Post on 10-Feb-2018
Rudi Campo MDLeuven Institute for Fertility and Embryology
LIFELeuven - Belgium
Fibroids
Fibroids and IVF outcome
1 Scientific evidence
2 Diagnostic strategy
3 Hysteroscopic surgery
4 Laparoscopic surgery
Effect of Uterine Fibroids on IVF Outcome
Subserosal
- Fahri 1995 normal- Elder-Garcia 1998 normal- Healy 2000 normal- Oliveira 2004 normal
Subserosal myoma seems not to influence
the IVF outcome
Effect of Uterine Fibroids on IVF Outcome
Submucosal
- Fahri 1995 decreased- Elder-Garcia 1998 decreased- Healy 2000 decreased - Shokeir (PRCT) 2010 decreased
Scientific evidence that Submucosal myoma interferes negatively with the success rate
First statement
If a myoma protrudes in the uterine cavity it is likely to interfere with the reproductive outcome
Conservative resection of submucosal myoma is recommended prior to any ART procedure
Intra mural myoma The Problem
Intra mural myoma are myomas completely surrounded by muscular wall of the uterus however they vary in size number and distance to the endometrial cavity
The effect of intramural fibroids on fertility and outcome of IVF treatment remain poorly understood
A new approach is necessay
Effect of Intra mural fibroids on IVF
MRI has demonstrated the clinical significance of the myometrial architecture
Junctional zone
small central zone of increased density
IMPORTANT IN REPRODUCTION
Submucosal myoma
Outer myometrium
Larger outer hypodenser zone
Subserosal myoma
Less cytogenetic abnormalities
Pattern of vascularisation
Expression of SSH receptors
More responsive to GnRH analogue
Fewer recurrences after surgery
Submucosal Uterine Fibroidsdiffers from subserosal fibroids
Literature showing conflicting results for IVF outcome in patients with intramural myoma
Fahri 1995 normal
Stovall 1998 decreased
Elder-Geva 1998 decreased
Ramzy 1998 normal
Healey 2000 decreased
Hart 2001 decreased lt 5 cm
Surrey 2001 normal
Check 2002 probably decreased
Ajayi 2003 decreased
Oliveira 2004 normal if lt 4cm
Bulleti 2004 decreased
Pritts 2009 decreased
Effect of INTRAMURAL myoma
Studies are inconclusive due to lack of correct documentation of size amount and localisation Study design is mostly retrospective
Questions are bull Does a myoma originating from the JZ myometrium
but with no penetration into the uterine cavity influences the reproductive outcome
bull If so is their a cutt of in size and amount of myoma
Q1 Scientific evidence
The effect of intramural fibroids without uterine cavity involvement on the outcome of IVF treatment a systematic review and meta-analysis
19 observational studies comprising 6087 IVF cycles were included
Sunkara SK Khairy M El-Toukhy T Khalaf Y Coomarasamy AHum Reprod 2010 Feb25(2)418-29
Effect of INTRAMURAL myoma
The presence of non-cavity-distorting intramural fibroids showed a significant decrease in the
live birth (RR = 079 95 CI 070-088 P lt 00001) clinical PRs (RR = 085 95 CI 077-094 P = 0002)
in women with non-cavity-distorting intramural fibroids compared with those without fibroids following IVF treatment
Q2 Size and amount
Fibroids not encroaching the endometrial cavity and IVF success rate a prospective study
Somigliana E De Benedictis S Vercellini P Nicolosi AE Benaglia L Scarduelli C Ragni G Fedele LSmall Myoma no influence
Hum Reprod 2011 Apr26(4)834-9
Q2 Size and amount
Fibroids not encroaching the endometrial cavity and IVF success rate a prospective study
In asymptomatic patients selected for IVF small (less than 05 cm) fibroids not encroaching the endometrial cavity did not impact on the rate of success of the procedure
There was no significant relationship between clinical outcome and either the number or size of the fibroids
Q2 Size and amount
Those findings are in conflict with the findings of Khalaf et al 2006 who also studied the effect of small intramuralUterine fibroids
IVF ICSI results in 322 women without fibroids and 112 with fibroids in 606 cycles were studied
Live birth rate in the study group was significantly lower (plt005) and the cumulative live birth rate was reduced by 47
Second statement
It is not yet very clear when non-cavity-distorting intramural fibroids will influence the pregnancy outcome in IVF
Myoma mapping seems mandatory to document the relation to the JZ myometrium
Intra mural myoma should be classified either to the submucous or sub serosal group
The diagnostic strategy is challenged
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Hysteroscopic surgery
4 Laparoscopic surgery
What do we have to know
1 Cavity involvement
2 Number of myomata
3 Size and location
Proper diagnosis of fibroids
Ultrasound
Fluid Mini-Hysteroscopy
Kontrast sonography
One Stop Uterine diagnosis
Proper diagnosis of fibroids
Ultrasound
Hysteroscopy
Contrast sonography
Overview of set up
Supplemantary exams necessary
When
1 dd adenomyoma ndash myoma
2 Multiple myoma
3 Diffuse enlargement of uterine wall
How
1 NMR imaging (3D US )
2 Hysteroscopic Myometrial exploration
LIFE vzw Leuven Institute for Fertility amp Embryology
Findings at MRI JZ Myoma
LIFE vzw Leuven Institute for Fertility amp Embryology
Allocation of Myoma to OM or JZM
LIFE vzw Leuven Institute for Fertility amp Embryology
MRI for diagnosis of Adenomyosis and Adenomyoma
Loss of differentiation JZ - OM
Normal
LIFE vzw Leuven Institute for Fertility amp Embryology
Enlarge the hysteroscopic diagnosis with
exploration of JZ myometrium
Trophy Hysteroscope acc to Campo
New generation of hysteroscope with interesting characteristics
named after the multicentre study TROPHY ldquoTrial of Outpatient
Hysteroscopyrdquo for which it was designedEl-Toukhy T Campo R et al Trial of Outpatient Hysteroscopy ndash (TROPHY) in IVF Reprod Health 2009 Dec 3620
Spirotome acc to Gordts
A device made to harvest high quality samples from soft tissues
built on the pioneering concept of a cutting helix on a cutting cannula
New Tools for exploration of the JZ myometrium
Trophy Scope 29 mm compactscope with Innovative gliding mechanism for accessory sheets
Can be loaded with accessory sheets which can be activated in case of necessity by gently push on the bottom and forward movement till locking in the active position supplementary functions are available without the need to remove the hysteroscope
Trophy Scope Diagnostic accessory sheet
In active positionAtraumatic cervical dilatation up to 37 mm under visual controlCreating double flowBlocking of cervix in case of passive outflow
In free positionSuction device for endometrial samplingGuide for ultrasound guided intrauterine procedures like positioning Embryo
transfer catheter or for Spirotome endomyometrial biopsy
active freepassive
Trophy Scope Operative accessory sheet
In passive position
Operative sheet does not interfere
the diagnostic phase (29mm)
In active positionAtraumatic cervical dilatation
up to 44 mm under visual control
Creating double flow and blocking
function in case of passive outflow
Introduction of 5 Fr instruments without
compromising inflow
A device made to harvest high quality samples from soft tissues
It is built on the pioneering concept of a cutting helix on a cutting
cannula well identified by Ultrasound
Spirotome acc to Gordts
Spirotome
The sample is harvested by turning the helix into the diseased area under
direct vision or ultrasound guidance The cannula turns subsequently over the
helix to free the sample from the surroundings
Spirotome myometrial biopsy
HSC post spirotome biopsy
Spirotome myometrial biopsy
Trophy Scope - Spirotome - US
Guide for ultrasound guided
Spirotome endomyometrial biopsy
cutting helixcutting cannula
Trophy Scope ndash Spirotome - Ultrasound
Exploration of JZ myometrium with Trophy hysteroscope
Resection intramural myoma
Resection adenomyoma
Resection adenomyoma
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Conventional hysteroscopic surgery
4 Laparoscopic surgery
Conventional Hysteroscopic Surgery
TYPE 0 TYPE 1 TYPE 2
The ESGE classificationof submucous myomas
Size volume = 43r3
bull2 cm ~ 42 cm3 8 min
bull3 cm ~ 141 cm3 28 min
bull4 cm ~ 335 cm3 67 min
Emanuel MH et al Fertil Steril 199768881-6
Operating time of critical importance
Reduction in volume of the fibroidsby GnRH-a therapy
Distension fluid
Monopolar surgery using non-ionic solutions
sa manitol sorbitol or glycine has higher risk of
side effects due to fluid overload effect
Stop surgery as soon as 1 L of fluid losses
Bipolar surgery using ionic solutions (saline)
Isotonic hyperhydration is less dangerous
In young patients up to 4 L of losses can be
accepted
Hysteroscopic Myomectomy
Always use a pressure and flow controlled pump system to work at minimal necessary pressure
Always perform continuous fluid balance independently of the medium used
Hysteroscopic Myomectomy
Operative Hysteroscopy Resectoscope Uni or Bipolar
Non ionic fluid
Unipolar polyp and myomaresection
Ionic fluid
First generation Bipolar (Versapoint)
Loop is smaller
chips are smaller
Longer OR time
Bipolar cautery induces
more bubbles
Bipolar resectoscope new generation
low-energy
Two or more small active electrodes very close to each other (active and return electrode)
bull Use Saline as distention medium
bull limited spread of electrical effect the current flow is essentially limited to a small area and it requires less voltage less risk for adhaesion formation
bull Loop different shape and size Different surgical
manoeuvres
bull Need of Modern generator
Bipolar resectoscope new generation
Storz bipolar resectoscope new generation
Return electrode opposite
side
Larger active electrode
Minimal gas bubbles
production
Less risk of perforation
Different surgical technique
Bipolar hysteroscopic myomectomy
Hysteroscopic Myomectomy
Long-term results depend on
bull Uterine Size (Plt0001)
bull Number of myomas (Plt0001)
The surgery-free percentage of 165 patients with normal sized uteri and not more than two
myomas was 943 (+- 18) at 2 years and 903 (+- 30) at 5 years
bull Type ( intra-mural part)
bull Size of myoma (significant increase of amount of particles between 2 and 3 cm)
Long-term results depend on the presence of concomitant pathology
or is a result of incomplete surgery
Emanuel MH Wamsteker K Obstet Gynecol 1999 May93743-8
Third Statement
1 Junctional Zone Myoma should preferentially be treated by hysteroscopy
2 Feasibility of hysteroscopic surgery is predominantly related with size location and amount of myoma
3 Independently of distension medium used continuous fluid balance and flow distension control is mandatory
4 Complication risk is related to experience and surgical technique used
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Conventional hysteroscopic surgery
4 Laparoscopic surgery
Introduction
Intramural myoma larger than 4 cm related to the JZ myometriumschould be operated on
Laparoscopic approach has had an important evolution over the
years
Series with high success rate are done by experts =gt it is difficult to extrapolate to less experienced surgeons
Laparoscopic myomectomy needs expert skills in haemostasis dissection and suturing
How to minimize blood loss
bullA lot of techniques in order to minimize blood loss
GnRH agonists
Intramyometrial vasopressine
Oxytocin IV 40 mUImin intraoperatively
Use of tourniquet or penrose at the lower part of uterus
Laparoscopic Myomectomy
J Ferro IVI Valencia Spain
Tips amp tricks ndash minimize blood loss
Clipping of the uterine arteries and infundilopelvic ligaments is another very efficient method
Artery ligation versus Control group (n=152)
173 +- 91 mL vs 402 +- 131 mL blood loss
62 vs 2075 reccurence rate
Alborzi S et al A comparison of combined laparoscopic uterine artery ligation and myomectomyversus laparoscopic myomectomy in the treatment of symptomatic myoma Fertil Steril 2009
Tips amp tricks ndash minimize blood loss
Technique Incision
Incision
J Ferro A Wattiez
Tips amp tricks- dissection
Tips amp tricks- closure
bull One versus multiples layers controversial
bull Adequate closure of the dead space to minimize the risk of hematoma formation
bull Interrupted figure of eight sutures are usually sufficient monocryl 1 or 0 with extracorporeal notes =gt extra strength
bull For the serosa approximate with interrupted 20 sutures if necessary (monofilament)
Tips amp tricks- closure
Removal Clips
Anti- adhesion agents
Fourth Statement
LAPAROSCOPIC MYOMECTOMY offers comparable results tolaparotomic myomectomy
Laparoscopic approach reduces adhesion formation blood loss and hospital stay
Laparoscopic myomectomy seems indicated in the infertile patient for the treatment of intramural myomarsquos
Laparoscopic Myomectomy requires a skilled laparoscopic surgeon with expert suturing skills optimal instrumental support and knowledge of some trickrsquos to provide an optimal result
Take Home message
Submucous myoma should always be removed prior to IVF
Hysteroscopic resection is the gold standard to treat those myoma
Intramural myoma originating from the sub endometrial
myometrium and larger than 4 cm are treated by Laproscopy
Subserosal myoma do not influence the outcome of IVF and are not removed for this indication
More info on the special training
programsin endoscopic
surgery
ESGEORG
More info on the ESGE website
wwwesgeorg
See you in London
Rudi Campo Stephan GordtsPatrick PuttemansRoger MolinasSylvie GordtsMarion Valkenburg Ivo Brosens
Leuven Institute for Fertility
amp Embryology
Trophy Scope a new generation
Interesting Characteristics
Gliding system that provides
Diagnostic ( 29 mm ) and
Operative (44 mm)
possibilities in one instrument
This hysteroscope has been named after the multicentre study
TROPHY ldquoTrial of Outpatient Hysteroscopyrdquo for which it was designed
El-Toukhy T Campo R et al Trial of Outpatient Hysteroscopy - [TROPHY] in IVF Reprod Health 2009 Dec 3620
Fibroids and IVF outcome
1 Scientific evidence
2 Diagnostic strategy
3 Hysteroscopic surgery
4 Laparoscopic surgery
Effect of Uterine Fibroids on IVF Outcome
Subserosal
- Fahri 1995 normal- Elder-Garcia 1998 normal- Healy 2000 normal- Oliveira 2004 normal
Subserosal myoma seems not to influence
the IVF outcome
Effect of Uterine Fibroids on IVF Outcome
Submucosal
- Fahri 1995 decreased- Elder-Garcia 1998 decreased- Healy 2000 decreased - Shokeir (PRCT) 2010 decreased
Scientific evidence that Submucosal myoma interferes negatively with the success rate
First statement
If a myoma protrudes in the uterine cavity it is likely to interfere with the reproductive outcome
Conservative resection of submucosal myoma is recommended prior to any ART procedure
Intra mural myoma The Problem
Intra mural myoma are myomas completely surrounded by muscular wall of the uterus however they vary in size number and distance to the endometrial cavity
The effect of intramural fibroids on fertility and outcome of IVF treatment remain poorly understood
A new approach is necessay
Effect of Intra mural fibroids on IVF
MRI has demonstrated the clinical significance of the myometrial architecture
Junctional zone
small central zone of increased density
IMPORTANT IN REPRODUCTION
Submucosal myoma
Outer myometrium
Larger outer hypodenser zone
Subserosal myoma
Less cytogenetic abnormalities
Pattern of vascularisation
Expression of SSH receptors
More responsive to GnRH analogue
Fewer recurrences after surgery
Submucosal Uterine Fibroidsdiffers from subserosal fibroids
Literature showing conflicting results for IVF outcome in patients with intramural myoma
Fahri 1995 normal
Stovall 1998 decreased
Elder-Geva 1998 decreased
Ramzy 1998 normal
Healey 2000 decreased
Hart 2001 decreased lt 5 cm
Surrey 2001 normal
Check 2002 probably decreased
Ajayi 2003 decreased
Oliveira 2004 normal if lt 4cm
Bulleti 2004 decreased
Pritts 2009 decreased
Effect of INTRAMURAL myoma
Studies are inconclusive due to lack of correct documentation of size amount and localisation Study design is mostly retrospective
Questions are bull Does a myoma originating from the JZ myometrium
but with no penetration into the uterine cavity influences the reproductive outcome
bull If so is their a cutt of in size and amount of myoma
Q1 Scientific evidence
The effect of intramural fibroids without uterine cavity involvement on the outcome of IVF treatment a systematic review and meta-analysis
19 observational studies comprising 6087 IVF cycles were included
Sunkara SK Khairy M El-Toukhy T Khalaf Y Coomarasamy AHum Reprod 2010 Feb25(2)418-29
Effect of INTRAMURAL myoma
The presence of non-cavity-distorting intramural fibroids showed a significant decrease in the
live birth (RR = 079 95 CI 070-088 P lt 00001) clinical PRs (RR = 085 95 CI 077-094 P = 0002)
in women with non-cavity-distorting intramural fibroids compared with those without fibroids following IVF treatment
Q2 Size and amount
Fibroids not encroaching the endometrial cavity and IVF success rate a prospective study
Somigliana E De Benedictis S Vercellini P Nicolosi AE Benaglia L Scarduelli C Ragni G Fedele LSmall Myoma no influence
Hum Reprod 2011 Apr26(4)834-9
Q2 Size and amount
Fibroids not encroaching the endometrial cavity and IVF success rate a prospective study
In asymptomatic patients selected for IVF small (less than 05 cm) fibroids not encroaching the endometrial cavity did not impact on the rate of success of the procedure
There was no significant relationship between clinical outcome and either the number or size of the fibroids
Q2 Size and amount
Those findings are in conflict with the findings of Khalaf et al 2006 who also studied the effect of small intramuralUterine fibroids
IVF ICSI results in 322 women without fibroids and 112 with fibroids in 606 cycles were studied
Live birth rate in the study group was significantly lower (plt005) and the cumulative live birth rate was reduced by 47
Second statement
It is not yet very clear when non-cavity-distorting intramural fibroids will influence the pregnancy outcome in IVF
Myoma mapping seems mandatory to document the relation to the JZ myometrium
Intra mural myoma should be classified either to the submucous or sub serosal group
The diagnostic strategy is challenged
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Hysteroscopic surgery
4 Laparoscopic surgery
What do we have to know
1 Cavity involvement
2 Number of myomata
3 Size and location
Proper diagnosis of fibroids
Ultrasound
Fluid Mini-Hysteroscopy
Kontrast sonography
One Stop Uterine diagnosis
Proper diagnosis of fibroids
Ultrasound
Hysteroscopy
Contrast sonography
Overview of set up
Supplemantary exams necessary
When
1 dd adenomyoma ndash myoma
2 Multiple myoma
3 Diffuse enlargement of uterine wall
How
1 NMR imaging (3D US )
2 Hysteroscopic Myometrial exploration
LIFE vzw Leuven Institute for Fertility amp Embryology
Findings at MRI JZ Myoma
LIFE vzw Leuven Institute for Fertility amp Embryology
Allocation of Myoma to OM or JZM
LIFE vzw Leuven Institute for Fertility amp Embryology
MRI for diagnosis of Adenomyosis and Adenomyoma
Loss of differentiation JZ - OM
Normal
LIFE vzw Leuven Institute for Fertility amp Embryology
Enlarge the hysteroscopic diagnosis with
exploration of JZ myometrium
Trophy Hysteroscope acc to Campo
New generation of hysteroscope with interesting characteristics
named after the multicentre study TROPHY ldquoTrial of Outpatient
Hysteroscopyrdquo for which it was designedEl-Toukhy T Campo R et al Trial of Outpatient Hysteroscopy ndash (TROPHY) in IVF Reprod Health 2009 Dec 3620
Spirotome acc to Gordts
A device made to harvest high quality samples from soft tissues
built on the pioneering concept of a cutting helix on a cutting cannula
New Tools for exploration of the JZ myometrium
Trophy Scope 29 mm compactscope with Innovative gliding mechanism for accessory sheets
Can be loaded with accessory sheets which can be activated in case of necessity by gently push on the bottom and forward movement till locking in the active position supplementary functions are available without the need to remove the hysteroscope
Trophy Scope Diagnostic accessory sheet
In active positionAtraumatic cervical dilatation up to 37 mm under visual controlCreating double flowBlocking of cervix in case of passive outflow
In free positionSuction device for endometrial samplingGuide for ultrasound guided intrauterine procedures like positioning Embryo
transfer catheter or for Spirotome endomyometrial biopsy
active freepassive
Trophy Scope Operative accessory sheet
In passive position
Operative sheet does not interfere
the diagnostic phase (29mm)
In active positionAtraumatic cervical dilatation
up to 44 mm under visual control
Creating double flow and blocking
function in case of passive outflow
Introduction of 5 Fr instruments without
compromising inflow
A device made to harvest high quality samples from soft tissues
It is built on the pioneering concept of a cutting helix on a cutting
cannula well identified by Ultrasound
Spirotome acc to Gordts
Spirotome
The sample is harvested by turning the helix into the diseased area under
direct vision or ultrasound guidance The cannula turns subsequently over the
helix to free the sample from the surroundings
Spirotome myometrial biopsy
HSC post spirotome biopsy
Spirotome myometrial biopsy
Trophy Scope - Spirotome - US
Guide for ultrasound guided
Spirotome endomyometrial biopsy
cutting helixcutting cannula
Trophy Scope ndash Spirotome - Ultrasound
Exploration of JZ myometrium with Trophy hysteroscope
Resection intramural myoma
Resection adenomyoma
Resection adenomyoma
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Conventional hysteroscopic surgery
4 Laparoscopic surgery
Conventional Hysteroscopic Surgery
TYPE 0 TYPE 1 TYPE 2
The ESGE classificationof submucous myomas
Size volume = 43r3
bull2 cm ~ 42 cm3 8 min
bull3 cm ~ 141 cm3 28 min
bull4 cm ~ 335 cm3 67 min
Emanuel MH et al Fertil Steril 199768881-6
Operating time of critical importance
Reduction in volume of the fibroidsby GnRH-a therapy
Distension fluid
Monopolar surgery using non-ionic solutions
sa manitol sorbitol or glycine has higher risk of
side effects due to fluid overload effect
Stop surgery as soon as 1 L of fluid losses
Bipolar surgery using ionic solutions (saline)
Isotonic hyperhydration is less dangerous
In young patients up to 4 L of losses can be
accepted
Hysteroscopic Myomectomy
Always use a pressure and flow controlled pump system to work at minimal necessary pressure
Always perform continuous fluid balance independently of the medium used
Hysteroscopic Myomectomy
Operative Hysteroscopy Resectoscope Uni or Bipolar
Non ionic fluid
Unipolar polyp and myomaresection
Ionic fluid
First generation Bipolar (Versapoint)
Loop is smaller
chips are smaller
Longer OR time
Bipolar cautery induces
more bubbles
Bipolar resectoscope new generation
low-energy
Two or more small active electrodes very close to each other (active and return electrode)
bull Use Saline as distention medium
bull limited spread of electrical effect the current flow is essentially limited to a small area and it requires less voltage less risk for adhaesion formation
bull Loop different shape and size Different surgical
manoeuvres
bull Need of Modern generator
Bipolar resectoscope new generation
Storz bipolar resectoscope new generation
Return electrode opposite
side
Larger active electrode
Minimal gas bubbles
production
Less risk of perforation
Different surgical technique
Bipolar hysteroscopic myomectomy
Hysteroscopic Myomectomy
Long-term results depend on
bull Uterine Size (Plt0001)
bull Number of myomas (Plt0001)
The surgery-free percentage of 165 patients with normal sized uteri and not more than two
myomas was 943 (+- 18) at 2 years and 903 (+- 30) at 5 years
bull Type ( intra-mural part)
bull Size of myoma (significant increase of amount of particles between 2 and 3 cm)
Long-term results depend on the presence of concomitant pathology
or is a result of incomplete surgery
Emanuel MH Wamsteker K Obstet Gynecol 1999 May93743-8
Third Statement
1 Junctional Zone Myoma should preferentially be treated by hysteroscopy
2 Feasibility of hysteroscopic surgery is predominantly related with size location and amount of myoma
3 Independently of distension medium used continuous fluid balance and flow distension control is mandatory
4 Complication risk is related to experience and surgical technique used
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Conventional hysteroscopic surgery
4 Laparoscopic surgery
Introduction
Intramural myoma larger than 4 cm related to the JZ myometriumschould be operated on
Laparoscopic approach has had an important evolution over the
years
Series with high success rate are done by experts =gt it is difficult to extrapolate to less experienced surgeons
Laparoscopic myomectomy needs expert skills in haemostasis dissection and suturing
How to minimize blood loss
bullA lot of techniques in order to minimize blood loss
GnRH agonists
Intramyometrial vasopressine
Oxytocin IV 40 mUImin intraoperatively
Use of tourniquet or penrose at the lower part of uterus
Laparoscopic Myomectomy
J Ferro IVI Valencia Spain
Tips amp tricks ndash minimize blood loss
Clipping of the uterine arteries and infundilopelvic ligaments is another very efficient method
Artery ligation versus Control group (n=152)
173 +- 91 mL vs 402 +- 131 mL blood loss
62 vs 2075 reccurence rate
Alborzi S et al A comparison of combined laparoscopic uterine artery ligation and myomectomyversus laparoscopic myomectomy in the treatment of symptomatic myoma Fertil Steril 2009
Tips amp tricks ndash minimize blood loss
Technique Incision
Incision
J Ferro A Wattiez
Tips amp tricks- dissection
Tips amp tricks- closure
bull One versus multiples layers controversial
bull Adequate closure of the dead space to minimize the risk of hematoma formation
bull Interrupted figure of eight sutures are usually sufficient monocryl 1 or 0 with extracorporeal notes =gt extra strength
bull For the serosa approximate with interrupted 20 sutures if necessary (monofilament)
Tips amp tricks- closure
Removal Clips
Anti- adhesion agents
Fourth Statement
LAPAROSCOPIC MYOMECTOMY offers comparable results tolaparotomic myomectomy
Laparoscopic approach reduces adhesion formation blood loss and hospital stay
Laparoscopic myomectomy seems indicated in the infertile patient for the treatment of intramural myomarsquos
Laparoscopic Myomectomy requires a skilled laparoscopic surgeon with expert suturing skills optimal instrumental support and knowledge of some trickrsquos to provide an optimal result
Take Home message
Submucous myoma should always be removed prior to IVF
Hysteroscopic resection is the gold standard to treat those myoma
Intramural myoma originating from the sub endometrial
myometrium and larger than 4 cm are treated by Laproscopy
Subserosal myoma do not influence the outcome of IVF and are not removed for this indication
More info on the special training
programsin endoscopic
surgery
ESGEORG
More info on the ESGE website
wwwesgeorg
See you in London
Rudi Campo Stephan GordtsPatrick PuttemansRoger MolinasSylvie GordtsMarion Valkenburg Ivo Brosens
Leuven Institute for Fertility
amp Embryology
Trophy Scope a new generation
Interesting Characteristics
Gliding system that provides
Diagnostic ( 29 mm ) and
Operative (44 mm)
possibilities in one instrument
This hysteroscope has been named after the multicentre study
TROPHY ldquoTrial of Outpatient Hysteroscopyrdquo for which it was designed
El-Toukhy T Campo R et al Trial of Outpatient Hysteroscopy - [TROPHY] in IVF Reprod Health 2009 Dec 3620
Effect of Uterine Fibroids on IVF Outcome
Subserosal
- Fahri 1995 normal- Elder-Garcia 1998 normal- Healy 2000 normal- Oliveira 2004 normal
Subserosal myoma seems not to influence
the IVF outcome
Effect of Uterine Fibroids on IVF Outcome
Submucosal
- Fahri 1995 decreased- Elder-Garcia 1998 decreased- Healy 2000 decreased - Shokeir (PRCT) 2010 decreased
Scientific evidence that Submucosal myoma interferes negatively with the success rate
First statement
If a myoma protrudes in the uterine cavity it is likely to interfere with the reproductive outcome
Conservative resection of submucosal myoma is recommended prior to any ART procedure
Intra mural myoma The Problem
Intra mural myoma are myomas completely surrounded by muscular wall of the uterus however they vary in size number and distance to the endometrial cavity
The effect of intramural fibroids on fertility and outcome of IVF treatment remain poorly understood
A new approach is necessay
Effect of Intra mural fibroids on IVF
MRI has demonstrated the clinical significance of the myometrial architecture
Junctional zone
small central zone of increased density
IMPORTANT IN REPRODUCTION
Submucosal myoma
Outer myometrium
Larger outer hypodenser zone
Subserosal myoma
Less cytogenetic abnormalities
Pattern of vascularisation
Expression of SSH receptors
More responsive to GnRH analogue
Fewer recurrences after surgery
Submucosal Uterine Fibroidsdiffers from subserosal fibroids
Literature showing conflicting results for IVF outcome in patients with intramural myoma
Fahri 1995 normal
Stovall 1998 decreased
Elder-Geva 1998 decreased
Ramzy 1998 normal
Healey 2000 decreased
Hart 2001 decreased lt 5 cm
Surrey 2001 normal
Check 2002 probably decreased
Ajayi 2003 decreased
Oliveira 2004 normal if lt 4cm
Bulleti 2004 decreased
Pritts 2009 decreased
Effect of INTRAMURAL myoma
Studies are inconclusive due to lack of correct documentation of size amount and localisation Study design is mostly retrospective
Questions are bull Does a myoma originating from the JZ myometrium
but with no penetration into the uterine cavity influences the reproductive outcome
bull If so is their a cutt of in size and amount of myoma
Q1 Scientific evidence
The effect of intramural fibroids without uterine cavity involvement on the outcome of IVF treatment a systematic review and meta-analysis
19 observational studies comprising 6087 IVF cycles were included
Sunkara SK Khairy M El-Toukhy T Khalaf Y Coomarasamy AHum Reprod 2010 Feb25(2)418-29
Effect of INTRAMURAL myoma
The presence of non-cavity-distorting intramural fibroids showed a significant decrease in the
live birth (RR = 079 95 CI 070-088 P lt 00001) clinical PRs (RR = 085 95 CI 077-094 P = 0002)
in women with non-cavity-distorting intramural fibroids compared with those without fibroids following IVF treatment
Q2 Size and amount
Fibroids not encroaching the endometrial cavity and IVF success rate a prospective study
Somigliana E De Benedictis S Vercellini P Nicolosi AE Benaglia L Scarduelli C Ragni G Fedele LSmall Myoma no influence
Hum Reprod 2011 Apr26(4)834-9
Q2 Size and amount
Fibroids not encroaching the endometrial cavity and IVF success rate a prospective study
In asymptomatic patients selected for IVF small (less than 05 cm) fibroids not encroaching the endometrial cavity did not impact on the rate of success of the procedure
There was no significant relationship between clinical outcome and either the number or size of the fibroids
Q2 Size and amount
Those findings are in conflict with the findings of Khalaf et al 2006 who also studied the effect of small intramuralUterine fibroids
IVF ICSI results in 322 women without fibroids and 112 with fibroids in 606 cycles were studied
Live birth rate in the study group was significantly lower (plt005) and the cumulative live birth rate was reduced by 47
Second statement
It is not yet very clear when non-cavity-distorting intramural fibroids will influence the pregnancy outcome in IVF
Myoma mapping seems mandatory to document the relation to the JZ myometrium
Intra mural myoma should be classified either to the submucous or sub serosal group
The diagnostic strategy is challenged
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Hysteroscopic surgery
4 Laparoscopic surgery
What do we have to know
1 Cavity involvement
2 Number of myomata
3 Size and location
Proper diagnosis of fibroids
Ultrasound
Fluid Mini-Hysteroscopy
Kontrast sonography
One Stop Uterine diagnosis
Proper diagnosis of fibroids
Ultrasound
Hysteroscopy
Contrast sonography
Overview of set up
Supplemantary exams necessary
When
1 dd adenomyoma ndash myoma
2 Multiple myoma
3 Diffuse enlargement of uterine wall
How
1 NMR imaging (3D US )
2 Hysteroscopic Myometrial exploration
LIFE vzw Leuven Institute for Fertility amp Embryology
Findings at MRI JZ Myoma
LIFE vzw Leuven Institute for Fertility amp Embryology
Allocation of Myoma to OM or JZM
LIFE vzw Leuven Institute for Fertility amp Embryology
MRI for diagnosis of Adenomyosis and Adenomyoma
Loss of differentiation JZ - OM
Normal
LIFE vzw Leuven Institute for Fertility amp Embryology
Enlarge the hysteroscopic diagnosis with
exploration of JZ myometrium
Trophy Hysteroscope acc to Campo
New generation of hysteroscope with interesting characteristics
named after the multicentre study TROPHY ldquoTrial of Outpatient
Hysteroscopyrdquo for which it was designedEl-Toukhy T Campo R et al Trial of Outpatient Hysteroscopy ndash (TROPHY) in IVF Reprod Health 2009 Dec 3620
Spirotome acc to Gordts
A device made to harvest high quality samples from soft tissues
built on the pioneering concept of a cutting helix on a cutting cannula
New Tools for exploration of the JZ myometrium
Trophy Scope 29 mm compactscope with Innovative gliding mechanism for accessory sheets
Can be loaded with accessory sheets which can be activated in case of necessity by gently push on the bottom and forward movement till locking in the active position supplementary functions are available without the need to remove the hysteroscope
Trophy Scope Diagnostic accessory sheet
In active positionAtraumatic cervical dilatation up to 37 mm under visual controlCreating double flowBlocking of cervix in case of passive outflow
In free positionSuction device for endometrial samplingGuide for ultrasound guided intrauterine procedures like positioning Embryo
transfer catheter or for Spirotome endomyometrial biopsy
active freepassive
Trophy Scope Operative accessory sheet
In passive position
Operative sheet does not interfere
the diagnostic phase (29mm)
In active positionAtraumatic cervical dilatation
up to 44 mm under visual control
Creating double flow and blocking
function in case of passive outflow
Introduction of 5 Fr instruments without
compromising inflow
A device made to harvest high quality samples from soft tissues
It is built on the pioneering concept of a cutting helix on a cutting
cannula well identified by Ultrasound
Spirotome acc to Gordts
Spirotome
The sample is harvested by turning the helix into the diseased area under
direct vision or ultrasound guidance The cannula turns subsequently over the
helix to free the sample from the surroundings
Spirotome myometrial biopsy
HSC post spirotome biopsy
Spirotome myometrial biopsy
Trophy Scope - Spirotome - US
Guide for ultrasound guided
Spirotome endomyometrial biopsy
cutting helixcutting cannula
Trophy Scope ndash Spirotome - Ultrasound
Exploration of JZ myometrium with Trophy hysteroscope
Resection intramural myoma
Resection adenomyoma
Resection adenomyoma
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Conventional hysteroscopic surgery
4 Laparoscopic surgery
Conventional Hysteroscopic Surgery
TYPE 0 TYPE 1 TYPE 2
The ESGE classificationof submucous myomas
Size volume = 43r3
bull2 cm ~ 42 cm3 8 min
bull3 cm ~ 141 cm3 28 min
bull4 cm ~ 335 cm3 67 min
Emanuel MH et al Fertil Steril 199768881-6
Operating time of critical importance
Reduction in volume of the fibroidsby GnRH-a therapy
Distension fluid
Monopolar surgery using non-ionic solutions
sa manitol sorbitol or glycine has higher risk of
side effects due to fluid overload effect
Stop surgery as soon as 1 L of fluid losses
Bipolar surgery using ionic solutions (saline)
Isotonic hyperhydration is less dangerous
In young patients up to 4 L of losses can be
accepted
Hysteroscopic Myomectomy
Always use a pressure and flow controlled pump system to work at minimal necessary pressure
Always perform continuous fluid balance independently of the medium used
Hysteroscopic Myomectomy
Operative Hysteroscopy Resectoscope Uni or Bipolar
Non ionic fluid
Unipolar polyp and myomaresection
Ionic fluid
First generation Bipolar (Versapoint)
Loop is smaller
chips are smaller
Longer OR time
Bipolar cautery induces
more bubbles
Bipolar resectoscope new generation
low-energy
Two or more small active electrodes very close to each other (active and return electrode)
bull Use Saline as distention medium
bull limited spread of electrical effect the current flow is essentially limited to a small area and it requires less voltage less risk for adhaesion formation
bull Loop different shape and size Different surgical
manoeuvres
bull Need of Modern generator
Bipolar resectoscope new generation
Storz bipolar resectoscope new generation
Return electrode opposite
side
Larger active electrode
Minimal gas bubbles
production
Less risk of perforation
Different surgical technique
Bipolar hysteroscopic myomectomy
Hysteroscopic Myomectomy
Long-term results depend on
bull Uterine Size (Plt0001)
bull Number of myomas (Plt0001)
The surgery-free percentage of 165 patients with normal sized uteri and not more than two
myomas was 943 (+- 18) at 2 years and 903 (+- 30) at 5 years
bull Type ( intra-mural part)
bull Size of myoma (significant increase of amount of particles between 2 and 3 cm)
Long-term results depend on the presence of concomitant pathology
or is a result of incomplete surgery
Emanuel MH Wamsteker K Obstet Gynecol 1999 May93743-8
Third Statement
1 Junctional Zone Myoma should preferentially be treated by hysteroscopy
2 Feasibility of hysteroscopic surgery is predominantly related with size location and amount of myoma
3 Independently of distension medium used continuous fluid balance and flow distension control is mandatory
4 Complication risk is related to experience and surgical technique used
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Conventional hysteroscopic surgery
4 Laparoscopic surgery
Introduction
Intramural myoma larger than 4 cm related to the JZ myometriumschould be operated on
Laparoscopic approach has had an important evolution over the
years
Series with high success rate are done by experts =gt it is difficult to extrapolate to less experienced surgeons
Laparoscopic myomectomy needs expert skills in haemostasis dissection and suturing
How to minimize blood loss
bullA lot of techniques in order to minimize blood loss
GnRH agonists
Intramyometrial vasopressine
Oxytocin IV 40 mUImin intraoperatively
Use of tourniquet or penrose at the lower part of uterus
Laparoscopic Myomectomy
J Ferro IVI Valencia Spain
Tips amp tricks ndash minimize blood loss
Clipping of the uterine arteries and infundilopelvic ligaments is another very efficient method
Artery ligation versus Control group (n=152)
173 +- 91 mL vs 402 +- 131 mL blood loss
62 vs 2075 reccurence rate
Alborzi S et al A comparison of combined laparoscopic uterine artery ligation and myomectomyversus laparoscopic myomectomy in the treatment of symptomatic myoma Fertil Steril 2009
Tips amp tricks ndash minimize blood loss
Technique Incision
Incision
J Ferro A Wattiez
Tips amp tricks- dissection
Tips amp tricks- closure
bull One versus multiples layers controversial
bull Adequate closure of the dead space to minimize the risk of hematoma formation
bull Interrupted figure of eight sutures are usually sufficient monocryl 1 or 0 with extracorporeal notes =gt extra strength
bull For the serosa approximate with interrupted 20 sutures if necessary (monofilament)
Tips amp tricks- closure
Removal Clips
Anti- adhesion agents
Fourth Statement
LAPAROSCOPIC MYOMECTOMY offers comparable results tolaparotomic myomectomy
Laparoscopic approach reduces adhesion formation blood loss and hospital stay
Laparoscopic myomectomy seems indicated in the infertile patient for the treatment of intramural myomarsquos
Laparoscopic Myomectomy requires a skilled laparoscopic surgeon with expert suturing skills optimal instrumental support and knowledge of some trickrsquos to provide an optimal result
Take Home message
Submucous myoma should always be removed prior to IVF
Hysteroscopic resection is the gold standard to treat those myoma
Intramural myoma originating from the sub endometrial
myometrium and larger than 4 cm are treated by Laproscopy
Subserosal myoma do not influence the outcome of IVF and are not removed for this indication
More info on the special training
programsin endoscopic
surgery
ESGEORG
More info on the ESGE website
wwwesgeorg
See you in London
Rudi Campo Stephan GordtsPatrick PuttemansRoger MolinasSylvie GordtsMarion Valkenburg Ivo Brosens
Leuven Institute for Fertility
amp Embryology
Trophy Scope a new generation
Interesting Characteristics
Gliding system that provides
Diagnostic ( 29 mm ) and
Operative (44 mm)
possibilities in one instrument
This hysteroscope has been named after the multicentre study
TROPHY ldquoTrial of Outpatient Hysteroscopyrdquo for which it was designed
El-Toukhy T Campo R et al Trial of Outpatient Hysteroscopy - [TROPHY] in IVF Reprod Health 2009 Dec 3620
Effect of Uterine Fibroids on IVF Outcome
Submucosal
- Fahri 1995 decreased- Elder-Garcia 1998 decreased- Healy 2000 decreased - Shokeir (PRCT) 2010 decreased
Scientific evidence that Submucosal myoma interferes negatively with the success rate
First statement
If a myoma protrudes in the uterine cavity it is likely to interfere with the reproductive outcome
Conservative resection of submucosal myoma is recommended prior to any ART procedure
Intra mural myoma The Problem
Intra mural myoma are myomas completely surrounded by muscular wall of the uterus however they vary in size number and distance to the endometrial cavity
The effect of intramural fibroids on fertility and outcome of IVF treatment remain poorly understood
A new approach is necessay
Effect of Intra mural fibroids on IVF
MRI has demonstrated the clinical significance of the myometrial architecture
Junctional zone
small central zone of increased density
IMPORTANT IN REPRODUCTION
Submucosal myoma
Outer myometrium
Larger outer hypodenser zone
Subserosal myoma
Less cytogenetic abnormalities
Pattern of vascularisation
Expression of SSH receptors
More responsive to GnRH analogue
Fewer recurrences after surgery
Submucosal Uterine Fibroidsdiffers from subserosal fibroids
Literature showing conflicting results for IVF outcome in patients with intramural myoma
Fahri 1995 normal
Stovall 1998 decreased
Elder-Geva 1998 decreased
Ramzy 1998 normal
Healey 2000 decreased
Hart 2001 decreased lt 5 cm
Surrey 2001 normal
Check 2002 probably decreased
Ajayi 2003 decreased
Oliveira 2004 normal if lt 4cm
Bulleti 2004 decreased
Pritts 2009 decreased
Effect of INTRAMURAL myoma
Studies are inconclusive due to lack of correct documentation of size amount and localisation Study design is mostly retrospective
Questions are bull Does a myoma originating from the JZ myometrium
but with no penetration into the uterine cavity influences the reproductive outcome
bull If so is their a cutt of in size and amount of myoma
Q1 Scientific evidence
The effect of intramural fibroids without uterine cavity involvement on the outcome of IVF treatment a systematic review and meta-analysis
19 observational studies comprising 6087 IVF cycles were included
Sunkara SK Khairy M El-Toukhy T Khalaf Y Coomarasamy AHum Reprod 2010 Feb25(2)418-29
Effect of INTRAMURAL myoma
The presence of non-cavity-distorting intramural fibroids showed a significant decrease in the
live birth (RR = 079 95 CI 070-088 P lt 00001) clinical PRs (RR = 085 95 CI 077-094 P = 0002)
in women with non-cavity-distorting intramural fibroids compared with those without fibroids following IVF treatment
Q2 Size and amount
Fibroids not encroaching the endometrial cavity and IVF success rate a prospective study
Somigliana E De Benedictis S Vercellini P Nicolosi AE Benaglia L Scarduelli C Ragni G Fedele LSmall Myoma no influence
Hum Reprod 2011 Apr26(4)834-9
Q2 Size and amount
Fibroids not encroaching the endometrial cavity and IVF success rate a prospective study
In asymptomatic patients selected for IVF small (less than 05 cm) fibroids not encroaching the endometrial cavity did not impact on the rate of success of the procedure
There was no significant relationship between clinical outcome and either the number or size of the fibroids
Q2 Size and amount
Those findings are in conflict with the findings of Khalaf et al 2006 who also studied the effect of small intramuralUterine fibroids
IVF ICSI results in 322 women without fibroids and 112 with fibroids in 606 cycles were studied
Live birth rate in the study group was significantly lower (plt005) and the cumulative live birth rate was reduced by 47
Second statement
It is not yet very clear when non-cavity-distorting intramural fibroids will influence the pregnancy outcome in IVF
Myoma mapping seems mandatory to document the relation to the JZ myometrium
Intra mural myoma should be classified either to the submucous or sub serosal group
The diagnostic strategy is challenged
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Hysteroscopic surgery
4 Laparoscopic surgery
What do we have to know
1 Cavity involvement
2 Number of myomata
3 Size and location
Proper diagnosis of fibroids
Ultrasound
Fluid Mini-Hysteroscopy
Kontrast sonography
One Stop Uterine diagnosis
Proper diagnosis of fibroids
Ultrasound
Hysteroscopy
Contrast sonography
Overview of set up
Supplemantary exams necessary
When
1 dd adenomyoma ndash myoma
2 Multiple myoma
3 Diffuse enlargement of uterine wall
How
1 NMR imaging (3D US )
2 Hysteroscopic Myometrial exploration
LIFE vzw Leuven Institute for Fertility amp Embryology
Findings at MRI JZ Myoma
LIFE vzw Leuven Institute for Fertility amp Embryology
Allocation of Myoma to OM or JZM
LIFE vzw Leuven Institute for Fertility amp Embryology
MRI for diagnosis of Adenomyosis and Adenomyoma
Loss of differentiation JZ - OM
Normal
LIFE vzw Leuven Institute for Fertility amp Embryology
Enlarge the hysteroscopic diagnosis with
exploration of JZ myometrium
Trophy Hysteroscope acc to Campo
New generation of hysteroscope with interesting characteristics
named after the multicentre study TROPHY ldquoTrial of Outpatient
Hysteroscopyrdquo for which it was designedEl-Toukhy T Campo R et al Trial of Outpatient Hysteroscopy ndash (TROPHY) in IVF Reprod Health 2009 Dec 3620
Spirotome acc to Gordts
A device made to harvest high quality samples from soft tissues
built on the pioneering concept of a cutting helix on a cutting cannula
New Tools for exploration of the JZ myometrium
Trophy Scope 29 mm compactscope with Innovative gliding mechanism for accessory sheets
Can be loaded with accessory sheets which can be activated in case of necessity by gently push on the bottom and forward movement till locking in the active position supplementary functions are available without the need to remove the hysteroscope
Trophy Scope Diagnostic accessory sheet
In active positionAtraumatic cervical dilatation up to 37 mm under visual controlCreating double flowBlocking of cervix in case of passive outflow
In free positionSuction device for endometrial samplingGuide for ultrasound guided intrauterine procedures like positioning Embryo
transfer catheter or for Spirotome endomyometrial biopsy
active freepassive
Trophy Scope Operative accessory sheet
In passive position
Operative sheet does not interfere
the diagnostic phase (29mm)
In active positionAtraumatic cervical dilatation
up to 44 mm under visual control
Creating double flow and blocking
function in case of passive outflow
Introduction of 5 Fr instruments without
compromising inflow
A device made to harvest high quality samples from soft tissues
It is built on the pioneering concept of a cutting helix on a cutting
cannula well identified by Ultrasound
Spirotome acc to Gordts
Spirotome
The sample is harvested by turning the helix into the diseased area under
direct vision or ultrasound guidance The cannula turns subsequently over the
helix to free the sample from the surroundings
Spirotome myometrial biopsy
HSC post spirotome biopsy
Spirotome myometrial biopsy
Trophy Scope - Spirotome - US
Guide for ultrasound guided
Spirotome endomyometrial biopsy
cutting helixcutting cannula
Trophy Scope ndash Spirotome - Ultrasound
Exploration of JZ myometrium with Trophy hysteroscope
Resection intramural myoma
Resection adenomyoma
Resection adenomyoma
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Conventional hysteroscopic surgery
4 Laparoscopic surgery
Conventional Hysteroscopic Surgery
TYPE 0 TYPE 1 TYPE 2
The ESGE classificationof submucous myomas
Size volume = 43r3
bull2 cm ~ 42 cm3 8 min
bull3 cm ~ 141 cm3 28 min
bull4 cm ~ 335 cm3 67 min
Emanuel MH et al Fertil Steril 199768881-6
Operating time of critical importance
Reduction in volume of the fibroidsby GnRH-a therapy
Distension fluid
Monopolar surgery using non-ionic solutions
sa manitol sorbitol or glycine has higher risk of
side effects due to fluid overload effect
Stop surgery as soon as 1 L of fluid losses
Bipolar surgery using ionic solutions (saline)
Isotonic hyperhydration is less dangerous
In young patients up to 4 L of losses can be
accepted
Hysteroscopic Myomectomy
Always use a pressure and flow controlled pump system to work at minimal necessary pressure
Always perform continuous fluid balance independently of the medium used
Hysteroscopic Myomectomy
Operative Hysteroscopy Resectoscope Uni or Bipolar
Non ionic fluid
Unipolar polyp and myomaresection
Ionic fluid
First generation Bipolar (Versapoint)
Loop is smaller
chips are smaller
Longer OR time
Bipolar cautery induces
more bubbles
Bipolar resectoscope new generation
low-energy
Two or more small active electrodes very close to each other (active and return electrode)
bull Use Saline as distention medium
bull limited spread of electrical effect the current flow is essentially limited to a small area and it requires less voltage less risk for adhaesion formation
bull Loop different shape and size Different surgical
manoeuvres
bull Need of Modern generator
Bipolar resectoscope new generation
Storz bipolar resectoscope new generation
Return electrode opposite
side
Larger active electrode
Minimal gas bubbles
production
Less risk of perforation
Different surgical technique
Bipolar hysteroscopic myomectomy
Hysteroscopic Myomectomy
Long-term results depend on
bull Uterine Size (Plt0001)
bull Number of myomas (Plt0001)
The surgery-free percentage of 165 patients with normal sized uteri and not more than two
myomas was 943 (+- 18) at 2 years and 903 (+- 30) at 5 years
bull Type ( intra-mural part)
bull Size of myoma (significant increase of amount of particles between 2 and 3 cm)
Long-term results depend on the presence of concomitant pathology
or is a result of incomplete surgery
Emanuel MH Wamsteker K Obstet Gynecol 1999 May93743-8
Third Statement
1 Junctional Zone Myoma should preferentially be treated by hysteroscopy
2 Feasibility of hysteroscopic surgery is predominantly related with size location and amount of myoma
3 Independently of distension medium used continuous fluid balance and flow distension control is mandatory
4 Complication risk is related to experience and surgical technique used
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Conventional hysteroscopic surgery
4 Laparoscopic surgery
Introduction
Intramural myoma larger than 4 cm related to the JZ myometriumschould be operated on
Laparoscopic approach has had an important evolution over the
years
Series with high success rate are done by experts =gt it is difficult to extrapolate to less experienced surgeons
Laparoscopic myomectomy needs expert skills in haemostasis dissection and suturing
How to minimize blood loss
bullA lot of techniques in order to minimize blood loss
GnRH agonists
Intramyometrial vasopressine
Oxytocin IV 40 mUImin intraoperatively
Use of tourniquet or penrose at the lower part of uterus
Laparoscopic Myomectomy
J Ferro IVI Valencia Spain
Tips amp tricks ndash minimize blood loss
Clipping of the uterine arteries and infundilopelvic ligaments is another very efficient method
Artery ligation versus Control group (n=152)
173 +- 91 mL vs 402 +- 131 mL blood loss
62 vs 2075 reccurence rate
Alborzi S et al A comparison of combined laparoscopic uterine artery ligation and myomectomyversus laparoscopic myomectomy in the treatment of symptomatic myoma Fertil Steril 2009
Tips amp tricks ndash minimize blood loss
Technique Incision
Incision
J Ferro A Wattiez
Tips amp tricks- dissection
Tips amp tricks- closure
bull One versus multiples layers controversial
bull Adequate closure of the dead space to minimize the risk of hematoma formation
bull Interrupted figure of eight sutures are usually sufficient monocryl 1 or 0 with extracorporeal notes =gt extra strength
bull For the serosa approximate with interrupted 20 sutures if necessary (monofilament)
Tips amp tricks- closure
Removal Clips
Anti- adhesion agents
Fourth Statement
LAPAROSCOPIC MYOMECTOMY offers comparable results tolaparotomic myomectomy
Laparoscopic approach reduces adhesion formation blood loss and hospital stay
Laparoscopic myomectomy seems indicated in the infertile patient for the treatment of intramural myomarsquos
Laparoscopic Myomectomy requires a skilled laparoscopic surgeon with expert suturing skills optimal instrumental support and knowledge of some trickrsquos to provide an optimal result
Take Home message
Submucous myoma should always be removed prior to IVF
Hysteroscopic resection is the gold standard to treat those myoma
Intramural myoma originating from the sub endometrial
myometrium and larger than 4 cm are treated by Laproscopy
Subserosal myoma do not influence the outcome of IVF and are not removed for this indication
More info on the special training
programsin endoscopic
surgery
ESGEORG
More info on the ESGE website
wwwesgeorg
See you in London
Rudi Campo Stephan GordtsPatrick PuttemansRoger MolinasSylvie GordtsMarion Valkenburg Ivo Brosens
Leuven Institute for Fertility
amp Embryology
Trophy Scope a new generation
Interesting Characteristics
Gliding system that provides
Diagnostic ( 29 mm ) and
Operative (44 mm)
possibilities in one instrument
This hysteroscope has been named after the multicentre study
TROPHY ldquoTrial of Outpatient Hysteroscopyrdquo for which it was designed
El-Toukhy T Campo R et al Trial of Outpatient Hysteroscopy - [TROPHY] in IVF Reprod Health 2009 Dec 3620
First statement
If a myoma protrudes in the uterine cavity it is likely to interfere with the reproductive outcome
Conservative resection of submucosal myoma is recommended prior to any ART procedure
Intra mural myoma The Problem
Intra mural myoma are myomas completely surrounded by muscular wall of the uterus however they vary in size number and distance to the endometrial cavity
The effect of intramural fibroids on fertility and outcome of IVF treatment remain poorly understood
A new approach is necessay
Effect of Intra mural fibroids on IVF
MRI has demonstrated the clinical significance of the myometrial architecture
Junctional zone
small central zone of increased density
IMPORTANT IN REPRODUCTION
Submucosal myoma
Outer myometrium
Larger outer hypodenser zone
Subserosal myoma
Less cytogenetic abnormalities
Pattern of vascularisation
Expression of SSH receptors
More responsive to GnRH analogue
Fewer recurrences after surgery
Submucosal Uterine Fibroidsdiffers from subserosal fibroids
Literature showing conflicting results for IVF outcome in patients with intramural myoma
Fahri 1995 normal
Stovall 1998 decreased
Elder-Geva 1998 decreased
Ramzy 1998 normal
Healey 2000 decreased
Hart 2001 decreased lt 5 cm
Surrey 2001 normal
Check 2002 probably decreased
Ajayi 2003 decreased
Oliveira 2004 normal if lt 4cm
Bulleti 2004 decreased
Pritts 2009 decreased
Effect of INTRAMURAL myoma
Studies are inconclusive due to lack of correct documentation of size amount and localisation Study design is mostly retrospective
Questions are bull Does a myoma originating from the JZ myometrium
but with no penetration into the uterine cavity influences the reproductive outcome
bull If so is their a cutt of in size and amount of myoma
Q1 Scientific evidence
The effect of intramural fibroids without uterine cavity involvement on the outcome of IVF treatment a systematic review and meta-analysis
19 observational studies comprising 6087 IVF cycles were included
Sunkara SK Khairy M El-Toukhy T Khalaf Y Coomarasamy AHum Reprod 2010 Feb25(2)418-29
Effect of INTRAMURAL myoma
The presence of non-cavity-distorting intramural fibroids showed a significant decrease in the
live birth (RR = 079 95 CI 070-088 P lt 00001) clinical PRs (RR = 085 95 CI 077-094 P = 0002)
in women with non-cavity-distorting intramural fibroids compared with those without fibroids following IVF treatment
Q2 Size and amount
Fibroids not encroaching the endometrial cavity and IVF success rate a prospective study
Somigliana E De Benedictis S Vercellini P Nicolosi AE Benaglia L Scarduelli C Ragni G Fedele LSmall Myoma no influence
Hum Reprod 2011 Apr26(4)834-9
Q2 Size and amount
Fibroids not encroaching the endometrial cavity and IVF success rate a prospective study
In asymptomatic patients selected for IVF small (less than 05 cm) fibroids not encroaching the endometrial cavity did not impact on the rate of success of the procedure
There was no significant relationship between clinical outcome and either the number or size of the fibroids
Q2 Size and amount
Those findings are in conflict with the findings of Khalaf et al 2006 who also studied the effect of small intramuralUterine fibroids
IVF ICSI results in 322 women without fibroids and 112 with fibroids in 606 cycles were studied
Live birth rate in the study group was significantly lower (plt005) and the cumulative live birth rate was reduced by 47
Second statement
It is not yet very clear when non-cavity-distorting intramural fibroids will influence the pregnancy outcome in IVF
Myoma mapping seems mandatory to document the relation to the JZ myometrium
Intra mural myoma should be classified either to the submucous or sub serosal group
The diagnostic strategy is challenged
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Hysteroscopic surgery
4 Laparoscopic surgery
What do we have to know
1 Cavity involvement
2 Number of myomata
3 Size and location
Proper diagnosis of fibroids
Ultrasound
Fluid Mini-Hysteroscopy
Kontrast sonography
One Stop Uterine diagnosis
Proper diagnosis of fibroids
Ultrasound
Hysteroscopy
Contrast sonography
Overview of set up
Supplemantary exams necessary
When
1 dd adenomyoma ndash myoma
2 Multiple myoma
3 Diffuse enlargement of uterine wall
How
1 NMR imaging (3D US )
2 Hysteroscopic Myometrial exploration
LIFE vzw Leuven Institute for Fertility amp Embryology
Findings at MRI JZ Myoma
LIFE vzw Leuven Institute for Fertility amp Embryology
Allocation of Myoma to OM or JZM
LIFE vzw Leuven Institute for Fertility amp Embryology
MRI for diagnosis of Adenomyosis and Adenomyoma
Loss of differentiation JZ - OM
Normal
LIFE vzw Leuven Institute for Fertility amp Embryology
Enlarge the hysteroscopic diagnosis with
exploration of JZ myometrium
Trophy Hysteroscope acc to Campo
New generation of hysteroscope with interesting characteristics
named after the multicentre study TROPHY ldquoTrial of Outpatient
Hysteroscopyrdquo for which it was designedEl-Toukhy T Campo R et al Trial of Outpatient Hysteroscopy ndash (TROPHY) in IVF Reprod Health 2009 Dec 3620
Spirotome acc to Gordts
A device made to harvest high quality samples from soft tissues
built on the pioneering concept of a cutting helix on a cutting cannula
New Tools for exploration of the JZ myometrium
Trophy Scope 29 mm compactscope with Innovative gliding mechanism for accessory sheets
Can be loaded with accessory sheets which can be activated in case of necessity by gently push on the bottom and forward movement till locking in the active position supplementary functions are available without the need to remove the hysteroscope
Trophy Scope Diagnostic accessory sheet
In active positionAtraumatic cervical dilatation up to 37 mm under visual controlCreating double flowBlocking of cervix in case of passive outflow
In free positionSuction device for endometrial samplingGuide for ultrasound guided intrauterine procedures like positioning Embryo
transfer catheter or for Spirotome endomyometrial biopsy
active freepassive
Trophy Scope Operative accessory sheet
In passive position
Operative sheet does not interfere
the diagnostic phase (29mm)
In active positionAtraumatic cervical dilatation
up to 44 mm under visual control
Creating double flow and blocking
function in case of passive outflow
Introduction of 5 Fr instruments without
compromising inflow
A device made to harvest high quality samples from soft tissues
It is built on the pioneering concept of a cutting helix on a cutting
cannula well identified by Ultrasound
Spirotome acc to Gordts
Spirotome
The sample is harvested by turning the helix into the diseased area under
direct vision or ultrasound guidance The cannula turns subsequently over the
helix to free the sample from the surroundings
Spirotome myometrial biopsy
HSC post spirotome biopsy
Spirotome myometrial biopsy
Trophy Scope - Spirotome - US
Guide for ultrasound guided
Spirotome endomyometrial biopsy
cutting helixcutting cannula
Trophy Scope ndash Spirotome - Ultrasound
Exploration of JZ myometrium with Trophy hysteroscope
Resection intramural myoma
Resection adenomyoma
Resection adenomyoma
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Conventional hysteroscopic surgery
4 Laparoscopic surgery
Conventional Hysteroscopic Surgery
TYPE 0 TYPE 1 TYPE 2
The ESGE classificationof submucous myomas
Size volume = 43r3
bull2 cm ~ 42 cm3 8 min
bull3 cm ~ 141 cm3 28 min
bull4 cm ~ 335 cm3 67 min
Emanuel MH et al Fertil Steril 199768881-6
Operating time of critical importance
Reduction in volume of the fibroidsby GnRH-a therapy
Distension fluid
Monopolar surgery using non-ionic solutions
sa manitol sorbitol or glycine has higher risk of
side effects due to fluid overload effect
Stop surgery as soon as 1 L of fluid losses
Bipolar surgery using ionic solutions (saline)
Isotonic hyperhydration is less dangerous
In young patients up to 4 L of losses can be
accepted
Hysteroscopic Myomectomy
Always use a pressure and flow controlled pump system to work at minimal necessary pressure
Always perform continuous fluid balance independently of the medium used
Hysteroscopic Myomectomy
Operative Hysteroscopy Resectoscope Uni or Bipolar
Non ionic fluid
Unipolar polyp and myomaresection
Ionic fluid
First generation Bipolar (Versapoint)
Loop is smaller
chips are smaller
Longer OR time
Bipolar cautery induces
more bubbles
Bipolar resectoscope new generation
low-energy
Two or more small active electrodes very close to each other (active and return electrode)
bull Use Saline as distention medium
bull limited spread of electrical effect the current flow is essentially limited to a small area and it requires less voltage less risk for adhaesion formation
bull Loop different shape and size Different surgical
manoeuvres
bull Need of Modern generator
Bipolar resectoscope new generation
Storz bipolar resectoscope new generation
Return electrode opposite
side
Larger active electrode
Minimal gas bubbles
production
Less risk of perforation
Different surgical technique
Bipolar hysteroscopic myomectomy
Hysteroscopic Myomectomy
Long-term results depend on
bull Uterine Size (Plt0001)
bull Number of myomas (Plt0001)
The surgery-free percentage of 165 patients with normal sized uteri and not more than two
myomas was 943 (+- 18) at 2 years and 903 (+- 30) at 5 years
bull Type ( intra-mural part)
bull Size of myoma (significant increase of amount of particles between 2 and 3 cm)
Long-term results depend on the presence of concomitant pathology
or is a result of incomplete surgery
Emanuel MH Wamsteker K Obstet Gynecol 1999 May93743-8
Third Statement
1 Junctional Zone Myoma should preferentially be treated by hysteroscopy
2 Feasibility of hysteroscopic surgery is predominantly related with size location and amount of myoma
3 Independently of distension medium used continuous fluid balance and flow distension control is mandatory
4 Complication risk is related to experience and surgical technique used
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Conventional hysteroscopic surgery
4 Laparoscopic surgery
Introduction
Intramural myoma larger than 4 cm related to the JZ myometriumschould be operated on
Laparoscopic approach has had an important evolution over the
years
Series with high success rate are done by experts =gt it is difficult to extrapolate to less experienced surgeons
Laparoscopic myomectomy needs expert skills in haemostasis dissection and suturing
How to minimize blood loss
bullA lot of techniques in order to minimize blood loss
GnRH agonists
Intramyometrial vasopressine
Oxytocin IV 40 mUImin intraoperatively
Use of tourniquet or penrose at the lower part of uterus
Laparoscopic Myomectomy
J Ferro IVI Valencia Spain
Tips amp tricks ndash minimize blood loss
Clipping of the uterine arteries and infundilopelvic ligaments is another very efficient method
Artery ligation versus Control group (n=152)
173 +- 91 mL vs 402 +- 131 mL blood loss
62 vs 2075 reccurence rate
Alborzi S et al A comparison of combined laparoscopic uterine artery ligation and myomectomyversus laparoscopic myomectomy in the treatment of symptomatic myoma Fertil Steril 2009
Tips amp tricks ndash minimize blood loss
Technique Incision
Incision
J Ferro A Wattiez
Tips amp tricks- dissection
Tips amp tricks- closure
bull One versus multiples layers controversial
bull Adequate closure of the dead space to minimize the risk of hematoma formation
bull Interrupted figure of eight sutures are usually sufficient monocryl 1 or 0 with extracorporeal notes =gt extra strength
bull For the serosa approximate with interrupted 20 sutures if necessary (monofilament)
Tips amp tricks- closure
Removal Clips
Anti- adhesion agents
Fourth Statement
LAPAROSCOPIC MYOMECTOMY offers comparable results tolaparotomic myomectomy
Laparoscopic approach reduces adhesion formation blood loss and hospital stay
Laparoscopic myomectomy seems indicated in the infertile patient for the treatment of intramural myomarsquos
Laparoscopic Myomectomy requires a skilled laparoscopic surgeon with expert suturing skills optimal instrumental support and knowledge of some trickrsquos to provide an optimal result
Take Home message
Submucous myoma should always be removed prior to IVF
Hysteroscopic resection is the gold standard to treat those myoma
Intramural myoma originating from the sub endometrial
myometrium and larger than 4 cm are treated by Laproscopy
Subserosal myoma do not influence the outcome of IVF and are not removed for this indication
More info on the special training
programsin endoscopic
surgery
ESGEORG
More info on the ESGE website
wwwesgeorg
See you in London
Rudi Campo Stephan GordtsPatrick PuttemansRoger MolinasSylvie GordtsMarion Valkenburg Ivo Brosens
Leuven Institute for Fertility
amp Embryology
Trophy Scope a new generation
Interesting Characteristics
Gliding system that provides
Diagnostic ( 29 mm ) and
Operative (44 mm)
possibilities in one instrument
This hysteroscope has been named after the multicentre study
TROPHY ldquoTrial of Outpatient Hysteroscopyrdquo for which it was designed
El-Toukhy T Campo R et al Trial of Outpatient Hysteroscopy - [TROPHY] in IVF Reprod Health 2009 Dec 3620
Intra mural myoma The Problem
Intra mural myoma are myomas completely surrounded by muscular wall of the uterus however they vary in size number and distance to the endometrial cavity
The effect of intramural fibroids on fertility and outcome of IVF treatment remain poorly understood
A new approach is necessay
Effect of Intra mural fibroids on IVF
MRI has demonstrated the clinical significance of the myometrial architecture
Junctional zone
small central zone of increased density
IMPORTANT IN REPRODUCTION
Submucosal myoma
Outer myometrium
Larger outer hypodenser zone
Subserosal myoma
Less cytogenetic abnormalities
Pattern of vascularisation
Expression of SSH receptors
More responsive to GnRH analogue
Fewer recurrences after surgery
Submucosal Uterine Fibroidsdiffers from subserosal fibroids
Literature showing conflicting results for IVF outcome in patients with intramural myoma
Fahri 1995 normal
Stovall 1998 decreased
Elder-Geva 1998 decreased
Ramzy 1998 normal
Healey 2000 decreased
Hart 2001 decreased lt 5 cm
Surrey 2001 normal
Check 2002 probably decreased
Ajayi 2003 decreased
Oliveira 2004 normal if lt 4cm
Bulleti 2004 decreased
Pritts 2009 decreased
Effect of INTRAMURAL myoma
Studies are inconclusive due to lack of correct documentation of size amount and localisation Study design is mostly retrospective
Questions are bull Does a myoma originating from the JZ myometrium
but with no penetration into the uterine cavity influences the reproductive outcome
bull If so is their a cutt of in size and amount of myoma
Q1 Scientific evidence
The effect of intramural fibroids without uterine cavity involvement on the outcome of IVF treatment a systematic review and meta-analysis
19 observational studies comprising 6087 IVF cycles were included
Sunkara SK Khairy M El-Toukhy T Khalaf Y Coomarasamy AHum Reprod 2010 Feb25(2)418-29
Effect of INTRAMURAL myoma
The presence of non-cavity-distorting intramural fibroids showed a significant decrease in the
live birth (RR = 079 95 CI 070-088 P lt 00001) clinical PRs (RR = 085 95 CI 077-094 P = 0002)
in women with non-cavity-distorting intramural fibroids compared with those without fibroids following IVF treatment
Q2 Size and amount
Fibroids not encroaching the endometrial cavity and IVF success rate a prospective study
Somigliana E De Benedictis S Vercellini P Nicolosi AE Benaglia L Scarduelli C Ragni G Fedele LSmall Myoma no influence
Hum Reprod 2011 Apr26(4)834-9
Q2 Size and amount
Fibroids not encroaching the endometrial cavity and IVF success rate a prospective study
In asymptomatic patients selected for IVF small (less than 05 cm) fibroids not encroaching the endometrial cavity did not impact on the rate of success of the procedure
There was no significant relationship between clinical outcome and either the number or size of the fibroids
Q2 Size and amount
Those findings are in conflict with the findings of Khalaf et al 2006 who also studied the effect of small intramuralUterine fibroids
IVF ICSI results in 322 women without fibroids and 112 with fibroids in 606 cycles were studied
Live birth rate in the study group was significantly lower (plt005) and the cumulative live birth rate was reduced by 47
Second statement
It is not yet very clear when non-cavity-distorting intramural fibroids will influence the pregnancy outcome in IVF
Myoma mapping seems mandatory to document the relation to the JZ myometrium
Intra mural myoma should be classified either to the submucous or sub serosal group
The diagnostic strategy is challenged
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Hysteroscopic surgery
4 Laparoscopic surgery
What do we have to know
1 Cavity involvement
2 Number of myomata
3 Size and location
Proper diagnosis of fibroids
Ultrasound
Fluid Mini-Hysteroscopy
Kontrast sonography
One Stop Uterine diagnosis
Proper diagnosis of fibroids
Ultrasound
Hysteroscopy
Contrast sonography
Overview of set up
Supplemantary exams necessary
When
1 dd adenomyoma ndash myoma
2 Multiple myoma
3 Diffuse enlargement of uterine wall
How
1 NMR imaging (3D US )
2 Hysteroscopic Myometrial exploration
LIFE vzw Leuven Institute for Fertility amp Embryology
Findings at MRI JZ Myoma
LIFE vzw Leuven Institute for Fertility amp Embryology
Allocation of Myoma to OM or JZM
LIFE vzw Leuven Institute for Fertility amp Embryology
MRI for diagnosis of Adenomyosis and Adenomyoma
Loss of differentiation JZ - OM
Normal
LIFE vzw Leuven Institute for Fertility amp Embryology
Enlarge the hysteroscopic diagnosis with
exploration of JZ myometrium
Trophy Hysteroscope acc to Campo
New generation of hysteroscope with interesting characteristics
named after the multicentre study TROPHY ldquoTrial of Outpatient
Hysteroscopyrdquo for which it was designedEl-Toukhy T Campo R et al Trial of Outpatient Hysteroscopy ndash (TROPHY) in IVF Reprod Health 2009 Dec 3620
Spirotome acc to Gordts
A device made to harvest high quality samples from soft tissues
built on the pioneering concept of a cutting helix on a cutting cannula
New Tools for exploration of the JZ myometrium
Trophy Scope 29 mm compactscope with Innovative gliding mechanism for accessory sheets
Can be loaded with accessory sheets which can be activated in case of necessity by gently push on the bottom and forward movement till locking in the active position supplementary functions are available without the need to remove the hysteroscope
Trophy Scope Diagnostic accessory sheet
In active positionAtraumatic cervical dilatation up to 37 mm under visual controlCreating double flowBlocking of cervix in case of passive outflow
In free positionSuction device for endometrial samplingGuide for ultrasound guided intrauterine procedures like positioning Embryo
transfer catheter or for Spirotome endomyometrial biopsy
active freepassive
Trophy Scope Operative accessory sheet
In passive position
Operative sheet does not interfere
the diagnostic phase (29mm)
In active positionAtraumatic cervical dilatation
up to 44 mm under visual control
Creating double flow and blocking
function in case of passive outflow
Introduction of 5 Fr instruments without
compromising inflow
A device made to harvest high quality samples from soft tissues
It is built on the pioneering concept of a cutting helix on a cutting
cannula well identified by Ultrasound
Spirotome acc to Gordts
Spirotome
The sample is harvested by turning the helix into the diseased area under
direct vision or ultrasound guidance The cannula turns subsequently over the
helix to free the sample from the surroundings
Spirotome myometrial biopsy
HSC post spirotome biopsy
Spirotome myometrial biopsy
Trophy Scope - Spirotome - US
Guide for ultrasound guided
Spirotome endomyometrial biopsy
cutting helixcutting cannula
Trophy Scope ndash Spirotome - Ultrasound
Exploration of JZ myometrium with Trophy hysteroscope
Resection intramural myoma
Resection adenomyoma
Resection adenomyoma
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Conventional hysteroscopic surgery
4 Laparoscopic surgery
Conventional Hysteroscopic Surgery
TYPE 0 TYPE 1 TYPE 2
The ESGE classificationof submucous myomas
Size volume = 43r3
bull2 cm ~ 42 cm3 8 min
bull3 cm ~ 141 cm3 28 min
bull4 cm ~ 335 cm3 67 min
Emanuel MH et al Fertil Steril 199768881-6
Operating time of critical importance
Reduction in volume of the fibroidsby GnRH-a therapy
Distension fluid
Monopolar surgery using non-ionic solutions
sa manitol sorbitol or glycine has higher risk of
side effects due to fluid overload effect
Stop surgery as soon as 1 L of fluid losses
Bipolar surgery using ionic solutions (saline)
Isotonic hyperhydration is less dangerous
In young patients up to 4 L of losses can be
accepted
Hysteroscopic Myomectomy
Always use a pressure and flow controlled pump system to work at minimal necessary pressure
Always perform continuous fluid balance independently of the medium used
Hysteroscopic Myomectomy
Operative Hysteroscopy Resectoscope Uni or Bipolar
Non ionic fluid
Unipolar polyp and myomaresection
Ionic fluid
First generation Bipolar (Versapoint)
Loop is smaller
chips are smaller
Longer OR time
Bipolar cautery induces
more bubbles
Bipolar resectoscope new generation
low-energy
Two or more small active electrodes very close to each other (active and return electrode)
bull Use Saline as distention medium
bull limited spread of electrical effect the current flow is essentially limited to a small area and it requires less voltage less risk for adhaesion formation
bull Loop different shape and size Different surgical
manoeuvres
bull Need of Modern generator
Bipolar resectoscope new generation
Storz bipolar resectoscope new generation
Return electrode opposite
side
Larger active electrode
Minimal gas bubbles
production
Less risk of perforation
Different surgical technique
Bipolar hysteroscopic myomectomy
Hysteroscopic Myomectomy
Long-term results depend on
bull Uterine Size (Plt0001)
bull Number of myomas (Plt0001)
The surgery-free percentage of 165 patients with normal sized uteri and not more than two
myomas was 943 (+- 18) at 2 years and 903 (+- 30) at 5 years
bull Type ( intra-mural part)
bull Size of myoma (significant increase of amount of particles between 2 and 3 cm)
Long-term results depend on the presence of concomitant pathology
or is a result of incomplete surgery
Emanuel MH Wamsteker K Obstet Gynecol 1999 May93743-8
Third Statement
1 Junctional Zone Myoma should preferentially be treated by hysteroscopy
2 Feasibility of hysteroscopic surgery is predominantly related with size location and amount of myoma
3 Independently of distension medium used continuous fluid balance and flow distension control is mandatory
4 Complication risk is related to experience and surgical technique used
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Conventional hysteroscopic surgery
4 Laparoscopic surgery
Introduction
Intramural myoma larger than 4 cm related to the JZ myometriumschould be operated on
Laparoscopic approach has had an important evolution over the
years
Series with high success rate are done by experts =gt it is difficult to extrapolate to less experienced surgeons
Laparoscopic myomectomy needs expert skills in haemostasis dissection and suturing
How to minimize blood loss
bullA lot of techniques in order to minimize blood loss
GnRH agonists
Intramyometrial vasopressine
Oxytocin IV 40 mUImin intraoperatively
Use of tourniquet or penrose at the lower part of uterus
Laparoscopic Myomectomy
J Ferro IVI Valencia Spain
Tips amp tricks ndash minimize blood loss
Clipping of the uterine arteries and infundilopelvic ligaments is another very efficient method
Artery ligation versus Control group (n=152)
173 +- 91 mL vs 402 +- 131 mL blood loss
62 vs 2075 reccurence rate
Alborzi S et al A comparison of combined laparoscopic uterine artery ligation and myomectomyversus laparoscopic myomectomy in the treatment of symptomatic myoma Fertil Steril 2009
Tips amp tricks ndash minimize blood loss
Technique Incision
Incision
J Ferro A Wattiez
Tips amp tricks- dissection
Tips amp tricks- closure
bull One versus multiples layers controversial
bull Adequate closure of the dead space to minimize the risk of hematoma formation
bull Interrupted figure of eight sutures are usually sufficient monocryl 1 or 0 with extracorporeal notes =gt extra strength
bull For the serosa approximate with interrupted 20 sutures if necessary (monofilament)
Tips amp tricks- closure
Removal Clips
Anti- adhesion agents
Fourth Statement
LAPAROSCOPIC MYOMECTOMY offers comparable results tolaparotomic myomectomy
Laparoscopic approach reduces adhesion formation blood loss and hospital stay
Laparoscopic myomectomy seems indicated in the infertile patient for the treatment of intramural myomarsquos
Laparoscopic Myomectomy requires a skilled laparoscopic surgeon with expert suturing skills optimal instrumental support and knowledge of some trickrsquos to provide an optimal result
Take Home message
Submucous myoma should always be removed prior to IVF
Hysteroscopic resection is the gold standard to treat those myoma
Intramural myoma originating from the sub endometrial
myometrium and larger than 4 cm are treated by Laproscopy
Subserosal myoma do not influence the outcome of IVF and are not removed for this indication
More info on the special training
programsin endoscopic
surgery
ESGEORG
More info on the ESGE website
wwwesgeorg
See you in London
Rudi Campo Stephan GordtsPatrick PuttemansRoger MolinasSylvie GordtsMarion Valkenburg Ivo Brosens
Leuven Institute for Fertility
amp Embryology
Trophy Scope a new generation
Interesting Characteristics
Gliding system that provides
Diagnostic ( 29 mm ) and
Operative (44 mm)
possibilities in one instrument
This hysteroscope has been named after the multicentre study
TROPHY ldquoTrial of Outpatient Hysteroscopyrdquo for which it was designed
El-Toukhy T Campo R et al Trial of Outpatient Hysteroscopy - [TROPHY] in IVF Reprod Health 2009 Dec 3620
Effect of Intra mural fibroids on IVF
MRI has demonstrated the clinical significance of the myometrial architecture
Junctional zone
small central zone of increased density
IMPORTANT IN REPRODUCTION
Submucosal myoma
Outer myometrium
Larger outer hypodenser zone
Subserosal myoma
Less cytogenetic abnormalities
Pattern of vascularisation
Expression of SSH receptors
More responsive to GnRH analogue
Fewer recurrences after surgery
Submucosal Uterine Fibroidsdiffers from subserosal fibroids
Literature showing conflicting results for IVF outcome in patients with intramural myoma
Fahri 1995 normal
Stovall 1998 decreased
Elder-Geva 1998 decreased
Ramzy 1998 normal
Healey 2000 decreased
Hart 2001 decreased lt 5 cm
Surrey 2001 normal
Check 2002 probably decreased
Ajayi 2003 decreased
Oliveira 2004 normal if lt 4cm
Bulleti 2004 decreased
Pritts 2009 decreased
Effect of INTRAMURAL myoma
Studies are inconclusive due to lack of correct documentation of size amount and localisation Study design is mostly retrospective
Questions are bull Does a myoma originating from the JZ myometrium
but with no penetration into the uterine cavity influences the reproductive outcome
bull If so is their a cutt of in size and amount of myoma
Q1 Scientific evidence
The effect of intramural fibroids without uterine cavity involvement on the outcome of IVF treatment a systematic review and meta-analysis
19 observational studies comprising 6087 IVF cycles were included
Sunkara SK Khairy M El-Toukhy T Khalaf Y Coomarasamy AHum Reprod 2010 Feb25(2)418-29
Effect of INTRAMURAL myoma
The presence of non-cavity-distorting intramural fibroids showed a significant decrease in the
live birth (RR = 079 95 CI 070-088 P lt 00001) clinical PRs (RR = 085 95 CI 077-094 P = 0002)
in women with non-cavity-distorting intramural fibroids compared with those without fibroids following IVF treatment
Q2 Size and amount
Fibroids not encroaching the endometrial cavity and IVF success rate a prospective study
Somigliana E De Benedictis S Vercellini P Nicolosi AE Benaglia L Scarduelli C Ragni G Fedele LSmall Myoma no influence
Hum Reprod 2011 Apr26(4)834-9
Q2 Size and amount
Fibroids not encroaching the endometrial cavity and IVF success rate a prospective study
In asymptomatic patients selected for IVF small (less than 05 cm) fibroids not encroaching the endometrial cavity did not impact on the rate of success of the procedure
There was no significant relationship between clinical outcome and either the number or size of the fibroids
Q2 Size and amount
Those findings are in conflict with the findings of Khalaf et al 2006 who also studied the effect of small intramuralUterine fibroids
IVF ICSI results in 322 women without fibroids and 112 with fibroids in 606 cycles were studied
Live birth rate in the study group was significantly lower (plt005) and the cumulative live birth rate was reduced by 47
Second statement
It is not yet very clear when non-cavity-distorting intramural fibroids will influence the pregnancy outcome in IVF
Myoma mapping seems mandatory to document the relation to the JZ myometrium
Intra mural myoma should be classified either to the submucous or sub serosal group
The diagnostic strategy is challenged
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Hysteroscopic surgery
4 Laparoscopic surgery
What do we have to know
1 Cavity involvement
2 Number of myomata
3 Size and location
Proper diagnosis of fibroids
Ultrasound
Fluid Mini-Hysteroscopy
Kontrast sonography
One Stop Uterine diagnosis
Proper diagnosis of fibroids
Ultrasound
Hysteroscopy
Contrast sonography
Overview of set up
Supplemantary exams necessary
When
1 dd adenomyoma ndash myoma
2 Multiple myoma
3 Diffuse enlargement of uterine wall
How
1 NMR imaging (3D US )
2 Hysteroscopic Myometrial exploration
LIFE vzw Leuven Institute for Fertility amp Embryology
Findings at MRI JZ Myoma
LIFE vzw Leuven Institute for Fertility amp Embryology
Allocation of Myoma to OM or JZM
LIFE vzw Leuven Institute for Fertility amp Embryology
MRI for diagnosis of Adenomyosis and Adenomyoma
Loss of differentiation JZ - OM
Normal
LIFE vzw Leuven Institute for Fertility amp Embryology
Enlarge the hysteroscopic diagnosis with
exploration of JZ myometrium
Trophy Hysteroscope acc to Campo
New generation of hysteroscope with interesting characteristics
named after the multicentre study TROPHY ldquoTrial of Outpatient
Hysteroscopyrdquo for which it was designedEl-Toukhy T Campo R et al Trial of Outpatient Hysteroscopy ndash (TROPHY) in IVF Reprod Health 2009 Dec 3620
Spirotome acc to Gordts
A device made to harvest high quality samples from soft tissues
built on the pioneering concept of a cutting helix on a cutting cannula
New Tools for exploration of the JZ myometrium
Trophy Scope 29 mm compactscope with Innovative gliding mechanism for accessory sheets
Can be loaded with accessory sheets which can be activated in case of necessity by gently push on the bottom and forward movement till locking in the active position supplementary functions are available without the need to remove the hysteroscope
Trophy Scope Diagnostic accessory sheet
In active positionAtraumatic cervical dilatation up to 37 mm under visual controlCreating double flowBlocking of cervix in case of passive outflow
In free positionSuction device for endometrial samplingGuide for ultrasound guided intrauterine procedures like positioning Embryo
transfer catheter or for Spirotome endomyometrial biopsy
active freepassive
Trophy Scope Operative accessory sheet
In passive position
Operative sheet does not interfere
the diagnostic phase (29mm)
In active positionAtraumatic cervical dilatation
up to 44 mm under visual control
Creating double flow and blocking
function in case of passive outflow
Introduction of 5 Fr instruments without
compromising inflow
A device made to harvest high quality samples from soft tissues
It is built on the pioneering concept of a cutting helix on a cutting
cannula well identified by Ultrasound
Spirotome acc to Gordts
Spirotome
The sample is harvested by turning the helix into the diseased area under
direct vision or ultrasound guidance The cannula turns subsequently over the
helix to free the sample from the surroundings
Spirotome myometrial biopsy
HSC post spirotome biopsy
Spirotome myometrial biopsy
Trophy Scope - Spirotome - US
Guide for ultrasound guided
Spirotome endomyometrial biopsy
cutting helixcutting cannula
Trophy Scope ndash Spirotome - Ultrasound
Exploration of JZ myometrium with Trophy hysteroscope
Resection intramural myoma
Resection adenomyoma
Resection adenomyoma
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Conventional hysteroscopic surgery
4 Laparoscopic surgery
Conventional Hysteroscopic Surgery
TYPE 0 TYPE 1 TYPE 2
The ESGE classificationof submucous myomas
Size volume = 43r3
bull2 cm ~ 42 cm3 8 min
bull3 cm ~ 141 cm3 28 min
bull4 cm ~ 335 cm3 67 min
Emanuel MH et al Fertil Steril 199768881-6
Operating time of critical importance
Reduction in volume of the fibroidsby GnRH-a therapy
Distension fluid
Monopolar surgery using non-ionic solutions
sa manitol sorbitol or glycine has higher risk of
side effects due to fluid overload effect
Stop surgery as soon as 1 L of fluid losses
Bipolar surgery using ionic solutions (saline)
Isotonic hyperhydration is less dangerous
In young patients up to 4 L of losses can be
accepted
Hysteroscopic Myomectomy
Always use a pressure and flow controlled pump system to work at minimal necessary pressure
Always perform continuous fluid balance independently of the medium used
Hysteroscopic Myomectomy
Operative Hysteroscopy Resectoscope Uni or Bipolar
Non ionic fluid
Unipolar polyp and myomaresection
Ionic fluid
First generation Bipolar (Versapoint)
Loop is smaller
chips are smaller
Longer OR time
Bipolar cautery induces
more bubbles
Bipolar resectoscope new generation
low-energy
Two or more small active electrodes very close to each other (active and return electrode)
bull Use Saline as distention medium
bull limited spread of electrical effect the current flow is essentially limited to a small area and it requires less voltage less risk for adhaesion formation
bull Loop different shape and size Different surgical
manoeuvres
bull Need of Modern generator
Bipolar resectoscope new generation
Storz bipolar resectoscope new generation
Return electrode opposite
side
Larger active electrode
Minimal gas bubbles
production
Less risk of perforation
Different surgical technique
Bipolar hysteroscopic myomectomy
Hysteroscopic Myomectomy
Long-term results depend on
bull Uterine Size (Plt0001)
bull Number of myomas (Plt0001)
The surgery-free percentage of 165 patients with normal sized uteri and not more than two
myomas was 943 (+- 18) at 2 years and 903 (+- 30) at 5 years
bull Type ( intra-mural part)
bull Size of myoma (significant increase of amount of particles between 2 and 3 cm)
Long-term results depend on the presence of concomitant pathology
or is a result of incomplete surgery
Emanuel MH Wamsteker K Obstet Gynecol 1999 May93743-8
Third Statement
1 Junctional Zone Myoma should preferentially be treated by hysteroscopy
2 Feasibility of hysteroscopic surgery is predominantly related with size location and amount of myoma
3 Independently of distension medium used continuous fluid balance and flow distension control is mandatory
4 Complication risk is related to experience and surgical technique used
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Conventional hysteroscopic surgery
4 Laparoscopic surgery
Introduction
Intramural myoma larger than 4 cm related to the JZ myometriumschould be operated on
Laparoscopic approach has had an important evolution over the
years
Series with high success rate are done by experts =gt it is difficult to extrapolate to less experienced surgeons
Laparoscopic myomectomy needs expert skills in haemostasis dissection and suturing
How to minimize blood loss
bullA lot of techniques in order to minimize blood loss
GnRH agonists
Intramyometrial vasopressine
Oxytocin IV 40 mUImin intraoperatively
Use of tourniquet or penrose at the lower part of uterus
Laparoscopic Myomectomy
J Ferro IVI Valencia Spain
Tips amp tricks ndash minimize blood loss
Clipping of the uterine arteries and infundilopelvic ligaments is another very efficient method
Artery ligation versus Control group (n=152)
173 +- 91 mL vs 402 +- 131 mL blood loss
62 vs 2075 reccurence rate
Alborzi S et al A comparison of combined laparoscopic uterine artery ligation and myomectomyversus laparoscopic myomectomy in the treatment of symptomatic myoma Fertil Steril 2009
Tips amp tricks ndash minimize blood loss
Technique Incision
Incision
J Ferro A Wattiez
Tips amp tricks- dissection
Tips amp tricks- closure
bull One versus multiples layers controversial
bull Adequate closure of the dead space to minimize the risk of hematoma formation
bull Interrupted figure of eight sutures are usually sufficient monocryl 1 or 0 with extracorporeal notes =gt extra strength
bull For the serosa approximate with interrupted 20 sutures if necessary (monofilament)
Tips amp tricks- closure
Removal Clips
Anti- adhesion agents
Fourth Statement
LAPAROSCOPIC MYOMECTOMY offers comparable results tolaparotomic myomectomy
Laparoscopic approach reduces adhesion formation blood loss and hospital stay
Laparoscopic myomectomy seems indicated in the infertile patient for the treatment of intramural myomarsquos
Laparoscopic Myomectomy requires a skilled laparoscopic surgeon with expert suturing skills optimal instrumental support and knowledge of some trickrsquos to provide an optimal result
Take Home message
Submucous myoma should always be removed prior to IVF
Hysteroscopic resection is the gold standard to treat those myoma
Intramural myoma originating from the sub endometrial
myometrium and larger than 4 cm are treated by Laproscopy
Subserosal myoma do not influence the outcome of IVF and are not removed for this indication
More info on the special training
programsin endoscopic
surgery
ESGEORG
More info on the ESGE website
wwwesgeorg
See you in London
Rudi Campo Stephan GordtsPatrick PuttemansRoger MolinasSylvie GordtsMarion Valkenburg Ivo Brosens
Leuven Institute for Fertility
amp Embryology
Trophy Scope a new generation
Interesting Characteristics
Gliding system that provides
Diagnostic ( 29 mm ) and
Operative (44 mm)
possibilities in one instrument
This hysteroscope has been named after the multicentre study
TROPHY ldquoTrial of Outpatient Hysteroscopyrdquo for which it was designed
El-Toukhy T Campo R et al Trial of Outpatient Hysteroscopy - [TROPHY] in IVF Reprod Health 2009 Dec 3620
Less cytogenetic abnormalities
Pattern of vascularisation
Expression of SSH receptors
More responsive to GnRH analogue
Fewer recurrences after surgery
Submucosal Uterine Fibroidsdiffers from subserosal fibroids
Literature showing conflicting results for IVF outcome in patients with intramural myoma
Fahri 1995 normal
Stovall 1998 decreased
Elder-Geva 1998 decreased
Ramzy 1998 normal
Healey 2000 decreased
Hart 2001 decreased lt 5 cm
Surrey 2001 normal
Check 2002 probably decreased
Ajayi 2003 decreased
Oliveira 2004 normal if lt 4cm
Bulleti 2004 decreased
Pritts 2009 decreased
Effect of INTRAMURAL myoma
Studies are inconclusive due to lack of correct documentation of size amount and localisation Study design is mostly retrospective
Questions are bull Does a myoma originating from the JZ myometrium
but with no penetration into the uterine cavity influences the reproductive outcome
bull If so is their a cutt of in size and amount of myoma
Q1 Scientific evidence
The effect of intramural fibroids without uterine cavity involvement on the outcome of IVF treatment a systematic review and meta-analysis
19 observational studies comprising 6087 IVF cycles were included
Sunkara SK Khairy M El-Toukhy T Khalaf Y Coomarasamy AHum Reprod 2010 Feb25(2)418-29
Effect of INTRAMURAL myoma
The presence of non-cavity-distorting intramural fibroids showed a significant decrease in the
live birth (RR = 079 95 CI 070-088 P lt 00001) clinical PRs (RR = 085 95 CI 077-094 P = 0002)
in women with non-cavity-distorting intramural fibroids compared with those without fibroids following IVF treatment
Q2 Size and amount
Fibroids not encroaching the endometrial cavity and IVF success rate a prospective study
Somigliana E De Benedictis S Vercellini P Nicolosi AE Benaglia L Scarduelli C Ragni G Fedele LSmall Myoma no influence
Hum Reprod 2011 Apr26(4)834-9
Q2 Size and amount
Fibroids not encroaching the endometrial cavity and IVF success rate a prospective study
In asymptomatic patients selected for IVF small (less than 05 cm) fibroids not encroaching the endometrial cavity did not impact on the rate of success of the procedure
There was no significant relationship between clinical outcome and either the number or size of the fibroids
Q2 Size and amount
Those findings are in conflict with the findings of Khalaf et al 2006 who also studied the effect of small intramuralUterine fibroids
IVF ICSI results in 322 women without fibroids and 112 with fibroids in 606 cycles were studied
Live birth rate in the study group was significantly lower (plt005) and the cumulative live birth rate was reduced by 47
Second statement
It is not yet very clear when non-cavity-distorting intramural fibroids will influence the pregnancy outcome in IVF
Myoma mapping seems mandatory to document the relation to the JZ myometrium
Intra mural myoma should be classified either to the submucous or sub serosal group
The diagnostic strategy is challenged
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Hysteroscopic surgery
4 Laparoscopic surgery
What do we have to know
1 Cavity involvement
2 Number of myomata
3 Size and location
Proper diagnosis of fibroids
Ultrasound
Fluid Mini-Hysteroscopy
Kontrast sonography
One Stop Uterine diagnosis
Proper diagnosis of fibroids
Ultrasound
Hysteroscopy
Contrast sonography
Overview of set up
Supplemantary exams necessary
When
1 dd adenomyoma ndash myoma
2 Multiple myoma
3 Diffuse enlargement of uterine wall
How
1 NMR imaging (3D US )
2 Hysteroscopic Myometrial exploration
LIFE vzw Leuven Institute for Fertility amp Embryology
Findings at MRI JZ Myoma
LIFE vzw Leuven Institute for Fertility amp Embryology
Allocation of Myoma to OM or JZM
LIFE vzw Leuven Institute for Fertility amp Embryology
MRI for diagnosis of Adenomyosis and Adenomyoma
Loss of differentiation JZ - OM
Normal
LIFE vzw Leuven Institute for Fertility amp Embryology
Enlarge the hysteroscopic diagnosis with
exploration of JZ myometrium
Trophy Hysteroscope acc to Campo
New generation of hysteroscope with interesting characteristics
named after the multicentre study TROPHY ldquoTrial of Outpatient
Hysteroscopyrdquo for which it was designedEl-Toukhy T Campo R et al Trial of Outpatient Hysteroscopy ndash (TROPHY) in IVF Reprod Health 2009 Dec 3620
Spirotome acc to Gordts
A device made to harvest high quality samples from soft tissues
built on the pioneering concept of a cutting helix on a cutting cannula
New Tools for exploration of the JZ myometrium
Trophy Scope 29 mm compactscope with Innovative gliding mechanism for accessory sheets
Can be loaded with accessory sheets which can be activated in case of necessity by gently push on the bottom and forward movement till locking in the active position supplementary functions are available without the need to remove the hysteroscope
Trophy Scope Diagnostic accessory sheet
In active positionAtraumatic cervical dilatation up to 37 mm under visual controlCreating double flowBlocking of cervix in case of passive outflow
In free positionSuction device for endometrial samplingGuide for ultrasound guided intrauterine procedures like positioning Embryo
transfer catheter or for Spirotome endomyometrial biopsy
active freepassive
Trophy Scope Operative accessory sheet
In passive position
Operative sheet does not interfere
the diagnostic phase (29mm)
In active positionAtraumatic cervical dilatation
up to 44 mm under visual control
Creating double flow and blocking
function in case of passive outflow
Introduction of 5 Fr instruments without
compromising inflow
A device made to harvest high quality samples from soft tissues
It is built on the pioneering concept of a cutting helix on a cutting
cannula well identified by Ultrasound
Spirotome acc to Gordts
Spirotome
The sample is harvested by turning the helix into the diseased area under
direct vision or ultrasound guidance The cannula turns subsequently over the
helix to free the sample from the surroundings
Spirotome myometrial biopsy
HSC post spirotome biopsy
Spirotome myometrial biopsy
Trophy Scope - Spirotome - US
Guide for ultrasound guided
Spirotome endomyometrial biopsy
cutting helixcutting cannula
Trophy Scope ndash Spirotome - Ultrasound
Exploration of JZ myometrium with Trophy hysteroscope
Resection intramural myoma
Resection adenomyoma
Resection adenomyoma
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Conventional hysteroscopic surgery
4 Laparoscopic surgery
Conventional Hysteroscopic Surgery
TYPE 0 TYPE 1 TYPE 2
The ESGE classificationof submucous myomas
Size volume = 43r3
bull2 cm ~ 42 cm3 8 min
bull3 cm ~ 141 cm3 28 min
bull4 cm ~ 335 cm3 67 min
Emanuel MH et al Fertil Steril 199768881-6
Operating time of critical importance
Reduction in volume of the fibroidsby GnRH-a therapy
Distension fluid
Monopolar surgery using non-ionic solutions
sa manitol sorbitol or glycine has higher risk of
side effects due to fluid overload effect
Stop surgery as soon as 1 L of fluid losses
Bipolar surgery using ionic solutions (saline)
Isotonic hyperhydration is less dangerous
In young patients up to 4 L of losses can be
accepted
Hysteroscopic Myomectomy
Always use a pressure and flow controlled pump system to work at minimal necessary pressure
Always perform continuous fluid balance independently of the medium used
Hysteroscopic Myomectomy
Operative Hysteroscopy Resectoscope Uni or Bipolar
Non ionic fluid
Unipolar polyp and myomaresection
Ionic fluid
First generation Bipolar (Versapoint)
Loop is smaller
chips are smaller
Longer OR time
Bipolar cautery induces
more bubbles
Bipolar resectoscope new generation
low-energy
Two or more small active electrodes very close to each other (active and return electrode)
bull Use Saline as distention medium
bull limited spread of electrical effect the current flow is essentially limited to a small area and it requires less voltage less risk for adhaesion formation
bull Loop different shape and size Different surgical
manoeuvres
bull Need of Modern generator
Bipolar resectoscope new generation
Storz bipolar resectoscope new generation
Return electrode opposite
side
Larger active electrode
Minimal gas bubbles
production
Less risk of perforation
Different surgical technique
Bipolar hysteroscopic myomectomy
Hysteroscopic Myomectomy
Long-term results depend on
bull Uterine Size (Plt0001)
bull Number of myomas (Plt0001)
The surgery-free percentage of 165 patients with normal sized uteri and not more than two
myomas was 943 (+- 18) at 2 years and 903 (+- 30) at 5 years
bull Type ( intra-mural part)
bull Size of myoma (significant increase of amount of particles between 2 and 3 cm)
Long-term results depend on the presence of concomitant pathology
or is a result of incomplete surgery
Emanuel MH Wamsteker K Obstet Gynecol 1999 May93743-8
Third Statement
1 Junctional Zone Myoma should preferentially be treated by hysteroscopy
2 Feasibility of hysteroscopic surgery is predominantly related with size location and amount of myoma
3 Independently of distension medium used continuous fluid balance and flow distension control is mandatory
4 Complication risk is related to experience and surgical technique used
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Conventional hysteroscopic surgery
4 Laparoscopic surgery
Introduction
Intramural myoma larger than 4 cm related to the JZ myometriumschould be operated on
Laparoscopic approach has had an important evolution over the
years
Series with high success rate are done by experts =gt it is difficult to extrapolate to less experienced surgeons
Laparoscopic myomectomy needs expert skills in haemostasis dissection and suturing
How to minimize blood loss
bullA lot of techniques in order to minimize blood loss
GnRH agonists
Intramyometrial vasopressine
Oxytocin IV 40 mUImin intraoperatively
Use of tourniquet or penrose at the lower part of uterus
Laparoscopic Myomectomy
J Ferro IVI Valencia Spain
Tips amp tricks ndash minimize blood loss
Clipping of the uterine arteries and infundilopelvic ligaments is another very efficient method
Artery ligation versus Control group (n=152)
173 +- 91 mL vs 402 +- 131 mL blood loss
62 vs 2075 reccurence rate
Alborzi S et al A comparison of combined laparoscopic uterine artery ligation and myomectomyversus laparoscopic myomectomy in the treatment of symptomatic myoma Fertil Steril 2009
Tips amp tricks ndash minimize blood loss
Technique Incision
Incision
J Ferro A Wattiez
Tips amp tricks- dissection
Tips amp tricks- closure
bull One versus multiples layers controversial
bull Adequate closure of the dead space to minimize the risk of hematoma formation
bull Interrupted figure of eight sutures are usually sufficient monocryl 1 or 0 with extracorporeal notes =gt extra strength
bull For the serosa approximate with interrupted 20 sutures if necessary (monofilament)
Tips amp tricks- closure
Removal Clips
Anti- adhesion agents
Fourth Statement
LAPAROSCOPIC MYOMECTOMY offers comparable results tolaparotomic myomectomy
Laparoscopic approach reduces adhesion formation blood loss and hospital stay
Laparoscopic myomectomy seems indicated in the infertile patient for the treatment of intramural myomarsquos
Laparoscopic Myomectomy requires a skilled laparoscopic surgeon with expert suturing skills optimal instrumental support and knowledge of some trickrsquos to provide an optimal result
Take Home message
Submucous myoma should always be removed prior to IVF
Hysteroscopic resection is the gold standard to treat those myoma
Intramural myoma originating from the sub endometrial
myometrium and larger than 4 cm are treated by Laproscopy
Subserosal myoma do not influence the outcome of IVF and are not removed for this indication
More info on the special training
programsin endoscopic
surgery
ESGEORG
More info on the ESGE website
wwwesgeorg
See you in London
Rudi Campo Stephan GordtsPatrick PuttemansRoger MolinasSylvie GordtsMarion Valkenburg Ivo Brosens
Leuven Institute for Fertility
amp Embryology
Trophy Scope a new generation
Interesting Characteristics
Gliding system that provides
Diagnostic ( 29 mm ) and
Operative (44 mm)
possibilities in one instrument
This hysteroscope has been named after the multicentre study
TROPHY ldquoTrial of Outpatient Hysteroscopyrdquo for which it was designed
El-Toukhy T Campo R et al Trial of Outpatient Hysteroscopy - [TROPHY] in IVF Reprod Health 2009 Dec 3620
Literature showing conflicting results for IVF outcome in patients with intramural myoma
Fahri 1995 normal
Stovall 1998 decreased
Elder-Geva 1998 decreased
Ramzy 1998 normal
Healey 2000 decreased
Hart 2001 decreased lt 5 cm
Surrey 2001 normal
Check 2002 probably decreased
Ajayi 2003 decreased
Oliveira 2004 normal if lt 4cm
Bulleti 2004 decreased
Pritts 2009 decreased
Effect of INTRAMURAL myoma
Studies are inconclusive due to lack of correct documentation of size amount and localisation Study design is mostly retrospective
Questions are bull Does a myoma originating from the JZ myometrium
but with no penetration into the uterine cavity influences the reproductive outcome
bull If so is their a cutt of in size and amount of myoma
Q1 Scientific evidence
The effect of intramural fibroids without uterine cavity involvement on the outcome of IVF treatment a systematic review and meta-analysis
19 observational studies comprising 6087 IVF cycles were included
Sunkara SK Khairy M El-Toukhy T Khalaf Y Coomarasamy AHum Reprod 2010 Feb25(2)418-29
Effect of INTRAMURAL myoma
The presence of non-cavity-distorting intramural fibroids showed a significant decrease in the
live birth (RR = 079 95 CI 070-088 P lt 00001) clinical PRs (RR = 085 95 CI 077-094 P = 0002)
in women with non-cavity-distorting intramural fibroids compared with those without fibroids following IVF treatment
Q2 Size and amount
Fibroids not encroaching the endometrial cavity and IVF success rate a prospective study
Somigliana E De Benedictis S Vercellini P Nicolosi AE Benaglia L Scarduelli C Ragni G Fedele LSmall Myoma no influence
Hum Reprod 2011 Apr26(4)834-9
Q2 Size and amount
Fibroids not encroaching the endometrial cavity and IVF success rate a prospective study
In asymptomatic patients selected for IVF small (less than 05 cm) fibroids not encroaching the endometrial cavity did not impact on the rate of success of the procedure
There was no significant relationship between clinical outcome and either the number or size of the fibroids
Q2 Size and amount
Those findings are in conflict with the findings of Khalaf et al 2006 who also studied the effect of small intramuralUterine fibroids
IVF ICSI results in 322 women without fibroids and 112 with fibroids in 606 cycles were studied
Live birth rate in the study group was significantly lower (plt005) and the cumulative live birth rate was reduced by 47
Second statement
It is not yet very clear when non-cavity-distorting intramural fibroids will influence the pregnancy outcome in IVF
Myoma mapping seems mandatory to document the relation to the JZ myometrium
Intra mural myoma should be classified either to the submucous or sub serosal group
The diagnostic strategy is challenged
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Hysteroscopic surgery
4 Laparoscopic surgery
What do we have to know
1 Cavity involvement
2 Number of myomata
3 Size and location
Proper diagnosis of fibroids
Ultrasound
Fluid Mini-Hysteroscopy
Kontrast sonography
One Stop Uterine diagnosis
Proper diagnosis of fibroids
Ultrasound
Hysteroscopy
Contrast sonography
Overview of set up
Supplemantary exams necessary
When
1 dd adenomyoma ndash myoma
2 Multiple myoma
3 Diffuse enlargement of uterine wall
How
1 NMR imaging (3D US )
2 Hysteroscopic Myometrial exploration
LIFE vzw Leuven Institute for Fertility amp Embryology
Findings at MRI JZ Myoma
LIFE vzw Leuven Institute for Fertility amp Embryology
Allocation of Myoma to OM or JZM
LIFE vzw Leuven Institute for Fertility amp Embryology
MRI for diagnosis of Adenomyosis and Adenomyoma
Loss of differentiation JZ - OM
Normal
LIFE vzw Leuven Institute for Fertility amp Embryology
Enlarge the hysteroscopic diagnosis with
exploration of JZ myometrium
Trophy Hysteroscope acc to Campo
New generation of hysteroscope with interesting characteristics
named after the multicentre study TROPHY ldquoTrial of Outpatient
Hysteroscopyrdquo for which it was designedEl-Toukhy T Campo R et al Trial of Outpatient Hysteroscopy ndash (TROPHY) in IVF Reprod Health 2009 Dec 3620
Spirotome acc to Gordts
A device made to harvest high quality samples from soft tissues
built on the pioneering concept of a cutting helix on a cutting cannula
New Tools for exploration of the JZ myometrium
Trophy Scope 29 mm compactscope with Innovative gliding mechanism for accessory sheets
Can be loaded with accessory sheets which can be activated in case of necessity by gently push on the bottom and forward movement till locking in the active position supplementary functions are available without the need to remove the hysteroscope
Trophy Scope Diagnostic accessory sheet
In active positionAtraumatic cervical dilatation up to 37 mm under visual controlCreating double flowBlocking of cervix in case of passive outflow
In free positionSuction device for endometrial samplingGuide for ultrasound guided intrauterine procedures like positioning Embryo
transfer catheter or for Spirotome endomyometrial biopsy
active freepassive
Trophy Scope Operative accessory sheet
In passive position
Operative sheet does not interfere
the diagnostic phase (29mm)
In active positionAtraumatic cervical dilatation
up to 44 mm under visual control
Creating double flow and blocking
function in case of passive outflow
Introduction of 5 Fr instruments without
compromising inflow
A device made to harvest high quality samples from soft tissues
It is built on the pioneering concept of a cutting helix on a cutting
cannula well identified by Ultrasound
Spirotome acc to Gordts
Spirotome
The sample is harvested by turning the helix into the diseased area under
direct vision or ultrasound guidance The cannula turns subsequently over the
helix to free the sample from the surroundings
Spirotome myometrial biopsy
HSC post spirotome biopsy
Spirotome myometrial biopsy
Trophy Scope - Spirotome - US
Guide for ultrasound guided
Spirotome endomyometrial biopsy
cutting helixcutting cannula
Trophy Scope ndash Spirotome - Ultrasound
Exploration of JZ myometrium with Trophy hysteroscope
Resection intramural myoma
Resection adenomyoma
Resection adenomyoma
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Conventional hysteroscopic surgery
4 Laparoscopic surgery
Conventional Hysteroscopic Surgery
TYPE 0 TYPE 1 TYPE 2
The ESGE classificationof submucous myomas
Size volume = 43r3
bull2 cm ~ 42 cm3 8 min
bull3 cm ~ 141 cm3 28 min
bull4 cm ~ 335 cm3 67 min
Emanuel MH et al Fertil Steril 199768881-6
Operating time of critical importance
Reduction in volume of the fibroidsby GnRH-a therapy
Distension fluid
Monopolar surgery using non-ionic solutions
sa manitol sorbitol or glycine has higher risk of
side effects due to fluid overload effect
Stop surgery as soon as 1 L of fluid losses
Bipolar surgery using ionic solutions (saline)
Isotonic hyperhydration is less dangerous
In young patients up to 4 L of losses can be
accepted
Hysteroscopic Myomectomy
Always use a pressure and flow controlled pump system to work at minimal necessary pressure
Always perform continuous fluid balance independently of the medium used
Hysteroscopic Myomectomy
Operative Hysteroscopy Resectoscope Uni or Bipolar
Non ionic fluid
Unipolar polyp and myomaresection
Ionic fluid
First generation Bipolar (Versapoint)
Loop is smaller
chips are smaller
Longer OR time
Bipolar cautery induces
more bubbles
Bipolar resectoscope new generation
low-energy
Two or more small active electrodes very close to each other (active and return electrode)
bull Use Saline as distention medium
bull limited spread of electrical effect the current flow is essentially limited to a small area and it requires less voltage less risk for adhaesion formation
bull Loop different shape and size Different surgical
manoeuvres
bull Need of Modern generator
Bipolar resectoscope new generation
Storz bipolar resectoscope new generation
Return electrode opposite
side
Larger active electrode
Minimal gas bubbles
production
Less risk of perforation
Different surgical technique
Bipolar hysteroscopic myomectomy
Hysteroscopic Myomectomy
Long-term results depend on
bull Uterine Size (Plt0001)
bull Number of myomas (Plt0001)
The surgery-free percentage of 165 patients with normal sized uteri and not more than two
myomas was 943 (+- 18) at 2 years and 903 (+- 30) at 5 years
bull Type ( intra-mural part)
bull Size of myoma (significant increase of amount of particles between 2 and 3 cm)
Long-term results depend on the presence of concomitant pathology
or is a result of incomplete surgery
Emanuel MH Wamsteker K Obstet Gynecol 1999 May93743-8
Third Statement
1 Junctional Zone Myoma should preferentially be treated by hysteroscopy
2 Feasibility of hysteroscopic surgery is predominantly related with size location and amount of myoma
3 Independently of distension medium used continuous fluid balance and flow distension control is mandatory
4 Complication risk is related to experience and surgical technique used
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Conventional hysteroscopic surgery
4 Laparoscopic surgery
Introduction
Intramural myoma larger than 4 cm related to the JZ myometriumschould be operated on
Laparoscopic approach has had an important evolution over the
years
Series with high success rate are done by experts =gt it is difficult to extrapolate to less experienced surgeons
Laparoscopic myomectomy needs expert skills in haemostasis dissection and suturing
How to minimize blood loss
bullA lot of techniques in order to minimize blood loss
GnRH agonists
Intramyometrial vasopressine
Oxytocin IV 40 mUImin intraoperatively
Use of tourniquet or penrose at the lower part of uterus
Laparoscopic Myomectomy
J Ferro IVI Valencia Spain
Tips amp tricks ndash minimize blood loss
Clipping of the uterine arteries and infundilopelvic ligaments is another very efficient method
Artery ligation versus Control group (n=152)
173 +- 91 mL vs 402 +- 131 mL blood loss
62 vs 2075 reccurence rate
Alborzi S et al A comparison of combined laparoscopic uterine artery ligation and myomectomyversus laparoscopic myomectomy in the treatment of symptomatic myoma Fertil Steril 2009
Tips amp tricks ndash minimize blood loss
Technique Incision
Incision
J Ferro A Wattiez
Tips amp tricks- dissection
Tips amp tricks- closure
bull One versus multiples layers controversial
bull Adequate closure of the dead space to minimize the risk of hematoma formation
bull Interrupted figure of eight sutures are usually sufficient monocryl 1 or 0 with extracorporeal notes =gt extra strength
bull For the serosa approximate with interrupted 20 sutures if necessary (monofilament)
Tips amp tricks- closure
Removal Clips
Anti- adhesion agents
Fourth Statement
LAPAROSCOPIC MYOMECTOMY offers comparable results tolaparotomic myomectomy
Laparoscopic approach reduces adhesion formation blood loss and hospital stay
Laparoscopic myomectomy seems indicated in the infertile patient for the treatment of intramural myomarsquos
Laparoscopic Myomectomy requires a skilled laparoscopic surgeon with expert suturing skills optimal instrumental support and knowledge of some trickrsquos to provide an optimal result
Take Home message
Submucous myoma should always be removed prior to IVF
Hysteroscopic resection is the gold standard to treat those myoma
Intramural myoma originating from the sub endometrial
myometrium and larger than 4 cm are treated by Laproscopy
Subserosal myoma do not influence the outcome of IVF and are not removed for this indication
More info on the special training
programsin endoscopic
surgery
ESGEORG
More info on the ESGE website
wwwesgeorg
See you in London
Rudi Campo Stephan GordtsPatrick PuttemansRoger MolinasSylvie GordtsMarion Valkenburg Ivo Brosens
Leuven Institute for Fertility
amp Embryology
Trophy Scope a new generation
Interesting Characteristics
Gliding system that provides
Diagnostic ( 29 mm ) and
Operative (44 mm)
possibilities in one instrument
This hysteroscope has been named after the multicentre study
TROPHY ldquoTrial of Outpatient Hysteroscopyrdquo for which it was designed
El-Toukhy T Campo R et al Trial of Outpatient Hysteroscopy - [TROPHY] in IVF Reprod Health 2009 Dec 3620
Effect of INTRAMURAL myoma
Studies are inconclusive due to lack of correct documentation of size amount and localisation Study design is mostly retrospective
Questions are bull Does a myoma originating from the JZ myometrium
but with no penetration into the uterine cavity influences the reproductive outcome
bull If so is their a cutt of in size and amount of myoma
Q1 Scientific evidence
The effect of intramural fibroids without uterine cavity involvement on the outcome of IVF treatment a systematic review and meta-analysis
19 observational studies comprising 6087 IVF cycles were included
Sunkara SK Khairy M El-Toukhy T Khalaf Y Coomarasamy AHum Reprod 2010 Feb25(2)418-29
Effect of INTRAMURAL myoma
The presence of non-cavity-distorting intramural fibroids showed a significant decrease in the
live birth (RR = 079 95 CI 070-088 P lt 00001) clinical PRs (RR = 085 95 CI 077-094 P = 0002)
in women with non-cavity-distorting intramural fibroids compared with those without fibroids following IVF treatment
Q2 Size and amount
Fibroids not encroaching the endometrial cavity and IVF success rate a prospective study
Somigliana E De Benedictis S Vercellini P Nicolosi AE Benaglia L Scarduelli C Ragni G Fedele LSmall Myoma no influence
Hum Reprod 2011 Apr26(4)834-9
Q2 Size and amount
Fibroids not encroaching the endometrial cavity and IVF success rate a prospective study
In asymptomatic patients selected for IVF small (less than 05 cm) fibroids not encroaching the endometrial cavity did not impact on the rate of success of the procedure
There was no significant relationship between clinical outcome and either the number or size of the fibroids
Q2 Size and amount
Those findings are in conflict with the findings of Khalaf et al 2006 who also studied the effect of small intramuralUterine fibroids
IVF ICSI results in 322 women without fibroids and 112 with fibroids in 606 cycles were studied
Live birth rate in the study group was significantly lower (plt005) and the cumulative live birth rate was reduced by 47
Second statement
It is not yet very clear when non-cavity-distorting intramural fibroids will influence the pregnancy outcome in IVF
Myoma mapping seems mandatory to document the relation to the JZ myometrium
Intra mural myoma should be classified either to the submucous or sub serosal group
The diagnostic strategy is challenged
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Hysteroscopic surgery
4 Laparoscopic surgery
What do we have to know
1 Cavity involvement
2 Number of myomata
3 Size and location
Proper diagnosis of fibroids
Ultrasound
Fluid Mini-Hysteroscopy
Kontrast sonography
One Stop Uterine diagnosis
Proper diagnosis of fibroids
Ultrasound
Hysteroscopy
Contrast sonography
Overview of set up
Supplemantary exams necessary
When
1 dd adenomyoma ndash myoma
2 Multiple myoma
3 Diffuse enlargement of uterine wall
How
1 NMR imaging (3D US )
2 Hysteroscopic Myometrial exploration
LIFE vzw Leuven Institute for Fertility amp Embryology
Findings at MRI JZ Myoma
LIFE vzw Leuven Institute for Fertility amp Embryology
Allocation of Myoma to OM or JZM
LIFE vzw Leuven Institute for Fertility amp Embryology
MRI for diagnosis of Adenomyosis and Adenomyoma
Loss of differentiation JZ - OM
Normal
LIFE vzw Leuven Institute for Fertility amp Embryology
Enlarge the hysteroscopic diagnosis with
exploration of JZ myometrium
Trophy Hysteroscope acc to Campo
New generation of hysteroscope with interesting characteristics
named after the multicentre study TROPHY ldquoTrial of Outpatient
Hysteroscopyrdquo for which it was designedEl-Toukhy T Campo R et al Trial of Outpatient Hysteroscopy ndash (TROPHY) in IVF Reprod Health 2009 Dec 3620
Spirotome acc to Gordts
A device made to harvest high quality samples from soft tissues
built on the pioneering concept of a cutting helix on a cutting cannula
New Tools for exploration of the JZ myometrium
Trophy Scope 29 mm compactscope with Innovative gliding mechanism for accessory sheets
Can be loaded with accessory sheets which can be activated in case of necessity by gently push on the bottom and forward movement till locking in the active position supplementary functions are available without the need to remove the hysteroscope
Trophy Scope Diagnostic accessory sheet
In active positionAtraumatic cervical dilatation up to 37 mm under visual controlCreating double flowBlocking of cervix in case of passive outflow
In free positionSuction device for endometrial samplingGuide for ultrasound guided intrauterine procedures like positioning Embryo
transfer catheter or for Spirotome endomyometrial biopsy
active freepassive
Trophy Scope Operative accessory sheet
In passive position
Operative sheet does not interfere
the diagnostic phase (29mm)
In active positionAtraumatic cervical dilatation
up to 44 mm under visual control
Creating double flow and blocking
function in case of passive outflow
Introduction of 5 Fr instruments without
compromising inflow
A device made to harvest high quality samples from soft tissues
It is built on the pioneering concept of a cutting helix on a cutting
cannula well identified by Ultrasound
Spirotome acc to Gordts
Spirotome
The sample is harvested by turning the helix into the diseased area under
direct vision or ultrasound guidance The cannula turns subsequently over the
helix to free the sample from the surroundings
Spirotome myometrial biopsy
HSC post spirotome biopsy
Spirotome myometrial biopsy
Trophy Scope - Spirotome - US
Guide for ultrasound guided
Spirotome endomyometrial biopsy
cutting helixcutting cannula
Trophy Scope ndash Spirotome - Ultrasound
Exploration of JZ myometrium with Trophy hysteroscope
Resection intramural myoma
Resection adenomyoma
Resection adenomyoma
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Conventional hysteroscopic surgery
4 Laparoscopic surgery
Conventional Hysteroscopic Surgery
TYPE 0 TYPE 1 TYPE 2
The ESGE classificationof submucous myomas
Size volume = 43r3
bull2 cm ~ 42 cm3 8 min
bull3 cm ~ 141 cm3 28 min
bull4 cm ~ 335 cm3 67 min
Emanuel MH et al Fertil Steril 199768881-6
Operating time of critical importance
Reduction in volume of the fibroidsby GnRH-a therapy
Distension fluid
Monopolar surgery using non-ionic solutions
sa manitol sorbitol or glycine has higher risk of
side effects due to fluid overload effect
Stop surgery as soon as 1 L of fluid losses
Bipolar surgery using ionic solutions (saline)
Isotonic hyperhydration is less dangerous
In young patients up to 4 L of losses can be
accepted
Hysteroscopic Myomectomy
Always use a pressure and flow controlled pump system to work at minimal necessary pressure
Always perform continuous fluid balance independently of the medium used
Hysteroscopic Myomectomy
Operative Hysteroscopy Resectoscope Uni or Bipolar
Non ionic fluid
Unipolar polyp and myomaresection
Ionic fluid
First generation Bipolar (Versapoint)
Loop is smaller
chips are smaller
Longer OR time
Bipolar cautery induces
more bubbles
Bipolar resectoscope new generation
low-energy
Two or more small active electrodes very close to each other (active and return electrode)
bull Use Saline as distention medium
bull limited spread of electrical effect the current flow is essentially limited to a small area and it requires less voltage less risk for adhaesion formation
bull Loop different shape and size Different surgical
manoeuvres
bull Need of Modern generator
Bipolar resectoscope new generation
Storz bipolar resectoscope new generation
Return electrode opposite
side
Larger active electrode
Minimal gas bubbles
production
Less risk of perforation
Different surgical technique
Bipolar hysteroscopic myomectomy
Hysteroscopic Myomectomy
Long-term results depend on
bull Uterine Size (Plt0001)
bull Number of myomas (Plt0001)
The surgery-free percentage of 165 patients with normal sized uteri and not more than two
myomas was 943 (+- 18) at 2 years and 903 (+- 30) at 5 years
bull Type ( intra-mural part)
bull Size of myoma (significant increase of amount of particles between 2 and 3 cm)
Long-term results depend on the presence of concomitant pathology
or is a result of incomplete surgery
Emanuel MH Wamsteker K Obstet Gynecol 1999 May93743-8
Third Statement
1 Junctional Zone Myoma should preferentially be treated by hysteroscopy
2 Feasibility of hysteroscopic surgery is predominantly related with size location and amount of myoma
3 Independently of distension medium used continuous fluid balance and flow distension control is mandatory
4 Complication risk is related to experience and surgical technique used
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Conventional hysteroscopic surgery
4 Laparoscopic surgery
Introduction
Intramural myoma larger than 4 cm related to the JZ myometriumschould be operated on
Laparoscopic approach has had an important evolution over the
years
Series with high success rate are done by experts =gt it is difficult to extrapolate to less experienced surgeons
Laparoscopic myomectomy needs expert skills in haemostasis dissection and suturing
How to minimize blood loss
bullA lot of techniques in order to minimize blood loss
GnRH agonists
Intramyometrial vasopressine
Oxytocin IV 40 mUImin intraoperatively
Use of tourniquet or penrose at the lower part of uterus
Laparoscopic Myomectomy
J Ferro IVI Valencia Spain
Tips amp tricks ndash minimize blood loss
Clipping of the uterine arteries and infundilopelvic ligaments is another very efficient method
Artery ligation versus Control group (n=152)
173 +- 91 mL vs 402 +- 131 mL blood loss
62 vs 2075 reccurence rate
Alborzi S et al A comparison of combined laparoscopic uterine artery ligation and myomectomyversus laparoscopic myomectomy in the treatment of symptomatic myoma Fertil Steril 2009
Tips amp tricks ndash minimize blood loss
Technique Incision
Incision
J Ferro A Wattiez
Tips amp tricks- dissection
Tips amp tricks- closure
bull One versus multiples layers controversial
bull Adequate closure of the dead space to minimize the risk of hematoma formation
bull Interrupted figure of eight sutures are usually sufficient monocryl 1 or 0 with extracorporeal notes =gt extra strength
bull For the serosa approximate with interrupted 20 sutures if necessary (monofilament)
Tips amp tricks- closure
Removal Clips
Anti- adhesion agents
Fourth Statement
LAPAROSCOPIC MYOMECTOMY offers comparable results tolaparotomic myomectomy
Laparoscopic approach reduces adhesion formation blood loss and hospital stay
Laparoscopic myomectomy seems indicated in the infertile patient for the treatment of intramural myomarsquos
Laparoscopic Myomectomy requires a skilled laparoscopic surgeon with expert suturing skills optimal instrumental support and knowledge of some trickrsquos to provide an optimal result
Take Home message
Submucous myoma should always be removed prior to IVF
Hysteroscopic resection is the gold standard to treat those myoma
Intramural myoma originating from the sub endometrial
myometrium and larger than 4 cm are treated by Laproscopy
Subserosal myoma do not influence the outcome of IVF and are not removed for this indication
More info on the special training
programsin endoscopic
surgery
ESGEORG
More info on the ESGE website
wwwesgeorg
See you in London
Rudi Campo Stephan GordtsPatrick PuttemansRoger MolinasSylvie GordtsMarion Valkenburg Ivo Brosens
Leuven Institute for Fertility
amp Embryology
Trophy Scope a new generation
Interesting Characteristics
Gliding system that provides
Diagnostic ( 29 mm ) and
Operative (44 mm)
possibilities in one instrument
This hysteroscope has been named after the multicentre study
TROPHY ldquoTrial of Outpatient Hysteroscopyrdquo for which it was designed
El-Toukhy T Campo R et al Trial of Outpatient Hysteroscopy - [TROPHY] in IVF Reprod Health 2009 Dec 3620
Q1 Scientific evidence
The effect of intramural fibroids without uterine cavity involvement on the outcome of IVF treatment a systematic review and meta-analysis
19 observational studies comprising 6087 IVF cycles were included
Sunkara SK Khairy M El-Toukhy T Khalaf Y Coomarasamy AHum Reprod 2010 Feb25(2)418-29
Effect of INTRAMURAL myoma
The presence of non-cavity-distorting intramural fibroids showed a significant decrease in the
live birth (RR = 079 95 CI 070-088 P lt 00001) clinical PRs (RR = 085 95 CI 077-094 P = 0002)
in women with non-cavity-distorting intramural fibroids compared with those without fibroids following IVF treatment
Q2 Size and amount
Fibroids not encroaching the endometrial cavity and IVF success rate a prospective study
Somigliana E De Benedictis S Vercellini P Nicolosi AE Benaglia L Scarduelli C Ragni G Fedele LSmall Myoma no influence
Hum Reprod 2011 Apr26(4)834-9
Q2 Size and amount
Fibroids not encroaching the endometrial cavity and IVF success rate a prospective study
In asymptomatic patients selected for IVF small (less than 05 cm) fibroids not encroaching the endometrial cavity did not impact on the rate of success of the procedure
There was no significant relationship between clinical outcome and either the number or size of the fibroids
Q2 Size and amount
Those findings are in conflict with the findings of Khalaf et al 2006 who also studied the effect of small intramuralUterine fibroids
IVF ICSI results in 322 women without fibroids and 112 with fibroids in 606 cycles were studied
Live birth rate in the study group was significantly lower (plt005) and the cumulative live birth rate was reduced by 47
Second statement
It is not yet very clear when non-cavity-distorting intramural fibroids will influence the pregnancy outcome in IVF
Myoma mapping seems mandatory to document the relation to the JZ myometrium
Intra mural myoma should be classified either to the submucous or sub serosal group
The diagnostic strategy is challenged
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Hysteroscopic surgery
4 Laparoscopic surgery
What do we have to know
1 Cavity involvement
2 Number of myomata
3 Size and location
Proper diagnosis of fibroids
Ultrasound
Fluid Mini-Hysteroscopy
Kontrast sonography
One Stop Uterine diagnosis
Proper diagnosis of fibroids
Ultrasound
Hysteroscopy
Contrast sonography
Overview of set up
Supplemantary exams necessary
When
1 dd adenomyoma ndash myoma
2 Multiple myoma
3 Diffuse enlargement of uterine wall
How
1 NMR imaging (3D US )
2 Hysteroscopic Myometrial exploration
LIFE vzw Leuven Institute for Fertility amp Embryology
Findings at MRI JZ Myoma
LIFE vzw Leuven Institute for Fertility amp Embryology
Allocation of Myoma to OM or JZM
LIFE vzw Leuven Institute for Fertility amp Embryology
MRI for diagnosis of Adenomyosis and Adenomyoma
Loss of differentiation JZ - OM
Normal
LIFE vzw Leuven Institute for Fertility amp Embryology
Enlarge the hysteroscopic diagnosis with
exploration of JZ myometrium
Trophy Hysteroscope acc to Campo
New generation of hysteroscope with interesting characteristics
named after the multicentre study TROPHY ldquoTrial of Outpatient
Hysteroscopyrdquo for which it was designedEl-Toukhy T Campo R et al Trial of Outpatient Hysteroscopy ndash (TROPHY) in IVF Reprod Health 2009 Dec 3620
Spirotome acc to Gordts
A device made to harvest high quality samples from soft tissues
built on the pioneering concept of a cutting helix on a cutting cannula
New Tools for exploration of the JZ myometrium
Trophy Scope 29 mm compactscope with Innovative gliding mechanism for accessory sheets
Can be loaded with accessory sheets which can be activated in case of necessity by gently push on the bottom and forward movement till locking in the active position supplementary functions are available without the need to remove the hysteroscope
Trophy Scope Diagnostic accessory sheet
In active positionAtraumatic cervical dilatation up to 37 mm under visual controlCreating double flowBlocking of cervix in case of passive outflow
In free positionSuction device for endometrial samplingGuide for ultrasound guided intrauterine procedures like positioning Embryo
transfer catheter or for Spirotome endomyometrial biopsy
active freepassive
Trophy Scope Operative accessory sheet
In passive position
Operative sheet does not interfere
the diagnostic phase (29mm)
In active positionAtraumatic cervical dilatation
up to 44 mm under visual control
Creating double flow and blocking
function in case of passive outflow
Introduction of 5 Fr instruments without
compromising inflow
A device made to harvest high quality samples from soft tissues
It is built on the pioneering concept of a cutting helix on a cutting
cannula well identified by Ultrasound
Spirotome acc to Gordts
Spirotome
The sample is harvested by turning the helix into the diseased area under
direct vision or ultrasound guidance The cannula turns subsequently over the
helix to free the sample from the surroundings
Spirotome myometrial biopsy
HSC post spirotome biopsy
Spirotome myometrial biopsy
Trophy Scope - Spirotome - US
Guide for ultrasound guided
Spirotome endomyometrial biopsy
cutting helixcutting cannula
Trophy Scope ndash Spirotome - Ultrasound
Exploration of JZ myometrium with Trophy hysteroscope
Resection intramural myoma
Resection adenomyoma
Resection adenomyoma
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Conventional hysteroscopic surgery
4 Laparoscopic surgery
Conventional Hysteroscopic Surgery
TYPE 0 TYPE 1 TYPE 2
The ESGE classificationof submucous myomas
Size volume = 43r3
bull2 cm ~ 42 cm3 8 min
bull3 cm ~ 141 cm3 28 min
bull4 cm ~ 335 cm3 67 min
Emanuel MH et al Fertil Steril 199768881-6
Operating time of critical importance
Reduction in volume of the fibroidsby GnRH-a therapy
Distension fluid
Monopolar surgery using non-ionic solutions
sa manitol sorbitol or glycine has higher risk of
side effects due to fluid overload effect
Stop surgery as soon as 1 L of fluid losses
Bipolar surgery using ionic solutions (saline)
Isotonic hyperhydration is less dangerous
In young patients up to 4 L of losses can be
accepted
Hysteroscopic Myomectomy
Always use a pressure and flow controlled pump system to work at minimal necessary pressure
Always perform continuous fluid balance independently of the medium used
Hysteroscopic Myomectomy
Operative Hysteroscopy Resectoscope Uni or Bipolar
Non ionic fluid
Unipolar polyp and myomaresection
Ionic fluid
First generation Bipolar (Versapoint)
Loop is smaller
chips are smaller
Longer OR time
Bipolar cautery induces
more bubbles
Bipolar resectoscope new generation
low-energy
Two or more small active electrodes very close to each other (active and return electrode)
bull Use Saline as distention medium
bull limited spread of electrical effect the current flow is essentially limited to a small area and it requires less voltage less risk for adhaesion formation
bull Loop different shape and size Different surgical
manoeuvres
bull Need of Modern generator
Bipolar resectoscope new generation
Storz bipolar resectoscope new generation
Return electrode opposite
side
Larger active electrode
Minimal gas bubbles
production
Less risk of perforation
Different surgical technique
Bipolar hysteroscopic myomectomy
Hysteroscopic Myomectomy
Long-term results depend on
bull Uterine Size (Plt0001)
bull Number of myomas (Plt0001)
The surgery-free percentage of 165 patients with normal sized uteri and not more than two
myomas was 943 (+- 18) at 2 years and 903 (+- 30) at 5 years
bull Type ( intra-mural part)
bull Size of myoma (significant increase of amount of particles between 2 and 3 cm)
Long-term results depend on the presence of concomitant pathology
or is a result of incomplete surgery
Emanuel MH Wamsteker K Obstet Gynecol 1999 May93743-8
Third Statement
1 Junctional Zone Myoma should preferentially be treated by hysteroscopy
2 Feasibility of hysteroscopic surgery is predominantly related with size location and amount of myoma
3 Independently of distension medium used continuous fluid balance and flow distension control is mandatory
4 Complication risk is related to experience and surgical technique used
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Conventional hysteroscopic surgery
4 Laparoscopic surgery
Introduction
Intramural myoma larger than 4 cm related to the JZ myometriumschould be operated on
Laparoscopic approach has had an important evolution over the
years
Series with high success rate are done by experts =gt it is difficult to extrapolate to less experienced surgeons
Laparoscopic myomectomy needs expert skills in haemostasis dissection and suturing
How to minimize blood loss
bullA lot of techniques in order to minimize blood loss
GnRH agonists
Intramyometrial vasopressine
Oxytocin IV 40 mUImin intraoperatively
Use of tourniquet or penrose at the lower part of uterus
Laparoscopic Myomectomy
J Ferro IVI Valencia Spain
Tips amp tricks ndash minimize blood loss
Clipping of the uterine arteries and infundilopelvic ligaments is another very efficient method
Artery ligation versus Control group (n=152)
173 +- 91 mL vs 402 +- 131 mL blood loss
62 vs 2075 reccurence rate
Alborzi S et al A comparison of combined laparoscopic uterine artery ligation and myomectomyversus laparoscopic myomectomy in the treatment of symptomatic myoma Fertil Steril 2009
Tips amp tricks ndash minimize blood loss
Technique Incision
Incision
J Ferro A Wattiez
Tips amp tricks- dissection
Tips amp tricks- closure
bull One versus multiples layers controversial
bull Adequate closure of the dead space to minimize the risk of hematoma formation
bull Interrupted figure of eight sutures are usually sufficient monocryl 1 or 0 with extracorporeal notes =gt extra strength
bull For the serosa approximate with interrupted 20 sutures if necessary (monofilament)
Tips amp tricks- closure
Removal Clips
Anti- adhesion agents
Fourth Statement
LAPAROSCOPIC MYOMECTOMY offers comparable results tolaparotomic myomectomy
Laparoscopic approach reduces adhesion formation blood loss and hospital stay
Laparoscopic myomectomy seems indicated in the infertile patient for the treatment of intramural myomarsquos
Laparoscopic Myomectomy requires a skilled laparoscopic surgeon with expert suturing skills optimal instrumental support and knowledge of some trickrsquos to provide an optimal result
Take Home message
Submucous myoma should always be removed prior to IVF
Hysteroscopic resection is the gold standard to treat those myoma
Intramural myoma originating from the sub endometrial
myometrium and larger than 4 cm are treated by Laproscopy
Subserosal myoma do not influence the outcome of IVF and are not removed for this indication
More info on the special training
programsin endoscopic
surgery
ESGEORG
More info on the ESGE website
wwwesgeorg
See you in London
Rudi Campo Stephan GordtsPatrick PuttemansRoger MolinasSylvie GordtsMarion Valkenburg Ivo Brosens
Leuven Institute for Fertility
amp Embryology
Trophy Scope a new generation
Interesting Characteristics
Gliding system that provides
Diagnostic ( 29 mm ) and
Operative (44 mm)
possibilities in one instrument
This hysteroscope has been named after the multicentre study
TROPHY ldquoTrial of Outpatient Hysteroscopyrdquo for which it was designed
El-Toukhy T Campo R et al Trial of Outpatient Hysteroscopy - [TROPHY] in IVF Reprod Health 2009 Dec 3620
Effect of INTRAMURAL myoma
The presence of non-cavity-distorting intramural fibroids showed a significant decrease in the
live birth (RR = 079 95 CI 070-088 P lt 00001) clinical PRs (RR = 085 95 CI 077-094 P = 0002)
in women with non-cavity-distorting intramural fibroids compared with those without fibroids following IVF treatment
Q2 Size and amount
Fibroids not encroaching the endometrial cavity and IVF success rate a prospective study
Somigliana E De Benedictis S Vercellini P Nicolosi AE Benaglia L Scarduelli C Ragni G Fedele LSmall Myoma no influence
Hum Reprod 2011 Apr26(4)834-9
Q2 Size and amount
Fibroids not encroaching the endometrial cavity and IVF success rate a prospective study
In asymptomatic patients selected for IVF small (less than 05 cm) fibroids not encroaching the endometrial cavity did not impact on the rate of success of the procedure
There was no significant relationship between clinical outcome and either the number or size of the fibroids
Q2 Size and amount
Those findings are in conflict with the findings of Khalaf et al 2006 who also studied the effect of small intramuralUterine fibroids
IVF ICSI results in 322 women without fibroids and 112 with fibroids in 606 cycles were studied
Live birth rate in the study group was significantly lower (plt005) and the cumulative live birth rate was reduced by 47
Second statement
It is not yet very clear when non-cavity-distorting intramural fibroids will influence the pregnancy outcome in IVF
Myoma mapping seems mandatory to document the relation to the JZ myometrium
Intra mural myoma should be classified either to the submucous or sub serosal group
The diagnostic strategy is challenged
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Hysteroscopic surgery
4 Laparoscopic surgery
What do we have to know
1 Cavity involvement
2 Number of myomata
3 Size and location
Proper diagnosis of fibroids
Ultrasound
Fluid Mini-Hysteroscopy
Kontrast sonography
One Stop Uterine diagnosis
Proper diagnosis of fibroids
Ultrasound
Hysteroscopy
Contrast sonography
Overview of set up
Supplemantary exams necessary
When
1 dd adenomyoma ndash myoma
2 Multiple myoma
3 Diffuse enlargement of uterine wall
How
1 NMR imaging (3D US )
2 Hysteroscopic Myometrial exploration
LIFE vzw Leuven Institute for Fertility amp Embryology
Findings at MRI JZ Myoma
LIFE vzw Leuven Institute for Fertility amp Embryology
Allocation of Myoma to OM or JZM
LIFE vzw Leuven Institute for Fertility amp Embryology
MRI for diagnosis of Adenomyosis and Adenomyoma
Loss of differentiation JZ - OM
Normal
LIFE vzw Leuven Institute for Fertility amp Embryology
Enlarge the hysteroscopic diagnosis with
exploration of JZ myometrium
Trophy Hysteroscope acc to Campo
New generation of hysteroscope with interesting characteristics
named after the multicentre study TROPHY ldquoTrial of Outpatient
Hysteroscopyrdquo for which it was designedEl-Toukhy T Campo R et al Trial of Outpatient Hysteroscopy ndash (TROPHY) in IVF Reprod Health 2009 Dec 3620
Spirotome acc to Gordts
A device made to harvest high quality samples from soft tissues
built on the pioneering concept of a cutting helix on a cutting cannula
New Tools for exploration of the JZ myometrium
Trophy Scope 29 mm compactscope with Innovative gliding mechanism for accessory sheets
Can be loaded with accessory sheets which can be activated in case of necessity by gently push on the bottom and forward movement till locking in the active position supplementary functions are available without the need to remove the hysteroscope
Trophy Scope Diagnostic accessory sheet
In active positionAtraumatic cervical dilatation up to 37 mm under visual controlCreating double flowBlocking of cervix in case of passive outflow
In free positionSuction device for endometrial samplingGuide for ultrasound guided intrauterine procedures like positioning Embryo
transfer catheter or for Spirotome endomyometrial biopsy
active freepassive
Trophy Scope Operative accessory sheet
In passive position
Operative sheet does not interfere
the diagnostic phase (29mm)
In active positionAtraumatic cervical dilatation
up to 44 mm under visual control
Creating double flow and blocking
function in case of passive outflow
Introduction of 5 Fr instruments without
compromising inflow
A device made to harvest high quality samples from soft tissues
It is built on the pioneering concept of a cutting helix on a cutting
cannula well identified by Ultrasound
Spirotome acc to Gordts
Spirotome
The sample is harvested by turning the helix into the diseased area under
direct vision or ultrasound guidance The cannula turns subsequently over the
helix to free the sample from the surroundings
Spirotome myometrial biopsy
HSC post spirotome biopsy
Spirotome myometrial biopsy
Trophy Scope - Spirotome - US
Guide for ultrasound guided
Spirotome endomyometrial biopsy
cutting helixcutting cannula
Trophy Scope ndash Spirotome - Ultrasound
Exploration of JZ myometrium with Trophy hysteroscope
Resection intramural myoma
Resection adenomyoma
Resection adenomyoma
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Conventional hysteroscopic surgery
4 Laparoscopic surgery
Conventional Hysteroscopic Surgery
TYPE 0 TYPE 1 TYPE 2
The ESGE classificationof submucous myomas
Size volume = 43r3
bull2 cm ~ 42 cm3 8 min
bull3 cm ~ 141 cm3 28 min
bull4 cm ~ 335 cm3 67 min
Emanuel MH et al Fertil Steril 199768881-6
Operating time of critical importance
Reduction in volume of the fibroidsby GnRH-a therapy
Distension fluid
Monopolar surgery using non-ionic solutions
sa manitol sorbitol or glycine has higher risk of
side effects due to fluid overload effect
Stop surgery as soon as 1 L of fluid losses
Bipolar surgery using ionic solutions (saline)
Isotonic hyperhydration is less dangerous
In young patients up to 4 L of losses can be
accepted
Hysteroscopic Myomectomy
Always use a pressure and flow controlled pump system to work at minimal necessary pressure
Always perform continuous fluid balance independently of the medium used
Hysteroscopic Myomectomy
Operative Hysteroscopy Resectoscope Uni or Bipolar
Non ionic fluid
Unipolar polyp and myomaresection
Ionic fluid
First generation Bipolar (Versapoint)
Loop is smaller
chips are smaller
Longer OR time
Bipolar cautery induces
more bubbles
Bipolar resectoscope new generation
low-energy
Two or more small active electrodes very close to each other (active and return electrode)
bull Use Saline as distention medium
bull limited spread of electrical effect the current flow is essentially limited to a small area and it requires less voltage less risk for adhaesion formation
bull Loop different shape and size Different surgical
manoeuvres
bull Need of Modern generator
Bipolar resectoscope new generation
Storz bipolar resectoscope new generation
Return electrode opposite
side
Larger active electrode
Minimal gas bubbles
production
Less risk of perforation
Different surgical technique
Bipolar hysteroscopic myomectomy
Hysteroscopic Myomectomy
Long-term results depend on
bull Uterine Size (Plt0001)
bull Number of myomas (Plt0001)
The surgery-free percentage of 165 patients with normal sized uteri and not more than two
myomas was 943 (+- 18) at 2 years and 903 (+- 30) at 5 years
bull Type ( intra-mural part)
bull Size of myoma (significant increase of amount of particles between 2 and 3 cm)
Long-term results depend on the presence of concomitant pathology
or is a result of incomplete surgery
Emanuel MH Wamsteker K Obstet Gynecol 1999 May93743-8
Third Statement
1 Junctional Zone Myoma should preferentially be treated by hysteroscopy
2 Feasibility of hysteroscopic surgery is predominantly related with size location and amount of myoma
3 Independently of distension medium used continuous fluid balance and flow distension control is mandatory
4 Complication risk is related to experience and surgical technique used
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Conventional hysteroscopic surgery
4 Laparoscopic surgery
Introduction
Intramural myoma larger than 4 cm related to the JZ myometriumschould be operated on
Laparoscopic approach has had an important evolution over the
years
Series with high success rate are done by experts =gt it is difficult to extrapolate to less experienced surgeons
Laparoscopic myomectomy needs expert skills in haemostasis dissection and suturing
How to minimize blood loss
bullA lot of techniques in order to minimize blood loss
GnRH agonists
Intramyometrial vasopressine
Oxytocin IV 40 mUImin intraoperatively
Use of tourniquet or penrose at the lower part of uterus
Laparoscopic Myomectomy
J Ferro IVI Valencia Spain
Tips amp tricks ndash minimize blood loss
Clipping of the uterine arteries and infundilopelvic ligaments is another very efficient method
Artery ligation versus Control group (n=152)
173 +- 91 mL vs 402 +- 131 mL blood loss
62 vs 2075 reccurence rate
Alborzi S et al A comparison of combined laparoscopic uterine artery ligation and myomectomyversus laparoscopic myomectomy in the treatment of symptomatic myoma Fertil Steril 2009
Tips amp tricks ndash minimize blood loss
Technique Incision
Incision
J Ferro A Wattiez
Tips amp tricks- dissection
Tips amp tricks- closure
bull One versus multiples layers controversial
bull Adequate closure of the dead space to minimize the risk of hematoma formation
bull Interrupted figure of eight sutures are usually sufficient monocryl 1 or 0 with extracorporeal notes =gt extra strength
bull For the serosa approximate with interrupted 20 sutures if necessary (monofilament)
Tips amp tricks- closure
Removal Clips
Anti- adhesion agents
Fourth Statement
LAPAROSCOPIC MYOMECTOMY offers comparable results tolaparotomic myomectomy
Laparoscopic approach reduces adhesion formation blood loss and hospital stay
Laparoscopic myomectomy seems indicated in the infertile patient for the treatment of intramural myomarsquos
Laparoscopic Myomectomy requires a skilled laparoscopic surgeon with expert suturing skills optimal instrumental support and knowledge of some trickrsquos to provide an optimal result
Take Home message
Submucous myoma should always be removed prior to IVF
Hysteroscopic resection is the gold standard to treat those myoma
Intramural myoma originating from the sub endometrial
myometrium and larger than 4 cm are treated by Laproscopy
Subserosal myoma do not influence the outcome of IVF and are not removed for this indication
More info on the special training
programsin endoscopic
surgery
ESGEORG
More info on the ESGE website
wwwesgeorg
See you in London
Rudi Campo Stephan GordtsPatrick PuttemansRoger MolinasSylvie GordtsMarion Valkenburg Ivo Brosens
Leuven Institute for Fertility
amp Embryology
Trophy Scope a new generation
Interesting Characteristics
Gliding system that provides
Diagnostic ( 29 mm ) and
Operative (44 mm)
possibilities in one instrument
This hysteroscope has been named after the multicentre study
TROPHY ldquoTrial of Outpatient Hysteroscopyrdquo for which it was designed
El-Toukhy T Campo R et al Trial of Outpatient Hysteroscopy - [TROPHY] in IVF Reprod Health 2009 Dec 3620
Q2 Size and amount
Fibroids not encroaching the endometrial cavity and IVF success rate a prospective study
Somigliana E De Benedictis S Vercellini P Nicolosi AE Benaglia L Scarduelli C Ragni G Fedele LSmall Myoma no influence
Hum Reprod 2011 Apr26(4)834-9
Q2 Size and amount
Fibroids not encroaching the endometrial cavity and IVF success rate a prospective study
In asymptomatic patients selected for IVF small (less than 05 cm) fibroids not encroaching the endometrial cavity did not impact on the rate of success of the procedure
There was no significant relationship between clinical outcome and either the number or size of the fibroids
Q2 Size and amount
Those findings are in conflict with the findings of Khalaf et al 2006 who also studied the effect of small intramuralUterine fibroids
IVF ICSI results in 322 women without fibroids and 112 with fibroids in 606 cycles were studied
Live birth rate in the study group was significantly lower (plt005) and the cumulative live birth rate was reduced by 47
Second statement
It is not yet very clear when non-cavity-distorting intramural fibroids will influence the pregnancy outcome in IVF
Myoma mapping seems mandatory to document the relation to the JZ myometrium
Intra mural myoma should be classified either to the submucous or sub serosal group
The diagnostic strategy is challenged
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Hysteroscopic surgery
4 Laparoscopic surgery
What do we have to know
1 Cavity involvement
2 Number of myomata
3 Size and location
Proper diagnosis of fibroids
Ultrasound
Fluid Mini-Hysteroscopy
Kontrast sonography
One Stop Uterine diagnosis
Proper diagnosis of fibroids
Ultrasound
Hysteroscopy
Contrast sonography
Overview of set up
Supplemantary exams necessary
When
1 dd adenomyoma ndash myoma
2 Multiple myoma
3 Diffuse enlargement of uterine wall
How
1 NMR imaging (3D US )
2 Hysteroscopic Myometrial exploration
LIFE vzw Leuven Institute for Fertility amp Embryology
Findings at MRI JZ Myoma
LIFE vzw Leuven Institute for Fertility amp Embryology
Allocation of Myoma to OM or JZM
LIFE vzw Leuven Institute for Fertility amp Embryology
MRI for diagnosis of Adenomyosis and Adenomyoma
Loss of differentiation JZ - OM
Normal
LIFE vzw Leuven Institute for Fertility amp Embryology
Enlarge the hysteroscopic diagnosis with
exploration of JZ myometrium
Trophy Hysteroscope acc to Campo
New generation of hysteroscope with interesting characteristics
named after the multicentre study TROPHY ldquoTrial of Outpatient
Hysteroscopyrdquo for which it was designedEl-Toukhy T Campo R et al Trial of Outpatient Hysteroscopy ndash (TROPHY) in IVF Reprod Health 2009 Dec 3620
Spirotome acc to Gordts
A device made to harvest high quality samples from soft tissues
built on the pioneering concept of a cutting helix on a cutting cannula
New Tools for exploration of the JZ myometrium
Trophy Scope 29 mm compactscope with Innovative gliding mechanism for accessory sheets
Can be loaded with accessory sheets which can be activated in case of necessity by gently push on the bottom and forward movement till locking in the active position supplementary functions are available without the need to remove the hysteroscope
Trophy Scope Diagnostic accessory sheet
In active positionAtraumatic cervical dilatation up to 37 mm under visual controlCreating double flowBlocking of cervix in case of passive outflow
In free positionSuction device for endometrial samplingGuide for ultrasound guided intrauterine procedures like positioning Embryo
transfer catheter or for Spirotome endomyometrial biopsy
active freepassive
Trophy Scope Operative accessory sheet
In passive position
Operative sheet does not interfere
the diagnostic phase (29mm)
In active positionAtraumatic cervical dilatation
up to 44 mm under visual control
Creating double flow and blocking
function in case of passive outflow
Introduction of 5 Fr instruments without
compromising inflow
A device made to harvest high quality samples from soft tissues
It is built on the pioneering concept of a cutting helix on a cutting
cannula well identified by Ultrasound
Spirotome acc to Gordts
Spirotome
The sample is harvested by turning the helix into the diseased area under
direct vision or ultrasound guidance The cannula turns subsequently over the
helix to free the sample from the surroundings
Spirotome myometrial biopsy
HSC post spirotome biopsy
Spirotome myometrial biopsy
Trophy Scope - Spirotome - US
Guide for ultrasound guided
Spirotome endomyometrial biopsy
cutting helixcutting cannula
Trophy Scope ndash Spirotome - Ultrasound
Exploration of JZ myometrium with Trophy hysteroscope
Resection intramural myoma
Resection adenomyoma
Resection adenomyoma
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Conventional hysteroscopic surgery
4 Laparoscopic surgery
Conventional Hysteroscopic Surgery
TYPE 0 TYPE 1 TYPE 2
The ESGE classificationof submucous myomas
Size volume = 43r3
bull2 cm ~ 42 cm3 8 min
bull3 cm ~ 141 cm3 28 min
bull4 cm ~ 335 cm3 67 min
Emanuel MH et al Fertil Steril 199768881-6
Operating time of critical importance
Reduction in volume of the fibroidsby GnRH-a therapy
Distension fluid
Monopolar surgery using non-ionic solutions
sa manitol sorbitol or glycine has higher risk of
side effects due to fluid overload effect
Stop surgery as soon as 1 L of fluid losses
Bipolar surgery using ionic solutions (saline)
Isotonic hyperhydration is less dangerous
In young patients up to 4 L of losses can be
accepted
Hysteroscopic Myomectomy
Always use a pressure and flow controlled pump system to work at minimal necessary pressure
Always perform continuous fluid balance independently of the medium used
Hysteroscopic Myomectomy
Operative Hysteroscopy Resectoscope Uni or Bipolar
Non ionic fluid
Unipolar polyp and myomaresection
Ionic fluid
First generation Bipolar (Versapoint)
Loop is smaller
chips are smaller
Longer OR time
Bipolar cautery induces
more bubbles
Bipolar resectoscope new generation
low-energy
Two or more small active electrodes very close to each other (active and return electrode)
bull Use Saline as distention medium
bull limited spread of electrical effect the current flow is essentially limited to a small area and it requires less voltage less risk for adhaesion formation
bull Loop different shape and size Different surgical
manoeuvres
bull Need of Modern generator
Bipolar resectoscope new generation
Storz bipolar resectoscope new generation
Return electrode opposite
side
Larger active electrode
Minimal gas bubbles
production
Less risk of perforation
Different surgical technique
Bipolar hysteroscopic myomectomy
Hysteroscopic Myomectomy
Long-term results depend on
bull Uterine Size (Plt0001)
bull Number of myomas (Plt0001)
The surgery-free percentage of 165 patients with normal sized uteri and not more than two
myomas was 943 (+- 18) at 2 years and 903 (+- 30) at 5 years
bull Type ( intra-mural part)
bull Size of myoma (significant increase of amount of particles between 2 and 3 cm)
Long-term results depend on the presence of concomitant pathology
or is a result of incomplete surgery
Emanuel MH Wamsteker K Obstet Gynecol 1999 May93743-8
Third Statement
1 Junctional Zone Myoma should preferentially be treated by hysteroscopy
2 Feasibility of hysteroscopic surgery is predominantly related with size location and amount of myoma
3 Independently of distension medium used continuous fluid balance and flow distension control is mandatory
4 Complication risk is related to experience and surgical technique used
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Conventional hysteroscopic surgery
4 Laparoscopic surgery
Introduction
Intramural myoma larger than 4 cm related to the JZ myometriumschould be operated on
Laparoscopic approach has had an important evolution over the
years
Series with high success rate are done by experts =gt it is difficult to extrapolate to less experienced surgeons
Laparoscopic myomectomy needs expert skills in haemostasis dissection and suturing
How to minimize blood loss
bullA lot of techniques in order to minimize blood loss
GnRH agonists
Intramyometrial vasopressine
Oxytocin IV 40 mUImin intraoperatively
Use of tourniquet or penrose at the lower part of uterus
Laparoscopic Myomectomy
J Ferro IVI Valencia Spain
Tips amp tricks ndash minimize blood loss
Clipping of the uterine arteries and infundilopelvic ligaments is another very efficient method
Artery ligation versus Control group (n=152)
173 +- 91 mL vs 402 +- 131 mL blood loss
62 vs 2075 reccurence rate
Alborzi S et al A comparison of combined laparoscopic uterine artery ligation and myomectomyversus laparoscopic myomectomy in the treatment of symptomatic myoma Fertil Steril 2009
Tips amp tricks ndash minimize blood loss
Technique Incision
Incision
J Ferro A Wattiez
Tips amp tricks- dissection
Tips amp tricks- closure
bull One versus multiples layers controversial
bull Adequate closure of the dead space to minimize the risk of hematoma formation
bull Interrupted figure of eight sutures are usually sufficient monocryl 1 or 0 with extracorporeal notes =gt extra strength
bull For the serosa approximate with interrupted 20 sutures if necessary (monofilament)
Tips amp tricks- closure
Removal Clips
Anti- adhesion agents
Fourth Statement
LAPAROSCOPIC MYOMECTOMY offers comparable results tolaparotomic myomectomy
Laparoscopic approach reduces adhesion formation blood loss and hospital stay
Laparoscopic myomectomy seems indicated in the infertile patient for the treatment of intramural myomarsquos
Laparoscopic Myomectomy requires a skilled laparoscopic surgeon with expert suturing skills optimal instrumental support and knowledge of some trickrsquos to provide an optimal result
Take Home message
Submucous myoma should always be removed prior to IVF
Hysteroscopic resection is the gold standard to treat those myoma
Intramural myoma originating from the sub endometrial
myometrium and larger than 4 cm are treated by Laproscopy
Subserosal myoma do not influence the outcome of IVF and are not removed for this indication
More info on the special training
programsin endoscopic
surgery
ESGEORG
More info on the ESGE website
wwwesgeorg
See you in London
Rudi Campo Stephan GordtsPatrick PuttemansRoger MolinasSylvie GordtsMarion Valkenburg Ivo Brosens
Leuven Institute for Fertility
amp Embryology
Trophy Scope a new generation
Interesting Characteristics
Gliding system that provides
Diagnostic ( 29 mm ) and
Operative (44 mm)
possibilities in one instrument
This hysteroscope has been named after the multicentre study
TROPHY ldquoTrial of Outpatient Hysteroscopyrdquo for which it was designed
El-Toukhy T Campo R et al Trial of Outpatient Hysteroscopy - [TROPHY] in IVF Reprod Health 2009 Dec 3620
Q2 Size and amount
Fibroids not encroaching the endometrial cavity and IVF success rate a prospective study
In asymptomatic patients selected for IVF small (less than 05 cm) fibroids not encroaching the endometrial cavity did not impact on the rate of success of the procedure
There was no significant relationship between clinical outcome and either the number or size of the fibroids
Q2 Size and amount
Those findings are in conflict with the findings of Khalaf et al 2006 who also studied the effect of small intramuralUterine fibroids
IVF ICSI results in 322 women without fibroids and 112 with fibroids in 606 cycles were studied
Live birth rate in the study group was significantly lower (plt005) and the cumulative live birth rate was reduced by 47
Second statement
It is not yet very clear when non-cavity-distorting intramural fibroids will influence the pregnancy outcome in IVF
Myoma mapping seems mandatory to document the relation to the JZ myometrium
Intra mural myoma should be classified either to the submucous or sub serosal group
The diagnostic strategy is challenged
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Hysteroscopic surgery
4 Laparoscopic surgery
What do we have to know
1 Cavity involvement
2 Number of myomata
3 Size and location
Proper diagnosis of fibroids
Ultrasound
Fluid Mini-Hysteroscopy
Kontrast sonography
One Stop Uterine diagnosis
Proper diagnosis of fibroids
Ultrasound
Hysteroscopy
Contrast sonography
Overview of set up
Supplemantary exams necessary
When
1 dd adenomyoma ndash myoma
2 Multiple myoma
3 Diffuse enlargement of uterine wall
How
1 NMR imaging (3D US )
2 Hysteroscopic Myometrial exploration
LIFE vzw Leuven Institute for Fertility amp Embryology
Findings at MRI JZ Myoma
LIFE vzw Leuven Institute for Fertility amp Embryology
Allocation of Myoma to OM or JZM
LIFE vzw Leuven Institute for Fertility amp Embryology
MRI for diagnosis of Adenomyosis and Adenomyoma
Loss of differentiation JZ - OM
Normal
LIFE vzw Leuven Institute for Fertility amp Embryology
Enlarge the hysteroscopic diagnosis with
exploration of JZ myometrium
Trophy Hysteroscope acc to Campo
New generation of hysteroscope with interesting characteristics
named after the multicentre study TROPHY ldquoTrial of Outpatient
Hysteroscopyrdquo for which it was designedEl-Toukhy T Campo R et al Trial of Outpatient Hysteroscopy ndash (TROPHY) in IVF Reprod Health 2009 Dec 3620
Spirotome acc to Gordts
A device made to harvest high quality samples from soft tissues
built on the pioneering concept of a cutting helix on a cutting cannula
New Tools for exploration of the JZ myometrium
Trophy Scope 29 mm compactscope with Innovative gliding mechanism for accessory sheets
Can be loaded with accessory sheets which can be activated in case of necessity by gently push on the bottom and forward movement till locking in the active position supplementary functions are available without the need to remove the hysteroscope
Trophy Scope Diagnostic accessory sheet
In active positionAtraumatic cervical dilatation up to 37 mm under visual controlCreating double flowBlocking of cervix in case of passive outflow
In free positionSuction device for endometrial samplingGuide for ultrasound guided intrauterine procedures like positioning Embryo
transfer catheter or for Spirotome endomyometrial biopsy
active freepassive
Trophy Scope Operative accessory sheet
In passive position
Operative sheet does not interfere
the diagnostic phase (29mm)
In active positionAtraumatic cervical dilatation
up to 44 mm under visual control
Creating double flow and blocking
function in case of passive outflow
Introduction of 5 Fr instruments without
compromising inflow
A device made to harvest high quality samples from soft tissues
It is built on the pioneering concept of a cutting helix on a cutting
cannula well identified by Ultrasound
Spirotome acc to Gordts
Spirotome
The sample is harvested by turning the helix into the diseased area under
direct vision or ultrasound guidance The cannula turns subsequently over the
helix to free the sample from the surroundings
Spirotome myometrial biopsy
HSC post spirotome biopsy
Spirotome myometrial biopsy
Trophy Scope - Spirotome - US
Guide for ultrasound guided
Spirotome endomyometrial biopsy
cutting helixcutting cannula
Trophy Scope ndash Spirotome - Ultrasound
Exploration of JZ myometrium with Trophy hysteroscope
Resection intramural myoma
Resection adenomyoma
Resection adenomyoma
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Conventional hysteroscopic surgery
4 Laparoscopic surgery
Conventional Hysteroscopic Surgery
TYPE 0 TYPE 1 TYPE 2
The ESGE classificationof submucous myomas
Size volume = 43r3
bull2 cm ~ 42 cm3 8 min
bull3 cm ~ 141 cm3 28 min
bull4 cm ~ 335 cm3 67 min
Emanuel MH et al Fertil Steril 199768881-6
Operating time of critical importance
Reduction in volume of the fibroidsby GnRH-a therapy
Distension fluid
Monopolar surgery using non-ionic solutions
sa manitol sorbitol or glycine has higher risk of
side effects due to fluid overload effect
Stop surgery as soon as 1 L of fluid losses
Bipolar surgery using ionic solutions (saline)
Isotonic hyperhydration is less dangerous
In young patients up to 4 L of losses can be
accepted
Hysteroscopic Myomectomy
Always use a pressure and flow controlled pump system to work at minimal necessary pressure
Always perform continuous fluid balance independently of the medium used
Hysteroscopic Myomectomy
Operative Hysteroscopy Resectoscope Uni or Bipolar
Non ionic fluid
Unipolar polyp and myomaresection
Ionic fluid
First generation Bipolar (Versapoint)
Loop is smaller
chips are smaller
Longer OR time
Bipolar cautery induces
more bubbles
Bipolar resectoscope new generation
low-energy
Two or more small active electrodes very close to each other (active and return electrode)
bull Use Saline as distention medium
bull limited spread of electrical effect the current flow is essentially limited to a small area and it requires less voltage less risk for adhaesion formation
bull Loop different shape and size Different surgical
manoeuvres
bull Need of Modern generator
Bipolar resectoscope new generation
Storz bipolar resectoscope new generation
Return electrode opposite
side
Larger active electrode
Minimal gas bubbles
production
Less risk of perforation
Different surgical technique
Bipolar hysteroscopic myomectomy
Hysteroscopic Myomectomy
Long-term results depend on
bull Uterine Size (Plt0001)
bull Number of myomas (Plt0001)
The surgery-free percentage of 165 patients with normal sized uteri and not more than two
myomas was 943 (+- 18) at 2 years and 903 (+- 30) at 5 years
bull Type ( intra-mural part)
bull Size of myoma (significant increase of amount of particles between 2 and 3 cm)
Long-term results depend on the presence of concomitant pathology
or is a result of incomplete surgery
Emanuel MH Wamsteker K Obstet Gynecol 1999 May93743-8
Third Statement
1 Junctional Zone Myoma should preferentially be treated by hysteroscopy
2 Feasibility of hysteroscopic surgery is predominantly related with size location and amount of myoma
3 Independently of distension medium used continuous fluid balance and flow distension control is mandatory
4 Complication risk is related to experience and surgical technique used
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Conventional hysteroscopic surgery
4 Laparoscopic surgery
Introduction
Intramural myoma larger than 4 cm related to the JZ myometriumschould be operated on
Laparoscopic approach has had an important evolution over the
years
Series with high success rate are done by experts =gt it is difficult to extrapolate to less experienced surgeons
Laparoscopic myomectomy needs expert skills in haemostasis dissection and suturing
How to minimize blood loss
bullA lot of techniques in order to minimize blood loss
GnRH agonists
Intramyometrial vasopressine
Oxytocin IV 40 mUImin intraoperatively
Use of tourniquet or penrose at the lower part of uterus
Laparoscopic Myomectomy
J Ferro IVI Valencia Spain
Tips amp tricks ndash minimize blood loss
Clipping of the uterine arteries and infundilopelvic ligaments is another very efficient method
Artery ligation versus Control group (n=152)
173 +- 91 mL vs 402 +- 131 mL blood loss
62 vs 2075 reccurence rate
Alborzi S et al A comparison of combined laparoscopic uterine artery ligation and myomectomyversus laparoscopic myomectomy in the treatment of symptomatic myoma Fertil Steril 2009
Tips amp tricks ndash minimize blood loss
Technique Incision
Incision
J Ferro A Wattiez
Tips amp tricks- dissection
Tips amp tricks- closure
bull One versus multiples layers controversial
bull Adequate closure of the dead space to minimize the risk of hematoma formation
bull Interrupted figure of eight sutures are usually sufficient monocryl 1 or 0 with extracorporeal notes =gt extra strength
bull For the serosa approximate with interrupted 20 sutures if necessary (monofilament)
Tips amp tricks- closure
Removal Clips
Anti- adhesion agents
Fourth Statement
LAPAROSCOPIC MYOMECTOMY offers comparable results tolaparotomic myomectomy
Laparoscopic approach reduces adhesion formation blood loss and hospital stay
Laparoscopic myomectomy seems indicated in the infertile patient for the treatment of intramural myomarsquos
Laparoscopic Myomectomy requires a skilled laparoscopic surgeon with expert suturing skills optimal instrumental support and knowledge of some trickrsquos to provide an optimal result
Take Home message
Submucous myoma should always be removed prior to IVF
Hysteroscopic resection is the gold standard to treat those myoma
Intramural myoma originating from the sub endometrial
myometrium and larger than 4 cm are treated by Laproscopy
Subserosal myoma do not influence the outcome of IVF and are not removed for this indication
More info on the special training
programsin endoscopic
surgery
ESGEORG
More info on the ESGE website
wwwesgeorg
See you in London
Rudi Campo Stephan GordtsPatrick PuttemansRoger MolinasSylvie GordtsMarion Valkenburg Ivo Brosens
Leuven Institute for Fertility
amp Embryology
Trophy Scope a new generation
Interesting Characteristics
Gliding system that provides
Diagnostic ( 29 mm ) and
Operative (44 mm)
possibilities in one instrument
This hysteroscope has been named after the multicentre study
TROPHY ldquoTrial of Outpatient Hysteroscopyrdquo for which it was designed
El-Toukhy T Campo R et al Trial of Outpatient Hysteroscopy - [TROPHY] in IVF Reprod Health 2009 Dec 3620
Q2 Size and amount
Those findings are in conflict with the findings of Khalaf et al 2006 who also studied the effect of small intramuralUterine fibroids
IVF ICSI results in 322 women without fibroids and 112 with fibroids in 606 cycles were studied
Live birth rate in the study group was significantly lower (plt005) and the cumulative live birth rate was reduced by 47
Second statement
It is not yet very clear when non-cavity-distorting intramural fibroids will influence the pregnancy outcome in IVF
Myoma mapping seems mandatory to document the relation to the JZ myometrium
Intra mural myoma should be classified either to the submucous or sub serosal group
The diagnostic strategy is challenged
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Hysteroscopic surgery
4 Laparoscopic surgery
What do we have to know
1 Cavity involvement
2 Number of myomata
3 Size and location
Proper diagnosis of fibroids
Ultrasound
Fluid Mini-Hysteroscopy
Kontrast sonography
One Stop Uterine diagnosis
Proper diagnosis of fibroids
Ultrasound
Hysteroscopy
Contrast sonography
Overview of set up
Supplemantary exams necessary
When
1 dd adenomyoma ndash myoma
2 Multiple myoma
3 Diffuse enlargement of uterine wall
How
1 NMR imaging (3D US )
2 Hysteroscopic Myometrial exploration
LIFE vzw Leuven Institute for Fertility amp Embryology
Findings at MRI JZ Myoma
LIFE vzw Leuven Institute for Fertility amp Embryology
Allocation of Myoma to OM or JZM
LIFE vzw Leuven Institute for Fertility amp Embryology
MRI for diagnosis of Adenomyosis and Adenomyoma
Loss of differentiation JZ - OM
Normal
LIFE vzw Leuven Institute for Fertility amp Embryology
Enlarge the hysteroscopic diagnosis with
exploration of JZ myometrium
Trophy Hysteroscope acc to Campo
New generation of hysteroscope with interesting characteristics
named after the multicentre study TROPHY ldquoTrial of Outpatient
Hysteroscopyrdquo for which it was designedEl-Toukhy T Campo R et al Trial of Outpatient Hysteroscopy ndash (TROPHY) in IVF Reprod Health 2009 Dec 3620
Spirotome acc to Gordts
A device made to harvest high quality samples from soft tissues
built on the pioneering concept of a cutting helix on a cutting cannula
New Tools for exploration of the JZ myometrium
Trophy Scope 29 mm compactscope with Innovative gliding mechanism for accessory sheets
Can be loaded with accessory sheets which can be activated in case of necessity by gently push on the bottom and forward movement till locking in the active position supplementary functions are available without the need to remove the hysteroscope
Trophy Scope Diagnostic accessory sheet
In active positionAtraumatic cervical dilatation up to 37 mm under visual controlCreating double flowBlocking of cervix in case of passive outflow
In free positionSuction device for endometrial samplingGuide for ultrasound guided intrauterine procedures like positioning Embryo
transfer catheter or for Spirotome endomyometrial biopsy
active freepassive
Trophy Scope Operative accessory sheet
In passive position
Operative sheet does not interfere
the diagnostic phase (29mm)
In active positionAtraumatic cervical dilatation
up to 44 mm under visual control
Creating double flow and blocking
function in case of passive outflow
Introduction of 5 Fr instruments without
compromising inflow
A device made to harvest high quality samples from soft tissues
It is built on the pioneering concept of a cutting helix on a cutting
cannula well identified by Ultrasound
Spirotome acc to Gordts
Spirotome
The sample is harvested by turning the helix into the diseased area under
direct vision or ultrasound guidance The cannula turns subsequently over the
helix to free the sample from the surroundings
Spirotome myometrial biopsy
HSC post spirotome biopsy
Spirotome myometrial biopsy
Trophy Scope - Spirotome - US
Guide for ultrasound guided
Spirotome endomyometrial biopsy
cutting helixcutting cannula
Trophy Scope ndash Spirotome - Ultrasound
Exploration of JZ myometrium with Trophy hysteroscope
Resection intramural myoma
Resection adenomyoma
Resection adenomyoma
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Conventional hysteroscopic surgery
4 Laparoscopic surgery
Conventional Hysteroscopic Surgery
TYPE 0 TYPE 1 TYPE 2
The ESGE classificationof submucous myomas
Size volume = 43r3
bull2 cm ~ 42 cm3 8 min
bull3 cm ~ 141 cm3 28 min
bull4 cm ~ 335 cm3 67 min
Emanuel MH et al Fertil Steril 199768881-6
Operating time of critical importance
Reduction in volume of the fibroidsby GnRH-a therapy
Distension fluid
Monopolar surgery using non-ionic solutions
sa manitol sorbitol or glycine has higher risk of
side effects due to fluid overload effect
Stop surgery as soon as 1 L of fluid losses
Bipolar surgery using ionic solutions (saline)
Isotonic hyperhydration is less dangerous
In young patients up to 4 L of losses can be
accepted
Hysteroscopic Myomectomy
Always use a pressure and flow controlled pump system to work at minimal necessary pressure
Always perform continuous fluid balance independently of the medium used
Hysteroscopic Myomectomy
Operative Hysteroscopy Resectoscope Uni or Bipolar
Non ionic fluid
Unipolar polyp and myomaresection
Ionic fluid
First generation Bipolar (Versapoint)
Loop is smaller
chips are smaller
Longer OR time
Bipolar cautery induces
more bubbles
Bipolar resectoscope new generation
low-energy
Two or more small active electrodes very close to each other (active and return electrode)
bull Use Saline as distention medium
bull limited spread of electrical effect the current flow is essentially limited to a small area and it requires less voltage less risk for adhaesion formation
bull Loop different shape and size Different surgical
manoeuvres
bull Need of Modern generator
Bipolar resectoscope new generation
Storz bipolar resectoscope new generation
Return electrode opposite
side
Larger active electrode
Minimal gas bubbles
production
Less risk of perforation
Different surgical technique
Bipolar hysteroscopic myomectomy
Hysteroscopic Myomectomy
Long-term results depend on
bull Uterine Size (Plt0001)
bull Number of myomas (Plt0001)
The surgery-free percentage of 165 patients with normal sized uteri and not more than two
myomas was 943 (+- 18) at 2 years and 903 (+- 30) at 5 years
bull Type ( intra-mural part)
bull Size of myoma (significant increase of amount of particles between 2 and 3 cm)
Long-term results depend on the presence of concomitant pathology
or is a result of incomplete surgery
Emanuel MH Wamsteker K Obstet Gynecol 1999 May93743-8
Third Statement
1 Junctional Zone Myoma should preferentially be treated by hysteroscopy
2 Feasibility of hysteroscopic surgery is predominantly related with size location and amount of myoma
3 Independently of distension medium used continuous fluid balance and flow distension control is mandatory
4 Complication risk is related to experience and surgical technique used
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Conventional hysteroscopic surgery
4 Laparoscopic surgery
Introduction
Intramural myoma larger than 4 cm related to the JZ myometriumschould be operated on
Laparoscopic approach has had an important evolution over the
years
Series with high success rate are done by experts =gt it is difficult to extrapolate to less experienced surgeons
Laparoscopic myomectomy needs expert skills in haemostasis dissection and suturing
How to minimize blood loss
bullA lot of techniques in order to minimize blood loss
GnRH agonists
Intramyometrial vasopressine
Oxytocin IV 40 mUImin intraoperatively
Use of tourniquet or penrose at the lower part of uterus
Laparoscopic Myomectomy
J Ferro IVI Valencia Spain
Tips amp tricks ndash minimize blood loss
Clipping of the uterine arteries and infundilopelvic ligaments is another very efficient method
Artery ligation versus Control group (n=152)
173 +- 91 mL vs 402 +- 131 mL blood loss
62 vs 2075 reccurence rate
Alborzi S et al A comparison of combined laparoscopic uterine artery ligation and myomectomyversus laparoscopic myomectomy in the treatment of symptomatic myoma Fertil Steril 2009
Tips amp tricks ndash minimize blood loss
Technique Incision
Incision
J Ferro A Wattiez
Tips amp tricks- dissection
Tips amp tricks- closure
bull One versus multiples layers controversial
bull Adequate closure of the dead space to minimize the risk of hematoma formation
bull Interrupted figure of eight sutures are usually sufficient monocryl 1 or 0 with extracorporeal notes =gt extra strength
bull For the serosa approximate with interrupted 20 sutures if necessary (monofilament)
Tips amp tricks- closure
Removal Clips
Anti- adhesion agents
Fourth Statement
LAPAROSCOPIC MYOMECTOMY offers comparable results tolaparotomic myomectomy
Laparoscopic approach reduces adhesion formation blood loss and hospital stay
Laparoscopic myomectomy seems indicated in the infertile patient for the treatment of intramural myomarsquos
Laparoscopic Myomectomy requires a skilled laparoscopic surgeon with expert suturing skills optimal instrumental support and knowledge of some trickrsquos to provide an optimal result
Take Home message
Submucous myoma should always be removed prior to IVF
Hysteroscopic resection is the gold standard to treat those myoma
Intramural myoma originating from the sub endometrial
myometrium and larger than 4 cm are treated by Laproscopy
Subserosal myoma do not influence the outcome of IVF and are not removed for this indication
More info on the special training
programsin endoscopic
surgery
ESGEORG
More info on the ESGE website
wwwesgeorg
See you in London
Rudi Campo Stephan GordtsPatrick PuttemansRoger MolinasSylvie GordtsMarion Valkenburg Ivo Brosens
Leuven Institute for Fertility
amp Embryology
Trophy Scope a new generation
Interesting Characteristics
Gliding system that provides
Diagnostic ( 29 mm ) and
Operative (44 mm)
possibilities in one instrument
This hysteroscope has been named after the multicentre study
TROPHY ldquoTrial of Outpatient Hysteroscopyrdquo for which it was designed
El-Toukhy T Campo R et al Trial of Outpatient Hysteroscopy - [TROPHY] in IVF Reprod Health 2009 Dec 3620
Second statement
It is not yet very clear when non-cavity-distorting intramural fibroids will influence the pregnancy outcome in IVF
Myoma mapping seems mandatory to document the relation to the JZ myometrium
Intra mural myoma should be classified either to the submucous or sub serosal group
The diagnostic strategy is challenged
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Hysteroscopic surgery
4 Laparoscopic surgery
What do we have to know
1 Cavity involvement
2 Number of myomata
3 Size and location
Proper diagnosis of fibroids
Ultrasound
Fluid Mini-Hysteroscopy
Kontrast sonography
One Stop Uterine diagnosis
Proper diagnosis of fibroids
Ultrasound
Hysteroscopy
Contrast sonography
Overview of set up
Supplemantary exams necessary
When
1 dd adenomyoma ndash myoma
2 Multiple myoma
3 Diffuse enlargement of uterine wall
How
1 NMR imaging (3D US )
2 Hysteroscopic Myometrial exploration
LIFE vzw Leuven Institute for Fertility amp Embryology
Findings at MRI JZ Myoma
LIFE vzw Leuven Institute for Fertility amp Embryology
Allocation of Myoma to OM or JZM
LIFE vzw Leuven Institute for Fertility amp Embryology
MRI for diagnosis of Adenomyosis and Adenomyoma
Loss of differentiation JZ - OM
Normal
LIFE vzw Leuven Institute for Fertility amp Embryology
Enlarge the hysteroscopic diagnosis with
exploration of JZ myometrium
Trophy Hysteroscope acc to Campo
New generation of hysteroscope with interesting characteristics
named after the multicentre study TROPHY ldquoTrial of Outpatient
Hysteroscopyrdquo for which it was designedEl-Toukhy T Campo R et al Trial of Outpatient Hysteroscopy ndash (TROPHY) in IVF Reprod Health 2009 Dec 3620
Spirotome acc to Gordts
A device made to harvest high quality samples from soft tissues
built on the pioneering concept of a cutting helix on a cutting cannula
New Tools for exploration of the JZ myometrium
Trophy Scope 29 mm compactscope with Innovative gliding mechanism for accessory sheets
Can be loaded with accessory sheets which can be activated in case of necessity by gently push on the bottom and forward movement till locking in the active position supplementary functions are available without the need to remove the hysteroscope
Trophy Scope Diagnostic accessory sheet
In active positionAtraumatic cervical dilatation up to 37 mm under visual controlCreating double flowBlocking of cervix in case of passive outflow
In free positionSuction device for endometrial samplingGuide for ultrasound guided intrauterine procedures like positioning Embryo
transfer catheter or for Spirotome endomyometrial biopsy
active freepassive
Trophy Scope Operative accessory sheet
In passive position
Operative sheet does not interfere
the diagnostic phase (29mm)
In active positionAtraumatic cervical dilatation
up to 44 mm under visual control
Creating double flow and blocking
function in case of passive outflow
Introduction of 5 Fr instruments without
compromising inflow
A device made to harvest high quality samples from soft tissues
It is built on the pioneering concept of a cutting helix on a cutting
cannula well identified by Ultrasound
Spirotome acc to Gordts
Spirotome
The sample is harvested by turning the helix into the diseased area under
direct vision or ultrasound guidance The cannula turns subsequently over the
helix to free the sample from the surroundings
Spirotome myometrial biopsy
HSC post spirotome biopsy
Spirotome myometrial biopsy
Trophy Scope - Spirotome - US
Guide for ultrasound guided
Spirotome endomyometrial biopsy
cutting helixcutting cannula
Trophy Scope ndash Spirotome - Ultrasound
Exploration of JZ myometrium with Trophy hysteroscope
Resection intramural myoma
Resection adenomyoma
Resection adenomyoma
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Conventional hysteroscopic surgery
4 Laparoscopic surgery
Conventional Hysteroscopic Surgery
TYPE 0 TYPE 1 TYPE 2
The ESGE classificationof submucous myomas
Size volume = 43r3
bull2 cm ~ 42 cm3 8 min
bull3 cm ~ 141 cm3 28 min
bull4 cm ~ 335 cm3 67 min
Emanuel MH et al Fertil Steril 199768881-6
Operating time of critical importance
Reduction in volume of the fibroidsby GnRH-a therapy
Distension fluid
Monopolar surgery using non-ionic solutions
sa manitol sorbitol or glycine has higher risk of
side effects due to fluid overload effect
Stop surgery as soon as 1 L of fluid losses
Bipolar surgery using ionic solutions (saline)
Isotonic hyperhydration is less dangerous
In young patients up to 4 L of losses can be
accepted
Hysteroscopic Myomectomy
Always use a pressure and flow controlled pump system to work at minimal necessary pressure
Always perform continuous fluid balance independently of the medium used
Hysteroscopic Myomectomy
Operative Hysteroscopy Resectoscope Uni or Bipolar
Non ionic fluid
Unipolar polyp and myomaresection
Ionic fluid
First generation Bipolar (Versapoint)
Loop is smaller
chips are smaller
Longer OR time
Bipolar cautery induces
more bubbles
Bipolar resectoscope new generation
low-energy
Two or more small active electrodes very close to each other (active and return electrode)
bull Use Saline as distention medium
bull limited spread of electrical effect the current flow is essentially limited to a small area and it requires less voltage less risk for adhaesion formation
bull Loop different shape and size Different surgical
manoeuvres
bull Need of Modern generator
Bipolar resectoscope new generation
Storz bipolar resectoscope new generation
Return electrode opposite
side
Larger active electrode
Minimal gas bubbles
production
Less risk of perforation
Different surgical technique
Bipolar hysteroscopic myomectomy
Hysteroscopic Myomectomy
Long-term results depend on
bull Uterine Size (Plt0001)
bull Number of myomas (Plt0001)
The surgery-free percentage of 165 patients with normal sized uteri and not more than two
myomas was 943 (+- 18) at 2 years and 903 (+- 30) at 5 years
bull Type ( intra-mural part)
bull Size of myoma (significant increase of amount of particles between 2 and 3 cm)
Long-term results depend on the presence of concomitant pathology
or is a result of incomplete surgery
Emanuel MH Wamsteker K Obstet Gynecol 1999 May93743-8
Third Statement
1 Junctional Zone Myoma should preferentially be treated by hysteroscopy
2 Feasibility of hysteroscopic surgery is predominantly related with size location and amount of myoma
3 Independently of distension medium used continuous fluid balance and flow distension control is mandatory
4 Complication risk is related to experience and surgical technique used
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Conventional hysteroscopic surgery
4 Laparoscopic surgery
Introduction
Intramural myoma larger than 4 cm related to the JZ myometriumschould be operated on
Laparoscopic approach has had an important evolution over the
years
Series with high success rate are done by experts =gt it is difficult to extrapolate to less experienced surgeons
Laparoscopic myomectomy needs expert skills in haemostasis dissection and suturing
How to minimize blood loss
bullA lot of techniques in order to minimize blood loss
GnRH agonists
Intramyometrial vasopressine
Oxytocin IV 40 mUImin intraoperatively
Use of tourniquet or penrose at the lower part of uterus
Laparoscopic Myomectomy
J Ferro IVI Valencia Spain
Tips amp tricks ndash minimize blood loss
Clipping of the uterine arteries and infundilopelvic ligaments is another very efficient method
Artery ligation versus Control group (n=152)
173 +- 91 mL vs 402 +- 131 mL blood loss
62 vs 2075 reccurence rate
Alborzi S et al A comparison of combined laparoscopic uterine artery ligation and myomectomyversus laparoscopic myomectomy in the treatment of symptomatic myoma Fertil Steril 2009
Tips amp tricks ndash minimize blood loss
Technique Incision
Incision
J Ferro A Wattiez
Tips amp tricks- dissection
Tips amp tricks- closure
bull One versus multiples layers controversial
bull Adequate closure of the dead space to minimize the risk of hematoma formation
bull Interrupted figure of eight sutures are usually sufficient monocryl 1 or 0 with extracorporeal notes =gt extra strength
bull For the serosa approximate with interrupted 20 sutures if necessary (monofilament)
Tips amp tricks- closure
Removal Clips
Anti- adhesion agents
Fourth Statement
LAPAROSCOPIC MYOMECTOMY offers comparable results tolaparotomic myomectomy
Laparoscopic approach reduces adhesion formation blood loss and hospital stay
Laparoscopic myomectomy seems indicated in the infertile patient for the treatment of intramural myomarsquos
Laparoscopic Myomectomy requires a skilled laparoscopic surgeon with expert suturing skills optimal instrumental support and knowledge of some trickrsquos to provide an optimal result
Take Home message
Submucous myoma should always be removed prior to IVF
Hysteroscopic resection is the gold standard to treat those myoma
Intramural myoma originating from the sub endometrial
myometrium and larger than 4 cm are treated by Laproscopy
Subserosal myoma do not influence the outcome of IVF and are not removed for this indication
More info on the special training
programsin endoscopic
surgery
ESGEORG
More info on the ESGE website
wwwesgeorg
See you in London
Rudi Campo Stephan GordtsPatrick PuttemansRoger MolinasSylvie GordtsMarion Valkenburg Ivo Brosens
Leuven Institute for Fertility
amp Embryology
Trophy Scope a new generation
Interesting Characteristics
Gliding system that provides
Diagnostic ( 29 mm ) and
Operative (44 mm)
possibilities in one instrument
This hysteroscope has been named after the multicentre study
TROPHY ldquoTrial of Outpatient Hysteroscopyrdquo for which it was designed
El-Toukhy T Campo R et al Trial of Outpatient Hysteroscopy - [TROPHY] in IVF Reprod Health 2009 Dec 3620
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Hysteroscopic surgery
4 Laparoscopic surgery
What do we have to know
1 Cavity involvement
2 Number of myomata
3 Size and location
Proper diagnosis of fibroids
Ultrasound
Fluid Mini-Hysteroscopy
Kontrast sonography
One Stop Uterine diagnosis
Proper diagnosis of fibroids
Ultrasound
Hysteroscopy
Contrast sonography
Overview of set up
Supplemantary exams necessary
When
1 dd adenomyoma ndash myoma
2 Multiple myoma
3 Diffuse enlargement of uterine wall
How
1 NMR imaging (3D US )
2 Hysteroscopic Myometrial exploration
LIFE vzw Leuven Institute for Fertility amp Embryology
Findings at MRI JZ Myoma
LIFE vzw Leuven Institute for Fertility amp Embryology
Allocation of Myoma to OM or JZM
LIFE vzw Leuven Institute for Fertility amp Embryology
MRI for diagnosis of Adenomyosis and Adenomyoma
Loss of differentiation JZ - OM
Normal
LIFE vzw Leuven Institute for Fertility amp Embryology
Enlarge the hysteroscopic diagnosis with
exploration of JZ myometrium
Trophy Hysteroscope acc to Campo
New generation of hysteroscope with interesting characteristics
named after the multicentre study TROPHY ldquoTrial of Outpatient
Hysteroscopyrdquo for which it was designedEl-Toukhy T Campo R et al Trial of Outpatient Hysteroscopy ndash (TROPHY) in IVF Reprod Health 2009 Dec 3620
Spirotome acc to Gordts
A device made to harvest high quality samples from soft tissues
built on the pioneering concept of a cutting helix on a cutting cannula
New Tools for exploration of the JZ myometrium
Trophy Scope 29 mm compactscope with Innovative gliding mechanism for accessory sheets
Can be loaded with accessory sheets which can be activated in case of necessity by gently push on the bottom and forward movement till locking in the active position supplementary functions are available without the need to remove the hysteroscope
Trophy Scope Diagnostic accessory sheet
In active positionAtraumatic cervical dilatation up to 37 mm under visual controlCreating double flowBlocking of cervix in case of passive outflow
In free positionSuction device for endometrial samplingGuide for ultrasound guided intrauterine procedures like positioning Embryo
transfer catheter or for Spirotome endomyometrial biopsy
active freepassive
Trophy Scope Operative accessory sheet
In passive position
Operative sheet does not interfere
the diagnostic phase (29mm)
In active positionAtraumatic cervical dilatation
up to 44 mm under visual control
Creating double flow and blocking
function in case of passive outflow
Introduction of 5 Fr instruments without
compromising inflow
A device made to harvest high quality samples from soft tissues
It is built on the pioneering concept of a cutting helix on a cutting
cannula well identified by Ultrasound
Spirotome acc to Gordts
Spirotome
The sample is harvested by turning the helix into the diseased area under
direct vision or ultrasound guidance The cannula turns subsequently over the
helix to free the sample from the surroundings
Spirotome myometrial biopsy
HSC post spirotome biopsy
Spirotome myometrial biopsy
Trophy Scope - Spirotome - US
Guide for ultrasound guided
Spirotome endomyometrial biopsy
cutting helixcutting cannula
Trophy Scope ndash Spirotome - Ultrasound
Exploration of JZ myometrium with Trophy hysteroscope
Resection intramural myoma
Resection adenomyoma
Resection adenomyoma
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Conventional hysteroscopic surgery
4 Laparoscopic surgery
Conventional Hysteroscopic Surgery
TYPE 0 TYPE 1 TYPE 2
The ESGE classificationof submucous myomas
Size volume = 43r3
bull2 cm ~ 42 cm3 8 min
bull3 cm ~ 141 cm3 28 min
bull4 cm ~ 335 cm3 67 min
Emanuel MH et al Fertil Steril 199768881-6
Operating time of critical importance
Reduction in volume of the fibroidsby GnRH-a therapy
Distension fluid
Monopolar surgery using non-ionic solutions
sa manitol sorbitol or glycine has higher risk of
side effects due to fluid overload effect
Stop surgery as soon as 1 L of fluid losses
Bipolar surgery using ionic solutions (saline)
Isotonic hyperhydration is less dangerous
In young patients up to 4 L of losses can be
accepted
Hysteroscopic Myomectomy
Always use a pressure and flow controlled pump system to work at minimal necessary pressure
Always perform continuous fluid balance independently of the medium used
Hysteroscopic Myomectomy
Operative Hysteroscopy Resectoscope Uni or Bipolar
Non ionic fluid
Unipolar polyp and myomaresection
Ionic fluid
First generation Bipolar (Versapoint)
Loop is smaller
chips are smaller
Longer OR time
Bipolar cautery induces
more bubbles
Bipolar resectoscope new generation
low-energy
Two or more small active electrodes very close to each other (active and return electrode)
bull Use Saline as distention medium
bull limited spread of electrical effect the current flow is essentially limited to a small area and it requires less voltage less risk for adhaesion formation
bull Loop different shape and size Different surgical
manoeuvres
bull Need of Modern generator
Bipolar resectoscope new generation
Storz bipolar resectoscope new generation
Return electrode opposite
side
Larger active electrode
Minimal gas bubbles
production
Less risk of perforation
Different surgical technique
Bipolar hysteroscopic myomectomy
Hysteroscopic Myomectomy
Long-term results depend on
bull Uterine Size (Plt0001)
bull Number of myomas (Plt0001)
The surgery-free percentage of 165 patients with normal sized uteri and not more than two
myomas was 943 (+- 18) at 2 years and 903 (+- 30) at 5 years
bull Type ( intra-mural part)
bull Size of myoma (significant increase of amount of particles between 2 and 3 cm)
Long-term results depend on the presence of concomitant pathology
or is a result of incomplete surgery
Emanuel MH Wamsteker K Obstet Gynecol 1999 May93743-8
Third Statement
1 Junctional Zone Myoma should preferentially be treated by hysteroscopy
2 Feasibility of hysteroscopic surgery is predominantly related with size location and amount of myoma
3 Independently of distension medium used continuous fluid balance and flow distension control is mandatory
4 Complication risk is related to experience and surgical technique used
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Conventional hysteroscopic surgery
4 Laparoscopic surgery
Introduction
Intramural myoma larger than 4 cm related to the JZ myometriumschould be operated on
Laparoscopic approach has had an important evolution over the
years
Series with high success rate are done by experts =gt it is difficult to extrapolate to less experienced surgeons
Laparoscopic myomectomy needs expert skills in haemostasis dissection and suturing
How to minimize blood loss
bullA lot of techniques in order to minimize blood loss
GnRH agonists
Intramyometrial vasopressine
Oxytocin IV 40 mUImin intraoperatively
Use of tourniquet or penrose at the lower part of uterus
Laparoscopic Myomectomy
J Ferro IVI Valencia Spain
Tips amp tricks ndash minimize blood loss
Clipping of the uterine arteries and infundilopelvic ligaments is another very efficient method
Artery ligation versus Control group (n=152)
173 +- 91 mL vs 402 +- 131 mL blood loss
62 vs 2075 reccurence rate
Alborzi S et al A comparison of combined laparoscopic uterine artery ligation and myomectomyversus laparoscopic myomectomy in the treatment of symptomatic myoma Fertil Steril 2009
Tips amp tricks ndash minimize blood loss
Technique Incision
Incision
J Ferro A Wattiez
Tips amp tricks- dissection
Tips amp tricks- closure
bull One versus multiples layers controversial
bull Adequate closure of the dead space to minimize the risk of hematoma formation
bull Interrupted figure of eight sutures are usually sufficient monocryl 1 or 0 with extracorporeal notes =gt extra strength
bull For the serosa approximate with interrupted 20 sutures if necessary (monofilament)
Tips amp tricks- closure
Removal Clips
Anti- adhesion agents
Fourth Statement
LAPAROSCOPIC MYOMECTOMY offers comparable results tolaparotomic myomectomy
Laparoscopic approach reduces adhesion formation blood loss and hospital stay
Laparoscopic myomectomy seems indicated in the infertile patient for the treatment of intramural myomarsquos
Laparoscopic Myomectomy requires a skilled laparoscopic surgeon with expert suturing skills optimal instrumental support and knowledge of some trickrsquos to provide an optimal result
Take Home message
Submucous myoma should always be removed prior to IVF
Hysteroscopic resection is the gold standard to treat those myoma
Intramural myoma originating from the sub endometrial
myometrium and larger than 4 cm are treated by Laproscopy
Subserosal myoma do not influence the outcome of IVF and are not removed for this indication
More info on the special training
programsin endoscopic
surgery
ESGEORG
More info on the ESGE website
wwwesgeorg
See you in London
Rudi Campo Stephan GordtsPatrick PuttemansRoger MolinasSylvie GordtsMarion Valkenburg Ivo Brosens
Leuven Institute for Fertility
amp Embryology
Trophy Scope a new generation
Interesting Characteristics
Gliding system that provides
Diagnostic ( 29 mm ) and
Operative (44 mm)
possibilities in one instrument
This hysteroscope has been named after the multicentre study
TROPHY ldquoTrial of Outpatient Hysteroscopyrdquo for which it was designed
El-Toukhy T Campo R et al Trial of Outpatient Hysteroscopy - [TROPHY] in IVF Reprod Health 2009 Dec 3620
What do we have to know
1 Cavity involvement
2 Number of myomata
3 Size and location
Proper diagnosis of fibroids
Ultrasound
Fluid Mini-Hysteroscopy
Kontrast sonography
One Stop Uterine diagnosis
Proper diagnosis of fibroids
Ultrasound
Hysteroscopy
Contrast sonography
Overview of set up
Supplemantary exams necessary
When
1 dd adenomyoma ndash myoma
2 Multiple myoma
3 Diffuse enlargement of uterine wall
How
1 NMR imaging (3D US )
2 Hysteroscopic Myometrial exploration
LIFE vzw Leuven Institute for Fertility amp Embryology
Findings at MRI JZ Myoma
LIFE vzw Leuven Institute for Fertility amp Embryology
Allocation of Myoma to OM or JZM
LIFE vzw Leuven Institute for Fertility amp Embryology
MRI for diagnosis of Adenomyosis and Adenomyoma
Loss of differentiation JZ - OM
Normal
LIFE vzw Leuven Institute for Fertility amp Embryology
Enlarge the hysteroscopic diagnosis with
exploration of JZ myometrium
Trophy Hysteroscope acc to Campo
New generation of hysteroscope with interesting characteristics
named after the multicentre study TROPHY ldquoTrial of Outpatient
Hysteroscopyrdquo for which it was designedEl-Toukhy T Campo R et al Trial of Outpatient Hysteroscopy ndash (TROPHY) in IVF Reprod Health 2009 Dec 3620
Spirotome acc to Gordts
A device made to harvest high quality samples from soft tissues
built on the pioneering concept of a cutting helix on a cutting cannula
New Tools for exploration of the JZ myometrium
Trophy Scope 29 mm compactscope with Innovative gliding mechanism for accessory sheets
Can be loaded with accessory sheets which can be activated in case of necessity by gently push on the bottom and forward movement till locking in the active position supplementary functions are available without the need to remove the hysteroscope
Trophy Scope Diagnostic accessory sheet
In active positionAtraumatic cervical dilatation up to 37 mm under visual controlCreating double flowBlocking of cervix in case of passive outflow
In free positionSuction device for endometrial samplingGuide for ultrasound guided intrauterine procedures like positioning Embryo
transfer catheter or for Spirotome endomyometrial biopsy
active freepassive
Trophy Scope Operative accessory sheet
In passive position
Operative sheet does not interfere
the diagnostic phase (29mm)
In active positionAtraumatic cervical dilatation
up to 44 mm under visual control
Creating double flow and blocking
function in case of passive outflow
Introduction of 5 Fr instruments without
compromising inflow
A device made to harvest high quality samples from soft tissues
It is built on the pioneering concept of a cutting helix on a cutting
cannula well identified by Ultrasound
Spirotome acc to Gordts
Spirotome
The sample is harvested by turning the helix into the diseased area under
direct vision or ultrasound guidance The cannula turns subsequently over the
helix to free the sample from the surroundings
Spirotome myometrial biopsy
HSC post spirotome biopsy
Spirotome myometrial biopsy
Trophy Scope - Spirotome - US
Guide for ultrasound guided
Spirotome endomyometrial biopsy
cutting helixcutting cannula
Trophy Scope ndash Spirotome - Ultrasound
Exploration of JZ myometrium with Trophy hysteroscope
Resection intramural myoma
Resection adenomyoma
Resection adenomyoma
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Conventional hysteroscopic surgery
4 Laparoscopic surgery
Conventional Hysteroscopic Surgery
TYPE 0 TYPE 1 TYPE 2
The ESGE classificationof submucous myomas
Size volume = 43r3
bull2 cm ~ 42 cm3 8 min
bull3 cm ~ 141 cm3 28 min
bull4 cm ~ 335 cm3 67 min
Emanuel MH et al Fertil Steril 199768881-6
Operating time of critical importance
Reduction in volume of the fibroidsby GnRH-a therapy
Distension fluid
Monopolar surgery using non-ionic solutions
sa manitol sorbitol or glycine has higher risk of
side effects due to fluid overload effect
Stop surgery as soon as 1 L of fluid losses
Bipolar surgery using ionic solutions (saline)
Isotonic hyperhydration is less dangerous
In young patients up to 4 L of losses can be
accepted
Hysteroscopic Myomectomy
Always use a pressure and flow controlled pump system to work at minimal necessary pressure
Always perform continuous fluid balance independently of the medium used
Hysteroscopic Myomectomy
Operative Hysteroscopy Resectoscope Uni or Bipolar
Non ionic fluid
Unipolar polyp and myomaresection
Ionic fluid
First generation Bipolar (Versapoint)
Loop is smaller
chips are smaller
Longer OR time
Bipolar cautery induces
more bubbles
Bipolar resectoscope new generation
low-energy
Two or more small active electrodes very close to each other (active and return electrode)
bull Use Saline as distention medium
bull limited spread of electrical effect the current flow is essentially limited to a small area and it requires less voltage less risk for adhaesion formation
bull Loop different shape and size Different surgical
manoeuvres
bull Need of Modern generator
Bipolar resectoscope new generation
Storz bipolar resectoscope new generation
Return electrode opposite
side
Larger active electrode
Minimal gas bubbles
production
Less risk of perforation
Different surgical technique
Bipolar hysteroscopic myomectomy
Hysteroscopic Myomectomy
Long-term results depend on
bull Uterine Size (Plt0001)
bull Number of myomas (Plt0001)
The surgery-free percentage of 165 patients with normal sized uteri and not more than two
myomas was 943 (+- 18) at 2 years and 903 (+- 30) at 5 years
bull Type ( intra-mural part)
bull Size of myoma (significant increase of amount of particles between 2 and 3 cm)
Long-term results depend on the presence of concomitant pathology
or is a result of incomplete surgery
Emanuel MH Wamsteker K Obstet Gynecol 1999 May93743-8
Third Statement
1 Junctional Zone Myoma should preferentially be treated by hysteroscopy
2 Feasibility of hysteroscopic surgery is predominantly related with size location and amount of myoma
3 Independently of distension medium used continuous fluid balance and flow distension control is mandatory
4 Complication risk is related to experience and surgical technique used
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Conventional hysteroscopic surgery
4 Laparoscopic surgery
Introduction
Intramural myoma larger than 4 cm related to the JZ myometriumschould be operated on
Laparoscopic approach has had an important evolution over the
years
Series with high success rate are done by experts =gt it is difficult to extrapolate to less experienced surgeons
Laparoscopic myomectomy needs expert skills in haemostasis dissection and suturing
How to minimize blood loss
bullA lot of techniques in order to minimize blood loss
GnRH agonists
Intramyometrial vasopressine
Oxytocin IV 40 mUImin intraoperatively
Use of tourniquet or penrose at the lower part of uterus
Laparoscopic Myomectomy
J Ferro IVI Valencia Spain
Tips amp tricks ndash minimize blood loss
Clipping of the uterine arteries and infundilopelvic ligaments is another very efficient method
Artery ligation versus Control group (n=152)
173 +- 91 mL vs 402 +- 131 mL blood loss
62 vs 2075 reccurence rate
Alborzi S et al A comparison of combined laparoscopic uterine artery ligation and myomectomyversus laparoscopic myomectomy in the treatment of symptomatic myoma Fertil Steril 2009
Tips amp tricks ndash minimize blood loss
Technique Incision
Incision
J Ferro A Wattiez
Tips amp tricks- dissection
Tips amp tricks- closure
bull One versus multiples layers controversial
bull Adequate closure of the dead space to minimize the risk of hematoma formation
bull Interrupted figure of eight sutures are usually sufficient monocryl 1 or 0 with extracorporeal notes =gt extra strength
bull For the serosa approximate with interrupted 20 sutures if necessary (monofilament)
Tips amp tricks- closure
Removal Clips
Anti- adhesion agents
Fourth Statement
LAPAROSCOPIC MYOMECTOMY offers comparable results tolaparotomic myomectomy
Laparoscopic approach reduces adhesion formation blood loss and hospital stay
Laparoscopic myomectomy seems indicated in the infertile patient for the treatment of intramural myomarsquos
Laparoscopic Myomectomy requires a skilled laparoscopic surgeon with expert suturing skills optimal instrumental support and knowledge of some trickrsquos to provide an optimal result
Take Home message
Submucous myoma should always be removed prior to IVF
Hysteroscopic resection is the gold standard to treat those myoma
Intramural myoma originating from the sub endometrial
myometrium and larger than 4 cm are treated by Laproscopy
Subserosal myoma do not influence the outcome of IVF and are not removed for this indication
More info on the special training
programsin endoscopic
surgery
ESGEORG
More info on the ESGE website
wwwesgeorg
See you in London
Rudi Campo Stephan GordtsPatrick PuttemansRoger MolinasSylvie GordtsMarion Valkenburg Ivo Brosens
Leuven Institute for Fertility
amp Embryology
Trophy Scope a new generation
Interesting Characteristics
Gliding system that provides
Diagnostic ( 29 mm ) and
Operative (44 mm)
possibilities in one instrument
This hysteroscope has been named after the multicentre study
TROPHY ldquoTrial of Outpatient Hysteroscopyrdquo for which it was designed
El-Toukhy T Campo R et al Trial of Outpatient Hysteroscopy - [TROPHY] in IVF Reprod Health 2009 Dec 3620
Ultrasound
Fluid Mini-Hysteroscopy
Kontrast sonography
One Stop Uterine diagnosis
Proper diagnosis of fibroids
Ultrasound
Hysteroscopy
Contrast sonography
Overview of set up
Supplemantary exams necessary
When
1 dd adenomyoma ndash myoma
2 Multiple myoma
3 Diffuse enlargement of uterine wall
How
1 NMR imaging (3D US )
2 Hysteroscopic Myometrial exploration
LIFE vzw Leuven Institute for Fertility amp Embryology
Findings at MRI JZ Myoma
LIFE vzw Leuven Institute for Fertility amp Embryology
Allocation of Myoma to OM or JZM
LIFE vzw Leuven Institute for Fertility amp Embryology
MRI for diagnosis of Adenomyosis and Adenomyoma
Loss of differentiation JZ - OM
Normal
LIFE vzw Leuven Institute for Fertility amp Embryology
Enlarge the hysteroscopic diagnosis with
exploration of JZ myometrium
Trophy Hysteroscope acc to Campo
New generation of hysteroscope with interesting characteristics
named after the multicentre study TROPHY ldquoTrial of Outpatient
Hysteroscopyrdquo for which it was designedEl-Toukhy T Campo R et al Trial of Outpatient Hysteroscopy ndash (TROPHY) in IVF Reprod Health 2009 Dec 3620
Spirotome acc to Gordts
A device made to harvest high quality samples from soft tissues
built on the pioneering concept of a cutting helix on a cutting cannula
New Tools for exploration of the JZ myometrium
Trophy Scope 29 mm compactscope with Innovative gliding mechanism for accessory sheets
Can be loaded with accessory sheets which can be activated in case of necessity by gently push on the bottom and forward movement till locking in the active position supplementary functions are available without the need to remove the hysteroscope
Trophy Scope Diagnostic accessory sheet
In active positionAtraumatic cervical dilatation up to 37 mm under visual controlCreating double flowBlocking of cervix in case of passive outflow
In free positionSuction device for endometrial samplingGuide for ultrasound guided intrauterine procedures like positioning Embryo
transfer catheter or for Spirotome endomyometrial biopsy
active freepassive
Trophy Scope Operative accessory sheet
In passive position
Operative sheet does not interfere
the diagnostic phase (29mm)
In active positionAtraumatic cervical dilatation
up to 44 mm under visual control
Creating double flow and blocking
function in case of passive outflow
Introduction of 5 Fr instruments without
compromising inflow
A device made to harvest high quality samples from soft tissues
It is built on the pioneering concept of a cutting helix on a cutting
cannula well identified by Ultrasound
Spirotome acc to Gordts
Spirotome
The sample is harvested by turning the helix into the diseased area under
direct vision or ultrasound guidance The cannula turns subsequently over the
helix to free the sample from the surroundings
Spirotome myometrial biopsy
HSC post spirotome biopsy
Spirotome myometrial biopsy
Trophy Scope - Spirotome - US
Guide for ultrasound guided
Spirotome endomyometrial biopsy
cutting helixcutting cannula
Trophy Scope ndash Spirotome - Ultrasound
Exploration of JZ myometrium with Trophy hysteroscope
Resection intramural myoma
Resection adenomyoma
Resection adenomyoma
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Conventional hysteroscopic surgery
4 Laparoscopic surgery
Conventional Hysteroscopic Surgery
TYPE 0 TYPE 1 TYPE 2
The ESGE classificationof submucous myomas
Size volume = 43r3
bull2 cm ~ 42 cm3 8 min
bull3 cm ~ 141 cm3 28 min
bull4 cm ~ 335 cm3 67 min
Emanuel MH et al Fertil Steril 199768881-6
Operating time of critical importance
Reduction in volume of the fibroidsby GnRH-a therapy
Distension fluid
Monopolar surgery using non-ionic solutions
sa manitol sorbitol or glycine has higher risk of
side effects due to fluid overload effect
Stop surgery as soon as 1 L of fluid losses
Bipolar surgery using ionic solutions (saline)
Isotonic hyperhydration is less dangerous
In young patients up to 4 L of losses can be
accepted
Hysteroscopic Myomectomy
Always use a pressure and flow controlled pump system to work at minimal necessary pressure
Always perform continuous fluid balance independently of the medium used
Hysteroscopic Myomectomy
Operative Hysteroscopy Resectoscope Uni or Bipolar
Non ionic fluid
Unipolar polyp and myomaresection
Ionic fluid
First generation Bipolar (Versapoint)
Loop is smaller
chips are smaller
Longer OR time
Bipolar cautery induces
more bubbles
Bipolar resectoscope new generation
low-energy
Two or more small active electrodes very close to each other (active and return electrode)
bull Use Saline as distention medium
bull limited spread of electrical effect the current flow is essentially limited to a small area and it requires less voltage less risk for adhaesion formation
bull Loop different shape and size Different surgical
manoeuvres
bull Need of Modern generator
Bipolar resectoscope new generation
Storz bipolar resectoscope new generation
Return electrode opposite
side
Larger active electrode
Minimal gas bubbles
production
Less risk of perforation
Different surgical technique
Bipolar hysteroscopic myomectomy
Hysteroscopic Myomectomy
Long-term results depend on
bull Uterine Size (Plt0001)
bull Number of myomas (Plt0001)
The surgery-free percentage of 165 patients with normal sized uteri and not more than two
myomas was 943 (+- 18) at 2 years and 903 (+- 30) at 5 years
bull Type ( intra-mural part)
bull Size of myoma (significant increase of amount of particles between 2 and 3 cm)
Long-term results depend on the presence of concomitant pathology
or is a result of incomplete surgery
Emanuel MH Wamsteker K Obstet Gynecol 1999 May93743-8
Third Statement
1 Junctional Zone Myoma should preferentially be treated by hysteroscopy
2 Feasibility of hysteroscopic surgery is predominantly related with size location and amount of myoma
3 Independently of distension medium used continuous fluid balance and flow distension control is mandatory
4 Complication risk is related to experience and surgical technique used
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Conventional hysteroscopic surgery
4 Laparoscopic surgery
Introduction
Intramural myoma larger than 4 cm related to the JZ myometriumschould be operated on
Laparoscopic approach has had an important evolution over the
years
Series with high success rate are done by experts =gt it is difficult to extrapolate to less experienced surgeons
Laparoscopic myomectomy needs expert skills in haemostasis dissection and suturing
How to minimize blood loss
bullA lot of techniques in order to minimize blood loss
GnRH agonists
Intramyometrial vasopressine
Oxytocin IV 40 mUImin intraoperatively
Use of tourniquet or penrose at the lower part of uterus
Laparoscopic Myomectomy
J Ferro IVI Valencia Spain
Tips amp tricks ndash minimize blood loss
Clipping of the uterine arteries and infundilopelvic ligaments is another very efficient method
Artery ligation versus Control group (n=152)
173 +- 91 mL vs 402 +- 131 mL blood loss
62 vs 2075 reccurence rate
Alborzi S et al A comparison of combined laparoscopic uterine artery ligation and myomectomyversus laparoscopic myomectomy in the treatment of symptomatic myoma Fertil Steril 2009
Tips amp tricks ndash minimize blood loss
Technique Incision
Incision
J Ferro A Wattiez
Tips amp tricks- dissection
Tips amp tricks- closure
bull One versus multiples layers controversial
bull Adequate closure of the dead space to minimize the risk of hematoma formation
bull Interrupted figure of eight sutures are usually sufficient monocryl 1 or 0 with extracorporeal notes =gt extra strength
bull For the serosa approximate with interrupted 20 sutures if necessary (monofilament)
Tips amp tricks- closure
Removal Clips
Anti- adhesion agents
Fourth Statement
LAPAROSCOPIC MYOMECTOMY offers comparable results tolaparotomic myomectomy
Laparoscopic approach reduces adhesion formation blood loss and hospital stay
Laparoscopic myomectomy seems indicated in the infertile patient for the treatment of intramural myomarsquos
Laparoscopic Myomectomy requires a skilled laparoscopic surgeon with expert suturing skills optimal instrumental support and knowledge of some trickrsquos to provide an optimal result
Take Home message
Submucous myoma should always be removed prior to IVF
Hysteroscopic resection is the gold standard to treat those myoma
Intramural myoma originating from the sub endometrial
myometrium and larger than 4 cm are treated by Laproscopy
Subserosal myoma do not influence the outcome of IVF and are not removed for this indication
More info on the special training
programsin endoscopic
surgery
ESGEORG
More info on the ESGE website
wwwesgeorg
See you in London
Rudi Campo Stephan GordtsPatrick PuttemansRoger MolinasSylvie GordtsMarion Valkenburg Ivo Brosens
Leuven Institute for Fertility
amp Embryology
Trophy Scope a new generation
Interesting Characteristics
Gliding system that provides
Diagnostic ( 29 mm ) and
Operative (44 mm)
possibilities in one instrument
This hysteroscope has been named after the multicentre study
TROPHY ldquoTrial of Outpatient Hysteroscopyrdquo for which it was designed
El-Toukhy T Campo R et al Trial of Outpatient Hysteroscopy - [TROPHY] in IVF Reprod Health 2009 Dec 3620
Proper diagnosis of fibroids
Ultrasound
Hysteroscopy
Contrast sonography
Overview of set up
Supplemantary exams necessary
When
1 dd adenomyoma ndash myoma
2 Multiple myoma
3 Diffuse enlargement of uterine wall
How
1 NMR imaging (3D US )
2 Hysteroscopic Myometrial exploration
LIFE vzw Leuven Institute for Fertility amp Embryology
Findings at MRI JZ Myoma
LIFE vzw Leuven Institute for Fertility amp Embryology
Allocation of Myoma to OM or JZM
LIFE vzw Leuven Institute for Fertility amp Embryology
MRI for diagnosis of Adenomyosis and Adenomyoma
Loss of differentiation JZ - OM
Normal
LIFE vzw Leuven Institute for Fertility amp Embryology
Enlarge the hysteroscopic diagnosis with
exploration of JZ myometrium
Trophy Hysteroscope acc to Campo
New generation of hysteroscope with interesting characteristics
named after the multicentre study TROPHY ldquoTrial of Outpatient
Hysteroscopyrdquo for which it was designedEl-Toukhy T Campo R et al Trial of Outpatient Hysteroscopy ndash (TROPHY) in IVF Reprod Health 2009 Dec 3620
Spirotome acc to Gordts
A device made to harvest high quality samples from soft tissues
built on the pioneering concept of a cutting helix on a cutting cannula
New Tools for exploration of the JZ myometrium
Trophy Scope 29 mm compactscope with Innovative gliding mechanism for accessory sheets
Can be loaded with accessory sheets which can be activated in case of necessity by gently push on the bottom and forward movement till locking in the active position supplementary functions are available without the need to remove the hysteroscope
Trophy Scope Diagnostic accessory sheet
In active positionAtraumatic cervical dilatation up to 37 mm under visual controlCreating double flowBlocking of cervix in case of passive outflow
In free positionSuction device for endometrial samplingGuide for ultrasound guided intrauterine procedures like positioning Embryo
transfer catheter or for Spirotome endomyometrial biopsy
active freepassive
Trophy Scope Operative accessory sheet
In passive position
Operative sheet does not interfere
the diagnostic phase (29mm)
In active positionAtraumatic cervical dilatation
up to 44 mm under visual control
Creating double flow and blocking
function in case of passive outflow
Introduction of 5 Fr instruments without
compromising inflow
A device made to harvest high quality samples from soft tissues
It is built on the pioneering concept of a cutting helix on a cutting
cannula well identified by Ultrasound
Spirotome acc to Gordts
Spirotome
The sample is harvested by turning the helix into the diseased area under
direct vision or ultrasound guidance The cannula turns subsequently over the
helix to free the sample from the surroundings
Spirotome myometrial biopsy
HSC post spirotome biopsy
Spirotome myometrial biopsy
Trophy Scope - Spirotome - US
Guide for ultrasound guided
Spirotome endomyometrial biopsy
cutting helixcutting cannula
Trophy Scope ndash Spirotome - Ultrasound
Exploration of JZ myometrium with Trophy hysteroscope
Resection intramural myoma
Resection adenomyoma
Resection adenomyoma
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Conventional hysteroscopic surgery
4 Laparoscopic surgery
Conventional Hysteroscopic Surgery
TYPE 0 TYPE 1 TYPE 2
The ESGE classificationof submucous myomas
Size volume = 43r3
bull2 cm ~ 42 cm3 8 min
bull3 cm ~ 141 cm3 28 min
bull4 cm ~ 335 cm3 67 min
Emanuel MH et al Fertil Steril 199768881-6
Operating time of critical importance
Reduction in volume of the fibroidsby GnRH-a therapy
Distension fluid
Monopolar surgery using non-ionic solutions
sa manitol sorbitol or glycine has higher risk of
side effects due to fluid overload effect
Stop surgery as soon as 1 L of fluid losses
Bipolar surgery using ionic solutions (saline)
Isotonic hyperhydration is less dangerous
In young patients up to 4 L of losses can be
accepted
Hysteroscopic Myomectomy
Always use a pressure and flow controlled pump system to work at minimal necessary pressure
Always perform continuous fluid balance independently of the medium used
Hysteroscopic Myomectomy
Operative Hysteroscopy Resectoscope Uni or Bipolar
Non ionic fluid
Unipolar polyp and myomaresection
Ionic fluid
First generation Bipolar (Versapoint)
Loop is smaller
chips are smaller
Longer OR time
Bipolar cautery induces
more bubbles
Bipolar resectoscope new generation
low-energy
Two or more small active electrodes very close to each other (active and return electrode)
bull Use Saline as distention medium
bull limited spread of electrical effect the current flow is essentially limited to a small area and it requires less voltage less risk for adhaesion formation
bull Loop different shape and size Different surgical
manoeuvres
bull Need of Modern generator
Bipolar resectoscope new generation
Storz bipolar resectoscope new generation
Return electrode opposite
side
Larger active electrode
Minimal gas bubbles
production
Less risk of perforation
Different surgical technique
Bipolar hysteroscopic myomectomy
Hysteroscopic Myomectomy
Long-term results depend on
bull Uterine Size (Plt0001)
bull Number of myomas (Plt0001)
The surgery-free percentage of 165 patients with normal sized uteri and not more than two
myomas was 943 (+- 18) at 2 years and 903 (+- 30) at 5 years
bull Type ( intra-mural part)
bull Size of myoma (significant increase of amount of particles between 2 and 3 cm)
Long-term results depend on the presence of concomitant pathology
or is a result of incomplete surgery
Emanuel MH Wamsteker K Obstet Gynecol 1999 May93743-8
Third Statement
1 Junctional Zone Myoma should preferentially be treated by hysteroscopy
2 Feasibility of hysteroscopic surgery is predominantly related with size location and amount of myoma
3 Independently of distension medium used continuous fluid balance and flow distension control is mandatory
4 Complication risk is related to experience and surgical technique used
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Conventional hysteroscopic surgery
4 Laparoscopic surgery
Introduction
Intramural myoma larger than 4 cm related to the JZ myometriumschould be operated on
Laparoscopic approach has had an important evolution over the
years
Series with high success rate are done by experts =gt it is difficult to extrapolate to less experienced surgeons
Laparoscopic myomectomy needs expert skills in haemostasis dissection and suturing
How to minimize blood loss
bullA lot of techniques in order to minimize blood loss
GnRH agonists
Intramyometrial vasopressine
Oxytocin IV 40 mUImin intraoperatively
Use of tourniquet or penrose at the lower part of uterus
Laparoscopic Myomectomy
J Ferro IVI Valencia Spain
Tips amp tricks ndash minimize blood loss
Clipping of the uterine arteries and infundilopelvic ligaments is another very efficient method
Artery ligation versus Control group (n=152)
173 +- 91 mL vs 402 +- 131 mL blood loss
62 vs 2075 reccurence rate
Alborzi S et al A comparison of combined laparoscopic uterine artery ligation and myomectomyversus laparoscopic myomectomy in the treatment of symptomatic myoma Fertil Steril 2009
Tips amp tricks ndash minimize blood loss
Technique Incision
Incision
J Ferro A Wattiez
Tips amp tricks- dissection
Tips amp tricks- closure
bull One versus multiples layers controversial
bull Adequate closure of the dead space to minimize the risk of hematoma formation
bull Interrupted figure of eight sutures are usually sufficient monocryl 1 or 0 with extracorporeal notes =gt extra strength
bull For the serosa approximate with interrupted 20 sutures if necessary (monofilament)
Tips amp tricks- closure
Removal Clips
Anti- adhesion agents
Fourth Statement
LAPAROSCOPIC MYOMECTOMY offers comparable results tolaparotomic myomectomy
Laparoscopic approach reduces adhesion formation blood loss and hospital stay
Laparoscopic myomectomy seems indicated in the infertile patient for the treatment of intramural myomarsquos
Laparoscopic Myomectomy requires a skilled laparoscopic surgeon with expert suturing skills optimal instrumental support and knowledge of some trickrsquos to provide an optimal result
Take Home message
Submucous myoma should always be removed prior to IVF
Hysteroscopic resection is the gold standard to treat those myoma
Intramural myoma originating from the sub endometrial
myometrium and larger than 4 cm are treated by Laproscopy
Subserosal myoma do not influence the outcome of IVF and are not removed for this indication
More info on the special training
programsin endoscopic
surgery
ESGEORG
More info on the ESGE website
wwwesgeorg
See you in London
Rudi Campo Stephan GordtsPatrick PuttemansRoger MolinasSylvie GordtsMarion Valkenburg Ivo Brosens
Leuven Institute for Fertility
amp Embryology
Trophy Scope a new generation
Interesting Characteristics
Gliding system that provides
Diagnostic ( 29 mm ) and
Operative (44 mm)
possibilities in one instrument
This hysteroscope has been named after the multicentre study
TROPHY ldquoTrial of Outpatient Hysteroscopyrdquo for which it was designed
El-Toukhy T Campo R et al Trial of Outpatient Hysteroscopy - [TROPHY] in IVF Reprod Health 2009 Dec 3620
Overview of set up
Supplemantary exams necessary
When
1 dd adenomyoma ndash myoma
2 Multiple myoma
3 Diffuse enlargement of uterine wall
How
1 NMR imaging (3D US )
2 Hysteroscopic Myometrial exploration
LIFE vzw Leuven Institute for Fertility amp Embryology
Findings at MRI JZ Myoma
LIFE vzw Leuven Institute for Fertility amp Embryology
Allocation of Myoma to OM or JZM
LIFE vzw Leuven Institute for Fertility amp Embryology
MRI for diagnosis of Adenomyosis and Adenomyoma
Loss of differentiation JZ - OM
Normal
LIFE vzw Leuven Institute for Fertility amp Embryology
Enlarge the hysteroscopic diagnosis with
exploration of JZ myometrium
Trophy Hysteroscope acc to Campo
New generation of hysteroscope with interesting characteristics
named after the multicentre study TROPHY ldquoTrial of Outpatient
Hysteroscopyrdquo for which it was designedEl-Toukhy T Campo R et al Trial of Outpatient Hysteroscopy ndash (TROPHY) in IVF Reprod Health 2009 Dec 3620
Spirotome acc to Gordts
A device made to harvest high quality samples from soft tissues
built on the pioneering concept of a cutting helix on a cutting cannula
New Tools for exploration of the JZ myometrium
Trophy Scope 29 mm compactscope with Innovative gliding mechanism for accessory sheets
Can be loaded with accessory sheets which can be activated in case of necessity by gently push on the bottom and forward movement till locking in the active position supplementary functions are available without the need to remove the hysteroscope
Trophy Scope Diagnostic accessory sheet
In active positionAtraumatic cervical dilatation up to 37 mm under visual controlCreating double flowBlocking of cervix in case of passive outflow
In free positionSuction device for endometrial samplingGuide for ultrasound guided intrauterine procedures like positioning Embryo
transfer catheter or for Spirotome endomyometrial biopsy
active freepassive
Trophy Scope Operative accessory sheet
In passive position
Operative sheet does not interfere
the diagnostic phase (29mm)
In active positionAtraumatic cervical dilatation
up to 44 mm under visual control
Creating double flow and blocking
function in case of passive outflow
Introduction of 5 Fr instruments without
compromising inflow
A device made to harvest high quality samples from soft tissues
It is built on the pioneering concept of a cutting helix on a cutting
cannula well identified by Ultrasound
Spirotome acc to Gordts
Spirotome
The sample is harvested by turning the helix into the diseased area under
direct vision or ultrasound guidance The cannula turns subsequently over the
helix to free the sample from the surroundings
Spirotome myometrial biopsy
HSC post spirotome biopsy
Spirotome myometrial biopsy
Trophy Scope - Spirotome - US
Guide for ultrasound guided
Spirotome endomyometrial biopsy
cutting helixcutting cannula
Trophy Scope ndash Spirotome - Ultrasound
Exploration of JZ myometrium with Trophy hysteroscope
Resection intramural myoma
Resection adenomyoma
Resection adenomyoma
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Conventional hysteroscopic surgery
4 Laparoscopic surgery
Conventional Hysteroscopic Surgery
TYPE 0 TYPE 1 TYPE 2
The ESGE classificationof submucous myomas
Size volume = 43r3
bull2 cm ~ 42 cm3 8 min
bull3 cm ~ 141 cm3 28 min
bull4 cm ~ 335 cm3 67 min
Emanuel MH et al Fertil Steril 199768881-6
Operating time of critical importance
Reduction in volume of the fibroidsby GnRH-a therapy
Distension fluid
Monopolar surgery using non-ionic solutions
sa manitol sorbitol or glycine has higher risk of
side effects due to fluid overload effect
Stop surgery as soon as 1 L of fluid losses
Bipolar surgery using ionic solutions (saline)
Isotonic hyperhydration is less dangerous
In young patients up to 4 L of losses can be
accepted
Hysteroscopic Myomectomy
Always use a pressure and flow controlled pump system to work at minimal necessary pressure
Always perform continuous fluid balance independently of the medium used
Hysteroscopic Myomectomy
Operative Hysteroscopy Resectoscope Uni or Bipolar
Non ionic fluid
Unipolar polyp and myomaresection
Ionic fluid
First generation Bipolar (Versapoint)
Loop is smaller
chips are smaller
Longer OR time
Bipolar cautery induces
more bubbles
Bipolar resectoscope new generation
low-energy
Two or more small active electrodes very close to each other (active and return electrode)
bull Use Saline as distention medium
bull limited spread of electrical effect the current flow is essentially limited to a small area and it requires less voltage less risk for adhaesion formation
bull Loop different shape and size Different surgical
manoeuvres
bull Need of Modern generator
Bipolar resectoscope new generation
Storz bipolar resectoscope new generation
Return electrode opposite
side
Larger active electrode
Minimal gas bubbles
production
Less risk of perforation
Different surgical technique
Bipolar hysteroscopic myomectomy
Hysteroscopic Myomectomy
Long-term results depend on
bull Uterine Size (Plt0001)
bull Number of myomas (Plt0001)
The surgery-free percentage of 165 patients with normal sized uteri and not more than two
myomas was 943 (+- 18) at 2 years and 903 (+- 30) at 5 years
bull Type ( intra-mural part)
bull Size of myoma (significant increase of amount of particles between 2 and 3 cm)
Long-term results depend on the presence of concomitant pathology
or is a result of incomplete surgery
Emanuel MH Wamsteker K Obstet Gynecol 1999 May93743-8
Third Statement
1 Junctional Zone Myoma should preferentially be treated by hysteroscopy
2 Feasibility of hysteroscopic surgery is predominantly related with size location and amount of myoma
3 Independently of distension medium used continuous fluid balance and flow distension control is mandatory
4 Complication risk is related to experience and surgical technique used
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Conventional hysteroscopic surgery
4 Laparoscopic surgery
Introduction
Intramural myoma larger than 4 cm related to the JZ myometriumschould be operated on
Laparoscopic approach has had an important evolution over the
years
Series with high success rate are done by experts =gt it is difficult to extrapolate to less experienced surgeons
Laparoscopic myomectomy needs expert skills in haemostasis dissection and suturing
How to minimize blood loss
bullA lot of techniques in order to minimize blood loss
GnRH agonists
Intramyometrial vasopressine
Oxytocin IV 40 mUImin intraoperatively
Use of tourniquet or penrose at the lower part of uterus
Laparoscopic Myomectomy
J Ferro IVI Valencia Spain
Tips amp tricks ndash minimize blood loss
Clipping of the uterine arteries and infundilopelvic ligaments is another very efficient method
Artery ligation versus Control group (n=152)
173 +- 91 mL vs 402 +- 131 mL blood loss
62 vs 2075 reccurence rate
Alborzi S et al A comparison of combined laparoscopic uterine artery ligation and myomectomyversus laparoscopic myomectomy in the treatment of symptomatic myoma Fertil Steril 2009
Tips amp tricks ndash minimize blood loss
Technique Incision
Incision
J Ferro A Wattiez
Tips amp tricks- dissection
Tips amp tricks- closure
bull One versus multiples layers controversial
bull Adequate closure of the dead space to minimize the risk of hematoma formation
bull Interrupted figure of eight sutures are usually sufficient monocryl 1 or 0 with extracorporeal notes =gt extra strength
bull For the serosa approximate with interrupted 20 sutures if necessary (monofilament)
Tips amp tricks- closure
Removal Clips
Anti- adhesion agents
Fourth Statement
LAPAROSCOPIC MYOMECTOMY offers comparable results tolaparotomic myomectomy
Laparoscopic approach reduces adhesion formation blood loss and hospital stay
Laparoscopic myomectomy seems indicated in the infertile patient for the treatment of intramural myomarsquos
Laparoscopic Myomectomy requires a skilled laparoscopic surgeon with expert suturing skills optimal instrumental support and knowledge of some trickrsquos to provide an optimal result
Take Home message
Submucous myoma should always be removed prior to IVF
Hysteroscopic resection is the gold standard to treat those myoma
Intramural myoma originating from the sub endometrial
myometrium and larger than 4 cm are treated by Laproscopy
Subserosal myoma do not influence the outcome of IVF and are not removed for this indication
More info on the special training
programsin endoscopic
surgery
ESGEORG
More info on the ESGE website
wwwesgeorg
See you in London
Rudi Campo Stephan GordtsPatrick PuttemansRoger MolinasSylvie GordtsMarion Valkenburg Ivo Brosens
Leuven Institute for Fertility
amp Embryology
Trophy Scope a new generation
Interesting Characteristics
Gliding system that provides
Diagnostic ( 29 mm ) and
Operative (44 mm)
possibilities in one instrument
This hysteroscope has been named after the multicentre study
TROPHY ldquoTrial of Outpatient Hysteroscopyrdquo for which it was designed
El-Toukhy T Campo R et al Trial of Outpatient Hysteroscopy - [TROPHY] in IVF Reprod Health 2009 Dec 3620
Supplemantary exams necessary
When
1 dd adenomyoma ndash myoma
2 Multiple myoma
3 Diffuse enlargement of uterine wall
How
1 NMR imaging (3D US )
2 Hysteroscopic Myometrial exploration
LIFE vzw Leuven Institute for Fertility amp Embryology
Findings at MRI JZ Myoma
LIFE vzw Leuven Institute for Fertility amp Embryology
Allocation of Myoma to OM or JZM
LIFE vzw Leuven Institute for Fertility amp Embryology
MRI for diagnosis of Adenomyosis and Adenomyoma
Loss of differentiation JZ - OM
Normal
LIFE vzw Leuven Institute for Fertility amp Embryology
Enlarge the hysteroscopic diagnosis with
exploration of JZ myometrium
Trophy Hysteroscope acc to Campo
New generation of hysteroscope with interesting characteristics
named after the multicentre study TROPHY ldquoTrial of Outpatient
Hysteroscopyrdquo for which it was designedEl-Toukhy T Campo R et al Trial of Outpatient Hysteroscopy ndash (TROPHY) in IVF Reprod Health 2009 Dec 3620
Spirotome acc to Gordts
A device made to harvest high quality samples from soft tissues
built on the pioneering concept of a cutting helix on a cutting cannula
New Tools for exploration of the JZ myometrium
Trophy Scope 29 mm compactscope with Innovative gliding mechanism for accessory sheets
Can be loaded with accessory sheets which can be activated in case of necessity by gently push on the bottom and forward movement till locking in the active position supplementary functions are available without the need to remove the hysteroscope
Trophy Scope Diagnostic accessory sheet
In active positionAtraumatic cervical dilatation up to 37 mm under visual controlCreating double flowBlocking of cervix in case of passive outflow
In free positionSuction device for endometrial samplingGuide for ultrasound guided intrauterine procedures like positioning Embryo
transfer catheter or for Spirotome endomyometrial biopsy
active freepassive
Trophy Scope Operative accessory sheet
In passive position
Operative sheet does not interfere
the diagnostic phase (29mm)
In active positionAtraumatic cervical dilatation
up to 44 mm under visual control
Creating double flow and blocking
function in case of passive outflow
Introduction of 5 Fr instruments without
compromising inflow
A device made to harvest high quality samples from soft tissues
It is built on the pioneering concept of a cutting helix on a cutting
cannula well identified by Ultrasound
Spirotome acc to Gordts
Spirotome
The sample is harvested by turning the helix into the diseased area under
direct vision or ultrasound guidance The cannula turns subsequently over the
helix to free the sample from the surroundings
Spirotome myometrial biopsy
HSC post spirotome biopsy
Spirotome myometrial biopsy
Trophy Scope - Spirotome - US
Guide for ultrasound guided
Spirotome endomyometrial biopsy
cutting helixcutting cannula
Trophy Scope ndash Spirotome - Ultrasound
Exploration of JZ myometrium with Trophy hysteroscope
Resection intramural myoma
Resection adenomyoma
Resection adenomyoma
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Conventional hysteroscopic surgery
4 Laparoscopic surgery
Conventional Hysteroscopic Surgery
TYPE 0 TYPE 1 TYPE 2
The ESGE classificationof submucous myomas
Size volume = 43r3
bull2 cm ~ 42 cm3 8 min
bull3 cm ~ 141 cm3 28 min
bull4 cm ~ 335 cm3 67 min
Emanuel MH et al Fertil Steril 199768881-6
Operating time of critical importance
Reduction in volume of the fibroidsby GnRH-a therapy
Distension fluid
Monopolar surgery using non-ionic solutions
sa manitol sorbitol or glycine has higher risk of
side effects due to fluid overload effect
Stop surgery as soon as 1 L of fluid losses
Bipolar surgery using ionic solutions (saline)
Isotonic hyperhydration is less dangerous
In young patients up to 4 L of losses can be
accepted
Hysteroscopic Myomectomy
Always use a pressure and flow controlled pump system to work at minimal necessary pressure
Always perform continuous fluid balance independently of the medium used
Hysteroscopic Myomectomy
Operative Hysteroscopy Resectoscope Uni or Bipolar
Non ionic fluid
Unipolar polyp and myomaresection
Ionic fluid
First generation Bipolar (Versapoint)
Loop is smaller
chips are smaller
Longer OR time
Bipolar cautery induces
more bubbles
Bipolar resectoscope new generation
low-energy
Two or more small active electrodes very close to each other (active and return electrode)
bull Use Saline as distention medium
bull limited spread of electrical effect the current flow is essentially limited to a small area and it requires less voltage less risk for adhaesion formation
bull Loop different shape and size Different surgical
manoeuvres
bull Need of Modern generator
Bipolar resectoscope new generation
Storz bipolar resectoscope new generation
Return electrode opposite
side
Larger active electrode
Minimal gas bubbles
production
Less risk of perforation
Different surgical technique
Bipolar hysteroscopic myomectomy
Hysteroscopic Myomectomy
Long-term results depend on
bull Uterine Size (Plt0001)
bull Number of myomas (Plt0001)
The surgery-free percentage of 165 patients with normal sized uteri and not more than two
myomas was 943 (+- 18) at 2 years and 903 (+- 30) at 5 years
bull Type ( intra-mural part)
bull Size of myoma (significant increase of amount of particles between 2 and 3 cm)
Long-term results depend on the presence of concomitant pathology
or is a result of incomplete surgery
Emanuel MH Wamsteker K Obstet Gynecol 1999 May93743-8
Third Statement
1 Junctional Zone Myoma should preferentially be treated by hysteroscopy
2 Feasibility of hysteroscopic surgery is predominantly related with size location and amount of myoma
3 Independently of distension medium used continuous fluid balance and flow distension control is mandatory
4 Complication risk is related to experience and surgical technique used
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Conventional hysteroscopic surgery
4 Laparoscopic surgery
Introduction
Intramural myoma larger than 4 cm related to the JZ myometriumschould be operated on
Laparoscopic approach has had an important evolution over the
years
Series with high success rate are done by experts =gt it is difficult to extrapolate to less experienced surgeons
Laparoscopic myomectomy needs expert skills in haemostasis dissection and suturing
How to minimize blood loss
bullA lot of techniques in order to minimize blood loss
GnRH agonists
Intramyometrial vasopressine
Oxytocin IV 40 mUImin intraoperatively
Use of tourniquet or penrose at the lower part of uterus
Laparoscopic Myomectomy
J Ferro IVI Valencia Spain
Tips amp tricks ndash minimize blood loss
Clipping of the uterine arteries and infundilopelvic ligaments is another very efficient method
Artery ligation versus Control group (n=152)
173 +- 91 mL vs 402 +- 131 mL blood loss
62 vs 2075 reccurence rate
Alborzi S et al A comparison of combined laparoscopic uterine artery ligation and myomectomyversus laparoscopic myomectomy in the treatment of symptomatic myoma Fertil Steril 2009
Tips amp tricks ndash minimize blood loss
Technique Incision
Incision
J Ferro A Wattiez
Tips amp tricks- dissection
Tips amp tricks- closure
bull One versus multiples layers controversial
bull Adequate closure of the dead space to minimize the risk of hematoma formation
bull Interrupted figure of eight sutures are usually sufficient monocryl 1 or 0 with extracorporeal notes =gt extra strength
bull For the serosa approximate with interrupted 20 sutures if necessary (monofilament)
Tips amp tricks- closure
Removal Clips
Anti- adhesion agents
Fourth Statement
LAPAROSCOPIC MYOMECTOMY offers comparable results tolaparotomic myomectomy
Laparoscopic approach reduces adhesion formation blood loss and hospital stay
Laparoscopic myomectomy seems indicated in the infertile patient for the treatment of intramural myomarsquos
Laparoscopic Myomectomy requires a skilled laparoscopic surgeon with expert suturing skills optimal instrumental support and knowledge of some trickrsquos to provide an optimal result
Take Home message
Submucous myoma should always be removed prior to IVF
Hysteroscopic resection is the gold standard to treat those myoma
Intramural myoma originating from the sub endometrial
myometrium and larger than 4 cm are treated by Laproscopy
Subserosal myoma do not influence the outcome of IVF and are not removed for this indication
More info on the special training
programsin endoscopic
surgery
ESGEORG
More info on the ESGE website
wwwesgeorg
See you in London
Rudi Campo Stephan GordtsPatrick PuttemansRoger MolinasSylvie GordtsMarion Valkenburg Ivo Brosens
Leuven Institute for Fertility
amp Embryology
Trophy Scope a new generation
Interesting Characteristics
Gliding system that provides
Diagnostic ( 29 mm ) and
Operative (44 mm)
possibilities in one instrument
This hysteroscope has been named after the multicentre study
TROPHY ldquoTrial of Outpatient Hysteroscopyrdquo for which it was designed
El-Toukhy T Campo R et al Trial of Outpatient Hysteroscopy - [TROPHY] in IVF Reprod Health 2009 Dec 3620
LIFE vzw Leuven Institute for Fertility amp Embryology
Findings at MRI JZ Myoma
LIFE vzw Leuven Institute for Fertility amp Embryology
Allocation of Myoma to OM or JZM
LIFE vzw Leuven Institute for Fertility amp Embryology
MRI for diagnosis of Adenomyosis and Adenomyoma
Loss of differentiation JZ - OM
Normal
LIFE vzw Leuven Institute for Fertility amp Embryology
Enlarge the hysteroscopic diagnosis with
exploration of JZ myometrium
Trophy Hysteroscope acc to Campo
New generation of hysteroscope with interesting characteristics
named after the multicentre study TROPHY ldquoTrial of Outpatient
Hysteroscopyrdquo for which it was designedEl-Toukhy T Campo R et al Trial of Outpatient Hysteroscopy ndash (TROPHY) in IVF Reprod Health 2009 Dec 3620
Spirotome acc to Gordts
A device made to harvest high quality samples from soft tissues
built on the pioneering concept of a cutting helix on a cutting cannula
New Tools for exploration of the JZ myometrium
Trophy Scope 29 mm compactscope with Innovative gliding mechanism for accessory sheets
Can be loaded with accessory sheets which can be activated in case of necessity by gently push on the bottom and forward movement till locking in the active position supplementary functions are available without the need to remove the hysteroscope
Trophy Scope Diagnostic accessory sheet
In active positionAtraumatic cervical dilatation up to 37 mm under visual controlCreating double flowBlocking of cervix in case of passive outflow
In free positionSuction device for endometrial samplingGuide for ultrasound guided intrauterine procedures like positioning Embryo
transfer catheter or for Spirotome endomyometrial biopsy
active freepassive
Trophy Scope Operative accessory sheet
In passive position
Operative sheet does not interfere
the diagnostic phase (29mm)
In active positionAtraumatic cervical dilatation
up to 44 mm under visual control
Creating double flow and blocking
function in case of passive outflow
Introduction of 5 Fr instruments without
compromising inflow
A device made to harvest high quality samples from soft tissues
It is built on the pioneering concept of a cutting helix on a cutting
cannula well identified by Ultrasound
Spirotome acc to Gordts
Spirotome
The sample is harvested by turning the helix into the diseased area under
direct vision or ultrasound guidance The cannula turns subsequently over the
helix to free the sample from the surroundings
Spirotome myometrial biopsy
HSC post spirotome biopsy
Spirotome myometrial biopsy
Trophy Scope - Spirotome - US
Guide for ultrasound guided
Spirotome endomyometrial biopsy
cutting helixcutting cannula
Trophy Scope ndash Spirotome - Ultrasound
Exploration of JZ myometrium with Trophy hysteroscope
Resection intramural myoma
Resection adenomyoma
Resection adenomyoma
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Conventional hysteroscopic surgery
4 Laparoscopic surgery
Conventional Hysteroscopic Surgery
TYPE 0 TYPE 1 TYPE 2
The ESGE classificationof submucous myomas
Size volume = 43r3
bull2 cm ~ 42 cm3 8 min
bull3 cm ~ 141 cm3 28 min
bull4 cm ~ 335 cm3 67 min
Emanuel MH et al Fertil Steril 199768881-6
Operating time of critical importance
Reduction in volume of the fibroidsby GnRH-a therapy
Distension fluid
Monopolar surgery using non-ionic solutions
sa manitol sorbitol or glycine has higher risk of
side effects due to fluid overload effect
Stop surgery as soon as 1 L of fluid losses
Bipolar surgery using ionic solutions (saline)
Isotonic hyperhydration is less dangerous
In young patients up to 4 L of losses can be
accepted
Hysteroscopic Myomectomy
Always use a pressure and flow controlled pump system to work at minimal necessary pressure
Always perform continuous fluid balance independently of the medium used
Hysteroscopic Myomectomy
Operative Hysteroscopy Resectoscope Uni or Bipolar
Non ionic fluid
Unipolar polyp and myomaresection
Ionic fluid
First generation Bipolar (Versapoint)
Loop is smaller
chips are smaller
Longer OR time
Bipolar cautery induces
more bubbles
Bipolar resectoscope new generation
low-energy
Two or more small active electrodes very close to each other (active and return electrode)
bull Use Saline as distention medium
bull limited spread of electrical effect the current flow is essentially limited to a small area and it requires less voltage less risk for adhaesion formation
bull Loop different shape and size Different surgical
manoeuvres
bull Need of Modern generator
Bipolar resectoscope new generation
Storz bipolar resectoscope new generation
Return electrode opposite
side
Larger active electrode
Minimal gas bubbles
production
Less risk of perforation
Different surgical technique
Bipolar hysteroscopic myomectomy
Hysteroscopic Myomectomy
Long-term results depend on
bull Uterine Size (Plt0001)
bull Number of myomas (Plt0001)
The surgery-free percentage of 165 patients with normal sized uteri and not more than two
myomas was 943 (+- 18) at 2 years and 903 (+- 30) at 5 years
bull Type ( intra-mural part)
bull Size of myoma (significant increase of amount of particles between 2 and 3 cm)
Long-term results depend on the presence of concomitant pathology
or is a result of incomplete surgery
Emanuel MH Wamsteker K Obstet Gynecol 1999 May93743-8
Third Statement
1 Junctional Zone Myoma should preferentially be treated by hysteroscopy
2 Feasibility of hysteroscopic surgery is predominantly related with size location and amount of myoma
3 Independently of distension medium used continuous fluid balance and flow distension control is mandatory
4 Complication risk is related to experience and surgical technique used
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Conventional hysteroscopic surgery
4 Laparoscopic surgery
Introduction
Intramural myoma larger than 4 cm related to the JZ myometriumschould be operated on
Laparoscopic approach has had an important evolution over the
years
Series with high success rate are done by experts =gt it is difficult to extrapolate to less experienced surgeons
Laparoscopic myomectomy needs expert skills in haemostasis dissection and suturing
How to minimize blood loss
bullA lot of techniques in order to minimize blood loss
GnRH agonists
Intramyometrial vasopressine
Oxytocin IV 40 mUImin intraoperatively
Use of tourniquet or penrose at the lower part of uterus
Laparoscopic Myomectomy
J Ferro IVI Valencia Spain
Tips amp tricks ndash minimize blood loss
Clipping of the uterine arteries and infundilopelvic ligaments is another very efficient method
Artery ligation versus Control group (n=152)
173 +- 91 mL vs 402 +- 131 mL blood loss
62 vs 2075 reccurence rate
Alborzi S et al A comparison of combined laparoscopic uterine artery ligation and myomectomyversus laparoscopic myomectomy in the treatment of symptomatic myoma Fertil Steril 2009
Tips amp tricks ndash minimize blood loss
Technique Incision
Incision
J Ferro A Wattiez
Tips amp tricks- dissection
Tips amp tricks- closure
bull One versus multiples layers controversial
bull Adequate closure of the dead space to minimize the risk of hematoma formation
bull Interrupted figure of eight sutures are usually sufficient monocryl 1 or 0 with extracorporeal notes =gt extra strength
bull For the serosa approximate with interrupted 20 sutures if necessary (monofilament)
Tips amp tricks- closure
Removal Clips
Anti- adhesion agents
Fourth Statement
LAPAROSCOPIC MYOMECTOMY offers comparable results tolaparotomic myomectomy
Laparoscopic approach reduces adhesion formation blood loss and hospital stay
Laparoscopic myomectomy seems indicated in the infertile patient for the treatment of intramural myomarsquos
Laparoscopic Myomectomy requires a skilled laparoscopic surgeon with expert suturing skills optimal instrumental support and knowledge of some trickrsquos to provide an optimal result
Take Home message
Submucous myoma should always be removed prior to IVF
Hysteroscopic resection is the gold standard to treat those myoma
Intramural myoma originating from the sub endometrial
myometrium and larger than 4 cm are treated by Laproscopy
Subserosal myoma do not influence the outcome of IVF and are not removed for this indication
More info on the special training
programsin endoscopic
surgery
ESGEORG
More info on the ESGE website
wwwesgeorg
See you in London
Rudi Campo Stephan GordtsPatrick PuttemansRoger MolinasSylvie GordtsMarion Valkenburg Ivo Brosens
Leuven Institute for Fertility
amp Embryology
Trophy Scope a new generation
Interesting Characteristics
Gliding system that provides
Diagnostic ( 29 mm ) and
Operative (44 mm)
possibilities in one instrument
This hysteroscope has been named after the multicentre study
TROPHY ldquoTrial of Outpatient Hysteroscopyrdquo for which it was designed
El-Toukhy T Campo R et al Trial of Outpatient Hysteroscopy - [TROPHY] in IVF Reprod Health 2009 Dec 3620
LIFE vzw Leuven Institute for Fertility amp Embryology
Allocation of Myoma to OM or JZM
LIFE vzw Leuven Institute for Fertility amp Embryology
MRI for diagnosis of Adenomyosis and Adenomyoma
Loss of differentiation JZ - OM
Normal
LIFE vzw Leuven Institute for Fertility amp Embryology
Enlarge the hysteroscopic diagnosis with
exploration of JZ myometrium
Trophy Hysteroscope acc to Campo
New generation of hysteroscope with interesting characteristics
named after the multicentre study TROPHY ldquoTrial of Outpatient
Hysteroscopyrdquo for which it was designedEl-Toukhy T Campo R et al Trial of Outpatient Hysteroscopy ndash (TROPHY) in IVF Reprod Health 2009 Dec 3620
Spirotome acc to Gordts
A device made to harvest high quality samples from soft tissues
built on the pioneering concept of a cutting helix on a cutting cannula
New Tools for exploration of the JZ myometrium
Trophy Scope 29 mm compactscope with Innovative gliding mechanism for accessory sheets
Can be loaded with accessory sheets which can be activated in case of necessity by gently push on the bottom and forward movement till locking in the active position supplementary functions are available without the need to remove the hysteroscope
Trophy Scope Diagnostic accessory sheet
In active positionAtraumatic cervical dilatation up to 37 mm under visual controlCreating double flowBlocking of cervix in case of passive outflow
In free positionSuction device for endometrial samplingGuide for ultrasound guided intrauterine procedures like positioning Embryo
transfer catheter or for Spirotome endomyometrial biopsy
active freepassive
Trophy Scope Operative accessory sheet
In passive position
Operative sheet does not interfere
the diagnostic phase (29mm)
In active positionAtraumatic cervical dilatation
up to 44 mm under visual control
Creating double flow and blocking
function in case of passive outflow
Introduction of 5 Fr instruments without
compromising inflow
A device made to harvest high quality samples from soft tissues
It is built on the pioneering concept of a cutting helix on a cutting
cannula well identified by Ultrasound
Spirotome acc to Gordts
Spirotome
The sample is harvested by turning the helix into the diseased area under
direct vision or ultrasound guidance The cannula turns subsequently over the
helix to free the sample from the surroundings
Spirotome myometrial biopsy
HSC post spirotome biopsy
Spirotome myometrial biopsy
Trophy Scope - Spirotome - US
Guide for ultrasound guided
Spirotome endomyometrial biopsy
cutting helixcutting cannula
Trophy Scope ndash Spirotome - Ultrasound
Exploration of JZ myometrium with Trophy hysteroscope
Resection intramural myoma
Resection adenomyoma
Resection adenomyoma
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Conventional hysteroscopic surgery
4 Laparoscopic surgery
Conventional Hysteroscopic Surgery
TYPE 0 TYPE 1 TYPE 2
The ESGE classificationof submucous myomas
Size volume = 43r3
bull2 cm ~ 42 cm3 8 min
bull3 cm ~ 141 cm3 28 min
bull4 cm ~ 335 cm3 67 min
Emanuel MH et al Fertil Steril 199768881-6
Operating time of critical importance
Reduction in volume of the fibroidsby GnRH-a therapy
Distension fluid
Monopolar surgery using non-ionic solutions
sa manitol sorbitol or glycine has higher risk of
side effects due to fluid overload effect
Stop surgery as soon as 1 L of fluid losses
Bipolar surgery using ionic solutions (saline)
Isotonic hyperhydration is less dangerous
In young patients up to 4 L of losses can be
accepted
Hysteroscopic Myomectomy
Always use a pressure and flow controlled pump system to work at minimal necessary pressure
Always perform continuous fluid balance independently of the medium used
Hysteroscopic Myomectomy
Operative Hysteroscopy Resectoscope Uni or Bipolar
Non ionic fluid
Unipolar polyp and myomaresection
Ionic fluid
First generation Bipolar (Versapoint)
Loop is smaller
chips are smaller
Longer OR time
Bipolar cautery induces
more bubbles
Bipolar resectoscope new generation
low-energy
Two or more small active electrodes very close to each other (active and return electrode)
bull Use Saline as distention medium
bull limited spread of electrical effect the current flow is essentially limited to a small area and it requires less voltage less risk for adhaesion formation
bull Loop different shape and size Different surgical
manoeuvres
bull Need of Modern generator
Bipolar resectoscope new generation
Storz bipolar resectoscope new generation
Return electrode opposite
side
Larger active electrode
Minimal gas bubbles
production
Less risk of perforation
Different surgical technique
Bipolar hysteroscopic myomectomy
Hysteroscopic Myomectomy
Long-term results depend on
bull Uterine Size (Plt0001)
bull Number of myomas (Plt0001)
The surgery-free percentage of 165 patients with normal sized uteri and not more than two
myomas was 943 (+- 18) at 2 years and 903 (+- 30) at 5 years
bull Type ( intra-mural part)
bull Size of myoma (significant increase of amount of particles between 2 and 3 cm)
Long-term results depend on the presence of concomitant pathology
or is a result of incomplete surgery
Emanuel MH Wamsteker K Obstet Gynecol 1999 May93743-8
Third Statement
1 Junctional Zone Myoma should preferentially be treated by hysteroscopy
2 Feasibility of hysteroscopic surgery is predominantly related with size location and amount of myoma
3 Independently of distension medium used continuous fluid balance and flow distension control is mandatory
4 Complication risk is related to experience and surgical technique used
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Conventional hysteroscopic surgery
4 Laparoscopic surgery
Introduction
Intramural myoma larger than 4 cm related to the JZ myometriumschould be operated on
Laparoscopic approach has had an important evolution over the
years
Series with high success rate are done by experts =gt it is difficult to extrapolate to less experienced surgeons
Laparoscopic myomectomy needs expert skills in haemostasis dissection and suturing
How to minimize blood loss
bullA lot of techniques in order to minimize blood loss
GnRH agonists
Intramyometrial vasopressine
Oxytocin IV 40 mUImin intraoperatively
Use of tourniquet or penrose at the lower part of uterus
Laparoscopic Myomectomy
J Ferro IVI Valencia Spain
Tips amp tricks ndash minimize blood loss
Clipping of the uterine arteries and infundilopelvic ligaments is another very efficient method
Artery ligation versus Control group (n=152)
173 +- 91 mL vs 402 +- 131 mL blood loss
62 vs 2075 reccurence rate
Alborzi S et al A comparison of combined laparoscopic uterine artery ligation and myomectomyversus laparoscopic myomectomy in the treatment of symptomatic myoma Fertil Steril 2009
Tips amp tricks ndash minimize blood loss
Technique Incision
Incision
J Ferro A Wattiez
Tips amp tricks- dissection
Tips amp tricks- closure
bull One versus multiples layers controversial
bull Adequate closure of the dead space to minimize the risk of hematoma formation
bull Interrupted figure of eight sutures are usually sufficient monocryl 1 or 0 with extracorporeal notes =gt extra strength
bull For the serosa approximate with interrupted 20 sutures if necessary (monofilament)
Tips amp tricks- closure
Removal Clips
Anti- adhesion agents
Fourth Statement
LAPAROSCOPIC MYOMECTOMY offers comparable results tolaparotomic myomectomy
Laparoscopic approach reduces adhesion formation blood loss and hospital stay
Laparoscopic myomectomy seems indicated in the infertile patient for the treatment of intramural myomarsquos
Laparoscopic Myomectomy requires a skilled laparoscopic surgeon with expert suturing skills optimal instrumental support and knowledge of some trickrsquos to provide an optimal result
Take Home message
Submucous myoma should always be removed prior to IVF
Hysteroscopic resection is the gold standard to treat those myoma
Intramural myoma originating from the sub endometrial
myometrium and larger than 4 cm are treated by Laproscopy
Subserosal myoma do not influence the outcome of IVF and are not removed for this indication
More info on the special training
programsin endoscopic
surgery
ESGEORG
More info on the ESGE website
wwwesgeorg
See you in London
Rudi Campo Stephan GordtsPatrick PuttemansRoger MolinasSylvie GordtsMarion Valkenburg Ivo Brosens
Leuven Institute for Fertility
amp Embryology
Trophy Scope a new generation
Interesting Characteristics
Gliding system that provides
Diagnostic ( 29 mm ) and
Operative (44 mm)
possibilities in one instrument
This hysteroscope has been named after the multicentre study
TROPHY ldquoTrial of Outpatient Hysteroscopyrdquo for which it was designed
El-Toukhy T Campo R et al Trial of Outpatient Hysteroscopy - [TROPHY] in IVF Reprod Health 2009 Dec 3620
LIFE vzw Leuven Institute for Fertility amp Embryology
MRI for diagnosis of Adenomyosis and Adenomyoma
Loss of differentiation JZ - OM
Normal
LIFE vzw Leuven Institute for Fertility amp Embryology
Enlarge the hysteroscopic diagnosis with
exploration of JZ myometrium
Trophy Hysteroscope acc to Campo
New generation of hysteroscope with interesting characteristics
named after the multicentre study TROPHY ldquoTrial of Outpatient
Hysteroscopyrdquo for which it was designedEl-Toukhy T Campo R et al Trial of Outpatient Hysteroscopy ndash (TROPHY) in IVF Reprod Health 2009 Dec 3620
Spirotome acc to Gordts
A device made to harvest high quality samples from soft tissues
built on the pioneering concept of a cutting helix on a cutting cannula
New Tools for exploration of the JZ myometrium
Trophy Scope 29 mm compactscope with Innovative gliding mechanism for accessory sheets
Can be loaded with accessory sheets which can be activated in case of necessity by gently push on the bottom and forward movement till locking in the active position supplementary functions are available without the need to remove the hysteroscope
Trophy Scope Diagnostic accessory sheet
In active positionAtraumatic cervical dilatation up to 37 mm under visual controlCreating double flowBlocking of cervix in case of passive outflow
In free positionSuction device for endometrial samplingGuide for ultrasound guided intrauterine procedures like positioning Embryo
transfer catheter or for Spirotome endomyometrial biopsy
active freepassive
Trophy Scope Operative accessory sheet
In passive position
Operative sheet does not interfere
the diagnostic phase (29mm)
In active positionAtraumatic cervical dilatation
up to 44 mm under visual control
Creating double flow and blocking
function in case of passive outflow
Introduction of 5 Fr instruments without
compromising inflow
A device made to harvest high quality samples from soft tissues
It is built on the pioneering concept of a cutting helix on a cutting
cannula well identified by Ultrasound
Spirotome acc to Gordts
Spirotome
The sample is harvested by turning the helix into the diseased area under
direct vision or ultrasound guidance The cannula turns subsequently over the
helix to free the sample from the surroundings
Spirotome myometrial biopsy
HSC post spirotome biopsy
Spirotome myometrial biopsy
Trophy Scope - Spirotome - US
Guide for ultrasound guided
Spirotome endomyometrial biopsy
cutting helixcutting cannula
Trophy Scope ndash Spirotome - Ultrasound
Exploration of JZ myometrium with Trophy hysteroscope
Resection intramural myoma
Resection adenomyoma
Resection adenomyoma
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Conventional hysteroscopic surgery
4 Laparoscopic surgery
Conventional Hysteroscopic Surgery
TYPE 0 TYPE 1 TYPE 2
The ESGE classificationof submucous myomas
Size volume = 43r3
bull2 cm ~ 42 cm3 8 min
bull3 cm ~ 141 cm3 28 min
bull4 cm ~ 335 cm3 67 min
Emanuel MH et al Fertil Steril 199768881-6
Operating time of critical importance
Reduction in volume of the fibroidsby GnRH-a therapy
Distension fluid
Monopolar surgery using non-ionic solutions
sa manitol sorbitol or glycine has higher risk of
side effects due to fluid overload effect
Stop surgery as soon as 1 L of fluid losses
Bipolar surgery using ionic solutions (saline)
Isotonic hyperhydration is less dangerous
In young patients up to 4 L of losses can be
accepted
Hysteroscopic Myomectomy
Always use a pressure and flow controlled pump system to work at minimal necessary pressure
Always perform continuous fluid balance independently of the medium used
Hysteroscopic Myomectomy
Operative Hysteroscopy Resectoscope Uni or Bipolar
Non ionic fluid
Unipolar polyp and myomaresection
Ionic fluid
First generation Bipolar (Versapoint)
Loop is smaller
chips are smaller
Longer OR time
Bipolar cautery induces
more bubbles
Bipolar resectoscope new generation
low-energy
Two or more small active electrodes very close to each other (active and return electrode)
bull Use Saline as distention medium
bull limited spread of electrical effect the current flow is essentially limited to a small area and it requires less voltage less risk for adhaesion formation
bull Loop different shape and size Different surgical
manoeuvres
bull Need of Modern generator
Bipolar resectoscope new generation
Storz bipolar resectoscope new generation
Return electrode opposite
side
Larger active electrode
Minimal gas bubbles
production
Less risk of perforation
Different surgical technique
Bipolar hysteroscopic myomectomy
Hysteroscopic Myomectomy
Long-term results depend on
bull Uterine Size (Plt0001)
bull Number of myomas (Plt0001)
The surgery-free percentage of 165 patients with normal sized uteri and not more than two
myomas was 943 (+- 18) at 2 years and 903 (+- 30) at 5 years
bull Type ( intra-mural part)
bull Size of myoma (significant increase of amount of particles between 2 and 3 cm)
Long-term results depend on the presence of concomitant pathology
or is a result of incomplete surgery
Emanuel MH Wamsteker K Obstet Gynecol 1999 May93743-8
Third Statement
1 Junctional Zone Myoma should preferentially be treated by hysteroscopy
2 Feasibility of hysteroscopic surgery is predominantly related with size location and amount of myoma
3 Independently of distension medium used continuous fluid balance and flow distension control is mandatory
4 Complication risk is related to experience and surgical technique used
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Conventional hysteroscopic surgery
4 Laparoscopic surgery
Introduction
Intramural myoma larger than 4 cm related to the JZ myometriumschould be operated on
Laparoscopic approach has had an important evolution over the
years
Series with high success rate are done by experts =gt it is difficult to extrapolate to less experienced surgeons
Laparoscopic myomectomy needs expert skills in haemostasis dissection and suturing
How to minimize blood loss
bullA lot of techniques in order to minimize blood loss
GnRH agonists
Intramyometrial vasopressine
Oxytocin IV 40 mUImin intraoperatively
Use of tourniquet or penrose at the lower part of uterus
Laparoscopic Myomectomy
J Ferro IVI Valencia Spain
Tips amp tricks ndash minimize blood loss
Clipping of the uterine arteries and infundilopelvic ligaments is another very efficient method
Artery ligation versus Control group (n=152)
173 +- 91 mL vs 402 +- 131 mL blood loss
62 vs 2075 reccurence rate
Alborzi S et al A comparison of combined laparoscopic uterine artery ligation and myomectomyversus laparoscopic myomectomy in the treatment of symptomatic myoma Fertil Steril 2009
Tips amp tricks ndash minimize blood loss
Technique Incision
Incision
J Ferro A Wattiez
Tips amp tricks- dissection
Tips amp tricks- closure
bull One versus multiples layers controversial
bull Adequate closure of the dead space to minimize the risk of hematoma formation
bull Interrupted figure of eight sutures are usually sufficient monocryl 1 or 0 with extracorporeal notes =gt extra strength
bull For the serosa approximate with interrupted 20 sutures if necessary (monofilament)
Tips amp tricks- closure
Removal Clips
Anti- adhesion agents
Fourth Statement
LAPAROSCOPIC MYOMECTOMY offers comparable results tolaparotomic myomectomy
Laparoscopic approach reduces adhesion formation blood loss and hospital stay
Laparoscopic myomectomy seems indicated in the infertile patient for the treatment of intramural myomarsquos
Laparoscopic Myomectomy requires a skilled laparoscopic surgeon with expert suturing skills optimal instrumental support and knowledge of some trickrsquos to provide an optimal result
Take Home message
Submucous myoma should always be removed prior to IVF
Hysteroscopic resection is the gold standard to treat those myoma
Intramural myoma originating from the sub endometrial
myometrium and larger than 4 cm are treated by Laproscopy
Subserosal myoma do not influence the outcome of IVF and are not removed for this indication
More info on the special training
programsin endoscopic
surgery
ESGEORG
More info on the ESGE website
wwwesgeorg
See you in London
Rudi Campo Stephan GordtsPatrick PuttemansRoger MolinasSylvie GordtsMarion Valkenburg Ivo Brosens
Leuven Institute for Fertility
amp Embryology
Trophy Scope a new generation
Interesting Characteristics
Gliding system that provides
Diagnostic ( 29 mm ) and
Operative (44 mm)
possibilities in one instrument
This hysteroscope has been named after the multicentre study
TROPHY ldquoTrial of Outpatient Hysteroscopyrdquo for which it was designed
El-Toukhy T Campo R et al Trial of Outpatient Hysteroscopy - [TROPHY] in IVF Reprod Health 2009 Dec 3620
LIFE vzw Leuven Institute for Fertility amp Embryology
Enlarge the hysteroscopic diagnosis with
exploration of JZ myometrium
Trophy Hysteroscope acc to Campo
New generation of hysteroscope with interesting characteristics
named after the multicentre study TROPHY ldquoTrial of Outpatient
Hysteroscopyrdquo for which it was designedEl-Toukhy T Campo R et al Trial of Outpatient Hysteroscopy ndash (TROPHY) in IVF Reprod Health 2009 Dec 3620
Spirotome acc to Gordts
A device made to harvest high quality samples from soft tissues
built on the pioneering concept of a cutting helix on a cutting cannula
New Tools for exploration of the JZ myometrium
Trophy Scope 29 mm compactscope with Innovative gliding mechanism for accessory sheets
Can be loaded with accessory sheets which can be activated in case of necessity by gently push on the bottom and forward movement till locking in the active position supplementary functions are available without the need to remove the hysteroscope
Trophy Scope Diagnostic accessory sheet
In active positionAtraumatic cervical dilatation up to 37 mm under visual controlCreating double flowBlocking of cervix in case of passive outflow
In free positionSuction device for endometrial samplingGuide for ultrasound guided intrauterine procedures like positioning Embryo
transfer catheter or for Spirotome endomyometrial biopsy
active freepassive
Trophy Scope Operative accessory sheet
In passive position
Operative sheet does not interfere
the diagnostic phase (29mm)
In active positionAtraumatic cervical dilatation
up to 44 mm under visual control
Creating double flow and blocking
function in case of passive outflow
Introduction of 5 Fr instruments without
compromising inflow
A device made to harvest high quality samples from soft tissues
It is built on the pioneering concept of a cutting helix on a cutting
cannula well identified by Ultrasound
Spirotome acc to Gordts
Spirotome
The sample is harvested by turning the helix into the diseased area under
direct vision or ultrasound guidance The cannula turns subsequently over the
helix to free the sample from the surroundings
Spirotome myometrial biopsy
HSC post spirotome biopsy
Spirotome myometrial biopsy
Trophy Scope - Spirotome - US
Guide for ultrasound guided
Spirotome endomyometrial biopsy
cutting helixcutting cannula
Trophy Scope ndash Spirotome - Ultrasound
Exploration of JZ myometrium with Trophy hysteroscope
Resection intramural myoma
Resection adenomyoma
Resection adenomyoma
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Conventional hysteroscopic surgery
4 Laparoscopic surgery
Conventional Hysteroscopic Surgery
TYPE 0 TYPE 1 TYPE 2
The ESGE classificationof submucous myomas
Size volume = 43r3
bull2 cm ~ 42 cm3 8 min
bull3 cm ~ 141 cm3 28 min
bull4 cm ~ 335 cm3 67 min
Emanuel MH et al Fertil Steril 199768881-6
Operating time of critical importance
Reduction in volume of the fibroidsby GnRH-a therapy
Distension fluid
Monopolar surgery using non-ionic solutions
sa manitol sorbitol or glycine has higher risk of
side effects due to fluid overload effect
Stop surgery as soon as 1 L of fluid losses
Bipolar surgery using ionic solutions (saline)
Isotonic hyperhydration is less dangerous
In young patients up to 4 L of losses can be
accepted
Hysteroscopic Myomectomy
Always use a pressure and flow controlled pump system to work at minimal necessary pressure
Always perform continuous fluid balance independently of the medium used
Hysteroscopic Myomectomy
Operative Hysteroscopy Resectoscope Uni or Bipolar
Non ionic fluid
Unipolar polyp and myomaresection
Ionic fluid
First generation Bipolar (Versapoint)
Loop is smaller
chips are smaller
Longer OR time
Bipolar cautery induces
more bubbles
Bipolar resectoscope new generation
low-energy
Two or more small active electrodes very close to each other (active and return electrode)
bull Use Saline as distention medium
bull limited spread of electrical effect the current flow is essentially limited to a small area and it requires less voltage less risk for adhaesion formation
bull Loop different shape and size Different surgical
manoeuvres
bull Need of Modern generator
Bipolar resectoscope new generation
Storz bipolar resectoscope new generation
Return electrode opposite
side
Larger active electrode
Minimal gas bubbles
production
Less risk of perforation
Different surgical technique
Bipolar hysteroscopic myomectomy
Hysteroscopic Myomectomy
Long-term results depend on
bull Uterine Size (Plt0001)
bull Number of myomas (Plt0001)
The surgery-free percentage of 165 patients with normal sized uteri and not more than two
myomas was 943 (+- 18) at 2 years and 903 (+- 30) at 5 years
bull Type ( intra-mural part)
bull Size of myoma (significant increase of amount of particles between 2 and 3 cm)
Long-term results depend on the presence of concomitant pathology
or is a result of incomplete surgery
Emanuel MH Wamsteker K Obstet Gynecol 1999 May93743-8
Third Statement
1 Junctional Zone Myoma should preferentially be treated by hysteroscopy
2 Feasibility of hysteroscopic surgery is predominantly related with size location and amount of myoma
3 Independently of distension medium used continuous fluid balance and flow distension control is mandatory
4 Complication risk is related to experience and surgical technique used
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Conventional hysteroscopic surgery
4 Laparoscopic surgery
Introduction
Intramural myoma larger than 4 cm related to the JZ myometriumschould be operated on
Laparoscopic approach has had an important evolution over the
years
Series with high success rate are done by experts =gt it is difficult to extrapolate to less experienced surgeons
Laparoscopic myomectomy needs expert skills in haemostasis dissection and suturing
How to minimize blood loss
bullA lot of techniques in order to minimize blood loss
GnRH agonists
Intramyometrial vasopressine
Oxytocin IV 40 mUImin intraoperatively
Use of tourniquet or penrose at the lower part of uterus
Laparoscopic Myomectomy
J Ferro IVI Valencia Spain
Tips amp tricks ndash minimize blood loss
Clipping of the uterine arteries and infundilopelvic ligaments is another very efficient method
Artery ligation versus Control group (n=152)
173 +- 91 mL vs 402 +- 131 mL blood loss
62 vs 2075 reccurence rate
Alborzi S et al A comparison of combined laparoscopic uterine artery ligation and myomectomyversus laparoscopic myomectomy in the treatment of symptomatic myoma Fertil Steril 2009
Tips amp tricks ndash minimize blood loss
Technique Incision
Incision
J Ferro A Wattiez
Tips amp tricks- dissection
Tips amp tricks- closure
bull One versus multiples layers controversial
bull Adequate closure of the dead space to minimize the risk of hematoma formation
bull Interrupted figure of eight sutures are usually sufficient monocryl 1 or 0 with extracorporeal notes =gt extra strength
bull For the serosa approximate with interrupted 20 sutures if necessary (monofilament)
Tips amp tricks- closure
Removal Clips
Anti- adhesion agents
Fourth Statement
LAPAROSCOPIC MYOMECTOMY offers comparable results tolaparotomic myomectomy
Laparoscopic approach reduces adhesion formation blood loss and hospital stay
Laparoscopic myomectomy seems indicated in the infertile patient for the treatment of intramural myomarsquos
Laparoscopic Myomectomy requires a skilled laparoscopic surgeon with expert suturing skills optimal instrumental support and knowledge of some trickrsquos to provide an optimal result
Take Home message
Submucous myoma should always be removed prior to IVF
Hysteroscopic resection is the gold standard to treat those myoma
Intramural myoma originating from the sub endometrial
myometrium and larger than 4 cm are treated by Laproscopy
Subserosal myoma do not influence the outcome of IVF and are not removed for this indication
More info on the special training
programsin endoscopic
surgery
ESGEORG
More info on the ESGE website
wwwesgeorg
See you in London
Rudi Campo Stephan GordtsPatrick PuttemansRoger MolinasSylvie GordtsMarion Valkenburg Ivo Brosens
Leuven Institute for Fertility
amp Embryology
Trophy Scope a new generation
Interesting Characteristics
Gliding system that provides
Diagnostic ( 29 mm ) and
Operative (44 mm)
possibilities in one instrument
This hysteroscope has been named after the multicentre study
TROPHY ldquoTrial of Outpatient Hysteroscopyrdquo for which it was designed
El-Toukhy T Campo R et al Trial of Outpatient Hysteroscopy - [TROPHY] in IVF Reprod Health 2009 Dec 3620
Trophy Hysteroscope acc to Campo
New generation of hysteroscope with interesting characteristics
named after the multicentre study TROPHY ldquoTrial of Outpatient
Hysteroscopyrdquo for which it was designedEl-Toukhy T Campo R et al Trial of Outpatient Hysteroscopy ndash (TROPHY) in IVF Reprod Health 2009 Dec 3620
Spirotome acc to Gordts
A device made to harvest high quality samples from soft tissues
built on the pioneering concept of a cutting helix on a cutting cannula
New Tools for exploration of the JZ myometrium
Trophy Scope 29 mm compactscope with Innovative gliding mechanism for accessory sheets
Can be loaded with accessory sheets which can be activated in case of necessity by gently push on the bottom and forward movement till locking in the active position supplementary functions are available without the need to remove the hysteroscope
Trophy Scope Diagnostic accessory sheet
In active positionAtraumatic cervical dilatation up to 37 mm under visual controlCreating double flowBlocking of cervix in case of passive outflow
In free positionSuction device for endometrial samplingGuide for ultrasound guided intrauterine procedures like positioning Embryo
transfer catheter or for Spirotome endomyometrial biopsy
active freepassive
Trophy Scope Operative accessory sheet
In passive position
Operative sheet does not interfere
the diagnostic phase (29mm)
In active positionAtraumatic cervical dilatation
up to 44 mm under visual control
Creating double flow and blocking
function in case of passive outflow
Introduction of 5 Fr instruments without
compromising inflow
A device made to harvest high quality samples from soft tissues
It is built on the pioneering concept of a cutting helix on a cutting
cannula well identified by Ultrasound
Spirotome acc to Gordts
Spirotome
The sample is harvested by turning the helix into the diseased area under
direct vision or ultrasound guidance The cannula turns subsequently over the
helix to free the sample from the surroundings
Spirotome myometrial biopsy
HSC post spirotome biopsy
Spirotome myometrial biopsy
Trophy Scope - Spirotome - US
Guide for ultrasound guided
Spirotome endomyometrial biopsy
cutting helixcutting cannula
Trophy Scope ndash Spirotome - Ultrasound
Exploration of JZ myometrium with Trophy hysteroscope
Resection intramural myoma
Resection adenomyoma
Resection adenomyoma
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Conventional hysteroscopic surgery
4 Laparoscopic surgery
Conventional Hysteroscopic Surgery
TYPE 0 TYPE 1 TYPE 2
The ESGE classificationof submucous myomas
Size volume = 43r3
bull2 cm ~ 42 cm3 8 min
bull3 cm ~ 141 cm3 28 min
bull4 cm ~ 335 cm3 67 min
Emanuel MH et al Fertil Steril 199768881-6
Operating time of critical importance
Reduction in volume of the fibroidsby GnRH-a therapy
Distension fluid
Monopolar surgery using non-ionic solutions
sa manitol sorbitol or glycine has higher risk of
side effects due to fluid overload effect
Stop surgery as soon as 1 L of fluid losses
Bipolar surgery using ionic solutions (saline)
Isotonic hyperhydration is less dangerous
In young patients up to 4 L of losses can be
accepted
Hysteroscopic Myomectomy
Always use a pressure and flow controlled pump system to work at minimal necessary pressure
Always perform continuous fluid balance independently of the medium used
Hysteroscopic Myomectomy
Operative Hysteroscopy Resectoscope Uni or Bipolar
Non ionic fluid
Unipolar polyp and myomaresection
Ionic fluid
First generation Bipolar (Versapoint)
Loop is smaller
chips are smaller
Longer OR time
Bipolar cautery induces
more bubbles
Bipolar resectoscope new generation
low-energy
Two or more small active electrodes very close to each other (active and return electrode)
bull Use Saline as distention medium
bull limited spread of electrical effect the current flow is essentially limited to a small area and it requires less voltage less risk for adhaesion formation
bull Loop different shape and size Different surgical
manoeuvres
bull Need of Modern generator
Bipolar resectoscope new generation
Storz bipolar resectoscope new generation
Return electrode opposite
side
Larger active electrode
Minimal gas bubbles
production
Less risk of perforation
Different surgical technique
Bipolar hysteroscopic myomectomy
Hysteroscopic Myomectomy
Long-term results depend on
bull Uterine Size (Plt0001)
bull Number of myomas (Plt0001)
The surgery-free percentage of 165 patients with normal sized uteri and not more than two
myomas was 943 (+- 18) at 2 years and 903 (+- 30) at 5 years
bull Type ( intra-mural part)
bull Size of myoma (significant increase of amount of particles between 2 and 3 cm)
Long-term results depend on the presence of concomitant pathology
or is a result of incomplete surgery
Emanuel MH Wamsteker K Obstet Gynecol 1999 May93743-8
Third Statement
1 Junctional Zone Myoma should preferentially be treated by hysteroscopy
2 Feasibility of hysteroscopic surgery is predominantly related with size location and amount of myoma
3 Independently of distension medium used continuous fluid balance and flow distension control is mandatory
4 Complication risk is related to experience and surgical technique used
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Conventional hysteroscopic surgery
4 Laparoscopic surgery
Introduction
Intramural myoma larger than 4 cm related to the JZ myometriumschould be operated on
Laparoscopic approach has had an important evolution over the
years
Series with high success rate are done by experts =gt it is difficult to extrapolate to less experienced surgeons
Laparoscopic myomectomy needs expert skills in haemostasis dissection and suturing
How to minimize blood loss
bullA lot of techniques in order to minimize blood loss
GnRH agonists
Intramyometrial vasopressine
Oxytocin IV 40 mUImin intraoperatively
Use of tourniquet or penrose at the lower part of uterus
Laparoscopic Myomectomy
J Ferro IVI Valencia Spain
Tips amp tricks ndash minimize blood loss
Clipping of the uterine arteries and infundilopelvic ligaments is another very efficient method
Artery ligation versus Control group (n=152)
173 +- 91 mL vs 402 +- 131 mL blood loss
62 vs 2075 reccurence rate
Alborzi S et al A comparison of combined laparoscopic uterine artery ligation and myomectomyversus laparoscopic myomectomy in the treatment of symptomatic myoma Fertil Steril 2009
Tips amp tricks ndash minimize blood loss
Technique Incision
Incision
J Ferro A Wattiez
Tips amp tricks- dissection
Tips amp tricks- closure
bull One versus multiples layers controversial
bull Adequate closure of the dead space to minimize the risk of hematoma formation
bull Interrupted figure of eight sutures are usually sufficient monocryl 1 or 0 with extracorporeal notes =gt extra strength
bull For the serosa approximate with interrupted 20 sutures if necessary (monofilament)
Tips amp tricks- closure
Removal Clips
Anti- adhesion agents
Fourth Statement
LAPAROSCOPIC MYOMECTOMY offers comparable results tolaparotomic myomectomy
Laparoscopic approach reduces adhesion formation blood loss and hospital stay
Laparoscopic myomectomy seems indicated in the infertile patient for the treatment of intramural myomarsquos
Laparoscopic Myomectomy requires a skilled laparoscopic surgeon with expert suturing skills optimal instrumental support and knowledge of some trickrsquos to provide an optimal result
Take Home message
Submucous myoma should always be removed prior to IVF
Hysteroscopic resection is the gold standard to treat those myoma
Intramural myoma originating from the sub endometrial
myometrium and larger than 4 cm are treated by Laproscopy
Subserosal myoma do not influence the outcome of IVF and are not removed for this indication
More info on the special training
programsin endoscopic
surgery
ESGEORG
More info on the ESGE website
wwwesgeorg
See you in London
Rudi Campo Stephan GordtsPatrick PuttemansRoger MolinasSylvie GordtsMarion Valkenburg Ivo Brosens
Leuven Institute for Fertility
amp Embryology
Trophy Scope a new generation
Interesting Characteristics
Gliding system that provides
Diagnostic ( 29 mm ) and
Operative (44 mm)
possibilities in one instrument
This hysteroscope has been named after the multicentre study
TROPHY ldquoTrial of Outpatient Hysteroscopyrdquo for which it was designed
El-Toukhy T Campo R et al Trial of Outpatient Hysteroscopy - [TROPHY] in IVF Reprod Health 2009 Dec 3620
Trophy Scope 29 mm compactscope with Innovative gliding mechanism for accessory sheets
Can be loaded with accessory sheets which can be activated in case of necessity by gently push on the bottom and forward movement till locking in the active position supplementary functions are available without the need to remove the hysteroscope
Trophy Scope Diagnostic accessory sheet
In active positionAtraumatic cervical dilatation up to 37 mm under visual controlCreating double flowBlocking of cervix in case of passive outflow
In free positionSuction device for endometrial samplingGuide for ultrasound guided intrauterine procedures like positioning Embryo
transfer catheter or for Spirotome endomyometrial biopsy
active freepassive
Trophy Scope Operative accessory sheet
In passive position
Operative sheet does not interfere
the diagnostic phase (29mm)
In active positionAtraumatic cervical dilatation
up to 44 mm under visual control
Creating double flow and blocking
function in case of passive outflow
Introduction of 5 Fr instruments without
compromising inflow
A device made to harvest high quality samples from soft tissues
It is built on the pioneering concept of a cutting helix on a cutting
cannula well identified by Ultrasound
Spirotome acc to Gordts
Spirotome
The sample is harvested by turning the helix into the diseased area under
direct vision or ultrasound guidance The cannula turns subsequently over the
helix to free the sample from the surroundings
Spirotome myometrial biopsy
HSC post spirotome biopsy
Spirotome myometrial biopsy
Trophy Scope - Spirotome - US
Guide for ultrasound guided
Spirotome endomyometrial biopsy
cutting helixcutting cannula
Trophy Scope ndash Spirotome - Ultrasound
Exploration of JZ myometrium with Trophy hysteroscope
Resection intramural myoma
Resection adenomyoma
Resection adenomyoma
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Conventional hysteroscopic surgery
4 Laparoscopic surgery
Conventional Hysteroscopic Surgery
TYPE 0 TYPE 1 TYPE 2
The ESGE classificationof submucous myomas
Size volume = 43r3
bull2 cm ~ 42 cm3 8 min
bull3 cm ~ 141 cm3 28 min
bull4 cm ~ 335 cm3 67 min
Emanuel MH et al Fertil Steril 199768881-6
Operating time of critical importance
Reduction in volume of the fibroidsby GnRH-a therapy
Distension fluid
Monopolar surgery using non-ionic solutions
sa manitol sorbitol or glycine has higher risk of
side effects due to fluid overload effect
Stop surgery as soon as 1 L of fluid losses
Bipolar surgery using ionic solutions (saline)
Isotonic hyperhydration is less dangerous
In young patients up to 4 L of losses can be
accepted
Hysteroscopic Myomectomy
Always use a pressure and flow controlled pump system to work at minimal necessary pressure
Always perform continuous fluid balance independently of the medium used
Hysteroscopic Myomectomy
Operative Hysteroscopy Resectoscope Uni or Bipolar
Non ionic fluid
Unipolar polyp and myomaresection
Ionic fluid
First generation Bipolar (Versapoint)
Loop is smaller
chips are smaller
Longer OR time
Bipolar cautery induces
more bubbles
Bipolar resectoscope new generation
low-energy
Two or more small active electrodes very close to each other (active and return electrode)
bull Use Saline as distention medium
bull limited spread of electrical effect the current flow is essentially limited to a small area and it requires less voltage less risk for adhaesion formation
bull Loop different shape and size Different surgical
manoeuvres
bull Need of Modern generator
Bipolar resectoscope new generation
Storz bipolar resectoscope new generation
Return electrode opposite
side
Larger active electrode
Minimal gas bubbles
production
Less risk of perforation
Different surgical technique
Bipolar hysteroscopic myomectomy
Hysteroscopic Myomectomy
Long-term results depend on
bull Uterine Size (Plt0001)
bull Number of myomas (Plt0001)
The surgery-free percentage of 165 patients with normal sized uteri and not more than two
myomas was 943 (+- 18) at 2 years and 903 (+- 30) at 5 years
bull Type ( intra-mural part)
bull Size of myoma (significant increase of amount of particles between 2 and 3 cm)
Long-term results depend on the presence of concomitant pathology
or is a result of incomplete surgery
Emanuel MH Wamsteker K Obstet Gynecol 1999 May93743-8
Third Statement
1 Junctional Zone Myoma should preferentially be treated by hysteroscopy
2 Feasibility of hysteroscopic surgery is predominantly related with size location and amount of myoma
3 Independently of distension medium used continuous fluid balance and flow distension control is mandatory
4 Complication risk is related to experience and surgical technique used
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Conventional hysteroscopic surgery
4 Laparoscopic surgery
Introduction
Intramural myoma larger than 4 cm related to the JZ myometriumschould be operated on
Laparoscopic approach has had an important evolution over the
years
Series with high success rate are done by experts =gt it is difficult to extrapolate to less experienced surgeons
Laparoscopic myomectomy needs expert skills in haemostasis dissection and suturing
How to minimize blood loss
bullA lot of techniques in order to minimize blood loss
GnRH agonists
Intramyometrial vasopressine
Oxytocin IV 40 mUImin intraoperatively
Use of tourniquet or penrose at the lower part of uterus
Laparoscopic Myomectomy
J Ferro IVI Valencia Spain
Tips amp tricks ndash minimize blood loss
Clipping of the uterine arteries and infundilopelvic ligaments is another very efficient method
Artery ligation versus Control group (n=152)
173 +- 91 mL vs 402 +- 131 mL blood loss
62 vs 2075 reccurence rate
Alborzi S et al A comparison of combined laparoscopic uterine artery ligation and myomectomyversus laparoscopic myomectomy in the treatment of symptomatic myoma Fertil Steril 2009
Tips amp tricks ndash minimize blood loss
Technique Incision
Incision
J Ferro A Wattiez
Tips amp tricks- dissection
Tips amp tricks- closure
bull One versus multiples layers controversial
bull Adequate closure of the dead space to minimize the risk of hematoma formation
bull Interrupted figure of eight sutures are usually sufficient monocryl 1 or 0 with extracorporeal notes =gt extra strength
bull For the serosa approximate with interrupted 20 sutures if necessary (monofilament)
Tips amp tricks- closure
Removal Clips
Anti- adhesion agents
Fourth Statement
LAPAROSCOPIC MYOMECTOMY offers comparable results tolaparotomic myomectomy
Laparoscopic approach reduces adhesion formation blood loss and hospital stay
Laparoscopic myomectomy seems indicated in the infertile patient for the treatment of intramural myomarsquos
Laparoscopic Myomectomy requires a skilled laparoscopic surgeon with expert suturing skills optimal instrumental support and knowledge of some trickrsquos to provide an optimal result
Take Home message
Submucous myoma should always be removed prior to IVF
Hysteroscopic resection is the gold standard to treat those myoma
Intramural myoma originating from the sub endometrial
myometrium and larger than 4 cm are treated by Laproscopy
Subserosal myoma do not influence the outcome of IVF and are not removed for this indication
More info on the special training
programsin endoscopic
surgery
ESGEORG
More info on the ESGE website
wwwesgeorg
See you in London
Rudi Campo Stephan GordtsPatrick PuttemansRoger MolinasSylvie GordtsMarion Valkenburg Ivo Brosens
Leuven Institute for Fertility
amp Embryology
Trophy Scope a new generation
Interesting Characteristics
Gliding system that provides
Diagnostic ( 29 mm ) and
Operative (44 mm)
possibilities in one instrument
This hysteroscope has been named after the multicentre study
TROPHY ldquoTrial of Outpatient Hysteroscopyrdquo for which it was designed
El-Toukhy T Campo R et al Trial of Outpatient Hysteroscopy - [TROPHY] in IVF Reprod Health 2009 Dec 3620
Trophy Scope Diagnostic accessory sheet
In active positionAtraumatic cervical dilatation up to 37 mm under visual controlCreating double flowBlocking of cervix in case of passive outflow
In free positionSuction device for endometrial samplingGuide for ultrasound guided intrauterine procedures like positioning Embryo
transfer catheter or for Spirotome endomyometrial biopsy
active freepassive
Trophy Scope Operative accessory sheet
In passive position
Operative sheet does not interfere
the diagnostic phase (29mm)
In active positionAtraumatic cervical dilatation
up to 44 mm under visual control
Creating double flow and blocking
function in case of passive outflow
Introduction of 5 Fr instruments without
compromising inflow
A device made to harvest high quality samples from soft tissues
It is built on the pioneering concept of a cutting helix on a cutting
cannula well identified by Ultrasound
Spirotome acc to Gordts
Spirotome
The sample is harvested by turning the helix into the diseased area under
direct vision or ultrasound guidance The cannula turns subsequently over the
helix to free the sample from the surroundings
Spirotome myometrial biopsy
HSC post spirotome biopsy
Spirotome myometrial biopsy
Trophy Scope - Spirotome - US
Guide for ultrasound guided
Spirotome endomyometrial biopsy
cutting helixcutting cannula
Trophy Scope ndash Spirotome - Ultrasound
Exploration of JZ myometrium with Trophy hysteroscope
Resection intramural myoma
Resection adenomyoma
Resection adenomyoma
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Conventional hysteroscopic surgery
4 Laparoscopic surgery
Conventional Hysteroscopic Surgery
TYPE 0 TYPE 1 TYPE 2
The ESGE classificationof submucous myomas
Size volume = 43r3
bull2 cm ~ 42 cm3 8 min
bull3 cm ~ 141 cm3 28 min
bull4 cm ~ 335 cm3 67 min
Emanuel MH et al Fertil Steril 199768881-6
Operating time of critical importance
Reduction in volume of the fibroidsby GnRH-a therapy
Distension fluid
Monopolar surgery using non-ionic solutions
sa manitol sorbitol or glycine has higher risk of
side effects due to fluid overload effect
Stop surgery as soon as 1 L of fluid losses
Bipolar surgery using ionic solutions (saline)
Isotonic hyperhydration is less dangerous
In young patients up to 4 L of losses can be
accepted
Hysteroscopic Myomectomy
Always use a pressure and flow controlled pump system to work at minimal necessary pressure
Always perform continuous fluid balance independently of the medium used
Hysteroscopic Myomectomy
Operative Hysteroscopy Resectoscope Uni or Bipolar
Non ionic fluid
Unipolar polyp and myomaresection
Ionic fluid
First generation Bipolar (Versapoint)
Loop is smaller
chips are smaller
Longer OR time
Bipolar cautery induces
more bubbles
Bipolar resectoscope new generation
low-energy
Two or more small active electrodes very close to each other (active and return electrode)
bull Use Saline as distention medium
bull limited spread of electrical effect the current flow is essentially limited to a small area and it requires less voltage less risk for adhaesion formation
bull Loop different shape and size Different surgical
manoeuvres
bull Need of Modern generator
Bipolar resectoscope new generation
Storz bipolar resectoscope new generation
Return electrode opposite
side
Larger active electrode
Minimal gas bubbles
production
Less risk of perforation
Different surgical technique
Bipolar hysteroscopic myomectomy
Hysteroscopic Myomectomy
Long-term results depend on
bull Uterine Size (Plt0001)
bull Number of myomas (Plt0001)
The surgery-free percentage of 165 patients with normal sized uteri and not more than two
myomas was 943 (+- 18) at 2 years and 903 (+- 30) at 5 years
bull Type ( intra-mural part)
bull Size of myoma (significant increase of amount of particles between 2 and 3 cm)
Long-term results depend on the presence of concomitant pathology
or is a result of incomplete surgery
Emanuel MH Wamsteker K Obstet Gynecol 1999 May93743-8
Third Statement
1 Junctional Zone Myoma should preferentially be treated by hysteroscopy
2 Feasibility of hysteroscopic surgery is predominantly related with size location and amount of myoma
3 Independently of distension medium used continuous fluid balance and flow distension control is mandatory
4 Complication risk is related to experience and surgical technique used
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Conventional hysteroscopic surgery
4 Laparoscopic surgery
Introduction
Intramural myoma larger than 4 cm related to the JZ myometriumschould be operated on
Laparoscopic approach has had an important evolution over the
years
Series with high success rate are done by experts =gt it is difficult to extrapolate to less experienced surgeons
Laparoscopic myomectomy needs expert skills in haemostasis dissection and suturing
How to minimize blood loss
bullA lot of techniques in order to minimize blood loss
GnRH agonists
Intramyometrial vasopressine
Oxytocin IV 40 mUImin intraoperatively
Use of tourniquet or penrose at the lower part of uterus
Laparoscopic Myomectomy
J Ferro IVI Valencia Spain
Tips amp tricks ndash minimize blood loss
Clipping of the uterine arteries and infundilopelvic ligaments is another very efficient method
Artery ligation versus Control group (n=152)
173 +- 91 mL vs 402 +- 131 mL blood loss
62 vs 2075 reccurence rate
Alborzi S et al A comparison of combined laparoscopic uterine artery ligation and myomectomyversus laparoscopic myomectomy in the treatment of symptomatic myoma Fertil Steril 2009
Tips amp tricks ndash minimize blood loss
Technique Incision
Incision
J Ferro A Wattiez
Tips amp tricks- dissection
Tips amp tricks- closure
bull One versus multiples layers controversial
bull Adequate closure of the dead space to minimize the risk of hematoma formation
bull Interrupted figure of eight sutures are usually sufficient monocryl 1 or 0 with extracorporeal notes =gt extra strength
bull For the serosa approximate with interrupted 20 sutures if necessary (monofilament)
Tips amp tricks- closure
Removal Clips
Anti- adhesion agents
Fourth Statement
LAPAROSCOPIC MYOMECTOMY offers comparable results tolaparotomic myomectomy
Laparoscopic approach reduces adhesion formation blood loss and hospital stay
Laparoscopic myomectomy seems indicated in the infertile patient for the treatment of intramural myomarsquos
Laparoscopic Myomectomy requires a skilled laparoscopic surgeon with expert suturing skills optimal instrumental support and knowledge of some trickrsquos to provide an optimal result
Take Home message
Submucous myoma should always be removed prior to IVF
Hysteroscopic resection is the gold standard to treat those myoma
Intramural myoma originating from the sub endometrial
myometrium and larger than 4 cm are treated by Laproscopy
Subserosal myoma do not influence the outcome of IVF and are not removed for this indication
More info on the special training
programsin endoscopic
surgery
ESGEORG
More info on the ESGE website
wwwesgeorg
See you in London
Rudi Campo Stephan GordtsPatrick PuttemansRoger MolinasSylvie GordtsMarion Valkenburg Ivo Brosens
Leuven Institute for Fertility
amp Embryology
Trophy Scope a new generation
Interesting Characteristics
Gliding system that provides
Diagnostic ( 29 mm ) and
Operative (44 mm)
possibilities in one instrument
This hysteroscope has been named after the multicentre study
TROPHY ldquoTrial of Outpatient Hysteroscopyrdquo for which it was designed
El-Toukhy T Campo R et al Trial of Outpatient Hysteroscopy - [TROPHY] in IVF Reprod Health 2009 Dec 3620
Trophy Scope Operative accessory sheet
In passive position
Operative sheet does not interfere
the diagnostic phase (29mm)
In active positionAtraumatic cervical dilatation
up to 44 mm under visual control
Creating double flow and blocking
function in case of passive outflow
Introduction of 5 Fr instruments without
compromising inflow
A device made to harvest high quality samples from soft tissues
It is built on the pioneering concept of a cutting helix on a cutting
cannula well identified by Ultrasound
Spirotome acc to Gordts
Spirotome
The sample is harvested by turning the helix into the diseased area under
direct vision or ultrasound guidance The cannula turns subsequently over the
helix to free the sample from the surroundings
Spirotome myometrial biopsy
HSC post spirotome biopsy
Spirotome myometrial biopsy
Trophy Scope - Spirotome - US
Guide for ultrasound guided
Spirotome endomyometrial biopsy
cutting helixcutting cannula
Trophy Scope ndash Spirotome - Ultrasound
Exploration of JZ myometrium with Trophy hysteroscope
Resection intramural myoma
Resection adenomyoma
Resection adenomyoma
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Conventional hysteroscopic surgery
4 Laparoscopic surgery
Conventional Hysteroscopic Surgery
TYPE 0 TYPE 1 TYPE 2
The ESGE classificationof submucous myomas
Size volume = 43r3
bull2 cm ~ 42 cm3 8 min
bull3 cm ~ 141 cm3 28 min
bull4 cm ~ 335 cm3 67 min
Emanuel MH et al Fertil Steril 199768881-6
Operating time of critical importance
Reduction in volume of the fibroidsby GnRH-a therapy
Distension fluid
Monopolar surgery using non-ionic solutions
sa manitol sorbitol or glycine has higher risk of
side effects due to fluid overload effect
Stop surgery as soon as 1 L of fluid losses
Bipolar surgery using ionic solutions (saline)
Isotonic hyperhydration is less dangerous
In young patients up to 4 L of losses can be
accepted
Hysteroscopic Myomectomy
Always use a pressure and flow controlled pump system to work at minimal necessary pressure
Always perform continuous fluid balance independently of the medium used
Hysteroscopic Myomectomy
Operative Hysteroscopy Resectoscope Uni or Bipolar
Non ionic fluid
Unipolar polyp and myomaresection
Ionic fluid
First generation Bipolar (Versapoint)
Loop is smaller
chips are smaller
Longer OR time
Bipolar cautery induces
more bubbles
Bipolar resectoscope new generation
low-energy
Two or more small active electrodes very close to each other (active and return electrode)
bull Use Saline as distention medium
bull limited spread of electrical effect the current flow is essentially limited to a small area and it requires less voltage less risk for adhaesion formation
bull Loop different shape and size Different surgical
manoeuvres
bull Need of Modern generator
Bipolar resectoscope new generation
Storz bipolar resectoscope new generation
Return electrode opposite
side
Larger active electrode
Minimal gas bubbles
production
Less risk of perforation
Different surgical technique
Bipolar hysteroscopic myomectomy
Hysteroscopic Myomectomy
Long-term results depend on
bull Uterine Size (Plt0001)
bull Number of myomas (Plt0001)
The surgery-free percentage of 165 patients with normal sized uteri and not more than two
myomas was 943 (+- 18) at 2 years and 903 (+- 30) at 5 years
bull Type ( intra-mural part)
bull Size of myoma (significant increase of amount of particles between 2 and 3 cm)
Long-term results depend on the presence of concomitant pathology
or is a result of incomplete surgery
Emanuel MH Wamsteker K Obstet Gynecol 1999 May93743-8
Third Statement
1 Junctional Zone Myoma should preferentially be treated by hysteroscopy
2 Feasibility of hysteroscopic surgery is predominantly related with size location and amount of myoma
3 Independently of distension medium used continuous fluid balance and flow distension control is mandatory
4 Complication risk is related to experience and surgical technique used
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Conventional hysteroscopic surgery
4 Laparoscopic surgery
Introduction
Intramural myoma larger than 4 cm related to the JZ myometriumschould be operated on
Laparoscopic approach has had an important evolution over the
years
Series with high success rate are done by experts =gt it is difficult to extrapolate to less experienced surgeons
Laparoscopic myomectomy needs expert skills in haemostasis dissection and suturing
How to minimize blood loss
bullA lot of techniques in order to minimize blood loss
GnRH agonists
Intramyometrial vasopressine
Oxytocin IV 40 mUImin intraoperatively
Use of tourniquet or penrose at the lower part of uterus
Laparoscopic Myomectomy
J Ferro IVI Valencia Spain
Tips amp tricks ndash minimize blood loss
Clipping of the uterine arteries and infundilopelvic ligaments is another very efficient method
Artery ligation versus Control group (n=152)
173 +- 91 mL vs 402 +- 131 mL blood loss
62 vs 2075 reccurence rate
Alborzi S et al A comparison of combined laparoscopic uterine artery ligation and myomectomyversus laparoscopic myomectomy in the treatment of symptomatic myoma Fertil Steril 2009
Tips amp tricks ndash minimize blood loss
Technique Incision
Incision
J Ferro A Wattiez
Tips amp tricks- dissection
Tips amp tricks- closure
bull One versus multiples layers controversial
bull Adequate closure of the dead space to minimize the risk of hematoma formation
bull Interrupted figure of eight sutures are usually sufficient monocryl 1 or 0 with extracorporeal notes =gt extra strength
bull For the serosa approximate with interrupted 20 sutures if necessary (monofilament)
Tips amp tricks- closure
Removal Clips
Anti- adhesion agents
Fourth Statement
LAPAROSCOPIC MYOMECTOMY offers comparable results tolaparotomic myomectomy
Laparoscopic approach reduces adhesion formation blood loss and hospital stay
Laparoscopic myomectomy seems indicated in the infertile patient for the treatment of intramural myomarsquos
Laparoscopic Myomectomy requires a skilled laparoscopic surgeon with expert suturing skills optimal instrumental support and knowledge of some trickrsquos to provide an optimal result
Take Home message
Submucous myoma should always be removed prior to IVF
Hysteroscopic resection is the gold standard to treat those myoma
Intramural myoma originating from the sub endometrial
myometrium and larger than 4 cm are treated by Laproscopy
Subserosal myoma do not influence the outcome of IVF and are not removed for this indication
More info on the special training
programsin endoscopic
surgery
ESGEORG
More info on the ESGE website
wwwesgeorg
See you in London
Rudi Campo Stephan GordtsPatrick PuttemansRoger MolinasSylvie GordtsMarion Valkenburg Ivo Brosens
Leuven Institute for Fertility
amp Embryology
Trophy Scope a new generation
Interesting Characteristics
Gliding system that provides
Diagnostic ( 29 mm ) and
Operative (44 mm)
possibilities in one instrument
This hysteroscope has been named after the multicentre study
TROPHY ldquoTrial of Outpatient Hysteroscopyrdquo for which it was designed
El-Toukhy T Campo R et al Trial of Outpatient Hysteroscopy - [TROPHY] in IVF Reprod Health 2009 Dec 3620
A device made to harvest high quality samples from soft tissues
It is built on the pioneering concept of a cutting helix on a cutting
cannula well identified by Ultrasound
Spirotome acc to Gordts
Spirotome
The sample is harvested by turning the helix into the diseased area under
direct vision or ultrasound guidance The cannula turns subsequently over the
helix to free the sample from the surroundings
Spirotome myometrial biopsy
HSC post spirotome biopsy
Spirotome myometrial biopsy
Trophy Scope - Spirotome - US
Guide for ultrasound guided
Spirotome endomyometrial biopsy
cutting helixcutting cannula
Trophy Scope ndash Spirotome - Ultrasound
Exploration of JZ myometrium with Trophy hysteroscope
Resection intramural myoma
Resection adenomyoma
Resection adenomyoma
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Conventional hysteroscopic surgery
4 Laparoscopic surgery
Conventional Hysteroscopic Surgery
TYPE 0 TYPE 1 TYPE 2
The ESGE classificationof submucous myomas
Size volume = 43r3
bull2 cm ~ 42 cm3 8 min
bull3 cm ~ 141 cm3 28 min
bull4 cm ~ 335 cm3 67 min
Emanuel MH et al Fertil Steril 199768881-6
Operating time of critical importance
Reduction in volume of the fibroidsby GnRH-a therapy
Distension fluid
Monopolar surgery using non-ionic solutions
sa manitol sorbitol or glycine has higher risk of
side effects due to fluid overload effect
Stop surgery as soon as 1 L of fluid losses
Bipolar surgery using ionic solutions (saline)
Isotonic hyperhydration is less dangerous
In young patients up to 4 L of losses can be
accepted
Hysteroscopic Myomectomy
Always use a pressure and flow controlled pump system to work at minimal necessary pressure
Always perform continuous fluid balance independently of the medium used
Hysteroscopic Myomectomy
Operative Hysteroscopy Resectoscope Uni or Bipolar
Non ionic fluid
Unipolar polyp and myomaresection
Ionic fluid
First generation Bipolar (Versapoint)
Loop is smaller
chips are smaller
Longer OR time
Bipolar cautery induces
more bubbles
Bipolar resectoscope new generation
low-energy
Two or more small active electrodes very close to each other (active and return electrode)
bull Use Saline as distention medium
bull limited spread of electrical effect the current flow is essentially limited to a small area and it requires less voltage less risk for adhaesion formation
bull Loop different shape and size Different surgical
manoeuvres
bull Need of Modern generator
Bipolar resectoscope new generation
Storz bipolar resectoscope new generation
Return electrode opposite
side
Larger active electrode
Minimal gas bubbles
production
Less risk of perforation
Different surgical technique
Bipolar hysteroscopic myomectomy
Hysteroscopic Myomectomy
Long-term results depend on
bull Uterine Size (Plt0001)
bull Number of myomas (Plt0001)
The surgery-free percentage of 165 patients with normal sized uteri and not more than two
myomas was 943 (+- 18) at 2 years and 903 (+- 30) at 5 years
bull Type ( intra-mural part)
bull Size of myoma (significant increase of amount of particles between 2 and 3 cm)
Long-term results depend on the presence of concomitant pathology
or is a result of incomplete surgery
Emanuel MH Wamsteker K Obstet Gynecol 1999 May93743-8
Third Statement
1 Junctional Zone Myoma should preferentially be treated by hysteroscopy
2 Feasibility of hysteroscopic surgery is predominantly related with size location and amount of myoma
3 Independently of distension medium used continuous fluid balance and flow distension control is mandatory
4 Complication risk is related to experience and surgical technique used
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Conventional hysteroscopic surgery
4 Laparoscopic surgery
Introduction
Intramural myoma larger than 4 cm related to the JZ myometriumschould be operated on
Laparoscopic approach has had an important evolution over the
years
Series with high success rate are done by experts =gt it is difficult to extrapolate to less experienced surgeons
Laparoscopic myomectomy needs expert skills in haemostasis dissection and suturing
How to minimize blood loss
bullA lot of techniques in order to minimize blood loss
GnRH agonists
Intramyometrial vasopressine
Oxytocin IV 40 mUImin intraoperatively
Use of tourniquet or penrose at the lower part of uterus
Laparoscopic Myomectomy
J Ferro IVI Valencia Spain
Tips amp tricks ndash minimize blood loss
Clipping of the uterine arteries and infundilopelvic ligaments is another very efficient method
Artery ligation versus Control group (n=152)
173 +- 91 mL vs 402 +- 131 mL blood loss
62 vs 2075 reccurence rate
Alborzi S et al A comparison of combined laparoscopic uterine artery ligation and myomectomyversus laparoscopic myomectomy in the treatment of symptomatic myoma Fertil Steril 2009
Tips amp tricks ndash minimize blood loss
Technique Incision
Incision
J Ferro A Wattiez
Tips amp tricks- dissection
Tips amp tricks- closure
bull One versus multiples layers controversial
bull Adequate closure of the dead space to minimize the risk of hematoma formation
bull Interrupted figure of eight sutures are usually sufficient monocryl 1 or 0 with extracorporeal notes =gt extra strength
bull For the serosa approximate with interrupted 20 sutures if necessary (monofilament)
Tips amp tricks- closure
Removal Clips
Anti- adhesion agents
Fourth Statement
LAPAROSCOPIC MYOMECTOMY offers comparable results tolaparotomic myomectomy
Laparoscopic approach reduces adhesion formation blood loss and hospital stay
Laparoscopic myomectomy seems indicated in the infertile patient for the treatment of intramural myomarsquos
Laparoscopic Myomectomy requires a skilled laparoscopic surgeon with expert suturing skills optimal instrumental support and knowledge of some trickrsquos to provide an optimal result
Take Home message
Submucous myoma should always be removed prior to IVF
Hysteroscopic resection is the gold standard to treat those myoma
Intramural myoma originating from the sub endometrial
myometrium and larger than 4 cm are treated by Laproscopy
Subserosal myoma do not influence the outcome of IVF and are not removed for this indication
More info on the special training
programsin endoscopic
surgery
ESGEORG
More info on the ESGE website
wwwesgeorg
See you in London
Rudi Campo Stephan GordtsPatrick PuttemansRoger MolinasSylvie GordtsMarion Valkenburg Ivo Brosens
Leuven Institute for Fertility
amp Embryology
Trophy Scope a new generation
Interesting Characteristics
Gliding system that provides
Diagnostic ( 29 mm ) and
Operative (44 mm)
possibilities in one instrument
This hysteroscope has been named after the multicentre study
TROPHY ldquoTrial of Outpatient Hysteroscopyrdquo for which it was designed
El-Toukhy T Campo R et al Trial of Outpatient Hysteroscopy - [TROPHY] in IVF Reprod Health 2009 Dec 3620
Spirotome
The sample is harvested by turning the helix into the diseased area under
direct vision or ultrasound guidance The cannula turns subsequently over the
helix to free the sample from the surroundings
Spirotome myometrial biopsy
HSC post spirotome biopsy
Spirotome myometrial biopsy
Trophy Scope - Spirotome - US
Guide for ultrasound guided
Spirotome endomyometrial biopsy
cutting helixcutting cannula
Trophy Scope ndash Spirotome - Ultrasound
Exploration of JZ myometrium with Trophy hysteroscope
Resection intramural myoma
Resection adenomyoma
Resection adenomyoma
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Conventional hysteroscopic surgery
4 Laparoscopic surgery
Conventional Hysteroscopic Surgery
TYPE 0 TYPE 1 TYPE 2
The ESGE classificationof submucous myomas
Size volume = 43r3
bull2 cm ~ 42 cm3 8 min
bull3 cm ~ 141 cm3 28 min
bull4 cm ~ 335 cm3 67 min
Emanuel MH et al Fertil Steril 199768881-6
Operating time of critical importance
Reduction in volume of the fibroidsby GnRH-a therapy
Distension fluid
Monopolar surgery using non-ionic solutions
sa manitol sorbitol or glycine has higher risk of
side effects due to fluid overload effect
Stop surgery as soon as 1 L of fluid losses
Bipolar surgery using ionic solutions (saline)
Isotonic hyperhydration is less dangerous
In young patients up to 4 L of losses can be
accepted
Hysteroscopic Myomectomy
Always use a pressure and flow controlled pump system to work at minimal necessary pressure
Always perform continuous fluid balance independently of the medium used
Hysteroscopic Myomectomy
Operative Hysteroscopy Resectoscope Uni or Bipolar
Non ionic fluid
Unipolar polyp and myomaresection
Ionic fluid
First generation Bipolar (Versapoint)
Loop is smaller
chips are smaller
Longer OR time
Bipolar cautery induces
more bubbles
Bipolar resectoscope new generation
low-energy
Two or more small active electrodes very close to each other (active and return electrode)
bull Use Saline as distention medium
bull limited spread of electrical effect the current flow is essentially limited to a small area and it requires less voltage less risk for adhaesion formation
bull Loop different shape and size Different surgical
manoeuvres
bull Need of Modern generator
Bipolar resectoscope new generation
Storz bipolar resectoscope new generation
Return electrode opposite
side
Larger active electrode
Minimal gas bubbles
production
Less risk of perforation
Different surgical technique
Bipolar hysteroscopic myomectomy
Hysteroscopic Myomectomy
Long-term results depend on
bull Uterine Size (Plt0001)
bull Number of myomas (Plt0001)
The surgery-free percentage of 165 patients with normal sized uteri and not more than two
myomas was 943 (+- 18) at 2 years and 903 (+- 30) at 5 years
bull Type ( intra-mural part)
bull Size of myoma (significant increase of amount of particles between 2 and 3 cm)
Long-term results depend on the presence of concomitant pathology
or is a result of incomplete surgery
Emanuel MH Wamsteker K Obstet Gynecol 1999 May93743-8
Third Statement
1 Junctional Zone Myoma should preferentially be treated by hysteroscopy
2 Feasibility of hysteroscopic surgery is predominantly related with size location and amount of myoma
3 Independently of distension medium used continuous fluid balance and flow distension control is mandatory
4 Complication risk is related to experience and surgical technique used
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Conventional hysteroscopic surgery
4 Laparoscopic surgery
Introduction
Intramural myoma larger than 4 cm related to the JZ myometriumschould be operated on
Laparoscopic approach has had an important evolution over the
years
Series with high success rate are done by experts =gt it is difficult to extrapolate to less experienced surgeons
Laparoscopic myomectomy needs expert skills in haemostasis dissection and suturing
How to minimize blood loss
bullA lot of techniques in order to minimize blood loss
GnRH agonists
Intramyometrial vasopressine
Oxytocin IV 40 mUImin intraoperatively
Use of tourniquet or penrose at the lower part of uterus
Laparoscopic Myomectomy
J Ferro IVI Valencia Spain
Tips amp tricks ndash minimize blood loss
Clipping of the uterine arteries and infundilopelvic ligaments is another very efficient method
Artery ligation versus Control group (n=152)
173 +- 91 mL vs 402 +- 131 mL blood loss
62 vs 2075 reccurence rate
Alborzi S et al A comparison of combined laparoscopic uterine artery ligation and myomectomyversus laparoscopic myomectomy in the treatment of symptomatic myoma Fertil Steril 2009
Tips amp tricks ndash minimize blood loss
Technique Incision
Incision
J Ferro A Wattiez
Tips amp tricks- dissection
Tips amp tricks- closure
bull One versus multiples layers controversial
bull Adequate closure of the dead space to minimize the risk of hematoma formation
bull Interrupted figure of eight sutures are usually sufficient monocryl 1 or 0 with extracorporeal notes =gt extra strength
bull For the serosa approximate with interrupted 20 sutures if necessary (monofilament)
Tips amp tricks- closure
Removal Clips
Anti- adhesion agents
Fourth Statement
LAPAROSCOPIC MYOMECTOMY offers comparable results tolaparotomic myomectomy
Laparoscopic approach reduces adhesion formation blood loss and hospital stay
Laparoscopic myomectomy seems indicated in the infertile patient for the treatment of intramural myomarsquos
Laparoscopic Myomectomy requires a skilled laparoscopic surgeon with expert suturing skills optimal instrumental support and knowledge of some trickrsquos to provide an optimal result
Take Home message
Submucous myoma should always be removed prior to IVF
Hysteroscopic resection is the gold standard to treat those myoma
Intramural myoma originating from the sub endometrial
myometrium and larger than 4 cm are treated by Laproscopy
Subserosal myoma do not influence the outcome of IVF and are not removed for this indication
More info on the special training
programsin endoscopic
surgery
ESGEORG
More info on the ESGE website
wwwesgeorg
See you in London
Rudi Campo Stephan GordtsPatrick PuttemansRoger MolinasSylvie GordtsMarion Valkenburg Ivo Brosens
Leuven Institute for Fertility
amp Embryology
Trophy Scope a new generation
Interesting Characteristics
Gliding system that provides
Diagnostic ( 29 mm ) and
Operative (44 mm)
possibilities in one instrument
This hysteroscope has been named after the multicentre study
TROPHY ldquoTrial of Outpatient Hysteroscopyrdquo for which it was designed
El-Toukhy T Campo R et al Trial of Outpatient Hysteroscopy - [TROPHY] in IVF Reprod Health 2009 Dec 3620
Spirotome myometrial biopsy
HSC post spirotome biopsy
Spirotome myometrial biopsy
Trophy Scope - Spirotome - US
Guide for ultrasound guided
Spirotome endomyometrial biopsy
cutting helixcutting cannula
Trophy Scope ndash Spirotome - Ultrasound
Exploration of JZ myometrium with Trophy hysteroscope
Resection intramural myoma
Resection adenomyoma
Resection adenomyoma
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Conventional hysteroscopic surgery
4 Laparoscopic surgery
Conventional Hysteroscopic Surgery
TYPE 0 TYPE 1 TYPE 2
The ESGE classificationof submucous myomas
Size volume = 43r3
bull2 cm ~ 42 cm3 8 min
bull3 cm ~ 141 cm3 28 min
bull4 cm ~ 335 cm3 67 min
Emanuel MH et al Fertil Steril 199768881-6
Operating time of critical importance
Reduction in volume of the fibroidsby GnRH-a therapy
Distension fluid
Monopolar surgery using non-ionic solutions
sa manitol sorbitol or glycine has higher risk of
side effects due to fluid overload effect
Stop surgery as soon as 1 L of fluid losses
Bipolar surgery using ionic solutions (saline)
Isotonic hyperhydration is less dangerous
In young patients up to 4 L of losses can be
accepted
Hysteroscopic Myomectomy
Always use a pressure and flow controlled pump system to work at minimal necessary pressure
Always perform continuous fluid balance independently of the medium used
Hysteroscopic Myomectomy
Operative Hysteroscopy Resectoscope Uni or Bipolar
Non ionic fluid
Unipolar polyp and myomaresection
Ionic fluid
First generation Bipolar (Versapoint)
Loop is smaller
chips are smaller
Longer OR time
Bipolar cautery induces
more bubbles
Bipolar resectoscope new generation
low-energy
Two or more small active electrodes very close to each other (active and return electrode)
bull Use Saline as distention medium
bull limited spread of electrical effect the current flow is essentially limited to a small area and it requires less voltage less risk for adhaesion formation
bull Loop different shape and size Different surgical
manoeuvres
bull Need of Modern generator
Bipolar resectoscope new generation
Storz bipolar resectoscope new generation
Return electrode opposite
side
Larger active electrode
Minimal gas bubbles
production
Less risk of perforation
Different surgical technique
Bipolar hysteroscopic myomectomy
Hysteroscopic Myomectomy
Long-term results depend on
bull Uterine Size (Plt0001)
bull Number of myomas (Plt0001)
The surgery-free percentage of 165 patients with normal sized uteri and not more than two
myomas was 943 (+- 18) at 2 years and 903 (+- 30) at 5 years
bull Type ( intra-mural part)
bull Size of myoma (significant increase of amount of particles between 2 and 3 cm)
Long-term results depend on the presence of concomitant pathology
or is a result of incomplete surgery
Emanuel MH Wamsteker K Obstet Gynecol 1999 May93743-8
Third Statement
1 Junctional Zone Myoma should preferentially be treated by hysteroscopy
2 Feasibility of hysteroscopic surgery is predominantly related with size location and amount of myoma
3 Independently of distension medium used continuous fluid balance and flow distension control is mandatory
4 Complication risk is related to experience and surgical technique used
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Conventional hysteroscopic surgery
4 Laparoscopic surgery
Introduction
Intramural myoma larger than 4 cm related to the JZ myometriumschould be operated on
Laparoscopic approach has had an important evolution over the
years
Series with high success rate are done by experts =gt it is difficult to extrapolate to less experienced surgeons
Laparoscopic myomectomy needs expert skills in haemostasis dissection and suturing
How to minimize blood loss
bullA lot of techniques in order to minimize blood loss
GnRH agonists
Intramyometrial vasopressine
Oxytocin IV 40 mUImin intraoperatively
Use of tourniquet or penrose at the lower part of uterus
Laparoscopic Myomectomy
J Ferro IVI Valencia Spain
Tips amp tricks ndash minimize blood loss
Clipping of the uterine arteries and infundilopelvic ligaments is another very efficient method
Artery ligation versus Control group (n=152)
173 +- 91 mL vs 402 +- 131 mL blood loss
62 vs 2075 reccurence rate
Alborzi S et al A comparison of combined laparoscopic uterine artery ligation and myomectomyversus laparoscopic myomectomy in the treatment of symptomatic myoma Fertil Steril 2009
Tips amp tricks ndash minimize blood loss
Technique Incision
Incision
J Ferro A Wattiez
Tips amp tricks- dissection
Tips amp tricks- closure
bull One versus multiples layers controversial
bull Adequate closure of the dead space to minimize the risk of hematoma formation
bull Interrupted figure of eight sutures are usually sufficient monocryl 1 or 0 with extracorporeal notes =gt extra strength
bull For the serosa approximate with interrupted 20 sutures if necessary (monofilament)
Tips amp tricks- closure
Removal Clips
Anti- adhesion agents
Fourth Statement
LAPAROSCOPIC MYOMECTOMY offers comparable results tolaparotomic myomectomy
Laparoscopic approach reduces adhesion formation blood loss and hospital stay
Laparoscopic myomectomy seems indicated in the infertile patient for the treatment of intramural myomarsquos
Laparoscopic Myomectomy requires a skilled laparoscopic surgeon with expert suturing skills optimal instrumental support and knowledge of some trickrsquos to provide an optimal result
Take Home message
Submucous myoma should always be removed prior to IVF
Hysteroscopic resection is the gold standard to treat those myoma
Intramural myoma originating from the sub endometrial
myometrium and larger than 4 cm are treated by Laproscopy
Subserosal myoma do not influence the outcome of IVF and are not removed for this indication
More info on the special training
programsin endoscopic
surgery
ESGEORG
More info on the ESGE website
wwwesgeorg
See you in London
Rudi Campo Stephan GordtsPatrick PuttemansRoger MolinasSylvie GordtsMarion Valkenburg Ivo Brosens
Leuven Institute for Fertility
amp Embryology
Trophy Scope a new generation
Interesting Characteristics
Gliding system that provides
Diagnostic ( 29 mm ) and
Operative (44 mm)
possibilities in one instrument
This hysteroscope has been named after the multicentre study
TROPHY ldquoTrial of Outpatient Hysteroscopyrdquo for which it was designed
El-Toukhy T Campo R et al Trial of Outpatient Hysteroscopy - [TROPHY] in IVF Reprod Health 2009 Dec 3620
HSC post spirotome biopsy
Spirotome myometrial biopsy
Trophy Scope - Spirotome - US
Guide for ultrasound guided
Spirotome endomyometrial biopsy
cutting helixcutting cannula
Trophy Scope ndash Spirotome - Ultrasound
Exploration of JZ myometrium with Trophy hysteroscope
Resection intramural myoma
Resection adenomyoma
Resection adenomyoma
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Conventional hysteroscopic surgery
4 Laparoscopic surgery
Conventional Hysteroscopic Surgery
TYPE 0 TYPE 1 TYPE 2
The ESGE classificationof submucous myomas
Size volume = 43r3
bull2 cm ~ 42 cm3 8 min
bull3 cm ~ 141 cm3 28 min
bull4 cm ~ 335 cm3 67 min
Emanuel MH et al Fertil Steril 199768881-6
Operating time of critical importance
Reduction in volume of the fibroidsby GnRH-a therapy
Distension fluid
Monopolar surgery using non-ionic solutions
sa manitol sorbitol or glycine has higher risk of
side effects due to fluid overload effect
Stop surgery as soon as 1 L of fluid losses
Bipolar surgery using ionic solutions (saline)
Isotonic hyperhydration is less dangerous
In young patients up to 4 L of losses can be
accepted
Hysteroscopic Myomectomy
Always use a pressure and flow controlled pump system to work at minimal necessary pressure
Always perform continuous fluid balance independently of the medium used
Hysteroscopic Myomectomy
Operative Hysteroscopy Resectoscope Uni or Bipolar
Non ionic fluid
Unipolar polyp and myomaresection
Ionic fluid
First generation Bipolar (Versapoint)
Loop is smaller
chips are smaller
Longer OR time
Bipolar cautery induces
more bubbles
Bipolar resectoscope new generation
low-energy
Two or more small active electrodes very close to each other (active and return electrode)
bull Use Saline as distention medium
bull limited spread of electrical effect the current flow is essentially limited to a small area and it requires less voltage less risk for adhaesion formation
bull Loop different shape and size Different surgical
manoeuvres
bull Need of Modern generator
Bipolar resectoscope new generation
Storz bipolar resectoscope new generation
Return electrode opposite
side
Larger active electrode
Minimal gas bubbles
production
Less risk of perforation
Different surgical technique
Bipolar hysteroscopic myomectomy
Hysteroscopic Myomectomy
Long-term results depend on
bull Uterine Size (Plt0001)
bull Number of myomas (Plt0001)
The surgery-free percentage of 165 patients with normal sized uteri and not more than two
myomas was 943 (+- 18) at 2 years and 903 (+- 30) at 5 years
bull Type ( intra-mural part)
bull Size of myoma (significant increase of amount of particles between 2 and 3 cm)
Long-term results depend on the presence of concomitant pathology
or is a result of incomplete surgery
Emanuel MH Wamsteker K Obstet Gynecol 1999 May93743-8
Third Statement
1 Junctional Zone Myoma should preferentially be treated by hysteroscopy
2 Feasibility of hysteroscopic surgery is predominantly related with size location and amount of myoma
3 Independently of distension medium used continuous fluid balance and flow distension control is mandatory
4 Complication risk is related to experience and surgical technique used
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Conventional hysteroscopic surgery
4 Laparoscopic surgery
Introduction
Intramural myoma larger than 4 cm related to the JZ myometriumschould be operated on
Laparoscopic approach has had an important evolution over the
years
Series with high success rate are done by experts =gt it is difficult to extrapolate to less experienced surgeons
Laparoscopic myomectomy needs expert skills in haemostasis dissection and suturing
How to minimize blood loss
bullA lot of techniques in order to minimize blood loss
GnRH agonists
Intramyometrial vasopressine
Oxytocin IV 40 mUImin intraoperatively
Use of tourniquet or penrose at the lower part of uterus
Laparoscopic Myomectomy
J Ferro IVI Valencia Spain
Tips amp tricks ndash minimize blood loss
Clipping of the uterine arteries and infundilopelvic ligaments is another very efficient method
Artery ligation versus Control group (n=152)
173 +- 91 mL vs 402 +- 131 mL blood loss
62 vs 2075 reccurence rate
Alborzi S et al A comparison of combined laparoscopic uterine artery ligation and myomectomyversus laparoscopic myomectomy in the treatment of symptomatic myoma Fertil Steril 2009
Tips amp tricks ndash minimize blood loss
Technique Incision
Incision
J Ferro A Wattiez
Tips amp tricks- dissection
Tips amp tricks- closure
bull One versus multiples layers controversial
bull Adequate closure of the dead space to minimize the risk of hematoma formation
bull Interrupted figure of eight sutures are usually sufficient monocryl 1 or 0 with extracorporeal notes =gt extra strength
bull For the serosa approximate with interrupted 20 sutures if necessary (monofilament)
Tips amp tricks- closure
Removal Clips
Anti- adhesion agents
Fourth Statement
LAPAROSCOPIC MYOMECTOMY offers comparable results tolaparotomic myomectomy
Laparoscopic approach reduces adhesion formation blood loss and hospital stay
Laparoscopic myomectomy seems indicated in the infertile patient for the treatment of intramural myomarsquos
Laparoscopic Myomectomy requires a skilled laparoscopic surgeon with expert suturing skills optimal instrumental support and knowledge of some trickrsquos to provide an optimal result
Take Home message
Submucous myoma should always be removed prior to IVF
Hysteroscopic resection is the gold standard to treat those myoma
Intramural myoma originating from the sub endometrial
myometrium and larger than 4 cm are treated by Laproscopy
Subserosal myoma do not influence the outcome of IVF and are not removed for this indication
More info on the special training
programsin endoscopic
surgery
ESGEORG
More info on the ESGE website
wwwesgeorg
See you in London
Rudi Campo Stephan GordtsPatrick PuttemansRoger MolinasSylvie GordtsMarion Valkenburg Ivo Brosens
Leuven Institute for Fertility
amp Embryology
Trophy Scope a new generation
Interesting Characteristics
Gliding system that provides
Diagnostic ( 29 mm ) and
Operative (44 mm)
possibilities in one instrument
This hysteroscope has been named after the multicentre study
TROPHY ldquoTrial of Outpatient Hysteroscopyrdquo for which it was designed
El-Toukhy T Campo R et al Trial of Outpatient Hysteroscopy - [TROPHY] in IVF Reprod Health 2009 Dec 3620
Spirotome myometrial biopsy
Trophy Scope - Spirotome - US
Guide for ultrasound guided
Spirotome endomyometrial biopsy
cutting helixcutting cannula
Trophy Scope ndash Spirotome - Ultrasound
Exploration of JZ myometrium with Trophy hysteroscope
Resection intramural myoma
Resection adenomyoma
Resection adenomyoma
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Conventional hysteroscopic surgery
4 Laparoscopic surgery
Conventional Hysteroscopic Surgery
TYPE 0 TYPE 1 TYPE 2
The ESGE classificationof submucous myomas
Size volume = 43r3
bull2 cm ~ 42 cm3 8 min
bull3 cm ~ 141 cm3 28 min
bull4 cm ~ 335 cm3 67 min
Emanuel MH et al Fertil Steril 199768881-6
Operating time of critical importance
Reduction in volume of the fibroidsby GnRH-a therapy
Distension fluid
Monopolar surgery using non-ionic solutions
sa manitol sorbitol or glycine has higher risk of
side effects due to fluid overload effect
Stop surgery as soon as 1 L of fluid losses
Bipolar surgery using ionic solutions (saline)
Isotonic hyperhydration is less dangerous
In young patients up to 4 L of losses can be
accepted
Hysteroscopic Myomectomy
Always use a pressure and flow controlled pump system to work at minimal necessary pressure
Always perform continuous fluid balance independently of the medium used
Hysteroscopic Myomectomy
Operative Hysteroscopy Resectoscope Uni or Bipolar
Non ionic fluid
Unipolar polyp and myomaresection
Ionic fluid
First generation Bipolar (Versapoint)
Loop is smaller
chips are smaller
Longer OR time
Bipolar cautery induces
more bubbles
Bipolar resectoscope new generation
low-energy
Two or more small active electrodes very close to each other (active and return electrode)
bull Use Saline as distention medium
bull limited spread of electrical effect the current flow is essentially limited to a small area and it requires less voltage less risk for adhaesion formation
bull Loop different shape and size Different surgical
manoeuvres
bull Need of Modern generator
Bipolar resectoscope new generation
Storz bipolar resectoscope new generation
Return electrode opposite
side
Larger active electrode
Minimal gas bubbles
production
Less risk of perforation
Different surgical technique
Bipolar hysteroscopic myomectomy
Hysteroscopic Myomectomy
Long-term results depend on
bull Uterine Size (Plt0001)
bull Number of myomas (Plt0001)
The surgery-free percentage of 165 patients with normal sized uteri and not more than two
myomas was 943 (+- 18) at 2 years and 903 (+- 30) at 5 years
bull Type ( intra-mural part)
bull Size of myoma (significant increase of amount of particles between 2 and 3 cm)
Long-term results depend on the presence of concomitant pathology
or is a result of incomplete surgery
Emanuel MH Wamsteker K Obstet Gynecol 1999 May93743-8
Third Statement
1 Junctional Zone Myoma should preferentially be treated by hysteroscopy
2 Feasibility of hysteroscopic surgery is predominantly related with size location and amount of myoma
3 Independently of distension medium used continuous fluid balance and flow distension control is mandatory
4 Complication risk is related to experience and surgical technique used
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Conventional hysteroscopic surgery
4 Laparoscopic surgery
Introduction
Intramural myoma larger than 4 cm related to the JZ myometriumschould be operated on
Laparoscopic approach has had an important evolution over the
years
Series with high success rate are done by experts =gt it is difficult to extrapolate to less experienced surgeons
Laparoscopic myomectomy needs expert skills in haemostasis dissection and suturing
How to minimize blood loss
bullA lot of techniques in order to minimize blood loss
GnRH agonists
Intramyometrial vasopressine
Oxytocin IV 40 mUImin intraoperatively
Use of tourniquet or penrose at the lower part of uterus
Laparoscopic Myomectomy
J Ferro IVI Valencia Spain
Tips amp tricks ndash minimize blood loss
Clipping of the uterine arteries and infundilopelvic ligaments is another very efficient method
Artery ligation versus Control group (n=152)
173 +- 91 mL vs 402 +- 131 mL blood loss
62 vs 2075 reccurence rate
Alborzi S et al A comparison of combined laparoscopic uterine artery ligation and myomectomyversus laparoscopic myomectomy in the treatment of symptomatic myoma Fertil Steril 2009
Tips amp tricks ndash minimize blood loss
Technique Incision
Incision
J Ferro A Wattiez
Tips amp tricks- dissection
Tips amp tricks- closure
bull One versus multiples layers controversial
bull Adequate closure of the dead space to minimize the risk of hematoma formation
bull Interrupted figure of eight sutures are usually sufficient monocryl 1 or 0 with extracorporeal notes =gt extra strength
bull For the serosa approximate with interrupted 20 sutures if necessary (monofilament)
Tips amp tricks- closure
Removal Clips
Anti- adhesion agents
Fourth Statement
LAPAROSCOPIC MYOMECTOMY offers comparable results tolaparotomic myomectomy
Laparoscopic approach reduces adhesion formation blood loss and hospital stay
Laparoscopic myomectomy seems indicated in the infertile patient for the treatment of intramural myomarsquos
Laparoscopic Myomectomy requires a skilled laparoscopic surgeon with expert suturing skills optimal instrumental support and knowledge of some trickrsquos to provide an optimal result
Take Home message
Submucous myoma should always be removed prior to IVF
Hysteroscopic resection is the gold standard to treat those myoma
Intramural myoma originating from the sub endometrial
myometrium and larger than 4 cm are treated by Laproscopy
Subserosal myoma do not influence the outcome of IVF and are not removed for this indication
More info on the special training
programsin endoscopic
surgery
ESGEORG
More info on the ESGE website
wwwesgeorg
See you in London
Rudi Campo Stephan GordtsPatrick PuttemansRoger MolinasSylvie GordtsMarion Valkenburg Ivo Brosens
Leuven Institute for Fertility
amp Embryology
Trophy Scope a new generation
Interesting Characteristics
Gliding system that provides
Diagnostic ( 29 mm ) and
Operative (44 mm)
possibilities in one instrument
This hysteroscope has been named after the multicentre study
TROPHY ldquoTrial of Outpatient Hysteroscopyrdquo for which it was designed
El-Toukhy T Campo R et al Trial of Outpatient Hysteroscopy - [TROPHY] in IVF Reprod Health 2009 Dec 3620
Trophy Scope - Spirotome - US
Guide for ultrasound guided
Spirotome endomyometrial biopsy
cutting helixcutting cannula
Trophy Scope ndash Spirotome - Ultrasound
Exploration of JZ myometrium with Trophy hysteroscope
Resection intramural myoma
Resection adenomyoma
Resection adenomyoma
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Conventional hysteroscopic surgery
4 Laparoscopic surgery
Conventional Hysteroscopic Surgery
TYPE 0 TYPE 1 TYPE 2
The ESGE classificationof submucous myomas
Size volume = 43r3
bull2 cm ~ 42 cm3 8 min
bull3 cm ~ 141 cm3 28 min
bull4 cm ~ 335 cm3 67 min
Emanuel MH et al Fertil Steril 199768881-6
Operating time of critical importance
Reduction in volume of the fibroidsby GnRH-a therapy
Distension fluid
Monopolar surgery using non-ionic solutions
sa manitol sorbitol or glycine has higher risk of
side effects due to fluid overload effect
Stop surgery as soon as 1 L of fluid losses
Bipolar surgery using ionic solutions (saline)
Isotonic hyperhydration is less dangerous
In young patients up to 4 L of losses can be
accepted
Hysteroscopic Myomectomy
Always use a pressure and flow controlled pump system to work at minimal necessary pressure
Always perform continuous fluid balance independently of the medium used
Hysteroscopic Myomectomy
Operative Hysteroscopy Resectoscope Uni or Bipolar
Non ionic fluid
Unipolar polyp and myomaresection
Ionic fluid
First generation Bipolar (Versapoint)
Loop is smaller
chips are smaller
Longer OR time
Bipolar cautery induces
more bubbles
Bipolar resectoscope new generation
low-energy
Two or more small active electrodes very close to each other (active and return electrode)
bull Use Saline as distention medium
bull limited spread of electrical effect the current flow is essentially limited to a small area and it requires less voltage less risk for adhaesion formation
bull Loop different shape and size Different surgical
manoeuvres
bull Need of Modern generator
Bipolar resectoscope new generation
Storz bipolar resectoscope new generation
Return electrode opposite
side
Larger active electrode
Minimal gas bubbles
production
Less risk of perforation
Different surgical technique
Bipolar hysteroscopic myomectomy
Hysteroscopic Myomectomy
Long-term results depend on
bull Uterine Size (Plt0001)
bull Number of myomas (Plt0001)
The surgery-free percentage of 165 patients with normal sized uteri and not more than two
myomas was 943 (+- 18) at 2 years and 903 (+- 30) at 5 years
bull Type ( intra-mural part)
bull Size of myoma (significant increase of amount of particles between 2 and 3 cm)
Long-term results depend on the presence of concomitant pathology
or is a result of incomplete surgery
Emanuel MH Wamsteker K Obstet Gynecol 1999 May93743-8
Third Statement
1 Junctional Zone Myoma should preferentially be treated by hysteroscopy
2 Feasibility of hysteroscopic surgery is predominantly related with size location and amount of myoma
3 Independently of distension medium used continuous fluid balance and flow distension control is mandatory
4 Complication risk is related to experience and surgical technique used
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Conventional hysteroscopic surgery
4 Laparoscopic surgery
Introduction
Intramural myoma larger than 4 cm related to the JZ myometriumschould be operated on
Laparoscopic approach has had an important evolution over the
years
Series with high success rate are done by experts =gt it is difficult to extrapolate to less experienced surgeons
Laparoscopic myomectomy needs expert skills in haemostasis dissection and suturing
How to minimize blood loss
bullA lot of techniques in order to minimize blood loss
GnRH agonists
Intramyometrial vasopressine
Oxytocin IV 40 mUImin intraoperatively
Use of tourniquet or penrose at the lower part of uterus
Laparoscopic Myomectomy
J Ferro IVI Valencia Spain
Tips amp tricks ndash minimize blood loss
Clipping of the uterine arteries and infundilopelvic ligaments is another very efficient method
Artery ligation versus Control group (n=152)
173 +- 91 mL vs 402 +- 131 mL blood loss
62 vs 2075 reccurence rate
Alborzi S et al A comparison of combined laparoscopic uterine artery ligation and myomectomyversus laparoscopic myomectomy in the treatment of symptomatic myoma Fertil Steril 2009
Tips amp tricks ndash minimize blood loss
Technique Incision
Incision
J Ferro A Wattiez
Tips amp tricks- dissection
Tips amp tricks- closure
bull One versus multiples layers controversial
bull Adequate closure of the dead space to minimize the risk of hematoma formation
bull Interrupted figure of eight sutures are usually sufficient monocryl 1 or 0 with extracorporeal notes =gt extra strength
bull For the serosa approximate with interrupted 20 sutures if necessary (monofilament)
Tips amp tricks- closure
Removal Clips
Anti- adhesion agents
Fourth Statement
LAPAROSCOPIC MYOMECTOMY offers comparable results tolaparotomic myomectomy
Laparoscopic approach reduces adhesion formation blood loss and hospital stay
Laparoscopic myomectomy seems indicated in the infertile patient for the treatment of intramural myomarsquos
Laparoscopic Myomectomy requires a skilled laparoscopic surgeon with expert suturing skills optimal instrumental support and knowledge of some trickrsquos to provide an optimal result
Take Home message
Submucous myoma should always be removed prior to IVF
Hysteroscopic resection is the gold standard to treat those myoma
Intramural myoma originating from the sub endometrial
myometrium and larger than 4 cm are treated by Laproscopy
Subserosal myoma do not influence the outcome of IVF and are not removed for this indication
More info on the special training
programsin endoscopic
surgery
ESGEORG
More info on the ESGE website
wwwesgeorg
See you in London
Rudi Campo Stephan GordtsPatrick PuttemansRoger MolinasSylvie GordtsMarion Valkenburg Ivo Brosens
Leuven Institute for Fertility
amp Embryology
Trophy Scope a new generation
Interesting Characteristics
Gliding system that provides
Diagnostic ( 29 mm ) and
Operative (44 mm)
possibilities in one instrument
This hysteroscope has been named after the multicentre study
TROPHY ldquoTrial of Outpatient Hysteroscopyrdquo for which it was designed
El-Toukhy T Campo R et al Trial of Outpatient Hysteroscopy - [TROPHY] in IVF Reprod Health 2009 Dec 3620
Trophy Scope ndash Spirotome - Ultrasound
Exploration of JZ myometrium with Trophy hysteroscope
Resection intramural myoma
Resection adenomyoma
Resection adenomyoma
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Conventional hysteroscopic surgery
4 Laparoscopic surgery
Conventional Hysteroscopic Surgery
TYPE 0 TYPE 1 TYPE 2
The ESGE classificationof submucous myomas
Size volume = 43r3
bull2 cm ~ 42 cm3 8 min
bull3 cm ~ 141 cm3 28 min
bull4 cm ~ 335 cm3 67 min
Emanuel MH et al Fertil Steril 199768881-6
Operating time of critical importance
Reduction in volume of the fibroidsby GnRH-a therapy
Distension fluid
Monopolar surgery using non-ionic solutions
sa manitol sorbitol or glycine has higher risk of
side effects due to fluid overload effect
Stop surgery as soon as 1 L of fluid losses
Bipolar surgery using ionic solutions (saline)
Isotonic hyperhydration is less dangerous
In young patients up to 4 L of losses can be
accepted
Hysteroscopic Myomectomy
Always use a pressure and flow controlled pump system to work at minimal necessary pressure
Always perform continuous fluid balance independently of the medium used
Hysteroscopic Myomectomy
Operative Hysteroscopy Resectoscope Uni or Bipolar
Non ionic fluid
Unipolar polyp and myomaresection
Ionic fluid
First generation Bipolar (Versapoint)
Loop is smaller
chips are smaller
Longer OR time
Bipolar cautery induces
more bubbles
Bipolar resectoscope new generation
low-energy
Two or more small active electrodes very close to each other (active and return electrode)
bull Use Saline as distention medium
bull limited spread of electrical effect the current flow is essentially limited to a small area and it requires less voltage less risk for adhaesion formation
bull Loop different shape and size Different surgical
manoeuvres
bull Need of Modern generator
Bipolar resectoscope new generation
Storz bipolar resectoscope new generation
Return electrode opposite
side
Larger active electrode
Minimal gas bubbles
production
Less risk of perforation
Different surgical technique
Bipolar hysteroscopic myomectomy
Hysteroscopic Myomectomy
Long-term results depend on
bull Uterine Size (Plt0001)
bull Number of myomas (Plt0001)
The surgery-free percentage of 165 patients with normal sized uteri and not more than two
myomas was 943 (+- 18) at 2 years and 903 (+- 30) at 5 years
bull Type ( intra-mural part)
bull Size of myoma (significant increase of amount of particles between 2 and 3 cm)
Long-term results depend on the presence of concomitant pathology
or is a result of incomplete surgery
Emanuel MH Wamsteker K Obstet Gynecol 1999 May93743-8
Third Statement
1 Junctional Zone Myoma should preferentially be treated by hysteroscopy
2 Feasibility of hysteroscopic surgery is predominantly related with size location and amount of myoma
3 Independently of distension medium used continuous fluid balance and flow distension control is mandatory
4 Complication risk is related to experience and surgical technique used
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Conventional hysteroscopic surgery
4 Laparoscopic surgery
Introduction
Intramural myoma larger than 4 cm related to the JZ myometriumschould be operated on
Laparoscopic approach has had an important evolution over the
years
Series with high success rate are done by experts =gt it is difficult to extrapolate to less experienced surgeons
Laparoscopic myomectomy needs expert skills in haemostasis dissection and suturing
How to minimize blood loss
bullA lot of techniques in order to minimize blood loss
GnRH agonists
Intramyometrial vasopressine
Oxytocin IV 40 mUImin intraoperatively
Use of tourniquet or penrose at the lower part of uterus
Laparoscopic Myomectomy
J Ferro IVI Valencia Spain
Tips amp tricks ndash minimize blood loss
Clipping of the uterine arteries and infundilopelvic ligaments is another very efficient method
Artery ligation versus Control group (n=152)
173 +- 91 mL vs 402 +- 131 mL blood loss
62 vs 2075 reccurence rate
Alborzi S et al A comparison of combined laparoscopic uterine artery ligation and myomectomyversus laparoscopic myomectomy in the treatment of symptomatic myoma Fertil Steril 2009
Tips amp tricks ndash minimize blood loss
Technique Incision
Incision
J Ferro A Wattiez
Tips amp tricks- dissection
Tips amp tricks- closure
bull One versus multiples layers controversial
bull Adequate closure of the dead space to minimize the risk of hematoma formation
bull Interrupted figure of eight sutures are usually sufficient monocryl 1 or 0 with extracorporeal notes =gt extra strength
bull For the serosa approximate with interrupted 20 sutures if necessary (monofilament)
Tips amp tricks- closure
Removal Clips
Anti- adhesion agents
Fourth Statement
LAPAROSCOPIC MYOMECTOMY offers comparable results tolaparotomic myomectomy
Laparoscopic approach reduces adhesion formation blood loss and hospital stay
Laparoscopic myomectomy seems indicated in the infertile patient for the treatment of intramural myomarsquos
Laparoscopic Myomectomy requires a skilled laparoscopic surgeon with expert suturing skills optimal instrumental support and knowledge of some trickrsquos to provide an optimal result
Take Home message
Submucous myoma should always be removed prior to IVF
Hysteroscopic resection is the gold standard to treat those myoma
Intramural myoma originating from the sub endometrial
myometrium and larger than 4 cm are treated by Laproscopy
Subserosal myoma do not influence the outcome of IVF and are not removed for this indication
More info on the special training
programsin endoscopic
surgery
ESGEORG
More info on the ESGE website
wwwesgeorg
See you in London
Rudi Campo Stephan GordtsPatrick PuttemansRoger MolinasSylvie GordtsMarion Valkenburg Ivo Brosens
Leuven Institute for Fertility
amp Embryology
Trophy Scope a new generation
Interesting Characteristics
Gliding system that provides
Diagnostic ( 29 mm ) and
Operative (44 mm)
possibilities in one instrument
This hysteroscope has been named after the multicentre study
TROPHY ldquoTrial of Outpatient Hysteroscopyrdquo for which it was designed
El-Toukhy T Campo R et al Trial of Outpatient Hysteroscopy - [TROPHY] in IVF Reprod Health 2009 Dec 3620
Exploration of JZ myometrium with Trophy hysteroscope
Resection intramural myoma
Resection adenomyoma
Resection adenomyoma
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Conventional hysteroscopic surgery
4 Laparoscopic surgery
Conventional Hysteroscopic Surgery
TYPE 0 TYPE 1 TYPE 2
The ESGE classificationof submucous myomas
Size volume = 43r3
bull2 cm ~ 42 cm3 8 min
bull3 cm ~ 141 cm3 28 min
bull4 cm ~ 335 cm3 67 min
Emanuel MH et al Fertil Steril 199768881-6
Operating time of critical importance
Reduction in volume of the fibroidsby GnRH-a therapy
Distension fluid
Monopolar surgery using non-ionic solutions
sa manitol sorbitol or glycine has higher risk of
side effects due to fluid overload effect
Stop surgery as soon as 1 L of fluid losses
Bipolar surgery using ionic solutions (saline)
Isotonic hyperhydration is less dangerous
In young patients up to 4 L of losses can be
accepted
Hysteroscopic Myomectomy
Always use a pressure and flow controlled pump system to work at minimal necessary pressure
Always perform continuous fluid balance independently of the medium used
Hysteroscopic Myomectomy
Operative Hysteroscopy Resectoscope Uni or Bipolar
Non ionic fluid
Unipolar polyp and myomaresection
Ionic fluid
First generation Bipolar (Versapoint)
Loop is smaller
chips are smaller
Longer OR time
Bipolar cautery induces
more bubbles
Bipolar resectoscope new generation
low-energy
Two or more small active electrodes very close to each other (active and return electrode)
bull Use Saline as distention medium
bull limited spread of electrical effect the current flow is essentially limited to a small area and it requires less voltage less risk for adhaesion formation
bull Loop different shape and size Different surgical
manoeuvres
bull Need of Modern generator
Bipolar resectoscope new generation
Storz bipolar resectoscope new generation
Return electrode opposite
side
Larger active electrode
Minimal gas bubbles
production
Less risk of perforation
Different surgical technique
Bipolar hysteroscopic myomectomy
Hysteroscopic Myomectomy
Long-term results depend on
bull Uterine Size (Plt0001)
bull Number of myomas (Plt0001)
The surgery-free percentage of 165 patients with normal sized uteri and not more than two
myomas was 943 (+- 18) at 2 years and 903 (+- 30) at 5 years
bull Type ( intra-mural part)
bull Size of myoma (significant increase of amount of particles between 2 and 3 cm)
Long-term results depend on the presence of concomitant pathology
or is a result of incomplete surgery
Emanuel MH Wamsteker K Obstet Gynecol 1999 May93743-8
Third Statement
1 Junctional Zone Myoma should preferentially be treated by hysteroscopy
2 Feasibility of hysteroscopic surgery is predominantly related with size location and amount of myoma
3 Independently of distension medium used continuous fluid balance and flow distension control is mandatory
4 Complication risk is related to experience and surgical technique used
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Conventional hysteroscopic surgery
4 Laparoscopic surgery
Introduction
Intramural myoma larger than 4 cm related to the JZ myometriumschould be operated on
Laparoscopic approach has had an important evolution over the
years
Series with high success rate are done by experts =gt it is difficult to extrapolate to less experienced surgeons
Laparoscopic myomectomy needs expert skills in haemostasis dissection and suturing
How to minimize blood loss
bullA lot of techniques in order to minimize blood loss
GnRH agonists
Intramyometrial vasopressine
Oxytocin IV 40 mUImin intraoperatively
Use of tourniquet or penrose at the lower part of uterus
Laparoscopic Myomectomy
J Ferro IVI Valencia Spain
Tips amp tricks ndash minimize blood loss
Clipping of the uterine arteries and infundilopelvic ligaments is another very efficient method
Artery ligation versus Control group (n=152)
173 +- 91 mL vs 402 +- 131 mL blood loss
62 vs 2075 reccurence rate
Alborzi S et al A comparison of combined laparoscopic uterine artery ligation and myomectomyversus laparoscopic myomectomy in the treatment of symptomatic myoma Fertil Steril 2009
Tips amp tricks ndash minimize blood loss
Technique Incision
Incision
J Ferro A Wattiez
Tips amp tricks- dissection
Tips amp tricks- closure
bull One versus multiples layers controversial
bull Adequate closure of the dead space to minimize the risk of hematoma formation
bull Interrupted figure of eight sutures are usually sufficient monocryl 1 or 0 with extracorporeal notes =gt extra strength
bull For the serosa approximate with interrupted 20 sutures if necessary (monofilament)
Tips amp tricks- closure
Removal Clips
Anti- adhesion agents
Fourth Statement
LAPAROSCOPIC MYOMECTOMY offers comparable results tolaparotomic myomectomy
Laparoscopic approach reduces adhesion formation blood loss and hospital stay
Laparoscopic myomectomy seems indicated in the infertile patient for the treatment of intramural myomarsquos
Laparoscopic Myomectomy requires a skilled laparoscopic surgeon with expert suturing skills optimal instrumental support and knowledge of some trickrsquos to provide an optimal result
Take Home message
Submucous myoma should always be removed prior to IVF
Hysteroscopic resection is the gold standard to treat those myoma
Intramural myoma originating from the sub endometrial
myometrium and larger than 4 cm are treated by Laproscopy
Subserosal myoma do not influence the outcome of IVF and are not removed for this indication
More info on the special training
programsin endoscopic
surgery
ESGEORG
More info on the ESGE website
wwwesgeorg
See you in London
Rudi Campo Stephan GordtsPatrick PuttemansRoger MolinasSylvie GordtsMarion Valkenburg Ivo Brosens
Leuven Institute for Fertility
amp Embryology
Trophy Scope a new generation
Interesting Characteristics
Gliding system that provides
Diagnostic ( 29 mm ) and
Operative (44 mm)
possibilities in one instrument
This hysteroscope has been named after the multicentre study
TROPHY ldquoTrial of Outpatient Hysteroscopyrdquo for which it was designed
El-Toukhy T Campo R et al Trial of Outpatient Hysteroscopy - [TROPHY] in IVF Reprod Health 2009 Dec 3620
Resection intramural myoma
Resection adenomyoma
Resection adenomyoma
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Conventional hysteroscopic surgery
4 Laparoscopic surgery
Conventional Hysteroscopic Surgery
TYPE 0 TYPE 1 TYPE 2
The ESGE classificationof submucous myomas
Size volume = 43r3
bull2 cm ~ 42 cm3 8 min
bull3 cm ~ 141 cm3 28 min
bull4 cm ~ 335 cm3 67 min
Emanuel MH et al Fertil Steril 199768881-6
Operating time of critical importance
Reduction in volume of the fibroidsby GnRH-a therapy
Distension fluid
Monopolar surgery using non-ionic solutions
sa manitol sorbitol or glycine has higher risk of
side effects due to fluid overload effect
Stop surgery as soon as 1 L of fluid losses
Bipolar surgery using ionic solutions (saline)
Isotonic hyperhydration is less dangerous
In young patients up to 4 L of losses can be
accepted
Hysteroscopic Myomectomy
Always use a pressure and flow controlled pump system to work at minimal necessary pressure
Always perform continuous fluid balance independently of the medium used
Hysteroscopic Myomectomy
Operative Hysteroscopy Resectoscope Uni or Bipolar
Non ionic fluid
Unipolar polyp and myomaresection
Ionic fluid
First generation Bipolar (Versapoint)
Loop is smaller
chips are smaller
Longer OR time
Bipolar cautery induces
more bubbles
Bipolar resectoscope new generation
low-energy
Two or more small active electrodes very close to each other (active and return electrode)
bull Use Saline as distention medium
bull limited spread of electrical effect the current flow is essentially limited to a small area and it requires less voltage less risk for adhaesion formation
bull Loop different shape and size Different surgical
manoeuvres
bull Need of Modern generator
Bipolar resectoscope new generation
Storz bipolar resectoscope new generation
Return electrode opposite
side
Larger active electrode
Minimal gas bubbles
production
Less risk of perforation
Different surgical technique
Bipolar hysteroscopic myomectomy
Hysteroscopic Myomectomy
Long-term results depend on
bull Uterine Size (Plt0001)
bull Number of myomas (Plt0001)
The surgery-free percentage of 165 patients with normal sized uteri and not more than two
myomas was 943 (+- 18) at 2 years and 903 (+- 30) at 5 years
bull Type ( intra-mural part)
bull Size of myoma (significant increase of amount of particles between 2 and 3 cm)
Long-term results depend on the presence of concomitant pathology
or is a result of incomplete surgery
Emanuel MH Wamsteker K Obstet Gynecol 1999 May93743-8
Third Statement
1 Junctional Zone Myoma should preferentially be treated by hysteroscopy
2 Feasibility of hysteroscopic surgery is predominantly related with size location and amount of myoma
3 Independently of distension medium used continuous fluid balance and flow distension control is mandatory
4 Complication risk is related to experience and surgical technique used
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Conventional hysteroscopic surgery
4 Laparoscopic surgery
Introduction
Intramural myoma larger than 4 cm related to the JZ myometriumschould be operated on
Laparoscopic approach has had an important evolution over the
years
Series with high success rate are done by experts =gt it is difficult to extrapolate to less experienced surgeons
Laparoscopic myomectomy needs expert skills in haemostasis dissection and suturing
How to minimize blood loss
bullA lot of techniques in order to minimize blood loss
GnRH agonists
Intramyometrial vasopressine
Oxytocin IV 40 mUImin intraoperatively
Use of tourniquet or penrose at the lower part of uterus
Laparoscopic Myomectomy
J Ferro IVI Valencia Spain
Tips amp tricks ndash minimize blood loss
Clipping of the uterine arteries and infundilopelvic ligaments is another very efficient method
Artery ligation versus Control group (n=152)
173 +- 91 mL vs 402 +- 131 mL blood loss
62 vs 2075 reccurence rate
Alborzi S et al A comparison of combined laparoscopic uterine artery ligation and myomectomyversus laparoscopic myomectomy in the treatment of symptomatic myoma Fertil Steril 2009
Tips amp tricks ndash minimize blood loss
Technique Incision
Incision
J Ferro A Wattiez
Tips amp tricks- dissection
Tips amp tricks- closure
bull One versus multiples layers controversial
bull Adequate closure of the dead space to minimize the risk of hematoma formation
bull Interrupted figure of eight sutures are usually sufficient monocryl 1 or 0 with extracorporeal notes =gt extra strength
bull For the serosa approximate with interrupted 20 sutures if necessary (monofilament)
Tips amp tricks- closure
Removal Clips
Anti- adhesion agents
Fourth Statement
LAPAROSCOPIC MYOMECTOMY offers comparable results tolaparotomic myomectomy
Laparoscopic approach reduces adhesion formation blood loss and hospital stay
Laparoscopic myomectomy seems indicated in the infertile patient for the treatment of intramural myomarsquos
Laparoscopic Myomectomy requires a skilled laparoscopic surgeon with expert suturing skills optimal instrumental support and knowledge of some trickrsquos to provide an optimal result
Take Home message
Submucous myoma should always be removed prior to IVF
Hysteroscopic resection is the gold standard to treat those myoma
Intramural myoma originating from the sub endometrial
myometrium and larger than 4 cm are treated by Laproscopy
Subserosal myoma do not influence the outcome of IVF and are not removed for this indication
More info on the special training
programsin endoscopic
surgery
ESGEORG
More info on the ESGE website
wwwesgeorg
See you in London
Rudi Campo Stephan GordtsPatrick PuttemansRoger MolinasSylvie GordtsMarion Valkenburg Ivo Brosens
Leuven Institute for Fertility
amp Embryology
Trophy Scope a new generation
Interesting Characteristics
Gliding system that provides
Diagnostic ( 29 mm ) and
Operative (44 mm)
possibilities in one instrument
This hysteroscope has been named after the multicentre study
TROPHY ldquoTrial of Outpatient Hysteroscopyrdquo for which it was designed
El-Toukhy T Campo R et al Trial of Outpatient Hysteroscopy - [TROPHY] in IVF Reprod Health 2009 Dec 3620
Resection adenomyoma
Resection adenomyoma
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Conventional hysteroscopic surgery
4 Laparoscopic surgery
Conventional Hysteroscopic Surgery
TYPE 0 TYPE 1 TYPE 2
The ESGE classificationof submucous myomas
Size volume = 43r3
bull2 cm ~ 42 cm3 8 min
bull3 cm ~ 141 cm3 28 min
bull4 cm ~ 335 cm3 67 min
Emanuel MH et al Fertil Steril 199768881-6
Operating time of critical importance
Reduction in volume of the fibroidsby GnRH-a therapy
Distension fluid
Monopolar surgery using non-ionic solutions
sa manitol sorbitol or glycine has higher risk of
side effects due to fluid overload effect
Stop surgery as soon as 1 L of fluid losses
Bipolar surgery using ionic solutions (saline)
Isotonic hyperhydration is less dangerous
In young patients up to 4 L of losses can be
accepted
Hysteroscopic Myomectomy
Always use a pressure and flow controlled pump system to work at minimal necessary pressure
Always perform continuous fluid balance independently of the medium used
Hysteroscopic Myomectomy
Operative Hysteroscopy Resectoscope Uni or Bipolar
Non ionic fluid
Unipolar polyp and myomaresection
Ionic fluid
First generation Bipolar (Versapoint)
Loop is smaller
chips are smaller
Longer OR time
Bipolar cautery induces
more bubbles
Bipolar resectoscope new generation
low-energy
Two or more small active electrodes very close to each other (active and return electrode)
bull Use Saline as distention medium
bull limited spread of electrical effect the current flow is essentially limited to a small area and it requires less voltage less risk for adhaesion formation
bull Loop different shape and size Different surgical
manoeuvres
bull Need of Modern generator
Bipolar resectoscope new generation
Storz bipolar resectoscope new generation
Return electrode opposite
side
Larger active electrode
Minimal gas bubbles
production
Less risk of perforation
Different surgical technique
Bipolar hysteroscopic myomectomy
Hysteroscopic Myomectomy
Long-term results depend on
bull Uterine Size (Plt0001)
bull Number of myomas (Plt0001)
The surgery-free percentage of 165 patients with normal sized uteri and not more than two
myomas was 943 (+- 18) at 2 years and 903 (+- 30) at 5 years
bull Type ( intra-mural part)
bull Size of myoma (significant increase of amount of particles between 2 and 3 cm)
Long-term results depend on the presence of concomitant pathology
or is a result of incomplete surgery
Emanuel MH Wamsteker K Obstet Gynecol 1999 May93743-8
Third Statement
1 Junctional Zone Myoma should preferentially be treated by hysteroscopy
2 Feasibility of hysteroscopic surgery is predominantly related with size location and amount of myoma
3 Independently of distension medium used continuous fluid balance and flow distension control is mandatory
4 Complication risk is related to experience and surgical technique used
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Conventional hysteroscopic surgery
4 Laparoscopic surgery
Introduction
Intramural myoma larger than 4 cm related to the JZ myometriumschould be operated on
Laparoscopic approach has had an important evolution over the
years
Series with high success rate are done by experts =gt it is difficult to extrapolate to less experienced surgeons
Laparoscopic myomectomy needs expert skills in haemostasis dissection and suturing
How to minimize blood loss
bullA lot of techniques in order to minimize blood loss
GnRH agonists
Intramyometrial vasopressine
Oxytocin IV 40 mUImin intraoperatively
Use of tourniquet or penrose at the lower part of uterus
Laparoscopic Myomectomy
J Ferro IVI Valencia Spain
Tips amp tricks ndash minimize blood loss
Clipping of the uterine arteries and infundilopelvic ligaments is another very efficient method
Artery ligation versus Control group (n=152)
173 +- 91 mL vs 402 +- 131 mL blood loss
62 vs 2075 reccurence rate
Alborzi S et al A comparison of combined laparoscopic uterine artery ligation and myomectomyversus laparoscopic myomectomy in the treatment of symptomatic myoma Fertil Steril 2009
Tips amp tricks ndash minimize blood loss
Technique Incision
Incision
J Ferro A Wattiez
Tips amp tricks- dissection
Tips amp tricks- closure
bull One versus multiples layers controversial
bull Adequate closure of the dead space to minimize the risk of hematoma formation
bull Interrupted figure of eight sutures are usually sufficient monocryl 1 or 0 with extracorporeal notes =gt extra strength
bull For the serosa approximate with interrupted 20 sutures if necessary (monofilament)
Tips amp tricks- closure
Removal Clips
Anti- adhesion agents
Fourth Statement
LAPAROSCOPIC MYOMECTOMY offers comparable results tolaparotomic myomectomy
Laparoscopic approach reduces adhesion formation blood loss and hospital stay
Laparoscopic myomectomy seems indicated in the infertile patient for the treatment of intramural myomarsquos
Laparoscopic Myomectomy requires a skilled laparoscopic surgeon with expert suturing skills optimal instrumental support and knowledge of some trickrsquos to provide an optimal result
Take Home message
Submucous myoma should always be removed prior to IVF
Hysteroscopic resection is the gold standard to treat those myoma
Intramural myoma originating from the sub endometrial
myometrium and larger than 4 cm are treated by Laproscopy
Subserosal myoma do not influence the outcome of IVF and are not removed for this indication
More info on the special training
programsin endoscopic
surgery
ESGEORG
More info on the ESGE website
wwwesgeorg
See you in London
Rudi Campo Stephan GordtsPatrick PuttemansRoger MolinasSylvie GordtsMarion Valkenburg Ivo Brosens
Leuven Institute for Fertility
amp Embryology
Trophy Scope a new generation
Interesting Characteristics
Gliding system that provides
Diagnostic ( 29 mm ) and
Operative (44 mm)
possibilities in one instrument
This hysteroscope has been named after the multicentre study
TROPHY ldquoTrial of Outpatient Hysteroscopyrdquo for which it was designed
El-Toukhy T Campo R et al Trial of Outpatient Hysteroscopy - [TROPHY] in IVF Reprod Health 2009 Dec 3620
Resection adenomyoma
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Conventional hysteroscopic surgery
4 Laparoscopic surgery
Conventional Hysteroscopic Surgery
TYPE 0 TYPE 1 TYPE 2
The ESGE classificationof submucous myomas
Size volume = 43r3
bull2 cm ~ 42 cm3 8 min
bull3 cm ~ 141 cm3 28 min
bull4 cm ~ 335 cm3 67 min
Emanuel MH et al Fertil Steril 199768881-6
Operating time of critical importance
Reduction in volume of the fibroidsby GnRH-a therapy
Distension fluid
Monopolar surgery using non-ionic solutions
sa manitol sorbitol or glycine has higher risk of
side effects due to fluid overload effect
Stop surgery as soon as 1 L of fluid losses
Bipolar surgery using ionic solutions (saline)
Isotonic hyperhydration is less dangerous
In young patients up to 4 L of losses can be
accepted
Hysteroscopic Myomectomy
Always use a pressure and flow controlled pump system to work at minimal necessary pressure
Always perform continuous fluid balance independently of the medium used
Hysteroscopic Myomectomy
Operative Hysteroscopy Resectoscope Uni or Bipolar
Non ionic fluid
Unipolar polyp and myomaresection
Ionic fluid
First generation Bipolar (Versapoint)
Loop is smaller
chips are smaller
Longer OR time
Bipolar cautery induces
more bubbles
Bipolar resectoscope new generation
low-energy
Two or more small active electrodes very close to each other (active and return electrode)
bull Use Saline as distention medium
bull limited spread of electrical effect the current flow is essentially limited to a small area and it requires less voltage less risk for adhaesion formation
bull Loop different shape and size Different surgical
manoeuvres
bull Need of Modern generator
Bipolar resectoscope new generation
Storz bipolar resectoscope new generation
Return electrode opposite
side
Larger active electrode
Minimal gas bubbles
production
Less risk of perforation
Different surgical technique
Bipolar hysteroscopic myomectomy
Hysteroscopic Myomectomy
Long-term results depend on
bull Uterine Size (Plt0001)
bull Number of myomas (Plt0001)
The surgery-free percentage of 165 patients with normal sized uteri and not more than two
myomas was 943 (+- 18) at 2 years and 903 (+- 30) at 5 years
bull Type ( intra-mural part)
bull Size of myoma (significant increase of amount of particles between 2 and 3 cm)
Long-term results depend on the presence of concomitant pathology
or is a result of incomplete surgery
Emanuel MH Wamsteker K Obstet Gynecol 1999 May93743-8
Third Statement
1 Junctional Zone Myoma should preferentially be treated by hysteroscopy
2 Feasibility of hysteroscopic surgery is predominantly related with size location and amount of myoma
3 Independently of distension medium used continuous fluid balance and flow distension control is mandatory
4 Complication risk is related to experience and surgical technique used
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Conventional hysteroscopic surgery
4 Laparoscopic surgery
Introduction
Intramural myoma larger than 4 cm related to the JZ myometriumschould be operated on
Laparoscopic approach has had an important evolution over the
years
Series with high success rate are done by experts =gt it is difficult to extrapolate to less experienced surgeons
Laparoscopic myomectomy needs expert skills in haemostasis dissection and suturing
How to minimize blood loss
bullA lot of techniques in order to minimize blood loss
GnRH agonists
Intramyometrial vasopressine
Oxytocin IV 40 mUImin intraoperatively
Use of tourniquet or penrose at the lower part of uterus
Laparoscopic Myomectomy
J Ferro IVI Valencia Spain
Tips amp tricks ndash minimize blood loss
Clipping of the uterine arteries and infundilopelvic ligaments is another very efficient method
Artery ligation versus Control group (n=152)
173 +- 91 mL vs 402 +- 131 mL blood loss
62 vs 2075 reccurence rate
Alborzi S et al A comparison of combined laparoscopic uterine artery ligation and myomectomyversus laparoscopic myomectomy in the treatment of symptomatic myoma Fertil Steril 2009
Tips amp tricks ndash minimize blood loss
Technique Incision
Incision
J Ferro A Wattiez
Tips amp tricks- dissection
Tips amp tricks- closure
bull One versus multiples layers controversial
bull Adequate closure of the dead space to minimize the risk of hematoma formation
bull Interrupted figure of eight sutures are usually sufficient monocryl 1 or 0 with extracorporeal notes =gt extra strength
bull For the serosa approximate with interrupted 20 sutures if necessary (monofilament)
Tips amp tricks- closure
Removal Clips
Anti- adhesion agents
Fourth Statement
LAPAROSCOPIC MYOMECTOMY offers comparable results tolaparotomic myomectomy
Laparoscopic approach reduces adhesion formation blood loss and hospital stay
Laparoscopic myomectomy seems indicated in the infertile patient for the treatment of intramural myomarsquos
Laparoscopic Myomectomy requires a skilled laparoscopic surgeon with expert suturing skills optimal instrumental support and knowledge of some trickrsquos to provide an optimal result
Take Home message
Submucous myoma should always be removed prior to IVF
Hysteroscopic resection is the gold standard to treat those myoma
Intramural myoma originating from the sub endometrial
myometrium and larger than 4 cm are treated by Laproscopy
Subserosal myoma do not influence the outcome of IVF and are not removed for this indication
More info on the special training
programsin endoscopic
surgery
ESGEORG
More info on the ESGE website
wwwesgeorg
See you in London
Rudi Campo Stephan GordtsPatrick PuttemansRoger MolinasSylvie GordtsMarion Valkenburg Ivo Brosens
Leuven Institute for Fertility
amp Embryology
Trophy Scope a new generation
Interesting Characteristics
Gliding system that provides
Diagnostic ( 29 mm ) and
Operative (44 mm)
possibilities in one instrument
This hysteroscope has been named after the multicentre study
TROPHY ldquoTrial of Outpatient Hysteroscopyrdquo for which it was designed
El-Toukhy T Campo R et al Trial of Outpatient Hysteroscopy - [TROPHY] in IVF Reprod Health 2009 Dec 3620
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Conventional hysteroscopic surgery
4 Laparoscopic surgery
Conventional Hysteroscopic Surgery
TYPE 0 TYPE 1 TYPE 2
The ESGE classificationof submucous myomas
Size volume = 43r3
bull2 cm ~ 42 cm3 8 min
bull3 cm ~ 141 cm3 28 min
bull4 cm ~ 335 cm3 67 min
Emanuel MH et al Fertil Steril 199768881-6
Operating time of critical importance
Reduction in volume of the fibroidsby GnRH-a therapy
Distension fluid
Monopolar surgery using non-ionic solutions
sa manitol sorbitol or glycine has higher risk of
side effects due to fluid overload effect
Stop surgery as soon as 1 L of fluid losses
Bipolar surgery using ionic solutions (saline)
Isotonic hyperhydration is less dangerous
In young patients up to 4 L of losses can be
accepted
Hysteroscopic Myomectomy
Always use a pressure and flow controlled pump system to work at minimal necessary pressure
Always perform continuous fluid balance independently of the medium used
Hysteroscopic Myomectomy
Operative Hysteroscopy Resectoscope Uni or Bipolar
Non ionic fluid
Unipolar polyp and myomaresection
Ionic fluid
First generation Bipolar (Versapoint)
Loop is smaller
chips are smaller
Longer OR time
Bipolar cautery induces
more bubbles
Bipolar resectoscope new generation
low-energy
Two or more small active electrodes very close to each other (active and return electrode)
bull Use Saline as distention medium
bull limited spread of electrical effect the current flow is essentially limited to a small area and it requires less voltage less risk for adhaesion formation
bull Loop different shape and size Different surgical
manoeuvres
bull Need of Modern generator
Bipolar resectoscope new generation
Storz bipolar resectoscope new generation
Return electrode opposite
side
Larger active electrode
Minimal gas bubbles
production
Less risk of perforation
Different surgical technique
Bipolar hysteroscopic myomectomy
Hysteroscopic Myomectomy
Long-term results depend on
bull Uterine Size (Plt0001)
bull Number of myomas (Plt0001)
The surgery-free percentage of 165 patients with normal sized uteri and not more than two
myomas was 943 (+- 18) at 2 years and 903 (+- 30) at 5 years
bull Type ( intra-mural part)
bull Size of myoma (significant increase of amount of particles between 2 and 3 cm)
Long-term results depend on the presence of concomitant pathology
or is a result of incomplete surgery
Emanuel MH Wamsteker K Obstet Gynecol 1999 May93743-8
Third Statement
1 Junctional Zone Myoma should preferentially be treated by hysteroscopy
2 Feasibility of hysteroscopic surgery is predominantly related with size location and amount of myoma
3 Independently of distension medium used continuous fluid balance and flow distension control is mandatory
4 Complication risk is related to experience and surgical technique used
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Conventional hysteroscopic surgery
4 Laparoscopic surgery
Introduction
Intramural myoma larger than 4 cm related to the JZ myometriumschould be operated on
Laparoscopic approach has had an important evolution over the
years
Series with high success rate are done by experts =gt it is difficult to extrapolate to less experienced surgeons
Laparoscopic myomectomy needs expert skills in haemostasis dissection and suturing
How to minimize blood loss
bullA lot of techniques in order to minimize blood loss
GnRH agonists
Intramyometrial vasopressine
Oxytocin IV 40 mUImin intraoperatively
Use of tourniquet or penrose at the lower part of uterus
Laparoscopic Myomectomy
J Ferro IVI Valencia Spain
Tips amp tricks ndash minimize blood loss
Clipping of the uterine arteries and infundilopelvic ligaments is another very efficient method
Artery ligation versus Control group (n=152)
173 +- 91 mL vs 402 +- 131 mL blood loss
62 vs 2075 reccurence rate
Alborzi S et al A comparison of combined laparoscopic uterine artery ligation and myomectomyversus laparoscopic myomectomy in the treatment of symptomatic myoma Fertil Steril 2009
Tips amp tricks ndash minimize blood loss
Technique Incision
Incision
J Ferro A Wattiez
Tips amp tricks- dissection
Tips amp tricks- closure
bull One versus multiples layers controversial
bull Adequate closure of the dead space to minimize the risk of hematoma formation
bull Interrupted figure of eight sutures are usually sufficient monocryl 1 or 0 with extracorporeal notes =gt extra strength
bull For the serosa approximate with interrupted 20 sutures if necessary (monofilament)
Tips amp tricks- closure
Removal Clips
Anti- adhesion agents
Fourth Statement
LAPAROSCOPIC MYOMECTOMY offers comparable results tolaparotomic myomectomy
Laparoscopic approach reduces adhesion formation blood loss and hospital stay
Laparoscopic myomectomy seems indicated in the infertile patient for the treatment of intramural myomarsquos
Laparoscopic Myomectomy requires a skilled laparoscopic surgeon with expert suturing skills optimal instrumental support and knowledge of some trickrsquos to provide an optimal result
Take Home message
Submucous myoma should always be removed prior to IVF
Hysteroscopic resection is the gold standard to treat those myoma
Intramural myoma originating from the sub endometrial
myometrium and larger than 4 cm are treated by Laproscopy
Subserosal myoma do not influence the outcome of IVF and are not removed for this indication
More info on the special training
programsin endoscopic
surgery
ESGEORG
More info on the ESGE website
wwwesgeorg
See you in London
Rudi Campo Stephan GordtsPatrick PuttemansRoger MolinasSylvie GordtsMarion Valkenburg Ivo Brosens
Leuven Institute for Fertility
amp Embryology
Trophy Scope a new generation
Interesting Characteristics
Gliding system that provides
Diagnostic ( 29 mm ) and
Operative (44 mm)
possibilities in one instrument
This hysteroscope has been named after the multicentre study
TROPHY ldquoTrial of Outpatient Hysteroscopyrdquo for which it was designed
El-Toukhy T Campo R et al Trial of Outpatient Hysteroscopy - [TROPHY] in IVF Reprod Health 2009 Dec 3620
Conventional Hysteroscopic Surgery
TYPE 0 TYPE 1 TYPE 2
The ESGE classificationof submucous myomas
Size volume = 43r3
bull2 cm ~ 42 cm3 8 min
bull3 cm ~ 141 cm3 28 min
bull4 cm ~ 335 cm3 67 min
Emanuel MH et al Fertil Steril 199768881-6
Operating time of critical importance
Reduction in volume of the fibroidsby GnRH-a therapy
Distension fluid
Monopolar surgery using non-ionic solutions
sa manitol sorbitol or glycine has higher risk of
side effects due to fluid overload effect
Stop surgery as soon as 1 L of fluid losses
Bipolar surgery using ionic solutions (saline)
Isotonic hyperhydration is less dangerous
In young patients up to 4 L of losses can be
accepted
Hysteroscopic Myomectomy
Always use a pressure and flow controlled pump system to work at minimal necessary pressure
Always perform continuous fluid balance independently of the medium used
Hysteroscopic Myomectomy
Operative Hysteroscopy Resectoscope Uni or Bipolar
Non ionic fluid
Unipolar polyp and myomaresection
Ionic fluid
First generation Bipolar (Versapoint)
Loop is smaller
chips are smaller
Longer OR time
Bipolar cautery induces
more bubbles
Bipolar resectoscope new generation
low-energy
Two or more small active electrodes very close to each other (active and return electrode)
bull Use Saline as distention medium
bull limited spread of electrical effect the current flow is essentially limited to a small area and it requires less voltage less risk for adhaesion formation
bull Loop different shape and size Different surgical
manoeuvres
bull Need of Modern generator
Bipolar resectoscope new generation
Storz bipolar resectoscope new generation
Return electrode opposite
side
Larger active electrode
Minimal gas bubbles
production
Less risk of perforation
Different surgical technique
Bipolar hysteroscopic myomectomy
Hysteroscopic Myomectomy
Long-term results depend on
bull Uterine Size (Plt0001)
bull Number of myomas (Plt0001)
The surgery-free percentage of 165 patients with normal sized uteri and not more than two
myomas was 943 (+- 18) at 2 years and 903 (+- 30) at 5 years
bull Type ( intra-mural part)
bull Size of myoma (significant increase of amount of particles between 2 and 3 cm)
Long-term results depend on the presence of concomitant pathology
or is a result of incomplete surgery
Emanuel MH Wamsteker K Obstet Gynecol 1999 May93743-8
Third Statement
1 Junctional Zone Myoma should preferentially be treated by hysteroscopy
2 Feasibility of hysteroscopic surgery is predominantly related with size location and amount of myoma
3 Independently of distension medium used continuous fluid balance and flow distension control is mandatory
4 Complication risk is related to experience and surgical technique used
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Conventional hysteroscopic surgery
4 Laparoscopic surgery
Introduction
Intramural myoma larger than 4 cm related to the JZ myometriumschould be operated on
Laparoscopic approach has had an important evolution over the
years
Series with high success rate are done by experts =gt it is difficult to extrapolate to less experienced surgeons
Laparoscopic myomectomy needs expert skills in haemostasis dissection and suturing
How to minimize blood loss
bullA lot of techniques in order to minimize blood loss
GnRH agonists
Intramyometrial vasopressine
Oxytocin IV 40 mUImin intraoperatively
Use of tourniquet or penrose at the lower part of uterus
Laparoscopic Myomectomy
J Ferro IVI Valencia Spain
Tips amp tricks ndash minimize blood loss
Clipping of the uterine arteries and infundilopelvic ligaments is another very efficient method
Artery ligation versus Control group (n=152)
173 +- 91 mL vs 402 +- 131 mL blood loss
62 vs 2075 reccurence rate
Alborzi S et al A comparison of combined laparoscopic uterine artery ligation and myomectomyversus laparoscopic myomectomy in the treatment of symptomatic myoma Fertil Steril 2009
Tips amp tricks ndash minimize blood loss
Technique Incision
Incision
J Ferro A Wattiez
Tips amp tricks- dissection
Tips amp tricks- closure
bull One versus multiples layers controversial
bull Adequate closure of the dead space to minimize the risk of hematoma formation
bull Interrupted figure of eight sutures are usually sufficient monocryl 1 or 0 with extracorporeal notes =gt extra strength
bull For the serosa approximate with interrupted 20 sutures if necessary (monofilament)
Tips amp tricks- closure
Removal Clips
Anti- adhesion agents
Fourth Statement
LAPAROSCOPIC MYOMECTOMY offers comparable results tolaparotomic myomectomy
Laparoscopic approach reduces adhesion formation blood loss and hospital stay
Laparoscopic myomectomy seems indicated in the infertile patient for the treatment of intramural myomarsquos
Laparoscopic Myomectomy requires a skilled laparoscopic surgeon with expert suturing skills optimal instrumental support and knowledge of some trickrsquos to provide an optimal result
Take Home message
Submucous myoma should always be removed prior to IVF
Hysteroscopic resection is the gold standard to treat those myoma
Intramural myoma originating from the sub endometrial
myometrium and larger than 4 cm are treated by Laproscopy
Subserosal myoma do not influence the outcome of IVF and are not removed for this indication
More info on the special training
programsin endoscopic
surgery
ESGEORG
More info on the ESGE website
wwwesgeorg
See you in London
Rudi Campo Stephan GordtsPatrick PuttemansRoger MolinasSylvie GordtsMarion Valkenburg Ivo Brosens
Leuven Institute for Fertility
amp Embryology
Trophy Scope a new generation
Interesting Characteristics
Gliding system that provides
Diagnostic ( 29 mm ) and
Operative (44 mm)
possibilities in one instrument
This hysteroscope has been named after the multicentre study
TROPHY ldquoTrial of Outpatient Hysteroscopyrdquo for which it was designed
El-Toukhy T Campo R et al Trial of Outpatient Hysteroscopy - [TROPHY] in IVF Reprod Health 2009 Dec 3620
TYPE 0 TYPE 1 TYPE 2
The ESGE classificationof submucous myomas
Size volume = 43r3
bull2 cm ~ 42 cm3 8 min
bull3 cm ~ 141 cm3 28 min
bull4 cm ~ 335 cm3 67 min
Emanuel MH et al Fertil Steril 199768881-6
Operating time of critical importance
Reduction in volume of the fibroidsby GnRH-a therapy
Distension fluid
Monopolar surgery using non-ionic solutions
sa manitol sorbitol or glycine has higher risk of
side effects due to fluid overload effect
Stop surgery as soon as 1 L of fluid losses
Bipolar surgery using ionic solutions (saline)
Isotonic hyperhydration is less dangerous
In young patients up to 4 L of losses can be
accepted
Hysteroscopic Myomectomy
Always use a pressure and flow controlled pump system to work at minimal necessary pressure
Always perform continuous fluid balance independently of the medium used
Hysteroscopic Myomectomy
Operative Hysteroscopy Resectoscope Uni or Bipolar
Non ionic fluid
Unipolar polyp and myomaresection
Ionic fluid
First generation Bipolar (Versapoint)
Loop is smaller
chips are smaller
Longer OR time
Bipolar cautery induces
more bubbles
Bipolar resectoscope new generation
low-energy
Two or more small active electrodes very close to each other (active and return electrode)
bull Use Saline as distention medium
bull limited spread of electrical effect the current flow is essentially limited to a small area and it requires less voltage less risk for adhaesion formation
bull Loop different shape and size Different surgical
manoeuvres
bull Need of Modern generator
Bipolar resectoscope new generation
Storz bipolar resectoscope new generation
Return electrode opposite
side
Larger active electrode
Minimal gas bubbles
production
Less risk of perforation
Different surgical technique
Bipolar hysteroscopic myomectomy
Hysteroscopic Myomectomy
Long-term results depend on
bull Uterine Size (Plt0001)
bull Number of myomas (Plt0001)
The surgery-free percentage of 165 patients with normal sized uteri and not more than two
myomas was 943 (+- 18) at 2 years and 903 (+- 30) at 5 years
bull Type ( intra-mural part)
bull Size of myoma (significant increase of amount of particles between 2 and 3 cm)
Long-term results depend on the presence of concomitant pathology
or is a result of incomplete surgery
Emanuel MH Wamsteker K Obstet Gynecol 1999 May93743-8
Third Statement
1 Junctional Zone Myoma should preferentially be treated by hysteroscopy
2 Feasibility of hysteroscopic surgery is predominantly related with size location and amount of myoma
3 Independently of distension medium used continuous fluid balance and flow distension control is mandatory
4 Complication risk is related to experience and surgical technique used
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Conventional hysteroscopic surgery
4 Laparoscopic surgery
Introduction
Intramural myoma larger than 4 cm related to the JZ myometriumschould be operated on
Laparoscopic approach has had an important evolution over the
years
Series with high success rate are done by experts =gt it is difficult to extrapolate to less experienced surgeons
Laparoscopic myomectomy needs expert skills in haemostasis dissection and suturing
How to minimize blood loss
bullA lot of techniques in order to minimize blood loss
GnRH agonists
Intramyometrial vasopressine
Oxytocin IV 40 mUImin intraoperatively
Use of tourniquet or penrose at the lower part of uterus
Laparoscopic Myomectomy
J Ferro IVI Valencia Spain
Tips amp tricks ndash minimize blood loss
Clipping of the uterine arteries and infundilopelvic ligaments is another very efficient method
Artery ligation versus Control group (n=152)
173 +- 91 mL vs 402 +- 131 mL blood loss
62 vs 2075 reccurence rate
Alborzi S et al A comparison of combined laparoscopic uterine artery ligation and myomectomyversus laparoscopic myomectomy in the treatment of symptomatic myoma Fertil Steril 2009
Tips amp tricks ndash minimize blood loss
Technique Incision
Incision
J Ferro A Wattiez
Tips amp tricks- dissection
Tips amp tricks- closure
bull One versus multiples layers controversial
bull Adequate closure of the dead space to minimize the risk of hematoma formation
bull Interrupted figure of eight sutures are usually sufficient monocryl 1 or 0 with extracorporeal notes =gt extra strength
bull For the serosa approximate with interrupted 20 sutures if necessary (monofilament)
Tips amp tricks- closure
Removal Clips
Anti- adhesion agents
Fourth Statement
LAPAROSCOPIC MYOMECTOMY offers comparable results tolaparotomic myomectomy
Laparoscopic approach reduces adhesion formation blood loss and hospital stay
Laparoscopic myomectomy seems indicated in the infertile patient for the treatment of intramural myomarsquos
Laparoscopic Myomectomy requires a skilled laparoscopic surgeon with expert suturing skills optimal instrumental support and knowledge of some trickrsquos to provide an optimal result
Take Home message
Submucous myoma should always be removed prior to IVF
Hysteroscopic resection is the gold standard to treat those myoma
Intramural myoma originating from the sub endometrial
myometrium and larger than 4 cm are treated by Laproscopy
Subserosal myoma do not influence the outcome of IVF and are not removed for this indication
More info on the special training
programsin endoscopic
surgery
ESGEORG
More info on the ESGE website
wwwesgeorg
See you in London
Rudi Campo Stephan GordtsPatrick PuttemansRoger MolinasSylvie GordtsMarion Valkenburg Ivo Brosens
Leuven Institute for Fertility
amp Embryology
Trophy Scope a new generation
Interesting Characteristics
Gliding system that provides
Diagnostic ( 29 mm ) and
Operative (44 mm)
possibilities in one instrument
This hysteroscope has been named after the multicentre study
TROPHY ldquoTrial of Outpatient Hysteroscopyrdquo for which it was designed
El-Toukhy T Campo R et al Trial of Outpatient Hysteroscopy - [TROPHY] in IVF Reprod Health 2009 Dec 3620
Size volume = 43r3
bull2 cm ~ 42 cm3 8 min
bull3 cm ~ 141 cm3 28 min
bull4 cm ~ 335 cm3 67 min
Emanuel MH et al Fertil Steril 199768881-6
Operating time of critical importance
Reduction in volume of the fibroidsby GnRH-a therapy
Distension fluid
Monopolar surgery using non-ionic solutions
sa manitol sorbitol or glycine has higher risk of
side effects due to fluid overload effect
Stop surgery as soon as 1 L of fluid losses
Bipolar surgery using ionic solutions (saline)
Isotonic hyperhydration is less dangerous
In young patients up to 4 L of losses can be
accepted
Hysteroscopic Myomectomy
Always use a pressure and flow controlled pump system to work at minimal necessary pressure
Always perform continuous fluid balance independently of the medium used
Hysteroscopic Myomectomy
Operative Hysteroscopy Resectoscope Uni or Bipolar
Non ionic fluid
Unipolar polyp and myomaresection
Ionic fluid
First generation Bipolar (Versapoint)
Loop is smaller
chips are smaller
Longer OR time
Bipolar cautery induces
more bubbles
Bipolar resectoscope new generation
low-energy
Two or more small active electrodes very close to each other (active and return electrode)
bull Use Saline as distention medium
bull limited spread of electrical effect the current flow is essentially limited to a small area and it requires less voltage less risk for adhaesion formation
bull Loop different shape and size Different surgical
manoeuvres
bull Need of Modern generator
Bipolar resectoscope new generation
Storz bipolar resectoscope new generation
Return electrode opposite
side
Larger active electrode
Minimal gas bubbles
production
Less risk of perforation
Different surgical technique
Bipolar hysteroscopic myomectomy
Hysteroscopic Myomectomy
Long-term results depend on
bull Uterine Size (Plt0001)
bull Number of myomas (Plt0001)
The surgery-free percentage of 165 patients with normal sized uteri and not more than two
myomas was 943 (+- 18) at 2 years and 903 (+- 30) at 5 years
bull Type ( intra-mural part)
bull Size of myoma (significant increase of amount of particles between 2 and 3 cm)
Long-term results depend on the presence of concomitant pathology
or is a result of incomplete surgery
Emanuel MH Wamsteker K Obstet Gynecol 1999 May93743-8
Third Statement
1 Junctional Zone Myoma should preferentially be treated by hysteroscopy
2 Feasibility of hysteroscopic surgery is predominantly related with size location and amount of myoma
3 Independently of distension medium used continuous fluid balance and flow distension control is mandatory
4 Complication risk is related to experience and surgical technique used
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Conventional hysteroscopic surgery
4 Laparoscopic surgery
Introduction
Intramural myoma larger than 4 cm related to the JZ myometriumschould be operated on
Laparoscopic approach has had an important evolution over the
years
Series with high success rate are done by experts =gt it is difficult to extrapolate to less experienced surgeons
Laparoscopic myomectomy needs expert skills in haemostasis dissection and suturing
How to minimize blood loss
bullA lot of techniques in order to minimize blood loss
GnRH agonists
Intramyometrial vasopressine
Oxytocin IV 40 mUImin intraoperatively
Use of tourniquet or penrose at the lower part of uterus
Laparoscopic Myomectomy
J Ferro IVI Valencia Spain
Tips amp tricks ndash minimize blood loss
Clipping of the uterine arteries and infundilopelvic ligaments is another very efficient method
Artery ligation versus Control group (n=152)
173 +- 91 mL vs 402 +- 131 mL blood loss
62 vs 2075 reccurence rate
Alborzi S et al A comparison of combined laparoscopic uterine artery ligation and myomectomyversus laparoscopic myomectomy in the treatment of symptomatic myoma Fertil Steril 2009
Tips amp tricks ndash minimize blood loss
Technique Incision
Incision
J Ferro A Wattiez
Tips amp tricks- dissection
Tips amp tricks- closure
bull One versus multiples layers controversial
bull Adequate closure of the dead space to minimize the risk of hematoma formation
bull Interrupted figure of eight sutures are usually sufficient monocryl 1 or 0 with extracorporeal notes =gt extra strength
bull For the serosa approximate with interrupted 20 sutures if necessary (monofilament)
Tips amp tricks- closure
Removal Clips
Anti- adhesion agents
Fourth Statement
LAPAROSCOPIC MYOMECTOMY offers comparable results tolaparotomic myomectomy
Laparoscopic approach reduces adhesion formation blood loss and hospital stay
Laparoscopic myomectomy seems indicated in the infertile patient for the treatment of intramural myomarsquos
Laparoscopic Myomectomy requires a skilled laparoscopic surgeon with expert suturing skills optimal instrumental support and knowledge of some trickrsquos to provide an optimal result
Take Home message
Submucous myoma should always be removed prior to IVF
Hysteroscopic resection is the gold standard to treat those myoma
Intramural myoma originating from the sub endometrial
myometrium and larger than 4 cm are treated by Laproscopy
Subserosal myoma do not influence the outcome of IVF and are not removed for this indication
More info on the special training
programsin endoscopic
surgery
ESGEORG
More info on the ESGE website
wwwesgeorg
See you in London
Rudi Campo Stephan GordtsPatrick PuttemansRoger MolinasSylvie GordtsMarion Valkenburg Ivo Brosens
Leuven Institute for Fertility
amp Embryology
Trophy Scope a new generation
Interesting Characteristics
Gliding system that provides
Diagnostic ( 29 mm ) and
Operative (44 mm)
possibilities in one instrument
This hysteroscope has been named after the multicentre study
TROPHY ldquoTrial of Outpatient Hysteroscopyrdquo for which it was designed
El-Toukhy T Campo R et al Trial of Outpatient Hysteroscopy - [TROPHY] in IVF Reprod Health 2009 Dec 3620
Reduction in volume of the fibroidsby GnRH-a therapy
Distension fluid
Monopolar surgery using non-ionic solutions
sa manitol sorbitol or glycine has higher risk of
side effects due to fluid overload effect
Stop surgery as soon as 1 L of fluid losses
Bipolar surgery using ionic solutions (saline)
Isotonic hyperhydration is less dangerous
In young patients up to 4 L of losses can be
accepted
Hysteroscopic Myomectomy
Always use a pressure and flow controlled pump system to work at minimal necessary pressure
Always perform continuous fluid balance independently of the medium used
Hysteroscopic Myomectomy
Operative Hysteroscopy Resectoscope Uni or Bipolar
Non ionic fluid
Unipolar polyp and myomaresection
Ionic fluid
First generation Bipolar (Versapoint)
Loop is smaller
chips are smaller
Longer OR time
Bipolar cautery induces
more bubbles
Bipolar resectoscope new generation
low-energy
Two or more small active electrodes very close to each other (active and return electrode)
bull Use Saline as distention medium
bull limited spread of electrical effect the current flow is essentially limited to a small area and it requires less voltage less risk for adhaesion formation
bull Loop different shape and size Different surgical
manoeuvres
bull Need of Modern generator
Bipolar resectoscope new generation
Storz bipolar resectoscope new generation
Return electrode opposite
side
Larger active electrode
Minimal gas bubbles
production
Less risk of perforation
Different surgical technique
Bipolar hysteroscopic myomectomy
Hysteroscopic Myomectomy
Long-term results depend on
bull Uterine Size (Plt0001)
bull Number of myomas (Plt0001)
The surgery-free percentage of 165 patients with normal sized uteri and not more than two
myomas was 943 (+- 18) at 2 years and 903 (+- 30) at 5 years
bull Type ( intra-mural part)
bull Size of myoma (significant increase of amount of particles between 2 and 3 cm)
Long-term results depend on the presence of concomitant pathology
or is a result of incomplete surgery
Emanuel MH Wamsteker K Obstet Gynecol 1999 May93743-8
Third Statement
1 Junctional Zone Myoma should preferentially be treated by hysteroscopy
2 Feasibility of hysteroscopic surgery is predominantly related with size location and amount of myoma
3 Independently of distension medium used continuous fluid balance and flow distension control is mandatory
4 Complication risk is related to experience and surgical technique used
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Conventional hysteroscopic surgery
4 Laparoscopic surgery
Introduction
Intramural myoma larger than 4 cm related to the JZ myometriumschould be operated on
Laparoscopic approach has had an important evolution over the
years
Series with high success rate are done by experts =gt it is difficult to extrapolate to less experienced surgeons
Laparoscopic myomectomy needs expert skills in haemostasis dissection and suturing
How to minimize blood loss
bullA lot of techniques in order to minimize blood loss
GnRH agonists
Intramyometrial vasopressine
Oxytocin IV 40 mUImin intraoperatively
Use of tourniquet or penrose at the lower part of uterus
Laparoscopic Myomectomy
J Ferro IVI Valencia Spain
Tips amp tricks ndash minimize blood loss
Clipping of the uterine arteries and infundilopelvic ligaments is another very efficient method
Artery ligation versus Control group (n=152)
173 +- 91 mL vs 402 +- 131 mL blood loss
62 vs 2075 reccurence rate
Alborzi S et al A comparison of combined laparoscopic uterine artery ligation and myomectomyversus laparoscopic myomectomy in the treatment of symptomatic myoma Fertil Steril 2009
Tips amp tricks ndash minimize blood loss
Technique Incision
Incision
J Ferro A Wattiez
Tips amp tricks- dissection
Tips amp tricks- closure
bull One versus multiples layers controversial
bull Adequate closure of the dead space to minimize the risk of hematoma formation
bull Interrupted figure of eight sutures are usually sufficient monocryl 1 or 0 with extracorporeal notes =gt extra strength
bull For the serosa approximate with interrupted 20 sutures if necessary (monofilament)
Tips amp tricks- closure
Removal Clips
Anti- adhesion agents
Fourth Statement
LAPAROSCOPIC MYOMECTOMY offers comparable results tolaparotomic myomectomy
Laparoscopic approach reduces adhesion formation blood loss and hospital stay
Laparoscopic myomectomy seems indicated in the infertile patient for the treatment of intramural myomarsquos
Laparoscopic Myomectomy requires a skilled laparoscopic surgeon with expert suturing skills optimal instrumental support and knowledge of some trickrsquos to provide an optimal result
Take Home message
Submucous myoma should always be removed prior to IVF
Hysteroscopic resection is the gold standard to treat those myoma
Intramural myoma originating from the sub endometrial
myometrium and larger than 4 cm are treated by Laproscopy
Subserosal myoma do not influence the outcome of IVF and are not removed for this indication
More info on the special training
programsin endoscopic
surgery
ESGEORG
More info on the ESGE website
wwwesgeorg
See you in London
Rudi Campo Stephan GordtsPatrick PuttemansRoger MolinasSylvie GordtsMarion Valkenburg Ivo Brosens
Leuven Institute for Fertility
amp Embryology
Trophy Scope a new generation
Interesting Characteristics
Gliding system that provides
Diagnostic ( 29 mm ) and
Operative (44 mm)
possibilities in one instrument
This hysteroscope has been named after the multicentre study
TROPHY ldquoTrial of Outpatient Hysteroscopyrdquo for which it was designed
El-Toukhy T Campo R et al Trial of Outpatient Hysteroscopy - [TROPHY] in IVF Reprod Health 2009 Dec 3620
Distension fluid
Monopolar surgery using non-ionic solutions
sa manitol sorbitol or glycine has higher risk of
side effects due to fluid overload effect
Stop surgery as soon as 1 L of fluid losses
Bipolar surgery using ionic solutions (saline)
Isotonic hyperhydration is less dangerous
In young patients up to 4 L of losses can be
accepted
Hysteroscopic Myomectomy
Always use a pressure and flow controlled pump system to work at minimal necessary pressure
Always perform continuous fluid balance independently of the medium used
Hysteroscopic Myomectomy
Operative Hysteroscopy Resectoscope Uni or Bipolar
Non ionic fluid
Unipolar polyp and myomaresection
Ionic fluid
First generation Bipolar (Versapoint)
Loop is smaller
chips are smaller
Longer OR time
Bipolar cautery induces
more bubbles
Bipolar resectoscope new generation
low-energy
Two or more small active electrodes very close to each other (active and return electrode)
bull Use Saline as distention medium
bull limited spread of electrical effect the current flow is essentially limited to a small area and it requires less voltage less risk for adhaesion formation
bull Loop different shape and size Different surgical
manoeuvres
bull Need of Modern generator
Bipolar resectoscope new generation
Storz bipolar resectoscope new generation
Return electrode opposite
side
Larger active electrode
Minimal gas bubbles
production
Less risk of perforation
Different surgical technique
Bipolar hysteroscopic myomectomy
Hysteroscopic Myomectomy
Long-term results depend on
bull Uterine Size (Plt0001)
bull Number of myomas (Plt0001)
The surgery-free percentage of 165 patients with normal sized uteri and not more than two
myomas was 943 (+- 18) at 2 years and 903 (+- 30) at 5 years
bull Type ( intra-mural part)
bull Size of myoma (significant increase of amount of particles between 2 and 3 cm)
Long-term results depend on the presence of concomitant pathology
or is a result of incomplete surgery
Emanuel MH Wamsteker K Obstet Gynecol 1999 May93743-8
Third Statement
1 Junctional Zone Myoma should preferentially be treated by hysteroscopy
2 Feasibility of hysteroscopic surgery is predominantly related with size location and amount of myoma
3 Independently of distension medium used continuous fluid balance and flow distension control is mandatory
4 Complication risk is related to experience and surgical technique used
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Conventional hysteroscopic surgery
4 Laparoscopic surgery
Introduction
Intramural myoma larger than 4 cm related to the JZ myometriumschould be operated on
Laparoscopic approach has had an important evolution over the
years
Series with high success rate are done by experts =gt it is difficult to extrapolate to less experienced surgeons
Laparoscopic myomectomy needs expert skills in haemostasis dissection and suturing
How to minimize blood loss
bullA lot of techniques in order to minimize blood loss
GnRH agonists
Intramyometrial vasopressine
Oxytocin IV 40 mUImin intraoperatively
Use of tourniquet or penrose at the lower part of uterus
Laparoscopic Myomectomy
J Ferro IVI Valencia Spain
Tips amp tricks ndash minimize blood loss
Clipping of the uterine arteries and infundilopelvic ligaments is another very efficient method
Artery ligation versus Control group (n=152)
173 +- 91 mL vs 402 +- 131 mL blood loss
62 vs 2075 reccurence rate
Alborzi S et al A comparison of combined laparoscopic uterine artery ligation and myomectomyversus laparoscopic myomectomy in the treatment of symptomatic myoma Fertil Steril 2009
Tips amp tricks ndash minimize blood loss
Technique Incision
Incision
J Ferro A Wattiez
Tips amp tricks- dissection
Tips amp tricks- closure
bull One versus multiples layers controversial
bull Adequate closure of the dead space to minimize the risk of hematoma formation
bull Interrupted figure of eight sutures are usually sufficient monocryl 1 or 0 with extracorporeal notes =gt extra strength
bull For the serosa approximate with interrupted 20 sutures if necessary (monofilament)
Tips amp tricks- closure
Removal Clips
Anti- adhesion agents
Fourth Statement
LAPAROSCOPIC MYOMECTOMY offers comparable results tolaparotomic myomectomy
Laparoscopic approach reduces adhesion formation blood loss and hospital stay
Laparoscopic myomectomy seems indicated in the infertile patient for the treatment of intramural myomarsquos
Laparoscopic Myomectomy requires a skilled laparoscopic surgeon with expert suturing skills optimal instrumental support and knowledge of some trickrsquos to provide an optimal result
Take Home message
Submucous myoma should always be removed prior to IVF
Hysteroscopic resection is the gold standard to treat those myoma
Intramural myoma originating from the sub endometrial
myometrium and larger than 4 cm are treated by Laproscopy
Subserosal myoma do not influence the outcome of IVF and are not removed for this indication
More info on the special training
programsin endoscopic
surgery
ESGEORG
More info on the ESGE website
wwwesgeorg
See you in London
Rudi Campo Stephan GordtsPatrick PuttemansRoger MolinasSylvie GordtsMarion Valkenburg Ivo Brosens
Leuven Institute for Fertility
amp Embryology
Trophy Scope a new generation
Interesting Characteristics
Gliding system that provides
Diagnostic ( 29 mm ) and
Operative (44 mm)
possibilities in one instrument
This hysteroscope has been named after the multicentre study
TROPHY ldquoTrial of Outpatient Hysteroscopyrdquo for which it was designed
El-Toukhy T Campo R et al Trial of Outpatient Hysteroscopy - [TROPHY] in IVF Reprod Health 2009 Dec 3620
Always use a pressure and flow controlled pump system to work at minimal necessary pressure
Always perform continuous fluid balance independently of the medium used
Hysteroscopic Myomectomy
Operative Hysteroscopy Resectoscope Uni or Bipolar
Non ionic fluid
Unipolar polyp and myomaresection
Ionic fluid
First generation Bipolar (Versapoint)
Loop is smaller
chips are smaller
Longer OR time
Bipolar cautery induces
more bubbles
Bipolar resectoscope new generation
low-energy
Two or more small active electrodes very close to each other (active and return electrode)
bull Use Saline as distention medium
bull limited spread of electrical effect the current flow is essentially limited to a small area and it requires less voltage less risk for adhaesion formation
bull Loop different shape and size Different surgical
manoeuvres
bull Need of Modern generator
Bipolar resectoscope new generation
Storz bipolar resectoscope new generation
Return electrode opposite
side
Larger active electrode
Minimal gas bubbles
production
Less risk of perforation
Different surgical technique
Bipolar hysteroscopic myomectomy
Hysteroscopic Myomectomy
Long-term results depend on
bull Uterine Size (Plt0001)
bull Number of myomas (Plt0001)
The surgery-free percentage of 165 patients with normal sized uteri and not more than two
myomas was 943 (+- 18) at 2 years and 903 (+- 30) at 5 years
bull Type ( intra-mural part)
bull Size of myoma (significant increase of amount of particles between 2 and 3 cm)
Long-term results depend on the presence of concomitant pathology
or is a result of incomplete surgery
Emanuel MH Wamsteker K Obstet Gynecol 1999 May93743-8
Third Statement
1 Junctional Zone Myoma should preferentially be treated by hysteroscopy
2 Feasibility of hysteroscopic surgery is predominantly related with size location and amount of myoma
3 Independently of distension medium used continuous fluid balance and flow distension control is mandatory
4 Complication risk is related to experience and surgical technique used
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Conventional hysteroscopic surgery
4 Laparoscopic surgery
Introduction
Intramural myoma larger than 4 cm related to the JZ myometriumschould be operated on
Laparoscopic approach has had an important evolution over the
years
Series with high success rate are done by experts =gt it is difficult to extrapolate to less experienced surgeons
Laparoscopic myomectomy needs expert skills in haemostasis dissection and suturing
How to minimize blood loss
bullA lot of techniques in order to minimize blood loss
GnRH agonists
Intramyometrial vasopressine
Oxytocin IV 40 mUImin intraoperatively
Use of tourniquet or penrose at the lower part of uterus
Laparoscopic Myomectomy
J Ferro IVI Valencia Spain
Tips amp tricks ndash minimize blood loss
Clipping of the uterine arteries and infundilopelvic ligaments is another very efficient method
Artery ligation versus Control group (n=152)
173 +- 91 mL vs 402 +- 131 mL blood loss
62 vs 2075 reccurence rate
Alborzi S et al A comparison of combined laparoscopic uterine artery ligation and myomectomyversus laparoscopic myomectomy in the treatment of symptomatic myoma Fertil Steril 2009
Tips amp tricks ndash minimize blood loss
Technique Incision
Incision
J Ferro A Wattiez
Tips amp tricks- dissection
Tips amp tricks- closure
bull One versus multiples layers controversial
bull Adequate closure of the dead space to minimize the risk of hematoma formation
bull Interrupted figure of eight sutures are usually sufficient monocryl 1 or 0 with extracorporeal notes =gt extra strength
bull For the serosa approximate with interrupted 20 sutures if necessary (monofilament)
Tips amp tricks- closure
Removal Clips
Anti- adhesion agents
Fourth Statement
LAPAROSCOPIC MYOMECTOMY offers comparable results tolaparotomic myomectomy
Laparoscopic approach reduces adhesion formation blood loss and hospital stay
Laparoscopic myomectomy seems indicated in the infertile patient for the treatment of intramural myomarsquos
Laparoscopic Myomectomy requires a skilled laparoscopic surgeon with expert suturing skills optimal instrumental support and knowledge of some trickrsquos to provide an optimal result
Take Home message
Submucous myoma should always be removed prior to IVF
Hysteroscopic resection is the gold standard to treat those myoma
Intramural myoma originating from the sub endometrial
myometrium and larger than 4 cm are treated by Laproscopy
Subserosal myoma do not influence the outcome of IVF and are not removed for this indication
More info on the special training
programsin endoscopic
surgery
ESGEORG
More info on the ESGE website
wwwesgeorg
See you in London
Rudi Campo Stephan GordtsPatrick PuttemansRoger MolinasSylvie GordtsMarion Valkenburg Ivo Brosens
Leuven Institute for Fertility
amp Embryology
Trophy Scope a new generation
Interesting Characteristics
Gliding system that provides
Diagnostic ( 29 mm ) and
Operative (44 mm)
possibilities in one instrument
This hysteroscope has been named after the multicentre study
TROPHY ldquoTrial of Outpatient Hysteroscopyrdquo for which it was designed
El-Toukhy T Campo R et al Trial of Outpatient Hysteroscopy - [TROPHY] in IVF Reprod Health 2009 Dec 3620
Operative Hysteroscopy Resectoscope Uni or Bipolar
Non ionic fluid
Unipolar polyp and myomaresection
Ionic fluid
First generation Bipolar (Versapoint)
Loop is smaller
chips are smaller
Longer OR time
Bipolar cautery induces
more bubbles
Bipolar resectoscope new generation
low-energy
Two or more small active electrodes very close to each other (active and return electrode)
bull Use Saline as distention medium
bull limited spread of electrical effect the current flow is essentially limited to a small area and it requires less voltage less risk for adhaesion formation
bull Loop different shape and size Different surgical
manoeuvres
bull Need of Modern generator
Bipolar resectoscope new generation
Storz bipolar resectoscope new generation
Return electrode opposite
side
Larger active electrode
Minimal gas bubbles
production
Less risk of perforation
Different surgical technique
Bipolar hysteroscopic myomectomy
Hysteroscopic Myomectomy
Long-term results depend on
bull Uterine Size (Plt0001)
bull Number of myomas (Plt0001)
The surgery-free percentage of 165 patients with normal sized uteri and not more than two
myomas was 943 (+- 18) at 2 years and 903 (+- 30) at 5 years
bull Type ( intra-mural part)
bull Size of myoma (significant increase of amount of particles between 2 and 3 cm)
Long-term results depend on the presence of concomitant pathology
or is a result of incomplete surgery
Emanuel MH Wamsteker K Obstet Gynecol 1999 May93743-8
Third Statement
1 Junctional Zone Myoma should preferentially be treated by hysteroscopy
2 Feasibility of hysteroscopic surgery is predominantly related with size location and amount of myoma
3 Independently of distension medium used continuous fluid balance and flow distension control is mandatory
4 Complication risk is related to experience and surgical technique used
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Conventional hysteroscopic surgery
4 Laparoscopic surgery
Introduction
Intramural myoma larger than 4 cm related to the JZ myometriumschould be operated on
Laparoscopic approach has had an important evolution over the
years
Series with high success rate are done by experts =gt it is difficult to extrapolate to less experienced surgeons
Laparoscopic myomectomy needs expert skills in haemostasis dissection and suturing
How to minimize blood loss
bullA lot of techniques in order to minimize blood loss
GnRH agonists
Intramyometrial vasopressine
Oxytocin IV 40 mUImin intraoperatively
Use of tourniquet or penrose at the lower part of uterus
Laparoscopic Myomectomy
J Ferro IVI Valencia Spain
Tips amp tricks ndash minimize blood loss
Clipping of the uterine arteries and infundilopelvic ligaments is another very efficient method
Artery ligation versus Control group (n=152)
173 +- 91 mL vs 402 +- 131 mL blood loss
62 vs 2075 reccurence rate
Alborzi S et al A comparison of combined laparoscopic uterine artery ligation and myomectomyversus laparoscopic myomectomy in the treatment of symptomatic myoma Fertil Steril 2009
Tips amp tricks ndash minimize blood loss
Technique Incision
Incision
J Ferro A Wattiez
Tips amp tricks- dissection
Tips amp tricks- closure
bull One versus multiples layers controversial
bull Adequate closure of the dead space to minimize the risk of hematoma formation
bull Interrupted figure of eight sutures are usually sufficient monocryl 1 or 0 with extracorporeal notes =gt extra strength
bull For the serosa approximate with interrupted 20 sutures if necessary (monofilament)
Tips amp tricks- closure
Removal Clips
Anti- adhesion agents
Fourth Statement
LAPAROSCOPIC MYOMECTOMY offers comparable results tolaparotomic myomectomy
Laparoscopic approach reduces adhesion formation blood loss and hospital stay
Laparoscopic myomectomy seems indicated in the infertile patient for the treatment of intramural myomarsquos
Laparoscopic Myomectomy requires a skilled laparoscopic surgeon with expert suturing skills optimal instrumental support and knowledge of some trickrsquos to provide an optimal result
Take Home message
Submucous myoma should always be removed prior to IVF
Hysteroscopic resection is the gold standard to treat those myoma
Intramural myoma originating from the sub endometrial
myometrium and larger than 4 cm are treated by Laproscopy
Subserosal myoma do not influence the outcome of IVF and are not removed for this indication
More info on the special training
programsin endoscopic
surgery
ESGEORG
More info on the ESGE website
wwwesgeorg
See you in London
Rudi Campo Stephan GordtsPatrick PuttemansRoger MolinasSylvie GordtsMarion Valkenburg Ivo Brosens
Leuven Institute for Fertility
amp Embryology
Trophy Scope a new generation
Interesting Characteristics
Gliding system that provides
Diagnostic ( 29 mm ) and
Operative (44 mm)
possibilities in one instrument
This hysteroscope has been named after the multicentre study
TROPHY ldquoTrial of Outpatient Hysteroscopyrdquo for which it was designed
El-Toukhy T Campo R et al Trial of Outpatient Hysteroscopy - [TROPHY] in IVF Reprod Health 2009 Dec 3620
Non ionic fluid
Unipolar polyp and myomaresection
Ionic fluid
First generation Bipolar (Versapoint)
Loop is smaller
chips are smaller
Longer OR time
Bipolar cautery induces
more bubbles
Bipolar resectoscope new generation
low-energy
Two or more small active electrodes very close to each other (active and return electrode)
bull Use Saline as distention medium
bull limited spread of electrical effect the current flow is essentially limited to a small area and it requires less voltage less risk for adhaesion formation
bull Loop different shape and size Different surgical
manoeuvres
bull Need of Modern generator
Bipolar resectoscope new generation
Storz bipolar resectoscope new generation
Return electrode opposite
side
Larger active electrode
Minimal gas bubbles
production
Less risk of perforation
Different surgical technique
Bipolar hysteroscopic myomectomy
Hysteroscopic Myomectomy
Long-term results depend on
bull Uterine Size (Plt0001)
bull Number of myomas (Plt0001)
The surgery-free percentage of 165 patients with normal sized uteri and not more than two
myomas was 943 (+- 18) at 2 years and 903 (+- 30) at 5 years
bull Type ( intra-mural part)
bull Size of myoma (significant increase of amount of particles between 2 and 3 cm)
Long-term results depend on the presence of concomitant pathology
or is a result of incomplete surgery
Emanuel MH Wamsteker K Obstet Gynecol 1999 May93743-8
Third Statement
1 Junctional Zone Myoma should preferentially be treated by hysteroscopy
2 Feasibility of hysteroscopic surgery is predominantly related with size location and amount of myoma
3 Independently of distension medium used continuous fluid balance and flow distension control is mandatory
4 Complication risk is related to experience and surgical technique used
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Conventional hysteroscopic surgery
4 Laparoscopic surgery
Introduction
Intramural myoma larger than 4 cm related to the JZ myometriumschould be operated on
Laparoscopic approach has had an important evolution over the
years
Series with high success rate are done by experts =gt it is difficult to extrapolate to less experienced surgeons
Laparoscopic myomectomy needs expert skills in haemostasis dissection and suturing
How to minimize blood loss
bullA lot of techniques in order to minimize blood loss
GnRH agonists
Intramyometrial vasopressine
Oxytocin IV 40 mUImin intraoperatively
Use of tourniquet or penrose at the lower part of uterus
Laparoscopic Myomectomy
J Ferro IVI Valencia Spain
Tips amp tricks ndash minimize blood loss
Clipping of the uterine arteries and infundilopelvic ligaments is another very efficient method
Artery ligation versus Control group (n=152)
173 +- 91 mL vs 402 +- 131 mL blood loss
62 vs 2075 reccurence rate
Alborzi S et al A comparison of combined laparoscopic uterine artery ligation and myomectomyversus laparoscopic myomectomy in the treatment of symptomatic myoma Fertil Steril 2009
Tips amp tricks ndash minimize blood loss
Technique Incision
Incision
J Ferro A Wattiez
Tips amp tricks- dissection
Tips amp tricks- closure
bull One versus multiples layers controversial
bull Adequate closure of the dead space to minimize the risk of hematoma formation
bull Interrupted figure of eight sutures are usually sufficient monocryl 1 or 0 with extracorporeal notes =gt extra strength
bull For the serosa approximate with interrupted 20 sutures if necessary (monofilament)
Tips amp tricks- closure
Removal Clips
Anti- adhesion agents
Fourth Statement
LAPAROSCOPIC MYOMECTOMY offers comparable results tolaparotomic myomectomy
Laparoscopic approach reduces adhesion formation blood loss and hospital stay
Laparoscopic myomectomy seems indicated in the infertile patient for the treatment of intramural myomarsquos
Laparoscopic Myomectomy requires a skilled laparoscopic surgeon with expert suturing skills optimal instrumental support and knowledge of some trickrsquos to provide an optimal result
Take Home message
Submucous myoma should always be removed prior to IVF
Hysteroscopic resection is the gold standard to treat those myoma
Intramural myoma originating from the sub endometrial
myometrium and larger than 4 cm are treated by Laproscopy
Subserosal myoma do not influence the outcome of IVF and are not removed for this indication
More info on the special training
programsin endoscopic
surgery
ESGEORG
More info on the ESGE website
wwwesgeorg
See you in London
Rudi Campo Stephan GordtsPatrick PuttemansRoger MolinasSylvie GordtsMarion Valkenburg Ivo Brosens
Leuven Institute for Fertility
amp Embryology
Trophy Scope a new generation
Interesting Characteristics
Gliding system that provides
Diagnostic ( 29 mm ) and
Operative (44 mm)
possibilities in one instrument
This hysteroscope has been named after the multicentre study
TROPHY ldquoTrial of Outpatient Hysteroscopyrdquo for which it was designed
El-Toukhy T Campo R et al Trial of Outpatient Hysteroscopy - [TROPHY] in IVF Reprod Health 2009 Dec 3620
Ionic fluid
First generation Bipolar (Versapoint)
Loop is smaller
chips are smaller
Longer OR time
Bipolar cautery induces
more bubbles
Bipolar resectoscope new generation
low-energy
Two or more small active electrodes very close to each other (active and return electrode)
bull Use Saline as distention medium
bull limited spread of electrical effect the current flow is essentially limited to a small area and it requires less voltage less risk for adhaesion formation
bull Loop different shape and size Different surgical
manoeuvres
bull Need of Modern generator
Bipolar resectoscope new generation
Storz bipolar resectoscope new generation
Return electrode opposite
side
Larger active electrode
Minimal gas bubbles
production
Less risk of perforation
Different surgical technique
Bipolar hysteroscopic myomectomy
Hysteroscopic Myomectomy
Long-term results depend on
bull Uterine Size (Plt0001)
bull Number of myomas (Plt0001)
The surgery-free percentage of 165 patients with normal sized uteri and not more than two
myomas was 943 (+- 18) at 2 years and 903 (+- 30) at 5 years
bull Type ( intra-mural part)
bull Size of myoma (significant increase of amount of particles between 2 and 3 cm)
Long-term results depend on the presence of concomitant pathology
or is a result of incomplete surgery
Emanuel MH Wamsteker K Obstet Gynecol 1999 May93743-8
Third Statement
1 Junctional Zone Myoma should preferentially be treated by hysteroscopy
2 Feasibility of hysteroscopic surgery is predominantly related with size location and amount of myoma
3 Independently of distension medium used continuous fluid balance and flow distension control is mandatory
4 Complication risk is related to experience and surgical technique used
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Conventional hysteroscopic surgery
4 Laparoscopic surgery
Introduction
Intramural myoma larger than 4 cm related to the JZ myometriumschould be operated on
Laparoscopic approach has had an important evolution over the
years
Series with high success rate are done by experts =gt it is difficult to extrapolate to less experienced surgeons
Laparoscopic myomectomy needs expert skills in haemostasis dissection and suturing
How to minimize blood loss
bullA lot of techniques in order to minimize blood loss
GnRH agonists
Intramyometrial vasopressine
Oxytocin IV 40 mUImin intraoperatively
Use of tourniquet or penrose at the lower part of uterus
Laparoscopic Myomectomy
J Ferro IVI Valencia Spain
Tips amp tricks ndash minimize blood loss
Clipping of the uterine arteries and infundilopelvic ligaments is another very efficient method
Artery ligation versus Control group (n=152)
173 +- 91 mL vs 402 +- 131 mL blood loss
62 vs 2075 reccurence rate
Alborzi S et al A comparison of combined laparoscopic uterine artery ligation and myomectomyversus laparoscopic myomectomy in the treatment of symptomatic myoma Fertil Steril 2009
Tips amp tricks ndash minimize blood loss
Technique Incision
Incision
J Ferro A Wattiez
Tips amp tricks- dissection
Tips amp tricks- closure
bull One versus multiples layers controversial
bull Adequate closure of the dead space to minimize the risk of hematoma formation
bull Interrupted figure of eight sutures are usually sufficient monocryl 1 or 0 with extracorporeal notes =gt extra strength
bull For the serosa approximate with interrupted 20 sutures if necessary (monofilament)
Tips amp tricks- closure
Removal Clips
Anti- adhesion agents
Fourth Statement
LAPAROSCOPIC MYOMECTOMY offers comparable results tolaparotomic myomectomy
Laparoscopic approach reduces adhesion formation blood loss and hospital stay
Laparoscopic myomectomy seems indicated in the infertile patient for the treatment of intramural myomarsquos
Laparoscopic Myomectomy requires a skilled laparoscopic surgeon with expert suturing skills optimal instrumental support and knowledge of some trickrsquos to provide an optimal result
Take Home message
Submucous myoma should always be removed prior to IVF
Hysteroscopic resection is the gold standard to treat those myoma
Intramural myoma originating from the sub endometrial
myometrium and larger than 4 cm are treated by Laproscopy
Subserosal myoma do not influence the outcome of IVF and are not removed for this indication
More info on the special training
programsin endoscopic
surgery
ESGEORG
More info on the ESGE website
wwwesgeorg
See you in London
Rudi Campo Stephan GordtsPatrick PuttemansRoger MolinasSylvie GordtsMarion Valkenburg Ivo Brosens
Leuven Institute for Fertility
amp Embryology
Trophy Scope a new generation
Interesting Characteristics
Gliding system that provides
Diagnostic ( 29 mm ) and
Operative (44 mm)
possibilities in one instrument
This hysteroscope has been named after the multicentre study
TROPHY ldquoTrial of Outpatient Hysteroscopyrdquo for which it was designed
El-Toukhy T Campo R et al Trial of Outpatient Hysteroscopy - [TROPHY] in IVF Reprod Health 2009 Dec 3620
Bipolar resectoscope new generation
low-energy
Two or more small active electrodes very close to each other (active and return electrode)
bull Use Saline as distention medium
bull limited spread of electrical effect the current flow is essentially limited to a small area and it requires less voltage less risk for adhaesion formation
bull Loop different shape and size Different surgical
manoeuvres
bull Need of Modern generator
Bipolar resectoscope new generation
Storz bipolar resectoscope new generation
Return electrode opposite
side
Larger active electrode
Minimal gas bubbles
production
Less risk of perforation
Different surgical technique
Bipolar hysteroscopic myomectomy
Hysteroscopic Myomectomy
Long-term results depend on
bull Uterine Size (Plt0001)
bull Number of myomas (Plt0001)
The surgery-free percentage of 165 patients with normal sized uteri and not more than two
myomas was 943 (+- 18) at 2 years and 903 (+- 30) at 5 years
bull Type ( intra-mural part)
bull Size of myoma (significant increase of amount of particles between 2 and 3 cm)
Long-term results depend on the presence of concomitant pathology
or is a result of incomplete surgery
Emanuel MH Wamsteker K Obstet Gynecol 1999 May93743-8
Third Statement
1 Junctional Zone Myoma should preferentially be treated by hysteroscopy
2 Feasibility of hysteroscopic surgery is predominantly related with size location and amount of myoma
3 Independently of distension medium used continuous fluid balance and flow distension control is mandatory
4 Complication risk is related to experience and surgical technique used
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Conventional hysteroscopic surgery
4 Laparoscopic surgery
Introduction
Intramural myoma larger than 4 cm related to the JZ myometriumschould be operated on
Laparoscopic approach has had an important evolution over the
years
Series with high success rate are done by experts =gt it is difficult to extrapolate to less experienced surgeons
Laparoscopic myomectomy needs expert skills in haemostasis dissection and suturing
How to minimize blood loss
bullA lot of techniques in order to minimize blood loss
GnRH agonists
Intramyometrial vasopressine
Oxytocin IV 40 mUImin intraoperatively
Use of tourniquet or penrose at the lower part of uterus
Laparoscopic Myomectomy
J Ferro IVI Valencia Spain
Tips amp tricks ndash minimize blood loss
Clipping of the uterine arteries and infundilopelvic ligaments is another very efficient method
Artery ligation versus Control group (n=152)
173 +- 91 mL vs 402 +- 131 mL blood loss
62 vs 2075 reccurence rate
Alborzi S et al A comparison of combined laparoscopic uterine artery ligation and myomectomyversus laparoscopic myomectomy in the treatment of symptomatic myoma Fertil Steril 2009
Tips amp tricks ndash minimize blood loss
Technique Incision
Incision
J Ferro A Wattiez
Tips amp tricks- dissection
Tips amp tricks- closure
bull One versus multiples layers controversial
bull Adequate closure of the dead space to minimize the risk of hematoma formation
bull Interrupted figure of eight sutures are usually sufficient monocryl 1 or 0 with extracorporeal notes =gt extra strength
bull For the serosa approximate with interrupted 20 sutures if necessary (monofilament)
Tips amp tricks- closure
Removal Clips
Anti- adhesion agents
Fourth Statement
LAPAROSCOPIC MYOMECTOMY offers comparable results tolaparotomic myomectomy
Laparoscopic approach reduces adhesion formation blood loss and hospital stay
Laparoscopic myomectomy seems indicated in the infertile patient for the treatment of intramural myomarsquos
Laparoscopic Myomectomy requires a skilled laparoscopic surgeon with expert suturing skills optimal instrumental support and knowledge of some trickrsquos to provide an optimal result
Take Home message
Submucous myoma should always be removed prior to IVF
Hysteroscopic resection is the gold standard to treat those myoma
Intramural myoma originating from the sub endometrial
myometrium and larger than 4 cm are treated by Laproscopy
Subserosal myoma do not influence the outcome of IVF and are not removed for this indication
More info on the special training
programsin endoscopic
surgery
ESGEORG
More info on the ESGE website
wwwesgeorg
See you in London
Rudi Campo Stephan GordtsPatrick PuttemansRoger MolinasSylvie GordtsMarion Valkenburg Ivo Brosens
Leuven Institute for Fertility
amp Embryology
Trophy Scope a new generation
Interesting Characteristics
Gliding system that provides
Diagnostic ( 29 mm ) and
Operative (44 mm)
possibilities in one instrument
This hysteroscope has been named after the multicentre study
TROPHY ldquoTrial of Outpatient Hysteroscopyrdquo for which it was designed
El-Toukhy T Campo R et al Trial of Outpatient Hysteroscopy - [TROPHY] in IVF Reprod Health 2009 Dec 3620
bull Use Saline as distention medium
bull limited spread of electrical effect the current flow is essentially limited to a small area and it requires less voltage less risk for adhaesion formation
bull Loop different shape and size Different surgical
manoeuvres
bull Need of Modern generator
Bipolar resectoscope new generation
Storz bipolar resectoscope new generation
Return electrode opposite
side
Larger active electrode
Minimal gas bubbles
production
Less risk of perforation
Different surgical technique
Bipolar hysteroscopic myomectomy
Hysteroscopic Myomectomy
Long-term results depend on
bull Uterine Size (Plt0001)
bull Number of myomas (Plt0001)
The surgery-free percentage of 165 patients with normal sized uteri and not more than two
myomas was 943 (+- 18) at 2 years and 903 (+- 30) at 5 years
bull Type ( intra-mural part)
bull Size of myoma (significant increase of amount of particles between 2 and 3 cm)
Long-term results depend on the presence of concomitant pathology
or is a result of incomplete surgery
Emanuel MH Wamsteker K Obstet Gynecol 1999 May93743-8
Third Statement
1 Junctional Zone Myoma should preferentially be treated by hysteroscopy
2 Feasibility of hysteroscopic surgery is predominantly related with size location and amount of myoma
3 Independently of distension medium used continuous fluid balance and flow distension control is mandatory
4 Complication risk is related to experience and surgical technique used
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Conventional hysteroscopic surgery
4 Laparoscopic surgery
Introduction
Intramural myoma larger than 4 cm related to the JZ myometriumschould be operated on
Laparoscopic approach has had an important evolution over the
years
Series with high success rate are done by experts =gt it is difficult to extrapolate to less experienced surgeons
Laparoscopic myomectomy needs expert skills in haemostasis dissection and suturing
How to minimize blood loss
bullA lot of techniques in order to minimize blood loss
GnRH agonists
Intramyometrial vasopressine
Oxytocin IV 40 mUImin intraoperatively
Use of tourniquet or penrose at the lower part of uterus
Laparoscopic Myomectomy
J Ferro IVI Valencia Spain
Tips amp tricks ndash minimize blood loss
Clipping of the uterine arteries and infundilopelvic ligaments is another very efficient method
Artery ligation versus Control group (n=152)
173 +- 91 mL vs 402 +- 131 mL blood loss
62 vs 2075 reccurence rate
Alborzi S et al A comparison of combined laparoscopic uterine artery ligation and myomectomyversus laparoscopic myomectomy in the treatment of symptomatic myoma Fertil Steril 2009
Tips amp tricks ndash minimize blood loss
Technique Incision
Incision
J Ferro A Wattiez
Tips amp tricks- dissection
Tips amp tricks- closure
bull One versus multiples layers controversial
bull Adequate closure of the dead space to minimize the risk of hematoma formation
bull Interrupted figure of eight sutures are usually sufficient monocryl 1 or 0 with extracorporeal notes =gt extra strength
bull For the serosa approximate with interrupted 20 sutures if necessary (monofilament)
Tips amp tricks- closure
Removal Clips
Anti- adhesion agents
Fourth Statement
LAPAROSCOPIC MYOMECTOMY offers comparable results tolaparotomic myomectomy
Laparoscopic approach reduces adhesion formation blood loss and hospital stay
Laparoscopic myomectomy seems indicated in the infertile patient for the treatment of intramural myomarsquos
Laparoscopic Myomectomy requires a skilled laparoscopic surgeon with expert suturing skills optimal instrumental support and knowledge of some trickrsquos to provide an optimal result
Take Home message
Submucous myoma should always be removed prior to IVF
Hysteroscopic resection is the gold standard to treat those myoma
Intramural myoma originating from the sub endometrial
myometrium and larger than 4 cm are treated by Laproscopy
Subserosal myoma do not influence the outcome of IVF and are not removed for this indication
More info on the special training
programsin endoscopic
surgery
ESGEORG
More info on the ESGE website
wwwesgeorg
See you in London
Rudi Campo Stephan GordtsPatrick PuttemansRoger MolinasSylvie GordtsMarion Valkenburg Ivo Brosens
Leuven Institute for Fertility
amp Embryology
Trophy Scope a new generation
Interesting Characteristics
Gliding system that provides
Diagnostic ( 29 mm ) and
Operative (44 mm)
possibilities in one instrument
This hysteroscope has been named after the multicentre study
TROPHY ldquoTrial of Outpatient Hysteroscopyrdquo for which it was designed
El-Toukhy T Campo R et al Trial of Outpatient Hysteroscopy - [TROPHY] in IVF Reprod Health 2009 Dec 3620
Storz bipolar resectoscope new generation
Return electrode opposite
side
Larger active electrode
Minimal gas bubbles
production
Less risk of perforation
Different surgical technique
Bipolar hysteroscopic myomectomy
Hysteroscopic Myomectomy
Long-term results depend on
bull Uterine Size (Plt0001)
bull Number of myomas (Plt0001)
The surgery-free percentage of 165 patients with normal sized uteri and not more than two
myomas was 943 (+- 18) at 2 years and 903 (+- 30) at 5 years
bull Type ( intra-mural part)
bull Size of myoma (significant increase of amount of particles between 2 and 3 cm)
Long-term results depend on the presence of concomitant pathology
or is a result of incomplete surgery
Emanuel MH Wamsteker K Obstet Gynecol 1999 May93743-8
Third Statement
1 Junctional Zone Myoma should preferentially be treated by hysteroscopy
2 Feasibility of hysteroscopic surgery is predominantly related with size location and amount of myoma
3 Independently of distension medium used continuous fluid balance and flow distension control is mandatory
4 Complication risk is related to experience and surgical technique used
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Conventional hysteroscopic surgery
4 Laparoscopic surgery
Introduction
Intramural myoma larger than 4 cm related to the JZ myometriumschould be operated on
Laparoscopic approach has had an important evolution over the
years
Series with high success rate are done by experts =gt it is difficult to extrapolate to less experienced surgeons
Laparoscopic myomectomy needs expert skills in haemostasis dissection and suturing
How to minimize blood loss
bullA lot of techniques in order to minimize blood loss
GnRH agonists
Intramyometrial vasopressine
Oxytocin IV 40 mUImin intraoperatively
Use of tourniquet or penrose at the lower part of uterus
Laparoscopic Myomectomy
J Ferro IVI Valencia Spain
Tips amp tricks ndash minimize blood loss
Clipping of the uterine arteries and infundilopelvic ligaments is another very efficient method
Artery ligation versus Control group (n=152)
173 +- 91 mL vs 402 +- 131 mL blood loss
62 vs 2075 reccurence rate
Alborzi S et al A comparison of combined laparoscopic uterine artery ligation and myomectomyversus laparoscopic myomectomy in the treatment of symptomatic myoma Fertil Steril 2009
Tips amp tricks ndash minimize blood loss
Technique Incision
Incision
J Ferro A Wattiez
Tips amp tricks- dissection
Tips amp tricks- closure
bull One versus multiples layers controversial
bull Adequate closure of the dead space to minimize the risk of hematoma formation
bull Interrupted figure of eight sutures are usually sufficient monocryl 1 or 0 with extracorporeal notes =gt extra strength
bull For the serosa approximate with interrupted 20 sutures if necessary (monofilament)
Tips amp tricks- closure
Removal Clips
Anti- adhesion agents
Fourth Statement
LAPAROSCOPIC MYOMECTOMY offers comparable results tolaparotomic myomectomy
Laparoscopic approach reduces adhesion formation blood loss and hospital stay
Laparoscopic myomectomy seems indicated in the infertile patient for the treatment of intramural myomarsquos
Laparoscopic Myomectomy requires a skilled laparoscopic surgeon with expert suturing skills optimal instrumental support and knowledge of some trickrsquos to provide an optimal result
Take Home message
Submucous myoma should always be removed prior to IVF
Hysteroscopic resection is the gold standard to treat those myoma
Intramural myoma originating from the sub endometrial
myometrium and larger than 4 cm are treated by Laproscopy
Subserosal myoma do not influence the outcome of IVF and are not removed for this indication
More info on the special training
programsin endoscopic
surgery
ESGEORG
More info on the ESGE website
wwwesgeorg
See you in London
Rudi Campo Stephan GordtsPatrick PuttemansRoger MolinasSylvie GordtsMarion Valkenburg Ivo Brosens
Leuven Institute for Fertility
amp Embryology
Trophy Scope a new generation
Interesting Characteristics
Gliding system that provides
Diagnostic ( 29 mm ) and
Operative (44 mm)
possibilities in one instrument
This hysteroscope has been named after the multicentre study
TROPHY ldquoTrial of Outpatient Hysteroscopyrdquo for which it was designed
El-Toukhy T Campo R et al Trial of Outpatient Hysteroscopy - [TROPHY] in IVF Reprod Health 2009 Dec 3620
Bipolar hysteroscopic myomectomy
Hysteroscopic Myomectomy
Long-term results depend on
bull Uterine Size (Plt0001)
bull Number of myomas (Plt0001)
The surgery-free percentage of 165 patients with normal sized uteri and not more than two
myomas was 943 (+- 18) at 2 years and 903 (+- 30) at 5 years
bull Type ( intra-mural part)
bull Size of myoma (significant increase of amount of particles between 2 and 3 cm)
Long-term results depend on the presence of concomitant pathology
or is a result of incomplete surgery
Emanuel MH Wamsteker K Obstet Gynecol 1999 May93743-8
Third Statement
1 Junctional Zone Myoma should preferentially be treated by hysteroscopy
2 Feasibility of hysteroscopic surgery is predominantly related with size location and amount of myoma
3 Independently of distension medium used continuous fluid balance and flow distension control is mandatory
4 Complication risk is related to experience and surgical technique used
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Conventional hysteroscopic surgery
4 Laparoscopic surgery
Introduction
Intramural myoma larger than 4 cm related to the JZ myometriumschould be operated on
Laparoscopic approach has had an important evolution over the
years
Series with high success rate are done by experts =gt it is difficult to extrapolate to less experienced surgeons
Laparoscopic myomectomy needs expert skills in haemostasis dissection and suturing
How to minimize blood loss
bullA lot of techniques in order to minimize blood loss
GnRH agonists
Intramyometrial vasopressine
Oxytocin IV 40 mUImin intraoperatively
Use of tourniquet or penrose at the lower part of uterus
Laparoscopic Myomectomy
J Ferro IVI Valencia Spain
Tips amp tricks ndash minimize blood loss
Clipping of the uterine arteries and infundilopelvic ligaments is another very efficient method
Artery ligation versus Control group (n=152)
173 +- 91 mL vs 402 +- 131 mL blood loss
62 vs 2075 reccurence rate
Alborzi S et al A comparison of combined laparoscopic uterine artery ligation and myomectomyversus laparoscopic myomectomy in the treatment of symptomatic myoma Fertil Steril 2009
Tips amp tricks ndash minimize blood loss
Technique Incision
Incision
J Ferro A Wattiez
Tips amp tricks- dissection
Tips amp tricks- closure
bull One versus multiples layers controversial
bull Adequate closure of the dead space to minimize the risk of hematoma formation
bull Interrupted figure of eight sutures are usually sufficient monocryl 1 or 0 with extracorporeal notes =gt extra strength
bull For the serosa approximate with interrupted 20 sutures if necessary (monofilament)
Tips amp tricks- closure
Removal Clips
Anti- adhesion agents
Fourth Statement
LAPAROSCOPIC MYOMECTOMY offers comparable results tolaparotomic myomectomy
Laparoscopic approach reduces adhesion formation blood loss and hospital stay
Laparoscopic myomectomy seems indicated in the infertile patient for the treatment of intramural myomarsquos
Laparoscopic Myomectomy requires a skilled laparoscopic surgeon with expert suturing skills optimal instrumental support and knowledge of some trickrsquos to provide an optimal result
Take Home message
Submucous myoma should always be removed prior to IVF
Hysteroscopic resection is the gold standard to treat those myoma
Intramural myoma originating from the sub endometrial
myometrium and larger than 4 cm are treated by Laproscopy
Subserosal myoma do not influence the outcome of IVF and are not removed for this indication
More info on the special training
programsin endoscopic
surgery
ESGEORG
More info on the ESGE website
wwwesgeorg
See you in London
Rudi Campo Stephan GordtsPatrick PuttemansRoger MolinasSylvie GordtsMarion Valkenburg Ivo Brosens
Leuven Institute for Fertility
amp Embryology
Trophy Scope a new generation
Interesting Characteristics
Gliding system that provides
Diagnostic ( 29 mm ) and
Operative (44 mm)
possibilities in one instrument
This hysteroscope has been named after the multicentre study
TROPHY ldquoTrial of Outpatient Hysteroscopyrdquo for which it was designed
El-Toukhy T Campo R et al Trial of Outpatient Hysteroscopy - [TROPHY] in IVF Reprod Health 2009 Dec 3620
Hysteroscopic Myomectomy
Long-term results depend on
bull Uterine Size (Plt0001)
bull Number of myomas (Plt0001)
The surgery-free percentage of 165 patients with normal sized uteri and not more than two
myomas was 943 (+- 18) at 2 years and 903 (+- 30) at 5 years
bull Type ( intra-mural part)
bull Size of myoma (significant increase of amount of particles between 2 and 3 cm)
Long-term results depend on the presence of concomitant pathology
or is a result of incomplete surgery
Emanuel MH Wamsteker K Obstet Gynecol 1999 May93743-8
Third Statement
1 Junctional Zone Myoma should preferentially be treated by hysteroscopy
2 Feasibility of hysteroscopic surgery is predominantly related with size location and amount of myoma
3 Independently of distension medium used continuous fluid balance and flow distension control is mandatory
4 Complication risk is related to experience and surgical technique used
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Conventional hysteroscopic surgery
4 Laparoscopic surgery
Introduction
Intramural myoma larger than 4 cm related to the JZ myometriumschould be operated on
Laparoscopic approach has had an important evolution over the
years
Series with high success rate are done by experts =gt it is difficult to extrapolate to less experienced surgeons
Laparoscopic myomectomy needs expert skills in haemostasis dissection and suturing
How to minimize blood loss
bullA lot of techniques in order to minimize blood loss
GnRH agonists
Intramyometrial vasopressine
Oxytocin IV 40 mUImin intraoperatively
Use of tourniquet or penrose at the lower part of uterus
Laparoscopic Myomectomy
J Ferro IVI Valencia Spain
Tips amp tricks ndash minimize blood loss
Clipping of the uterine arteries and infundilopelvic ligaments is another very efficient method
Artery ligation versus Control group (n=152)
173 +- 91 mL vs 402 +- 131 mL blood loss
62 vs 2075 reccurence rate
Alborzi S et al A comparison of combined laparoscopic uterine artery ligation and myomectomyversus laparoscopic myomectomy in the treatment of symptomatic myoma Fertil Steril 2009
Tips amp tricks ndash minimize blood loss
Technique Incision
Incision
J Ferro A Wattiez
Tips amp tricks- dissection
Tips amp tricks- closure
bull One versus multiples layers controversial
bull Adequate closure of the dead space to minimize the risk of hematoma formation
bull Interrupted figure of eight sutures are usually sufficient monocryl 1 or 0 with extracorporeal notes =gt extra strength
bull For the serosa approximate with interrupted 20 sutures if necessary (monofilament)
Tips amp tricks- closure
Removal Clips
Anti- adhesion agents
Fourth Statement
LAPAROSCOPIC MYOMECTOMY offers comparable results tolaparotomic myomectomy
Laparoscopic approach reduces adhesion formation blood loss and hospital stay
Laparoscopic myomectomy seems indicated in the infertile patient for the treatment of intramural myomarsquos
Laparoscopic Myomectomy requires a skilled laparoscopic surgeon with expert suturing skills optimal instrumental support and knowledge of some trickrsquos to provide an optimal result
Take Home message
Submucous myoma should always be removed prior to IVF
Hysteroscopic resection is the gold standard to treat those myoma
Intramural myoma originating from the sub endometrial
myometrium and larger than 4 cm are treated by Laproscopy
Subserosal myoma do not influence the outcome of IVF and are not removed for this indication
More info on the special training
programsin endoscopic
surgery
ESGEORG
More info on the ESGE website
wwwesgeorg
See you in London
Rudi Campo Stephan GordtsPatrick PuttemansRoger MolinasSylvie GordtsMarion Valkenburg Ivo Brosens
Leuven Institute for Fertility
amp Embryology
Trophy Scope a new generation
Interesting Characteristics
Gliding system that provides
Diagnostic ( 29 mm ) and
Operative (44 mm)
possibilities in one instrument
This hysteroscope has been named after the multicentre study
TROPHY ldquoTrial of Outpatient Hysteroscopyrdquo for which it was designed
El-Toukhy T Campo R et al Trial of Outpatient Hysteroscopy - [TROPHY] in IVF Reprod Health 2009 Dec 3620
Third Statement
1 Junctional Zone Myoma should preferentially be treated by hysteroscopy
2 Feasibility of hysteroscopic surgery is predominantly related with size location and amount of myoma
3 Independently of distension medium used continuous fluid balance and flow distension control is mandatory
4 Complication risk is related to experience and surgical technique used
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Conventional hysteroscopic surgery
4 Laparoscopic surgery
Introduction
Intramural myoma larger than 4 cm related to the JZ myometriumschould be operated on
Laparoscopic approach has had an important evolution over the
years
Series with high success rate are done by experts =gt it is difficult to extrapolate to less experienced surgeons
Laparoscopic myomectomy needs expert skills in haemostasis dissection and suturing
How to minimize blood loss
bullA lot of techniques in order to minimize blood loss
GnRH agonists
Intramyometrial vasopressine
Oxytocin IV 40 mUImin intraoperatively
Use of tourniquet or penrose at the lower part of uterus
Laparoscopic Myomectomy
J Ferro IVI Valencia Spain
Tips amp tricks ndash minimize blood loss
Clipping of the uterine arteries and infundilopelvic ligaments is another very efficient method
Artery ligation versus Control group (n=152)
173 +- 91 mL vs 402 +- 131 mL blood loss
62 vs 2075 reccurence rate
Alborzi S et al A comparison of combined laparoscopic uterine artery ligation and myomectomyversus laparoscopic myomectomy in the treatment of symptomatic myoma Fertil Steril 2009
Tips amp tricks ndash minimize blood loss
Technique Incision
Incision
J Ferro A Wattiez
Tips amp tricks- dissection
Tips amp tricks- closure
bull One versus multiples layers controversial
bull Adequate closure of the dead space to minimize the risk of hematoma formation
bull Interrupted figure of eight sutures are usually sufficient monocryl 1 or 0 with extracorporeal notes =gt extra strength
bull For the serosa approximate with interrupted 20 sutures if necessary (monofilament)
Tips amp tricks- closure
Removal Clips
Anti- adhesion agents
Fourth Statement
LAPAROSCOPIC MYOMECTOMY offers comparable results tolaparotomic myomectomy
Laparoscopic approach reduces adhesion formation blood loss and hospital stay
Laparoscopic myomectomy seems indicated in the infertile patient for the treatment of intramural myomarsquos
Laparoscopic Myomectomy requires a skilled laparoscopic surgeon with expert suturing skills optimal instrumental support and knowledge of some trickrsquos to provide an optimal result
Take Home message
Submucous myoma should always be removed prior to IVF
Hysteroscopic resection is the gold standard to treat those myoma
Intramural myoma originating from the sub endometrial
myometrium and larger than 4 cm are treated by Laproscopy
Subserosal myoma do not influence the outcome of IVF and are not removed for this indication
More info on the special training
programsin endoscopic
surgery
ESGEORG
More info on the ESGE website
wwwesgeorg
See you in London
Rudi Campo Stephan GordtsPatrick PuttemansRoger MolinasSylvie GordtsMarion Valkenburg Ivo Brosens
Leuven Institute for Fertility
amp Embryology
Trophy Scope a new generation
Interesting Characteristics
Gliding system that provides
Diagnostic ( 29 mm ) and
Operative (44 mm)
possibilities in one instrument
This hysteroscope has been named after the multicentre study
TROPHY ldquoTrial of Outpatient Hysteroscopyrdquo for which it was designed
El-Toukhy T Campo R et al Trial of Outpatient Hysteroscopy - [TROPHY] in IVF Reprod Health 2009 Dec 3620
Fibroids and IVF
1 Scientific evidence
2 Diagnostic strategy
3 Conventional hysteroscopic surgery
4 Laparoscopic surgery
Introduction
Intramural myoma larger than 4 cm related to the JZ myometriumschould be operated on
Laparoscopic approach has had an important evolution over the
years
Series with high success rate are done by experts =gt it is difficult to extrapolate to less experienced surgeons
Laparoscopic myomectomy needs expert skills in haemostasis dissection and suturing
How to minimize blood loss
bullA lot of techniques in order to minimize blood loss
GnRH agonists
Intramyometrial vasopressine
Oxytocin IV 40 mUImin intraoperatively
Use of tourniquet or penrose at the lower part of uterus
Laparoscopic Myomectomy
J Ferro IVI Valencia Spain
Tips amp tricks ndash minimize blood loss
Clipping of the uterine arteries and infundilopelvic ligaments is another very efficient method
Artery ligation versus Control group (n=152)
173 +- 91 mL vs 402 +- 131 mL blood loss
62 vs 2075 reccurence rate
Alborzi S et al A comparison of combined laparoscopic uterine artery ligation and myomectomyversus laparoscopic myomectomy in the treatment of symptomatic myoma Fertil Steril 2009
Tips amp tricks ndash minimize blood loss
Technique Incision
Incision
J Ferro A Wattiez
Tips amp tricks- dissection
Tips amp tricks- closure
bull One versus multiples layers controversial
bull Adequate closure of the dead space to minimize the risk of hematoma formation
bull Interrupted figure of eight sutures are usually sufficient monocryl 1 or 0 with extracorporeal notes =gt extra strength
bull For the serosa approximate with interrupted 20 sutures if necessary (monofilament)
Tips amp tricks- closure
Removal Clips
Anti- adhesion agents
Fourth Statement
LAPAROSCOPIC MYOMECTOMY offers comparable results tolaparotomic myomectomy
Laparoscopic approach reduces adhesion formation blood loss and hospital stay
Laparoscopic myomectomy seems indicated in the infertile patient for the treatment of intramural myomarsquos
Laparoscopic Myomectomy requires a skilled laparoscopic surgeon with expert suturing skills optimal instrumental support and knowledge of some trickrsquos to provide an optimal result
Take Home message
Submucous myoma should always be removed prior to IVF
Hysteroscopic resection is the gold standard to treat those myoma
Intramural myoma originating from the sub endometrial
myometrium and larger than 4 cm are treated by Laproscopy
Subserosal myoma do not influence the outcome of IVF and are not removed for this indication
More info on the special training
programsin endoscopic
surgery
ESGEORG
More info on the ESGE website
wwwesgeorg
See you in London
Rudi Campo Stephan GordtsPatrick PuttemansRoger MolinasSylvie GordtsMarion Valkenburg Ivo Brosens
Leuven Institute for Fertility
amp Embryology
Trophy Scope a new generation
Interesting Characteristics
Gliding system that provides
Diagnostic ( 29 mm ) and
Operative (44 mm)
possibilities in one instrument
This hysteroscope has been named after the multicentre study
TROPHY ldquoTrial of Outpatient Hysteroscopyrdquo for which it was designed
El-Toukhy T Campo R et al Trial of Outpatient Hysteroscopy - [TROPHY] in IVF Reprod Health 2009 Dec 3620
Introduction
Intramural myoma larger than 4 cm related to the JZ myometriumschould be operated on
Laparoscopic approach has had an important evolution over the
years
Series with high success rate are done by experts =gt it is difficult to extrapolate to less experienced surgeons
Laparoscopic myomectomy needs expert skills in haemostasis dissection and suturing
How to minimize blood loss
bullA lot of techniques in order to minimize blood loss
GnRH agonists
Intramyometrial vasopressine
Oxytocin IV 40 mUImin intraoperatively
Use of tourniquet or penrose at the lower part of uterus
Laparoscopic Myomectomy
J Ferro IVI Valencia Spain
Tips amp tricks ndash minimize blood loss
Clipping of the uterine arteries and infundilopelvic ligaments is another very efficient method
Artery ligation versus Control group (n=152)
173 +- 91 mL vs 402 +- 131 mL blood loss
62 vs 2075 reccurence rate
Alborzi S et al A comparison of combined laparoscopic uterine artery ligation and myomectomyversus laparoscopic myomectomy in the treatment of symptomatic myoma Fertil Steril 2009
Tips amp tricks ndash minimize blood loss
Technique Incision
Incision
J Ferro A Wattiez
Tips amp tricks- dissection
Tips amp tricks- closure
bull One versus multiples layers controversial
bull Adequate closure of the dead space to minimize the risk of hematoma formation
bull Interrupted figure of eight sutures are usually sufficient monocryl 1 or 0 with extracorporeal notes =gt extra strength
bull For the serosa approximate with interrupted 20 sutures if necessary (monofilament)
Tips amp tricks- closure
Removal Clips
Anti- adhesion agents
Fourth Statement
LAPAROSCOPIC MYOMECTOMY offers comparable results tolaparotomic myomectomy
Laparoscopic approach reduces adhesion formation blood loss and hospital stay
Laparoscopic myomectomy seems indicated in the infertile patient for the treatment of intramural myomarsquos
Laparoscopic Myomectomy requires a skilled laparoscopic surgeon with expert suturing skills optimal instrumental support and knowledge of some trickrsquos to provide an optimal result
Take Home message
Submucous myoma should always be removed prior to IVF
Hysteroscopic resection is the gold standard to treat those myoma
Intramural myoma originating from the sub endometrial
myometrium and larger than 4 cm are treated by Laproscopy
Subserosal myoma do not influence the outcome of IVF and are not removed for this indication
More info on the special training
programsin endoscopic
surgery
ESGEORG
More info on the ESGE website
wwwesgeorg
See you in London
Rudi Campo Stephan GordtsPatrick PuttemansRoger MolinasSylvie GordtsMarion Valkenburg Ivo Brosens
Leuven Institute for Fertility
amp Embryology
Trophy Scope a new generation
Interesting Characteristics
Gliding system that provides
Diagnostic ( 29 mm ) and
Operative (44 mm)
possibilities in one instrument
This hysteroscope has been named after the multicentre study
TROPHY ldquoTrial of Outpatient Hysteroscopyrdquo for which it was designed
El-Toukhy T Campo R et al Trial of Outpatient Hysteroscopy - [TROPHY] in IVF Reprod Health 2009 Dec 3620
How to minimize blood loss
bullA lot of techniques in order to minimize blood loss
GnRH agonists
Intramyometrial vasopressine
Oxytocin IV 40 mUImin intraoperatively
Use of tourniquet or penrose at the lower part of uterus
Laparoscopic Myomectomy
J Ferro IVI Valencia Spain
Tips amp tricks ndash minimize blood loss
Clipping of the uterine arteries and infundilopelvic ligaments is another very efficient method
Artery ligation versus Control group (n=152)
173 +- 91 mL vs 402 +- 131 mL blood loss
62 vs 2075 reccurence rate
Alborzi S et al A comparison of combined laparoscopic uterine artery ligation and myomectomyversus laparoscopic myomectomy in the treatment of symptomatic myoma Fertil Steril 2009
Tips amp tricks ndash minimize blood loss
Technique Incision
Incision
J Ferro A Wattiez
Tips amp tricks- dissection
Tips amp tricks- closure
bull One versus multiples layers controversial
bull Adequate closure of the dead space to minimize the risk of hematoma formation
bull Interrupted figure of eight sutures are usually sufficient monocryl 1 or 0 with extracorporeal notes =gt extra strength
bull For the serosa approximate with interrupted 20 sutures if necessary (monofilament)
Tips amp tricks- closure
Removal Clips
Anti- adhesion agents
Fourth Statement
LAPAROSCOPIC MYOMECTOMY offers comparable results tolaparotomic myomectomy
Laparoscopic approach reduces adhesion formation blood loss and hospital stay
Laparoscopic myomectomy seems indicated in the infertile patient for the treatment of intramural myomarsquos
Laparoscopic Myomectomy requires a skilled laparoscopic surgeon with expert suturing skills optimal instrumental support and knowledge of some trickrsquos to provide an optimal result
Take Home message
Submucous myoma should always be removed prior to IVF
Hysteroscopic resection is the gold standard to treat those myoma
Intramural myoma originating from the sub endometrial
myometrium and larger than 4 cm are treated by Laproscopy
Subserosal myoma do not influence the outcome of IVF and are not removed for this indication
More info on the special training
programsin endoscopic
surgery
ESGEORG
More info on the ESGE website
wwwesgeorg
See you in London
Rudi Campo Stephan GordtsPatrick PuttemansRoger MolinasSylvie GordtsMarion Valkenburg Ivo Brosens
Leuven Institute for Fertility
amp Embryology
Trophy Scope a new generation
Interesting Characteristics
Gliding system that provides
Diagnostic ( 29 mm ) and
Operative (44 mm)
possibilities in one instrument
This hysteroscope has been named after the multicentre study
TROPHY ldquoTrial of Outpatient Hysteroscopyrdquo for which it was designed
El-Toukhy T Campo R et al Trial of Outpatient Hysteroscopy - [TROPHY] in IVF Reprod Health 2009 Dec 3620
Laparoscopic Myomectomy
J Ferro IVI Valencia Spain
Tips amp tricks ndash minimize blood loss
Clipping of the uterine arteries and infundilopelvic ligaments is another very efficient method
Artery ligation versus Control group (n=152)
173 +- 91 mL vs 402 +- 131 mL blood loss
62 vs 2075 reccurence rate
Alborzi S et al A comparison of combined laparoscopic uterine artery ligation and myomectomyversus laparoscopic myomectomy in the treatment of symptomatic myoma Fertil Steril 2009
Tips amp tricks ndash minimize blood loss
Technique Incision
Incision
J Ferro A Wattiez
Tips amp tricks- dissection
Tips amp tricks- closure
bull One versus multiples layers controversial
bull Adequate closure of the dead space to minimize the risk of hematoma formation
bull Interrupted figure of eight sutures are usually sufficient monocryl 1 or 0 with extracorporeal notes =gt extra strength
bull For the serosa approximate with interrupted 20 sutures if necessary (monofilament)
Tips amp tricks- closure
Removal Clips
Anti- adhesion agents
Fourth Statement
LAPAROSCOPIC MYOMECTOMY offers comparable results tolaparotomic myomectomy
Laparoscopic approach reduces adhesion formation blood loss and hospital stay
Laparoscopic myomectomy seems indicated in the infertile patient for the treatment of intramural myomarsquos
Laparoscopic Myomectomy requires a skilled laparoscopic surgeon with expert suturing skills optimal instrumental support and knowledge of some trickrsquos to provide an optimal result
Take Home message
Submucous myoma should always be removed prior to IVF
Hysteroscopic resection is the gold standard to treat those myoma
Intramural myoma originating from the sub endometrial
myometrium and larger than 4 cm are treated by Laproscopy
Subserosal myoma do not influence the outcome of IVF and are not removed for this indication
More info on the special training
programsin endoscopic
surgery
ESGEORG
More info on the ESGE website
wwwesgeorg
See you in London
Rudi Campo Stephan GordtsPatrick PuttemansRoger MolinasSylvie GordtsMarion Valkenburg Ivo Brosens
Leuven Institute for Fertility
amp Embryology
Trophy Scope a new generation
Interesting Characteristics
Gliding system that provides
Diagnostic ( 29 mm ) and
Operative (44 mm)
possibilities in one instrument
This hysteroscope has been named after the multicentre study
TROPHY ldquoTrial of Outpatient Hysteroscopyrdquo for which it was designed
El-Toukhy T Campo R et al Trial of Outpatient Hysteroscopy - [TROPHY] in IVF Reprod Health 2009 Dec 3620
Tips amp tricks ndash minimize blood loss
Clipping of the uterine arteries and infundilopelvic ligaments is another very efficient method
Artery ligation versus Control group (n=152)
173 +- 91 mL vs 402 +- 131 mL blood loss
62 vs 2075 reccurence rate
Alborzi S et al A comparison of combined laparoscopic uterine artery ligation and myomectomyversus laparoscopic myomectomy in the treatment of symptomatic myoma Fertil Steril 2009
Tips amp tricks ndash minimize blood loss
Technique Incision
Incision
J Ferro A Wattiez
Tips amp tricks- dissection
Tips amp tricks- closure
bull One versus multiples layers controversial
bull Adequate closure of the dead space to minimize the risk of hematoma formation
bull Interrupted figure of eight sutures are usually sufficient monocryl 1 or 0 with extracorporeal notes =gt extra strength
bull For the serosa approximate with interrupted 20 sutures if necessary (monofilament)
Tips amp tricks- closure
Removal Clips
Anti- adhesion agents
Fourth Statement
LAPAROSCOPIC MYOMECTOMY offers comparable results tolaparotomic myomectomy
Laparoscopic approach reduces adhesion formation blood loss and hospital stay
Laparoscopic myomectomy seems indicated in the infertile patient for the treatment of intramural myomarsquos
Laparoscopic Myomectomy requires a skilled laparoscopic surgeon with expert suturing skills optimal instrumental support and knowledge of some trickrsquos to provide an optimal result
Take Home message
Submucous myoma should always be removed prior to IVF
Hysteroscopic resection is the gold standard to treat those myoma
Intramural myoma originating from the sub endometrial
myometrium and larger than 4 cm are treated by Laproscopy
Subserosal myoma do not influence the outcome of IVF and are not removed for this indication
More info on the special training
programsin endoscopic
surgery
ESGEORG
More info on the ESGE website
wwwesgeorg
See you in London
Rudi Campo Stephan GordtsPatrick PuttemansRoger MolinasSylvie GordtsMarion Valkenburg Ivo Brosens
Leuven Institute for Fertility
amp Embryology
Trophy Scope a new generation
Interesting Characteristics
Gliding system that provides
Diagnostic ( 29 mm ) and
Operative (44 mm)
possibilities in one instrument
This hysteroscope has been named after the multicentre study
TROPHY ldquoTrial of Outpatient Hysteroscopyrdquo for which it was designed
El-Toukhy T Campo R et al Trial of Outpatient Hysteroscopy - [TROPHY] in IVF Reprod Health 2009 Dec 3620
Tips amp tricks ndash minimize blood loss
Technique Incision
Incision
J Ferro A Wattiez
Tips amp tricks- dissection
Tips amp tricks- closure
bull One versus multiples layers controversial
bull Adequate closure of the dead space to minimize the risk of hematoma formation
bull Interrupted figure of eight sutures are usually sufficient monocryl 1 or 0 with extracorporeal notes =gt extra strength
bull For the serosa approximate with interrupted 20 sutures if necessary (monofilament)
Tips amp tricks- closure
Removal Clips
Anti- adhesion agents
Fourth Statement
LAPAROSCOPIC MYOMECTOMY offers comparable results tolaparotomic myomectomy
Laparoscopic approach reduces adhesion formation blood loss and hospital stay
Laparoscopic myomectomy seems indicated in the infertile patient for the treatment of intramural myomarsquos
Laparoscopic Myomectomy requires a skilled laparoscopic surgeon with expert suturing skills optimal instrumental support and knowledge of some trickrsquos to provide an optimal result
Take Home message
Submucous myoma should always be removed prior to IVF
Hysteroscopic resection is the gold standard to treat those myoma
Intramural myoma originating from the sub endometrial
myometrium and larger than 4 cm are treated by Laproscopy
Subserosal myoma do not influence the outcome of IVF and are not removed for this indication
More info on the special training
programsin endoscopic
surgery
ESGEORG
More info on the ESGE website
wwwesgeorg
See you in London
Rudi Campo Stephan GordtsPatrick PuttemansRoger MolinasSylvie GordtsMarion Valkenburg Ivo Brosens
Leuven Institute for Fertility
amp Embryology
Trophy Scope a new generation
Interesting Characteristics
Gliding system that provides
Diagnostic ( 29 mm ) and
Operative (44 mm)
possibilities in one instrument
This hysteroscope has been named after the multicentre study
TROPHY ldquoTrial of Outpatient Hysteroscopyrdquo for which it was designed
El-Toukhy T Campo R et al Trial of Outpatient Hysteroscopy - [TROPHY] in IVF Reprod Health 2009 Dec 3620
Technique Incision
Incision
J Ferro A Wattiez
Tips amp tricks- dissection
Tips amp tricks- closure
bull One versus multiples layers controversial
bull Adequate closure of the dead space to minimize the risk of hematoma formation
bull Interrupted figure of eight sutures are usually sufficient monocryl 1 or 0 with extracorporeal notes =gt extra strength
bull For the serosa approximate with interrupted 20 sutures if necessary (monofilament)
Tips amp tricks- closure
Removal Clips
Anti- adhesion agents
Fourth Statement
LAPAROSCOPIC MYOMECTOMY offers comparable results tolaparotomic myomectomy
Laparoscopic approach reduces adhesion formation blood loss and hospital stay
Laparoscopic myomectomy seems indicated in the infertile patient for the treatment of intramural myomarsquos
Laparoscopic Myomectomy requires a skilled laparoscopic surgeon with expert suturing skills optimal instrumental support and knowledge of some trickrsquos to provide an optimal result
Take Home message
Submucous myoma should always be removed prior to IVF
Hysteroscopic resection is the gold standard to treat those myoma
Intramural myoma originating from the sub endometrial
myometrium and larger than 4 cm are treated by Laproscopy
Subserosal myoma do not influence the outcome of IVF and are not removed for this indication
More info on the special training
programsin endoscopic
surgery
ESGEORG
More info on the ESGE website
wwwesgeorg
See you in London
Rudi Campo Stephan GordtsPatrick PuttemansRoger MolinasSylvie GordtsMarion Valkenburg Ivo Brosens
Leuven Institute for Fertility
amp Embryology
Trophy Scope a new generation
Interesting Characteristics
Gliding system that provides
Diagnostic ( 29 mm ) and
Operative (44 mm)
possibilities in one instrument
This hysteroscope has been named after the multicentre study
TROPHY ldquoTrial of Outpatient Hysteroscopyrdquo for which it was designed
El-Toukhy T Campo R et al Trial of Outpatient Hysteroscopy - [TROPHY] in IVF Reprod Health 2009 Dec 3620
Incision
J Ferro A Wattiez
Tips amp tricks- dissection
Tips amp tricks- closure
bull One versus multiples layers controversial
bull Adequate closure of the dead space to minimize the risk of hematoma formation
bull Interrupted figure of eight sutures are usually sufficient monocryl 1 or 0 with extracorporeal notes =gt extra strength
bull For the serosa approximate with interrupted 20 sutures if necessary (monofilament)
Tips amp tricks- closure
Removal Clips
Anti- adhesion agents
Fourth Statement
LAPAROSCOPIC MYOMECTOMY offers comparable results tolaparotomic myomectomy
Laparoscopic approach reduces adhesion formation blood loss and hospital stay
Laparoscopic myomectomy seems indicated in the infertile patient for the treatment of intramural myomarsquos
Laparoscopic Myomectomy requires a skilled laparoscopic surgeon with expert suturing skills optimal instrumental support and knowledge of some trickrsquos to provide an optimal result
Take Home message
Submucous myoma should always be removed prior to IVF
Hysteroscopic resection is the gold standard to treat those myoma
Intramural myoma originating from the sub endometrial
myometrium and larger than 4 cm are treated by Laproscopy
Subserosal myoma do not influence the outcome of IVF and are not removed for this indication
More info on the special training
programsin endoscopic
surgery
ESGEORG
More info on the ESGE website
wwwesgeorg
See you in London
Rudi Campo Stephan GordtsPatrick PuttemansRoger MolinasSylvie GordtsMarion Valkenburg Ivo Brosens
Leuven Institute for Fertility
amp Embryology
Trophy Scope a new generation
Interesting Characteristics
Gliding system that provides
Diagnostic ( 29 mm ) and
Operative (44 mm)
possibilities in one instrument
This hysteroscope has been named after the multicentre study
TROPHY ldquoTrial of Outpatient Hysteroscopyrdquo for which it was designed
El-Toukhy T Campo R et al Trial of Outpatient Hysteroscopy - [TROPHY] in IVF Reprod Health 2009 Dec 3620
Tips amp tricks- dissection
Tips amp tricks- closure
bull One versus multiples layers controversial
bull Adequate closure of the dead space to minimize the risk of hematoma formation
bull Interrupted figure of eight sutures are usually sufficient monocryl 1 or 0 with extracorporeal notes =gt extra strength
bull For the serosa approximate with interrupted 20 sutures if necessary (monofilament)
Tips amp tricks- closure
Removal Clips
Anti- adhesion agents
Fourth Statement
LAPAROSCOPIC MYOMECTOMY offers comparable results tolaparotomic myomectomy
Laparoscopic approach reduces adhesion formation blood loss and hospital stay
Laparoscopic myomectomy seems indicated in the infertile patient for the treatment of intramural myomarsquos
Laparoscopic Myomectomy requires a skilled laparoscopic surgeon with expert suturing skills optimal instrumental support and knowledge of some trickrsquos to provide an optimal result
Take Home message
Submucous myoma should always be removed prior to IVF
Hysteroscopic resection is the gold standard to treat those myoma
Intramural myoma originating from the sub endometrial
myometrium and larger than 4 cm are treated by Laproscopy
Subserosal myoma do not influence the outcome of IVF and are not removed for this indication
More info on the special training
programsin endoscopic
surgery
ESGEORG
More info on the ESGE website
wwwesgeorg
See you in London
Rudi Campo Stephan GordtsPatrick PuttemansRoger MolinasSylvie GordtsMarion Valkenburg Ivo Brosens
Leuven Institute for Fertility
amp Embryology
Trophy Scope a new generation
Interesting Characteristics
Gliding system that provides
Diagnostic ( 29 mm ) and
Operative (44 mm)
possibilities in one instrument
This hysteroscope has been named after the multicentre study
TROPHY ldquoTrial of Outpatient Hysteroscopyrdquo for which it was designed
El-Toukhy T Campo R et al Trial of Outpatient Hysteroscopy - [TROPHY] in IVF Reprod Health 2009 Dec 3620
Tips amp tricks- closure
bull One versus multiples layers controversial
bull Adequate closure of the dead space to minimize the risk of hematoma formation
bull Interrupted figure of eight sutures are usually sufficient monocryl 1 or 0 with extracorporeal notes =gt extra strength
bull For the serosa approximate with interrupted 20 sutures if necessary (monofilament)
Tips amp tricks- closure
Removal Clips
Anti- adhesion agents
Fourth Statement
LAPAROSCOPIC MYOMECTOMY offers comparable results tolaparotomic myomectomy
Laparoscopic approach reduces adhesion formation blood loss and hospital stay
Laparoscopic myomectomy seems indicated in the infertile patient for the treatment of intramural myomarsquos
Laparoscopic Myomectomy requires a skilled laparoscopic surgeon with expert suturing skills optimal instrumental support and knowledge of some trickrsquos to provide an optimal result
Take Home message
Submucous myoma should always be removed prior to IVF
Hysteroscopic resection is the gold standard to treat those myoma
Intramural myoma originating from the sub endometrial
myometrium and larger than 4 cm are treated by Laproscopy
Subserosal myoma do not influence the outcome of IVF and are not removed for this indication
More info on the special training
programsin endoscopic
surgery
ESGEORG
More info on the ESGE website
wwwesgeorg
See you in London
Rudi Campo Stephan GordtsPatrick PuttemansRoger MolinasSylvie GordtsMarion Valkenburg Ivo Brosens
Leuven Institute for Fertility
amp Embryology
Trophy Scope a new generation
Interesting Characteristics
Gliding system that provides
Diagnostic ( 29 mm ) and
Operative (44 mm)
possibilities in one instrument
This hysteroscope has been named after the multicentre study
TROPHY ldquoTrial of Outpatient Hysteroscopyrdquo for which it was designed
El-Toukhy T Campo R et al Trial of Outpatient Hysteroscopy - [TROPHY] in IVF Reprod Health 2009 Dec 3620
Tips amp tricks- closure
Removal Clips
Anti- adhesion agents
Fourth Statement
LAPAROSCOPIC MYOMECTOMY offers comparable results tolaparotomic myomectomy
Laparoscopic approach reduces adhesion formation blood loss and hospital stay
Laparoscopic myomectomy seems indicated in the infertile patient for the treatment of intramural myomarsquos
Laparoscopic Myomectomy requires a skilled laparoscopic surgeon with expert suturing skills optimal instrumental support and knowledge of some trickrsquos to provide an optimal result
Take Home message
Submucous myoma should always be removed prior to IVF
Hysteroscopic resection is the gold standard to treat those myoma
Intramural myoma originating from the sub endometrial
myometrium and larger than 4 cm are treated by Laproscopy
Subserosal myoma do not influence the outcome of IVF and are not removed for this indication
More info on the special training
programsin endoscopic
surgery
ESGEORG
More info on the ESGE website
wwwesgeorg
See you in London
Rudi Campo Stephan GordtsPatrick PuttemansRoger MolinasSylvie GordtsMarion Valkenburg Ivo Brosens
Leuven Institute for Fertility
amp Embryology
Trophy Scope a new generation
Interesting Characteristics
Gliding system that provides
Diagnostic ( 29 mm ) and
Operative (44 mm)
possibilities in one instrument
This hysteroscope has been named after the multicentre study
TROPHY ldquoTrial of Outpatient Hysteroscopyrdquo for which it was designed
El-Toukhy T Campo R et al Trial of Outpatient Hysteroscopy - [TROPHY] in IVF Reprod Health 2009 Dec 3620
Removal Clips
Anti- adhesion agents
Fourth Statement
LAPAROSCOPIC MYOMECTOMY offers comparable results tolaparotomic myomectomy
Laparoscopic approach reduces adhesion formation blood loss and hospital stay
Laparoscopic myomectomy seems indicated in the infertile patient for the treatment of intramural myomarsquos
Laparoscopic Myomectomy requires a skilled laparoscopic surgeon with expert suturing skills optimal instrumental support and knowledge of some trickrsquos to provide an optimal result
Take Home message
Submucous myoma should always be removed prior to IVF
Hysteroscopic resection is the gold standard to treat those myoma
Intramural myoma originating from the sub endometrial
myometrium and larger than 4 cm are treated by Laproscopy
Subserosal myoma do not influence the outcome of IVF and are not removed for this indication
More info on the special training
programsin endoscopic
surgery
ESGEORG
More info on the ESGE website
wwwesgeorg
See you in London
Rudi Campo Stephan GordtsPatrick PuttemansRoger MolinasSylvie GordtsMarion Valkenburg Ivo Brosens
Leuven Institute for Fertility
amp Embryology
Trophy Scope a new generation
Interesting Characteristics
Gliding system that provides
Diagnostic ( 29 mm ) and
Operative (44 mm)
possibilities in one instrument
This hysteroscope has been named after the multicentre study
TROPHY ldquoTrial of Outpatient Hysteroscopyrdquo for which it was designed
El-Toukhy T Campo R et al Trial of Outpatient Hysteroscopy - [TROPHY] in IVF Reprod Health 2009 Dec 3620
Anti- adhesion agents
Fourth Statement
LAPAROSCOPIC MYOMECTOMY offers comparable results tolaparotomic myomectomy
Laparoscopic approach reduces adhesion formation blood loss and hospital stay
Laparoscopic myomectomy seems indicated in the infertile patient for the treatment of intramural myomarsquos
Laparoscopic Myomectomy requires a skilled laparoscopic surgeon with expert suturing skills optimal instrumental support and knowledge of some trickrsquos to provide an optimal result
Take Home message
Submucous myoma should always be removed prior to IVF
Hysteroscopic resection is the gold standard to treat those myoma
Intramural myoma originating from the sub endometrial
myometrium and larger than 4 cm are treated by Laproscopy
Subserosal myoma do not influence the outcome of IVF and are not removed for this indication
More info on the special training
programsin endoscopic
surgery
ESGEORG
More info on the ESGE website
wwwesgeorg
See you in London
Rudi Campo Stephan GordtsPatrick PuttemansRoger MolinasSylvie GordtsMarion Valkenburg Ivo Brosens
Leuven Institute for Fertility
amp Embryology
Trophy Scope a new generation
Interesting Characteristics
Gliding system that provides
Diagnostic ( 29 mm ) and
Operative (44 mm)
possibilities in one instrument
This hysteroscope has been named after the multicentre study
TROPHY ldquoTrial of Outpatient Hysteroscopyrdquo for which it was designed
El-Toukhy T Campo R et al Trial of Outpatient Hysteroscopy - [TROPHY] in IVF Reprod Health 2009 Dec 3620
Fourth Statement
LAPAROSCOPIC MYOMECTOMY offers comparable results tolaparotomic myomectomy
Laparoscopic approach reduces adhesion formation blood loss and hospital stay
Laparoscopic myomectomy seems indicated in the infertile patient for the treatment of intramural myomarsquos
Laparoscopic Myomectomy requires a skilled laparoscopic surgeon with expert suturing skills optimal instrumental support and knowledge of some trickrsquos to provide an optimal result
Take Home message
Submucous myoma should always be removed prior to IVF
Hysteroscopic resection is the gold standard to treat those myoma
Intramural myoma originating from the sub endometrial
myometrium and larger than 4 cm are treated by Laproscopy
Subserosal myoma do not influence the outcome of IVF and are not removed for this indication
More info on the special training
programsin endoscopic
surgery
ESGEORG
More info on the ESGE website
wwwesgeorg
See you in London
Rudi Campo Stephan GordtsPatrick PuttemansRoger MolinasSylvie GordtsMarion Valkenburg Ivo Brosens
Leuven Institute for Fertility
amp Embryology
Trophy Scope a new generation
Interesting Characteristics
Gliding system that provides
Diagnostic ( 29 mm ) and
Operative (44 mm)
possibilities in one instrument
This hysteroscope has been named after the multicentre study
TROPHY ldquoTrial of Outpatient Hysteroscopyrdquo for which it was designed
El-Toukhy T Campo R et al Trial of Outpatient Hysteroscopy - [TROPHY] in IVF Reprod Health 2009 Dec 3620
Take Home message
Submucous myoma should always be removed prior to IVF
Hysteroscopic resection is the gold standard to treat those myoma
Intramural myoma originating from the sub endometrial
myometrium and larger than 4 cm are treated by Laproscopy
Subserosal myoma do not influence the outcome of IVF and are not removed for this indication
More info on the special training
programsin endoscopic
surgery
ESGEORG
More info on the ESGE website
wwwesgeorg
See you in London
Rudi Campo Stephan GordtsPatrick PuttemansRoger MolinasSylvie GordtsMarion Valkenburg Ivo Brosens
Leuven Institute for Fertility
amp Embryology
Trophy Scope a new generation
Interesting Characteristics
Gliding system that provides
Diagnostic ( 29 mm ) and
Operative (44 mm)
possibilities in one instrument
This hysteroscope has been named after the multicentre study
TROPHY ldquoTrial of Outpatient Hysteroscopyrdquo for which it was designed
El-Toukhy T Campo R et al Trial of Outpatient Hysteroscopy - [TROPHY] in IVF Reprod Health 2009 Dec 3620
More info on the special training
programsin endoscopic
surgery
ESGEORG
More info on the ESGE website
wwwesgeorg
See you in London
Rudi Campo Stephan GordtsPatrick PuttemansRoger MolinasSylvie GordtsMarion Valkenburg Ivo Brosens
Leuven Institute for Fertility
amp Embryology
Trophy Scope a new generation
Interesting Characteristics
Gliding system that provides
Diagnostic ( 29 mm ) and
Operative (44 mm)
possibilities in one instrument
This hysteroscope has been named after the multicentre study
TROPHY ldquoTrial of Outpatient Hysteroscopyrdquo for which it was designed
El-Toukhy T Campo R et al Trial of Outpatient Hysteroscopy - [TROPHY] in IVF Reprod Health 2009 Dec 3620
More info on the ESGE website
wwwesgeorg
See you in London
Rudi Campo Stephan GordtsPatrick PuttemansRoger MolinasSylvie GordtsMarion Valkenburg Ivo Brosens
Leuven Institute for Fertility
amp Embryology
Trophy Scope a new generation
Interesting Characteristics
Gliding system that provides
Diagnostic ( 29 mm ) and
Operative (44 mm)
possibilities in one instrument
This hysteroscope has been named after the multicentre study
TROPHY ldquoTrial of Outpatient Hysteroscopyrdquo for which it was designed
El-Toukhy T Campo R et al Trial of Outpatient Hysteroscopy - [TROPHY] in IVF Reprod Health 2009 Dec 3620
Rudi Campo Stephan GordtsPatrick PuttemansRoger MolinasSylvie GordtsMarion Valkenburg Ivo Brosens
Leuven Institute for Fertility
amp Embryology
Trophy Scope a new generation
Interesting Characteristics
Gliding system that provides
Diagnostic ( 29 mm ) and
Operative (44 mm)
possibilities in one instrument
This hysteroscope has been named after the multicentre study
TROPHY ldquoTrial of Outpatient Hysteroscopyrdquo for which it was designed
El-Toukhy T Campo R et al Trial of Outpatient Hysteroscopy - [TROPHY] in IVF Reprod Health 2009 Dec 3620
Trophy Scope a new generation
Interesting Characteristics
Gliding system that provides
Diagnostic ( 29 mm ) and
Operative (44 mm)
possibilities in one instrument
This hysteroscope has been named after the multicentre study
TROPHY ldquoTrial of Outpatient Hysteroscopyrdquo for which it was designed
El-Toukhy T Campo R et al Trial of Outpatient Hysteroscopy - [TROPHY] in IVF Reprod Health 2009 Dec 3620