Uterine fibroids (leiomyomas) are one of the most common benign gynecological tumors in women of reproductive age. Among them, submucous fibroids—which protrude into the uterine cavity—are particularly associated with heavy menstrual bleeding, infertility, recurrent pregnancy loss, and abnormal uterine anatomy.

Hysteroscopic submucous myomectomy has become the gold standard for treating these fibroids because it is minimally invasive, precise, and fertility-preserving. This procedure allows surgeons to directly visualize and remove fibroids through the cervix, avoiding abdominal incisions, reducing recovery time, and minimizing complications.

Indications

Hysteroscopic submucous myomectomy is indicated in women with:

Abnormal uterine bleeding caused by submucous fibroids

Infertility or recurrent pregnancy loss due to intrauterine fibroids

Large or symptomatic fibroids distorting the endometrial cavity

Patients desiring fertility preservation or avoidance of open surgery

It is especially valuable in women with type 0 or type I submucous fibroids, which are completely or mostly within the uterine cavity.

Preoperative Evaluation

A thorough preoperative assessment is essential:

Imaging:

Transvaginal ultrasound or saline infusion sonography to assess fibroid size, location, and relation to the myometrium

MRI may be used in complex cases to map multiple fibroids or large lesions

Laboratory Work:

Complete blood count to evaluate anemia from heavy bleeding

Coagulation profile if necessary

Anesthesia:

General or regional anesthesia is preferred for patient comfort and optimal uterine relaxation

Cervical Preparation:

Misoprostol or mechanical dilation may be used in nulliparous or postmenopausal women to facilitate hysteroscope entry

Surgical Technique
Hysteroscopic Access

The cervix is gently dilated to allow introduction of the hysteroscope (typically 5–9 mm).

The uterine cavity is distended with saline or glycine to provide a clear view and working space.

Continuous monitoring of intrauterine pressure and fluid balance is critical to prevent complications.

Identification of Fibroid

The submucous fibroid is visualized, including its size, pedicle, and degree of protrusion into the cavity.

Classification:

Type 0: Completely within the cavity

Type I: Mostly within the cavity, <50% intramural

Type II: Mostly intramural, >50% within myometrium

Myomectomy Procedure

Fibroid resection is performed using:

Resectoscope with monopolar or bipolar energy

Mechanical instruments such as scissors or morcellators in selected cases

The fibroid is excised in small fragments, avoiding injury to the healthy endometrium.

Hemostasis is achieved using bipolar coagulation or minimal cautery to preserve the endometrium.

Removal of Tissue

Excised fibroid fragments are removed from the uterine cavity using graspers or suction to maintain clear visualization and prevent fluid overload.

Advantages of Hysteroscopic Submucous Myomectomy

Minimally invasive: No abdominal incision, resulting in reduced pain and faster recovery

Fertility-preserving: Maintains uterine integrity for future conception

Precise and controlled: Direct visualization allows accurate excision of fibroid tissue

Short hospital stay: Often performed as day-care surgery

Rapid return to normal activity: Most women resume work within 1–2 days

Safety Considerations

Although generally safe, potential complications include:

Fluid overload or hyponatremia from distension media

Uterine perforation, minimized by careful technique

Bleeding, controlled with bipolar coagulation

Infection, rare with prophylactic antibiotics in high-risk patients

Dr. R. K. Mishra emphasizes the importance of fluid monitoring, gentle instrumentation, and limiting resection time to reduce risks.

Postoperative Care

Patients are monitored for bleeding, fluid balance, and pain.

Vaginal discharge may persist for a few days; normal activities can usually resume within 24–48 hours.

Follow-up imaging may be performed to confirm complete removal and assess uterine healing.

Patients attempting conception are advised to wait at least one menstrual cycle before attempting pregnancy.

Outcomes

Hysteroscopic submucous myomectomy demonstrates:

High success rates in symptom relief and restoration of normal uterine cavity

Improved fertility outcomes in women with infertility caused by fibroids

Low recurrence rates when complete removal is achieved

Minimal complications compared to open or abdominal approaches

Conclusion

Hysteroscopic submucous myomectomy is a safe, effective, and fertility-preserving treatment for women with submucous fibroids. Its minimally invasive nature, combined with direct visualization and precise excision, makes it the preferred approach for both diagnostic and therapeutic management of intrauterine fibroids.

Mastery of this technique allows gynecologic surgeons to improve patient outcomes, reduce hospital stays, and enhance reproductive potential, making it a cornerstone of modern minimally invasive gynecologic surgery.