Extreme Intrauterine Surgery: Multiple-Step Hysteroscopic Approach to Treat a 4 cm Fibroid in a Complete Uterine Septum With Cervical Septum.

STUDY

OBJECTIVE

To describe a multiple-step hysteroscopic approach to restore normal uterine anatomy in a patient presenting with a single cervix, partial cervical septum, complete uterine septum, and a 4 cm intraseptal myoma. Uterine septum is the most common congenital anomaly of the female genital tract [1]. Its association with a septate cervix is rare [2]. In exceptional cases, a myoma may be found within the uterine septum. Published video demonstrations of intraseptal myoma management are limited.

DESIGN

Video article of a single-case surgical technique.

SETTING

The procedures were performed at the Digital Hysteroscopic Clinic CLASS Hysteroscopy of Fondazione Policlinico Gemelli IRCCS in Rome, Italy.

INTERVENTIONS: A 37-year-old infertile woman with cervical septum and complete uterine septum complicated by G2 intraseptal myoma [3] protruding into the left uterine hemicavity. A diagnostic approach, combining 2-/3-dimensional transvaginal ultrasound and office hysteroscopy, followed by magnetic resonance imaging before surgery was performed [4]. Institutional review board approval was obtained. A 3-step hysteroscopic approach under anesthesia with a laryngeal mask was performed, according to an ambulatory model of care [5]. The first step involved the incision of the cervical septum and partial incision of the uterine septum until the myoma plane, using the Collins loop of a 15 Fr bipolar mini-resectoscope, followed by the first step of myomectomy with a 90°-angled loop of a 26 Fr bipolar resectoscope. The second step was performed 1 month later to complete the myomectomy. The third procedure was performed 1 month after the second step, to remove the uterine septum using a 15 Fr bipolar mini-resectoscope. No complications occurred. The patient was discharged 3 hours after each procedure. Postoperative hysteroscopic control revealed a normal cervix and a normally shaped uterine cavity, with no intrauterine adhesions or residual myoma tissue.

CONCLUSION

The integration of 2-/3-dimensional transvaginal ultrasound and hysteroscopy, in the hands of experienced and skilled surgeons, is essential for managing rare and complex cases, minimizing complications, and ensuring optimal surgical outcomes. VIDEO ABSTRACT.