Surgical Options for FIGO Type 2 Fibroid in a 35-Year-Old Wanting to Preserve Fertility (After Failed Medical Management)

Understanding FIGO Type 2

Primary Option: Hysteroscopic Myomectomy (Preferred When Feasible)

• Avoids a uterine incision, so there is no scar in the myometrium - this eliminates the risk of uterine rupture in subsequent pregnancy
• Shorter recovery, same-day or overnight procedure
• Direct visualization of the endometrial cavity allows concurrent treatment of any cavity distortion
• Well-established improvement in pregnancy outcomes when submucosal fibroids distort the cavity

• Type 2 is the most challenging class for hysteroscopic resection because the majority of the fibroid is intramural
• For larger type 2 fibroids, a two-stage hysteroscopic procedure is often necessary: resect the intracavitary component first, then allow the remaining intramural component to migrate into the cavity over several weeks before resecting the rest
• Risks include: fluid overload from distension media (hyponatraemia), uterine perforation, thermal injury, intrauterine adhesion (Asherman's syndrome) formation post-resection
• A 2026 paper (PMID 42050576) specifically studied intrauterine adhesion formation after hysteroscopic myomectomy and found perioperative inflammatory response to be a key determinant - adjunctive measures (estrogen, hyaluronic acid gel) are used to reduce this risk

Second Option: Laparoscopic Myomectomy

• Shorter hospital stay (p=0.04)
• Less intraoperative blood loss (p<0.00001)
• Shorter ileus duration (p<0.00001)
• Fewer episodes of postoperative fever (p=0.04)
• Reproductive outcomes (pregnancy rate, preterm delivery, delivery mode) were equivalent to mini-laparotomy

Third Option: Open (Abdominal) Myomectomy

• Very large fibroids (>10 cm) or numerous fibroids making laparoscopy technically difficult
• Inaccessible fibroid location
• Failed laparoscopic approach
• Deep intramural involvement making multilayered closure difficult laparoscopically

Key Preoperative Consideration: GnRH Agonist Pretreatment

• GnRH agonist (e.g., leuprolide) for 2-3 months preoperatively can reduce fibroid volume by ~30% and uterine volume by ~35%, reduce blood loss at surgery, and correct anaemia
• This is especially helpful before hysteroscopic resection of large type 2 fibroids, as reducing the intramural component may make single-stage hysteroscopy feasible
• Ulipristal acetate (selective progesterone receptor modulator) was previously used for preoperative downsizing but has been suspended in many countries due to rare but serious hepatotoxicity

What to Avoid in a Fertility-Preserving Context

• Uterine artery embolization (UAE) - Not recommended if future pregnancy is desired. UAE can cause non-target embolization of ovarian vasculature, premature ovarian failure, and significantly higher rates of miscarriage and placental complications compared to myomectomy
• Endometrial ablation - Absolutely contraindicated if fertility is desired
• Radiofrequency ablation (Acessa/transcervical radiofrequency) - Fertility data are limited; currently not recommended as standard of care for women actively trying to conceive
• Hysterectomy - Definitively excluded given the patient's fertility wishes

Recommended Surgical Decision Pathway for This Patient

FIGO Type 2 fibroid, 35F, fertility-preserving, failed medical management
           ↓
Assess fibroid size, number, MRI to map intramural depth
           ↓
Size ≤4 cm, single, accessible → Attempt hysteroscopic myomectomy
  (consider 2-stage technique if large intramural component)
           ↓
Size >4-5 cm, multiple, or failed hysteroscopic attempt
           ↓
Laparoscopic myomectomy (surgeon experience essential; multilayer closure mandatory)
           ↓
Very large, numerous, or technically difficult laparoscopically
           ↓
Open (abdominal) myomectomy

Postoperative Fertility Counselling

• Trial of labor after myomectomy carries a 0.47% risk of uterine rupture (comparable to trial of labor after cesarean)
• Caesarean delivery is recommended if the endometrial cavity was entered during myomectomy or the repair was complex
• Allow 3-6 months of uterine healing before attempting conception
• Fibroid recurrence rates after myomectomy are meaningful (~20-30% at 5 years radiologically, ~10% requiring repeat surgery) - counsel regarding the reproductive time window

• Berek & Novak's Gynecology (Berek & Novak, 2020)
• Sabiston Textbook of Surgery, 21st ed.
• Bailey and Love's Short Practice of Surgery, 28th ed.
• Tsiampa et al. (2024) - Systematic review: laparoscopic vs. mini-laparotomy myomectomy [PMID 37566224]
• Zhao et al. (2026) - Meta-analysis: recurrence after laparoscopic myomectomy [PMID 41846572]
• Wang et al. (2025) - Review: TCRM technique [PMID 39794046]

Hysteroscopic Myomectomy (TCRM) - Images & Operative Steps

Fibroid Classification Diagram (Textbook)

Procedural Step Diagram

Step-by-Step Operative Technique

Preoperative Preparation

• MRI (preferred) or saline infusion sonography (SIS) to map the fibroid - specifically to measure the thickness of myometrium between the fibroid and serosa. For type 2 fibroids, this is the single most important safety parameter; if the residual myometrial mantle is <5 mm, the risk of perforation with the loop electrode is significantly elevated.
• Plan for single-stage vs. two-stage procedure based on size and intramural depth.

• 2-3 months of GnRH agonist (e.g. leuprolide 3.75 mg IM monthly) to reduce fibroid volume by ~30% and thin the endometrium, improving hysteroscopic visualization and potentially converting a type 2 to a more favorable type 1 profile.

• Misoprostol (Cytotec) 400 mcg vaginally 8-12 hours preoperatively to soften and partially dilate the cervix, facilitating easier and safer passage of the resectoscope.

Intraoperative Steps

• Under general or regional anaesthesia, dilate the cervix to Hegar 9-10 (sufficient to admit the resectoscope, typically 9 mm outer diameter).
• Dilation should be gentle and graduated to avoid false passages or perforation at the internal os.

• Insert the operative hysteroscope/resectoscope under continuous distension fluid flow.
• Distension media choice:
  • Bipolar resectoscope → normal saline or Lactated Ringer's (isotonic; safe fluid deficit limit: 2,500 mL)
  • Monopolar resectoscope → sorbitol 5%, sorbitol/mannitol, or glycine 1.5% (hypotonic; fluid deficit limit: 1,000 mL - must terminate earlier to prevent hyponatraemia)
• Modern practice strongly favours bipolar with isotonic saline to reduce electrolyte risk.
• Perform a full panoramic survey of the uterine cavity, identify the fibroid, note its relationship to the tubal ostia, assess the endometrium.

• Position the cutting loop beyond the fibroid (distal to it).
• Activate electrosurgical current only while drawing the loop toward the surgeon (never advancing the loop while powered - to prevent uncontrolled cutting).
• Shave the fibroid systematically in chips/slices from its most prominent intracavitary portion downward.
• Resect down to the level of the surrounding myometrium - do not go deeper.
• For fertility preservation: minimize thermal spread to surrounding normal myometrium; use short controlled bursts rather than continuous activation.

• Chips of fibroid tissue are removed from the cavity either:
  • With a grasping forceps (polyp forceps) - retrieve visible fragments
  • By capturing fragments with the loop and withdrawing the entire telescope together
  • With a hysteroscopic tissue removal (HTR/intrauterine morcellator) system - mechanically cuts and aspirates simultaneously in saline; systematic reviews show equivalent complete resection rates to classical resectoscopy with no significant increase in complications

• After resecting the intracavitary portion, the remaining intramural fibroid mass often spontaneously contracts and is pushed into the cavity by uterine muscle contractions over the following weeks.
• Two-stage approach: If significant intramural component remains after the first resection, terminate the procedure (especially if fluid deficit limits are approaching), allow 6-8 weeks for the residual fibroid to migrate into the cavity, then perform a second hysteroscopic resection. This is the standard, safe approach for type 2 fibroids rather than risking deep resection in a single sitting.

• A dedicated fluid management system must be used throughout. The scrub nurse or circulating nurse calls out the running fluid deficit at regular intervals.
• Warning threshold: 750 mL deficit - increase vigilance, consider expediting.
• Stop threshold: 1,000 mL (hypotonic) / 2,500 mL (isotonic) - terminate procedure, check electrolytes, give diuretics if needed.
• If the limit is reached before resection is complete, terminate and plan a second stage.

Postoperative Steps

• Since this patient wants fertility, adhesion prevention after resection is important (type 2 fibroids carry higher adhesion risk than type 0/1 due to deeper resection).
• Options: oral estrogen (conjugated estrogens 2.5 mg/day for 30 days + progestin withdrawal) to promote endometrial regeneration; hyaluronic acid gel instillation at end of procedure.
• Second-look hysteroscopy at 4-6 weeks post-op to check for adhesions and treat early if present.

• All resected tissue is sent for histopathological examination to confirm leiomyoma and exclude the rare possibility of leiomyosarcoma (important in a reproductive-age woman).

• Allow 3 months of uterine healing before attempting conception (for type 2, some surgeons advise 6 months given deeper myometrial involvement).
• No myometrial scar from hysteroscopic resection, so vaginal delivery is not contraindicated and caesarean is not mandatory.
• Repeat SIS or sonohysterography at 3 months to confirm complete cavity restoration before conception attempts.

Summary Table