What is Submucous (Submucous) Uterine Fibroids?
In 20-32% of patients, myomatous nodes have submucous localization, which in most cases is an indication for surgical treatment due to pronounced clinical symptoms.
Symptoms of Submucous (Submucous) Uterine Fibroids
Long, heavy menstruation with clots and metrorrhagia, anemizing the patient. Along with uterine bleeding, there are cramping pains. Submucous uterine fibroids are often accompanied by infertility and miscarriage.
Submucous myoma grows rapidly and is accompanied by a high risk of malignancy (0.13-0.29%; according to some authors, up to 2%).
Diagnosis of Submucous (Submucous) Uterine Fibroids
Metrography. The first method (in the historical aspect) for the diagnosis of submucous myomatous nodes in patients with complaints of heavy menstruation, cramping pain during menstruation, uterine bleeding in postmenopausal women was hysterosalpingography. The coincidence of the radiological and histological diagnoses for submucous uterine myoma is from 58 to 85%. Metrography is currently rarely used to diagnose uterine fibroids.
X-ray signs of uterine fibroids – expansion or curvature of the uterine shadow. Submucous myomatous nodes appear in the form of filling defects, with clear contours, often on a wide base, motionless under a monitor study.
Based on metrology data, J. Donnez et al. (1993) submucous nodes are divided into mainly located in the uterine cavity, mainly located in the uterine wall and multiple (more than 2) submucous nodes.
Most authors indicate that radiological symptoms are non-pathognomonic, they also occur in large endometrial polyps, nodular form of adenomyosis, and uterine cancer. The diagnostic value of metrography reduces the impossibility of its implementation with prolonged blood discharge. Currently, due to the possibilities of ultrasound and hysteroscopy, there is no need to use metrography for the diagnosis of submucous nodes.
Ultrasound scan. Ultrasound is used most often as one of the most informative methods for the diagnosis of submucous uterine fibroids. The informational content of ultrasound in the diagnosis of submucous fibroids, according to various authors, reaches 92.8-95.7%.
The submucous nodes of the fibroids inside the dilated uterine cavity have the appearance of rounded or oval formations of medium echogenicity with smooth contours. The sound conductivity of submucosal nodes of fibroids is higher than endometrial polyps.
Transvaginal ultrasound using a contrast medium is called hydrosonography. Hydrosonography allows you to differentiate a node with an endometrial polyp, more clearly determine the localization of the submucosal node and the deformation of the uterine cavity.
The informational content of ultrasound diagnostics of submucous uterine fibroids will significantly increase with the introduction into practice of intrauterine ultrasound using special sensors with an expanded uterine cavity. The conditions of the method are as close as possible to those with transcervical resection of myomatous nodes. This method can provide the most valuable information about the size of the intramural component of the submucous node in a preoperative examination.
More objective information with uterine fibroids can also be obtained using three-dimensional ultrasound imaging, which is increasingly used in gynecology.
Doppler ultrasound allows you to explore blood circulation in the structure of the node. Features of intra- and perinodular blood flow make it possible to predict node growth and evaluate structural changes in it.
Hysteroscopy. Hysteroscopy diagnoses with great accuracy even small submucous nodes. A filling defect in the uterine cavity is usually detected by ultrasound or metrography, but hysteroscopy is necessary to determine the nature of this defect. Submucous nodes have a spherical shape, clear contours, whitish in color, deform the uterine cavity, and the consistency is dense when touched with the tip of a hysteroscope. On the surface of the node there may be small-pointed or extensive hemorrhages, sometimes a network of stretched and dilated blood vessels covered with a thinned endometrium is sometimes visible. With a change in the rate of fluid supply to the uterine cavity, the submucosal myomatous nodes do not change shape and size, which makes it possible to distinguish from an endometrial polyp.
Interstitial-submucous myomatous nodes with hysteroscopy are determined in the form of a bulge of one of the walls of the uterus. The degree of bulging depends on the size and nature of the growth of the myomatous node.
When a submucosal node is detected, its size, localization, width of the base, and the value of the intramural component are determined.
With diagnostic hysteroscopy, the type of submucosal myomatous node is determined:
- Type 0 – submucous nodes on the pedicle, without intramural component;
- Type 1 – submucous nodes on a broad base with an intramural component of less than 50%;
- Type 2 – myomatous nodes with an intramural component of 50% or more.
The method of treatment and the need for preoperative hormonal preparation depend on the type of submucosal node.
In addition to the diagnosis of uterine fibroids, diagnostic hysteroscopy is necessary to assess the condition of the endometrium and exclude other types of intrauterine pathology (malformations of the uterus, foreign bodies, intrauterine synechia). With the introduction of hydrosonography into practice, it became possible to avoid diagnostic hysteroscopy in patients with submucous uterine myoma.
Treatment of Submucous (Submucous) Uterine Fibroids
Submucous (submucous) uterine fibroids is an indication for surgical treatment. The question of the volume of surgery and surgical access is decided individually. It depends on the woman’s age, her desire to maintain reproductive and menstrual functions, the size and type of submucous myomatous node, clinical manifestations and complications associated with gynecological and extragenital pathology. Both organ-preserving (myomectomy) and radical (hysterectomy) surgery are possible.
Operations can be performed both with traditional access (glancing) and endoscopic access (laparoscopic, hysteroscopic).
Hysteroscopic myomectomy (mechanical, electrosurgical and laser) has become the optimal method for removing submucous myomatous nodes.
The choice of transhisteroscopic myomectomy method depends on:
- the type of submucous node, its localization and size;
- endoscopic equipment;
- surgeon’s operational skills in endoscopy. Contraindications to hysteroscopic myomectomy:
– general contraindications for any hysteroscopy;
– the length of the uterine cavity is more than 10 cm;
– suspected endometrial cancer and leyosarcoma;
– a combination of a submucous node with severe adenomyosis and myomatous nodes of a different location (in a patient not planning a pregnancy).
Mechanical myomectomy is possible with submucous nodes of types 0 and 1 with a slight interstitial component. In this case, even large submucosal nodes can be removed. The ability to remove mechanically also depends on the location of the node, it is easiest to remove nodes in the bottom of the uterus. To remove submucous nodes, the site can be fixed with an abortion gland and untwisted, followed by hysteroscopic control or under the control of a hysteroscope to dissect the capsule of the node or its leg with a resector and remove the node from the uterine cavity.
Advantages of mechanical myomectomy: short duration of the operation (5-10 min), no additional equipment and special fluid required, complications of the electrosurgical operation (liquid overload of the vascular bed, possible damage to large vessels and burns of neighboring organs) are excluded.
Electrosurgical myomectomy is indicated for submucous nodes of types I and II with a large intramural component, small spherical nodes, and also located in the corners of the uterus, which are almost impossible to remove with mechanical myomectomy. Depending on the nature of the node (submucous node on a narrow base or submucous-interstitial node), the operation is performed simultaneously or in two stages. A two-stage operation is recommended for nodes in which most are located in the uterine wall (type II according to hysteroscopic classification).
Radical operations with uterine myoma include removal of the uterus with the cervix (total hysterectomy, hysterectomy) or without the cervix (subtotal hysterectomy, supravaginal amputation of the uterus).
Total hysterectomy can be performed with abdominal, vaginal and laparoscopic approaches, subtotal hysterectomy with abdominal and laparoscopic approaches. The choice of surgical access depends on the size of the uterus, experience and qualifications of the surgeon.
The question of leaving the uterus appendages is decided individually depending on the age of the patient and the condition of the appendages.
The prognosis after removal of fibroids is favorable. After myomectomy, as well as after subtotal hysterectomy, a follow-up is indicated with monitoring the condition of the cervical stump.