy in clinical practice. It can result in many symptoms and complications including pain, bleeding and infertility. [1]Types of SM myoma include type zero; one and two. [2] Excision of the submucous myoma could be performed by hysteroscopic or laparoscopic approaches. The choice is usually guided by type of the submucous myoma and its size. Type zero SM myoma is usually removed by hysteroscopic approach while in type1,2 SM myomas hysteroscopic approach might not be the best option. [3] Use of hysteroscopy for management is easy, minimally invasive and successful but might be associated with bleeding, uid overload and incomplete removal. [4,5]Moreover, reproductive function of the uterus after hysteroscopic myomectomy (HM) is questionable. [6,7] Aim of the work The objective of the cohort study was to evaluate the uterus after management of submucous broid type one and type two using two different surgical approaches. In this study either laparoscopic (group one) or hysteroscopic (group two) myomectomy was used as surgical management for submucous myomas type I and II.

Ethical approval
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 veri cation 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 [1] The endometrium and muscle layer were then sutured using one or two layered separate intracorporeal sutures using vicryl 1/0 whenever indicated to con rm 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, in ation and de ation 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 de cit 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. [8] Results Total, 74 patients with type I and II submucous myoma were included in this study. Type I submucous myoma were 42 cases of the study group (56.8%) and type II submucous myoma were 32 cases of the study group (43.2%).
Comparison between both groups as regards demographic data, number of myomas, volume of myomas and type of myomas. The number of sessions, duration of surgery, percent decrease in hematocrit level as well as delayed follow up included endometrial thickness. Both groups were matched in age, parity, BMI and mean diameter of myoma Table (1) Comparison of the differences in the general data between the two groups showed no statistical signi cance (Table 1).  Table 1) General data between the two groups showed no statistical signi cance The operative duration was shorter in the group two than group one (P<0.05) although the second group needed more sessions to complete the hysteroscopic myomectomy.
The six hours postoperative hematocrit level was less in the rst group denoting signi cantly more blood loss in the rst group (P<0.05). The hematocrit that was done one week after the surgery was signi cantly less in the second group than rst group denoting signi cantly more blood loss in the second group in the early postoperative period (P<0.05). The endometrium measured in the rst group had signi cant more thickness than in the second group.  Table (2) comparison between both groups for operative parameter The complication took place in 9 cases out of 37 in group one (24.3 %) while in the second group complications comprised 4 cases out of 37 (10.8 %).

Discussion
The main target in this study was to assess the laparoscopic management of the SM type I and II in comparison to the standard hysteroscopic approach. Many pros and cons were found in each approach. [9]There is no simple answer to the question wondering which is better? Although data from this study suggested the advantage of laparoscopic approach in the women wishing to preserve fertility.
The endometrium thickness was larger in group one than in group two and this nding was expected as the laparoscopic myomectomy preserve the endometrium while in hysteroscopic myomectomy removed part of the endometrium is proportionate to the size of the myoma. [10] The blood loss in the rst group was higher intraoperative and minimal postoperative while in group two intraoperative blood loss was small but it continued for longer period postoperatively that resulted in comparable hemoglobin level in both groups after one week of the surgery. These data are in accord with other trials to evaluate the blood loss during hysteroscopic myomectomy. [11,12] Operative hysteroscopy still the standard surgical approach of choice and the accepted treatment for submucous myomas. Many studies reported the impact of submucous myoma and subfertility and high pregnancy wastage rate. The improvement in both indications after myomectomy is also addressed. However, the role of the myomectomy of submucous myoma and its secondary outcome remain controversial. [9,13] Although many studies addressed the possibility of laparoscopic myomectomy of large submucous broid but no clear conclusion about fertility and pregnancy outcome after hysteroscopic and laparoscopic approaches could be found. [14,15] Unfortunately, we were not able to do o ce hysteroscopy for most but not all patients postoperatively. Evaluation of the myometrium and the endometrium using transvaginal ultrasound after 2-3 months was done. This study is the rst to evaluate between postoperative uterine cavity evaluation using 2 approaches of endoscopic myomectomy.

Conclusion
Both laparoscopy and hysteroscopy are effective methods to do successful myomectomy for type I and II. Use of laparoscopy has advantage of single session surgery and better endometrium for future