A Minimally Invasive Stepwise Hysteroscopic Myomectomy Using the Collins Loop of a 15 Fr Mini-resectoscope: The MiniLoop Enucleation Technique (MiLET).

OBJECTIVE

To describe the MiniLoop Enucleation Technique (MiLET), a novel minimally invasive stepwise hysteroscopic myomectomy performed using the Collins loop of a 15 Fr bipolar mini-resectoscope, highlighting its uterine-preserving features [1].

SETTING

Digital Hysteroscopic Clinic, CLASS Hysteroscopy, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.

PARTICIPANTS

A 40-year-old nulliparous woman with repeated implantation failures and a diagnosis of a FIGO (International Federation of Gynecology and Obstetrics) type 2 submucosal fibroid measuring 14 mm. Preoperative assessment included 2-dimensional and 3-dimensional transvaginal ultrasound and office hysteroscopy performed using a 5-mm Bettocchi hysteroscope with a vaginoscopic approach, which defined the lesion and confirmed its classification [2].

INTERVENTIONS: Hysteroscopic myomectomy was performed under general anesthesia with a laryngeal mask, using a 15 Fr bipolar mini-resectoscope introduced without cervical dilation. MiLET was carried out using the Collins loop as the only operative instrument throughout the procedure. The cleavage plane between the myoma and the surrounding myometrium was progressively opened while preserving the pseudocapsule [3,4]. Fibroconnective bridges were selectively divided to allow gradual enucleation of the intramural component and progressive mobilization of the myoma into the uterine cavity. Once adequately mobilized, the same Collins loop was used to divide the fibroid into removable pieces, completing the myomectomy in a single operative time [5]. Total operative time was 16 minutes. Hemostasis was satisfactory, and fluid balance was maintained. No intraoperative or postoperative complications occurred. A follow-up office hysteroscopy was performed 30 days after surgery, confirming regular healing and restoration of the uterine cavity. Reproductive outcomes are not yet available.

CONCLUSION

MiLET combines miniaturized instrumentation, stepwise enucleation, and selective bipolar energy to achieve complete hysteroscopic myomectomy while preserving the surrounding myometrium. By using the Collins loop as a single operative instrument throughout the procedure, this technique may represent a feasible minimally invasive option for the management of selected submucosal fibroids up to 30 mm without the need for cervical dilation, while maintaining optimal intrauterine maneuverability. Fibroid fragments should remain small to allow controlled extraction and avoid excessive traction.