Analiza comparativă între sistemul de rezecție tisulară histeroscopică și rezectoscopul bipolar în miomectomia histeroscopică: experiența Clinicii II de Obstetrică-Ginecologie din Târgu Mureș, România, 2019-2026

1. Introduction

Uterine myomas are common benign tumors in reproductive-age women, often causing heavy menstrual bleeding, dysmenorrhea, pelvic pain and infertility. These symptoms significantly impact quality of life, sexuality and employment⁽¹⁾. According to the International Federation of Gynecology and Obstetrics (FIGO), there are seven types of uterine myoma, based on their relationship to the endometrium and/or serosa. There are three types of submucous myoma: G0 is pedunculated intracavitary, G1 is less than 50% intramural, and G2 is more than 50% intramural⁽²⁾. Hysteroscopy is a minimally invasive technique used for the diagnosis and treatment of G0-G2 uterine myomas⁽²⁾. The bipolar resectoscope is effective for hysteroscopic myomectomy and offers safety benefits over the monopolar resectoscope, avoiding risks such as hyponatremia and electrical burns⁽³⁾.

Bipolar resectoscopy has several disadvantages: a suboptimal view caused by gas bubbles and swirling tissue chips, and the need to remove these chips by reinserting the hysteroscope or using additional instruments, which increases the risk of uterine perforation and cervical lacerations⁽⁴⁾.

The Hysteroscopic Tissue Removal system (HTR), introduced in 2005, integrates cutting and aspiration to facilitate the removal of endometrial polyps or submucous myomas, utilizing saline as a continuous-flow irrigation solution. The HTR comprises two metal, hollow, rigid and disposable tubes that are compatible with 5-9 mm hysteroscopes. Compared to bipolar resectoscopy, this technique offers several advantages. Firstly, mechanical cutting eliminates lateral electrical damage to adjacent intrauterine tissue. Secondly, the absence of gas bubble formation during device activation enhances visualization and may reduce the risk of gas embolism. Thirdly, continuous aspiration of tissue fragments during hysteroscopic morcellation maintains a clear operative field and enables immediate collection for histological analysis^(5,6). This study compares myomectomy outcomes using one HTR device and bipolar resectoscopy, focusing on procedure duration, success rate, and complications.

2. Materials and method

This was a retrospective study conducted at the Second Obstetrics and Gynecology Clinic, Târgu Mureș, Romania, between May 2019 and May 2026. The inclusion criteria were: patients with uterine myoma type G0, G1 or G2 who underwent at least one hysteroscopic myomectomy with the HTR device or bipolar resectoscope during the specified period. The exclusion criteria included patients who had undergone classical or laparoscopic myomectomy, those with suspected malignancy, untreated cervical stenosis, or any contraindication to operative hysteroscopy. This study received approval from the ethics committee of the Second Obstetrics and Gynecology Clinic in Târgu Mureș.

After the application of the inclusion and exclusion criteria, 35 patients were identified during the analyzed period: 14 underwent myomectomy with the HTR device and 21 with the bipolar resectoscope. For preoperative classification of myomas, we used the 2018 FIGO classification of uterine myomas, based on preoperative pelvic ultrasound findings documented in the patients’ medical records⁽²⁾. Abnormal uterine bleeding was diagnosed according to the FIGO Abnormal Uterine Bleeding (AUB) System 1 from 2005⁽⁷⁾. In this study, infertility was defined as the inability of a couple to achieve pregnancy after 12 months of unprotected sexual intercourse⁽⁸⁾.

Hysteroscopic myomectomy was performed by surgeons with comparable levels of experience. The procedures were conducted under either spinal or general anesthesia. A dose of 200 micrograms of misoprostol was administered vaginally for cervical ripening three hours prior to surgery. Antibiotic prophylaxis was provided in accordance with local protocols.

Hysteroscopic myoma resection was performed using a rigid 8.5 mm bipolar resectoscope with a 0⁰ optic. The slicing technique was used for resection⁽⁹⁾. Hysteroscopic morcellation was performed using a hysteroscopic tissue removal device equipped with a 0⁰ optic and a 9-mm sheath and using the 4.0 reciprocating blade. The morcellation technique followed the protocol previously described by van Wessel et al. (2021)⁽⁴⁾. For both procedures, the hysteroscope was inserted into the uterine cavity following cervical dilation with Hegar dilatators up to 9 mm. Normal saline served as the distention and irrigation medium for the uterine cavity. Hysteropump was set to a maximum pressure of 100 mmHg and a maximum flow of 400 ml/min for both procedures⁽¹⁰⁾. Fluid balance was monitored by measuring the difference between fluid consumption and aspiration.

The total procedure duration was calculated by summing the time required for the actual operation and the time needed for the bipolar hysteroscope and HTR setup. After the myomectomy, all patients were observed for 24 hours.

Statistical analysis was conducted using GraphPad Prism version 11 (GraphPad Software, Boston, MA, USA). Descriptive statistics included means, frequencies and percentages for qualitative variables. The Shapiro-Wilk test assessed data normality, while the chi-square or Fisher test evaluated associations among qualitative variables. Statistical significance was set at p<0.05.

3. Results

Our study found no statistical differences in age (p=0.22) or symptoms between the two groups (p>0.99). No differences were observed in the number, size, type or location of fibroids between the two patient groups. Table 1 presents demographic data, as well as the number, size, type and location of fibroids.

The analysis of the total procedure time, including assembly of the bipolar hysteroscope and HTR device, revealed no significant differences. However, myomectomy performed with HTR device was significantly faster than with the bipolar resectoscope (p=0.02). There was no significant difference between the two devices in the rate of complete fibroid removal. Table 2 presents data on operating time and myomectomy completion rate.

The reason for unsuccessful outcomes varied between the two techniques. Among patients who underwent HTR, myomectomy was completed with the resectoscope in two cases (14.28%) due to the hardness of the fibroids. In the resectoscope group, the procedure was discontinued in one patient (4.76%) after exceeding one hour of operation. This difference was not statistically significant (p=0.55).

No complications were observed during the myomectomies or in the first 24 hours after the myomectomies, regardless of the technique used.

Abbreviations: cm – centimeter, n – number

Abbreviations: min – minute, n – number, SD – standard deviation

4. Discussion

Foth et al.⁽¹¹⁾ report that 54.3% of women experience myoma-related symptoms. The four primary symptoms identified are heavy menstrual bleeding (40.7%), dysmenorrhea (28.2%), lower abdominal pain (14.9%) and intermenstrual bleeding (14.1%). In most cases, these symptoms occur simultaneously. The presence of symptoms does not follow a clear age-related trend; however, both the number and size of myomas are significant determinants. The submucosal location of myomas is the main factor influencing the occurrence of intermenstrual bleeding⁽¹¹⁾.

In our study, no significant differences in patients’ age were observed between groups (p=0.22). Similarly, van Wessel et al.⁽¹²⁾ and Valero et al.⁽¹³⁾ did not observe significant differences in patients’ age among those who underwent hysteroscopic myomectomy with either device. There were no statistically significant differences in symptoms between the two patient groups. Abnormal uterine bleeding was the predominant symptom in our groups, occurring in 84.61% of patients in the HTR device group and in 63.15% in the resectoscopy group. Also, abnormal uterine bleeding was identified as the most frequently encountered symptom in van Wessel et al. study⁽¹²⁾. An explanation of abnormal uterine bleeding in fibroid uteri is impaired venous drainage and endometrial vascular ectasis, secondary to increased intramural pressure⁽¹⁴⁾.

In our patient groups, G0 type fibroids were the most common, followed by G1 and G2 types. There were no statistical differences between the groups in the frequency of these types of fibroids (p>0.99). Van Wessel et al.⁽¹²⁾, Valero et al.⁽¹³⁾ and Hamidouche et al.⁽¹⁵⁾ found no differences between the groups in the type of fibroid based on the FIGO classification.

In both groups, most operated fibroids measured 1 to 3 cm, and no statistically significant difference was observed between the groups. Scheiber and Chen⁽¹⁶⁾ performed hysteroscopic myomectomy using HTR device for fibroids measuring 2.2±1.2 cm, with a complete fibroid removal rate of 86.8%. In contrast, among our patients who underwent surgery with HTR device, the complete fibroid removal rate was 71.42%. The lower rate of complete fibroid removal with the HTR device in our group compared to Scheiber and Chen study can be explained by the percentage of 14.2% type G2 fibroids in our group, whereas Scheiber and Chen did not report the percentage of type G2 fibroids in their group.

In our cohort treated with the bipolar resectoscope, the complete fibroid removal rate was 80.95%. This rate did not differ significantly from the complete removal rate observed with the HTR device in our cohort. Valero et al.⁽¹³⁾ reported similar findings in their prospective study involving 80 patients. Ren et al.⁽¹⁷⁾ reported no significant difference in success rates between HTR devices and conventional resectoscopy in their meta-analysis.

Regarding the location of fibroids in our cohort, a third were located on the anterior uterine wall, with no significant difference observed between patient groups (p>0.99). Scheiber and Chen⁽¹⁶⁾ reported a significantly more diverse distribution of fibroid locations, with only one quarter situated on the anterior uterine wall.

In our study, 92.85% of patients in the HTR group and 85.71% of patients in the bipolar resectoscopy group presented with a single G0, G1 or G2 fibroid. No statistically significant differences were observed between the groups (p=0.63). Comparable results were reported by van Wessel et al.⁽¹²⁾ and Valero et al.⁽¹³⁾

Regarding the time required to perform the procedure, consisting of the time required to assemble the devices and the time required to perform the myomectomy itself, it was shorter in the HTR group, but without being statistically significant (18.61 ± 6.14 minutes versus 25.79 ± 11.48 minutes; p=0.0507). Van Wessel et al.⁽¹²⁾ also found no statistical differences in the time required to perform the procedure (p=0.18), but the time required to perform myomectomy was statistically significantly shorter in the HTR group (p=0.006), and the time required to assemble the devices was not statistically significant (p=0.04). However, in our study, myomectomy performed with the HTR device was significantly faster than with the bipolar resectoscope (p=0.02). Also, van Wessel et al.⁽¹²⁾ found that myomectomy with HTR remained faster than resectoscopy after adjusting for myoma diameter. On the contrary, Valero et al.⁽¹³⁾ found longer myomectomy times, though not statistically significant, with HTR (13.43 ± 10.53 minutes versus 16.84 ± 11.11 minutes; p=0.129). Ren et al.⁽¹⁷⁾ reported that hysteroscopic morcellation results in shorter procedure and operative times for patients with endometrial lesions including submucous myoma, compared to resectoscopy.

In two cases (14.28%) within the HTR group, we converted the procedure to conventional resectoscopy because of the myoma’s hardness. The conversion percentage observed in this study was higher than that reported by van Wessel et al.⁽¹²⁾ (4%), which may be attributed to the smaller sample size in the HTR group.

We observed no complications during myomectomies performed with either device. In contrast, van Wessel et al. reported adverse events in three patients within the HTR group, including a fluid deficit exceeding 2500 mL requiring potassium supplementation, an asystolic vasovagal response following conversion to resection, and postoperative fever necessitating antibiotic treatment.

A strength of this research is its status as the first study in Romania to compare the success rates of hysteroscopic myomectomy performed with the HTR device to those achieved with bipolar resectoscopy. The limitations of this study include its retrospective design and its small sample size.

A practical implication of this study is that, where available, the HTR device represents a safe and efficient option for hysteroscopic myomectomy.

5. Conclusions

Although the HTR device has certain limitations, such as difficulty with myoma hardness, it remains a rapid and safe option for hysteroscopic myomectomy.

This work is permanently accessible online free of charge and published under the CC-BY.

Corresponding author: Mihai Muntean E-mail: munteanmihai@yahoo.com

Conflict of interests: none declared.

Financial support: none declared.