Hysteroscopy pp 363-374 | Cite as

Hysteroscopic Myomectomy Respecting the Pseudocapsule: The Cold Loop Hysteroscopic Myomectomy

  • Ivan Mazzon
  • Alessandro Favilli
  • Vittorio Villani
  • Sandro Gerli


Myomas, also called leiomyomas or fibroids, are benign, monoclonal tumors of the smooth muscle cells of the myometrium, widely considered as the most common of the female reproductive tract. Myomas can be responsible for pelvic pain, abnormal uterine bleeding, and infertility. Although more than 50% of fibroids are asymptomatic, the submucous myomas are associated with the most severe symptomatology. The advent of endoscopy in the gynecologic surgery revolutionized the treatment of submucous myomas, introducing a viable uterine-sparing alternative to hysterectomy. In the last four decades, several techniques have been described to perform hysteroscopic myomectomy. The hysteroscopic myomectomy should be a simple, well-tolerated and effective procedure. The cold loop technique, preferably accomplished in only one surgical procedure, seems to be the best option in the treatment of submucous myomas. Such technique, conceived in 1995, for the first time allowed to overcome the limits represented by the classical slicing technique and still today ensures a safe and effective myometrial sparing treatment of submucous myomas.


Uterine fibroid Myoma pseudocapsule Cold loop myomectomy Hysteroscopy Fertility Reproductive surgery 


  1. 1.
    Buttram VC Jr, Reiter RC. Uterine leiomyomata: etiology, symptomatology, and management. Fertil Steril. 1981;36(4):433–45.CrossRefPubMedGoogle Scholar
  2. 2.
    Parker WH. Etiology, symptomatology, and diagnosis of uterine myomas. Fertil Steril. 2007;87(4):725–36.CrossRefPubMedGoogle Scholar
  3. 3.
    Evans P, Brunsell S. Uterine fibroid tumors: diagnosis and treatment. Am Fam Physician. 2007;75(10):1503–8.PubMedGoogle Scholar
  4. 4.
    Stewart EA. Uterine fibroids. Lancet. 2001;357(9252):293–8.CrossRefPubMedGoogle Scholar
  5. 5.
    Di Spiezio Sardo A, Mazzon I, Bramante S, Bettocchi S, Bifulco G, Guida M, et al. Hysteroscopic myomectomy: a comprehensive review of surgical techniques. Hum Reprod Update. 2008;14(2):101–19.CrossRefPubMedGoogle Scholar
  6. 6.
    Divakar H. Asymptomatic uterine fibroids. Best Pract Res Clin Obstet Gynaecol. 2008;22(4):643–54.CrossRefPubMedGoogle Scholar
  7. 7.
    Roy KK, Singla S, Baruah J, Sharma JB, Kumar S, Singh N. Reproductive outcome following hysteroscopic myomectomy in patients with infertility and recurrent abortions. Arch Gynecol Obstet. 2010;282(5):553–60.CrossRefPubMedGoogle Scholar
  8. 8.
    Wen KC, Sung PL, Lee WL, Li YT, WH S, Wang PH. Myomectomy for uterine myomas through ultramini-laparotomy. J Obstet Gynaecol Res. 2011;37(5):383–92.CrossRefPubMedGoogle Scholar
  9. 9.
    Neuwirth RS. A new technique for and additional experience with hysteroscopic resection of submucous fibroids. Am J Obstet Gynecol. 1978;131(1):91–4.CrossRefPubMedGoogle Scholar
  10. 10.
    American Association of Gynecologic Laparoscopists: Advancing Minimally Invasive Gynecology W. AAGL practice report: practice guidelines for the diagnosis and management of submucous leiomyomas. J Minim Invasive Gynecol. 2012;19(2):152–71.CrossRefGoogle Scholar
  11. 11.
    Pakrashi T. New hysteroscopic techniques for submucosal uterine fibroids. Curr Opin Obstet Gynecol. 2014;26(4):308–13.CrossRefPubMedGoogle Scholar
  12. 12.
    Mazzon I, Favilli A, Grasso M, Horvath S, Bini V, Di Renzo GC, et al. Predicting success of single step hysteroscopic myomectomy: a single centre large cohort study of single myomas. Int J Surg. 2015;22:10–4.CrossRefPubMedGoogle Scholar
  13. 13.
    Mazzon I. Nuova tecnica per la miomectomia isteroscopica: enucleazione con ansa fredda. In: Cittadini E, Perino A, Angiolillo M, Minelli L, editors. Testo-Atlante di Chirurgia Endoscopica Ginecologica. Palermo: COFESE; 1995.Google Scholar
  14. 14.
    Wamsteker K, Emanuel MH, de Kruif JH. Transcervical hysteroscopic resection of submucous fibroids for abnormal uterine bleeding: results regarding the degree of intramural extension. Obstet Gynecol. 1993;82(5):736–40.PubMedGoogle Scholar
  15. 15.
    Mazzon I, Favilli A, Cocco P, Grasso M, Horvath S, Bini V, et al. Does cold loop hysteroscopic myomectomy reduce intrauterine adhesions? A retrospective study. Fertil Steril. 2014;101(1):294–8. e3CrossRefPubMedGoogle Scholar
  16. 16.
    Mazzon I, Favilli A, Grasso M, Horvath S, Di Renzo GC, Gerli S. Is cold loop hysteroscopic myomectomy a safe and effective technique for the treatment of submucous myomas with intramural development? A series of 1434 surgical procedures. J Minim Invasive Gynecol. 2015;22(5):792–8.CrossRefPubMedGoogle Scholar
  17. 17.
    Tinelli A, Malvasi A, Rahimi S, Negro R, Cavallotti C, Vergara D, et al. Myoma pseudocapsule: a distinct endocrino-anatomical entity in gynecological surgery. Gynecol Endocrinol. 2009;25(10):661–7.CrossRefPubMedGoogle Scholar
  18. 18.
    Tinelli A, Malvasi A, Cavallotti C, Dell'Edera D, Tsin DA, Stark M, et al. The management of fibroids based on immunohistochemical studies of their pseudocapsules. Expert Opin Ther Targets. 2011;15(11):1241–7.CrossRefPubMedGoogle Scholar
  19. 19.
    Malvasi A, Cavallotti C, Nicolardi G, Pellegrino M, Dell'Edera D, Vergara D, et al. NT, NPY and PGP 9.5 presence in myomeytrium and in fibroid pseudocapsule and their possible impact on muscular physiology. Gynecol Endocrinol. 2013;29(2):177–81.CrossRefPubMedGoogle Scholar
  20. 20.
    Malvasi A, Cavallotti C, Nicolardi G, Pellegrino M, Vergara D, Greco M, et al. The opioid neuropeptides in uterine fibroid pseudocapsules: a putative association with cervical integrity in human reproduction. Gynecol Endocrinol. 2013;29(11):982–8.CrossRefPubMedGoogle Scholar
  21. 21.
    Malvasi A, Tinelli A, Cavallotti C, Morroni M, Tsin DA, Nezhat C, et al. Distribution of substance P (SP) and vasoactive intestinal peptide (VIP) in pseudocapsules of uterine fibroids. Peptides. 2011;32(2):327–32.CrossRefPubMedGoogle Scholar
  22. 22.
    Vercellini P, Zaina B, Yaylayan L, Pisacreta A, De Giorgi O, Crosignani PG. Hysteroscopic myomectomy: long-term effects on menstrual pattern and fertility. Obstet Gynecol. 1999;94(3):341–7.PubMedGoogle Scholar
  23. 23.
    Casadio P, Youssef AM, Spagnolo E, Rizzo MA, Talamo MR, De Angelis D, et al. Should the myometrial free margin still be considered a limiting factor for hysteroscopic resection of submucous fibroids? A possible answer to an old question. Fertil Steril. 2011;95(5):1764–8. e1CrossRefPubMedGoogle Scholar
  24. 24.
    Mazzon I, Sbiroli C. Miomectomia. In: Mazzon I, Sbiroli C, editors. Manuale di Chirurgia Resettoscopica in Ginecologia. Torino: UTET; 1997. p. 191–217.Google Scholar
  25. 25.
    Mazzon I, Favilli A, Horvath S, Grasso M, Di Renzo GC, Laurenti E, et al. Pain during diagnostic hysteroscopy: what is the role of the cervical canal? A pilot study. Eur J Obstet Gynecol Reprod Biol. 2014;183:169–73.CrossRefPubMedGoogle Scholar
  26. 26.
    Mazzon I, Favilli A, Grasso M, Horvath S, Bini V, Di Renzo GC, et al. Pain in diagnostic hysteroscopy: a multivariate analysis after a randomized, controlled trial. Fertil Steril. 2014;102(5):1398–403.CrossRefPubMedGoogle Scholar
  27. 27.
    Yang JH, Lin BL. Changes in myometrial thickness during hysteroscopic resection of deeply invasive submucous myomas. J Am Assoc Gynecol Laparosc. 2001;8(4):501–5.CrossRefPubMedGoogle Scholar
  28. 28.
    Gutmann JN, Corson SL. GnRH agonist therapy before myomectomy or hysterectomy. J Minim Invasive Gynecol. 2005;12(6):529–37. quiz 8, 38–9CrossRefPubMedGoogle Scholar
  29. 29.
    Lethaby A, Vollenhoven B, Sowter M. Pre-operative GnRH analogue therapy before hysterectomy or myomectomy for uterine fibroids. Cochrane Database Syst Rev. 2001;2:CD000547.Google Scholar
  30. 30.
    Mencaglia L, Tantini C. GnRH agonist analogs and hysteroscopic resection of myomas. Int J Gynaecol Obstet. 1993;43(3):285–8.CrossRefPubMedGoogle Scholar
  31. 31.
    Muzii L, Boni T, Bellati F, Marana R, Ruggiero A, Zullo MA, et al. GnRH analogue treatment before hysteroscopic resection of submucous myomas: a prospective, randomized, multicenter study. Fertil Steril. 2010;94(4):1496–9.CrossRefPubMedGoogle Scholar
  32. 32.
    Perino A, Chianchiano N, Petronio M, Cittadini E. Role of leuprolide acetate depot in hysteroscopic surgery: a controlled study. Fertil Steril. 1993;59(3):507–10.CrossRefPubMedGoogle Scholar
  33. 33.
    Mavrelos D, Ben-Nagi J, Davies A, Lee C, Salim R, Jurkovic D. The value of pre-operative treatment with GnRH analogues in women with submucous fibroids: a double-blind, placebo-controlled randomized trial. Hum Reprod. 2010;25(9):2264–9.CrossRefPubMedGoogle Scholar
  34. 34.
    Kamath MS, Kalampokas EE, Kalampokas TE. Use of GnRH analogues pre-operatively for hysteroscopic resection of submucous fibroids: a systematic review and meta-analysis. Eur J Obstet Gynecol Reprod Biol. 2014;177:11–8.CrossRefPubMedGoogle Scholar
  35. 35.
    Campo S, Campo V, Gambadauro P. Short-term and long-term results of resectoscopic myomectomy with and without pretreatment with GnRH analogs in premenopausal women. Acta Obstet Gynecol Scand. 2005;84(8):756–60.CrossRefPubMedGoogle Scholar
  36. 36.
    Bradley LD. Complications in hysteroscopy: prevention, treatment and legal risk. Curr Opin Obstet Gynecol. 2002;14(4):409–15.CrossRefPubMedGoogle Scholar
  37. 37.
    Fedele L, Vercellini P, Bianchi S, Brioschi D, Dorta M. Treatment with GnRH agonists before myomectomy and the risk of short-term myoma recurrence. Br J Obstet Gynaecol. 1990;97(5):393–6.CrossRefPubMedGoogle Scholar
  38. 38.
    Mazzon I, Favilli A, Grasso M, Gerli S. Sinking myoma: a case of one-step cold loop hysteroscopic myomectomy. J Obstet Gynaecol. 2016;36:271–2.CrossRefPubMedGoogle Scholar
  39. 39.
    De Falco M, Staibano S, Mascolo M, Mignogna C, Improda L, Ciociola F, et al. Leiomyoma pseudocapsule after pre-surgical treatment with gonadotropin-releasing hormone agonists: relationship between clinical features and immunohistochemical changes. Eur J Obstet Gynecol Reprod Biol. 2009;144(1):44–7.CrossRefPubMedGoogle Scholar
  40. 40.
    Sutton C. Hysteroscopic surgery. Best Pract Res Clin Obstet Gynaecol. 2006;20(1):105–37.CrossRefPubMedGoogle Scholar
  41. 41.
    Di Spiezio Sardo A, Calagna G, Di Carlo C, Guida M, Perino A, Nappi C. Cold loops applied to bipolar resectoscope: a safe “one-step” myomectomy for treatment of submucosal myomas with intramural development. J Obstet Gynaecol Res. 2015;41(12):1935–41.CrossRefPubMedGoogle Scholar
  42. 42.
    Deffieux X, Gauthier T, Menager N, Legendre G, Agostini A, Pierre F, et al. Hysteroscopy: guidelines for clinical practice from the French College of Gynaecologists and Obstetricians. Eur J Obstet Gynecol Reprod Biol. 2014;178:114–22.CrossRefPubMedGoogle Scholar
  43. 43.
    Mazzon I, Favilli A, Grasso M, Gerli S. Sinking myoma: a case of one-step cold loop hysteroscopic myomectomy. J Obstet Gynaecol. 2016;36(2):271–2.CrossRefPubMedGoogle Scholar
  44. 44.
    Jansen FW, Vredevoogd CB, van Ulzen K, Hermans J, Trimbos JB, Trimbos-Kemper TC. Complications of hysteroscopy: a prospective, multicenter study. Obstet Gynecol. 2000;96(2):266–70.PubMedGoogle Scholar
  45. 45.
    Aydeniz B, Gruber IV, Schauf B, Kurek R, Meyer A, Wallwiener D. A multicenter survey of complications associated with 21,676 operative hysteroscopies. Eur J Obstet Gynecol Reprod Biol. 2002;104(2):160–4.CrossRefPubMedGoogle Scholar
  46. 46.
    Hallez JP. Single-stage total hysteroscopic myomectomies: indications, techniques, and results. Fertil Steril. 1995;63(4):703–8.CrossRefPubMedGoogle Scholar
  47. 47.
    Corson SL, Brooks PG. Resectoscopic myomectomy. Fertil Steril. 1991;55(6):1041–4.CrossRefPubMedGoogle Scholar
  48. 48.
    Darwish A. Modified hysteroscopic myomectomy of large submucous fibroids. Gynecol Obstet Invest. 2003;56(4):192–6.CrossRefPubMedGoogle Scholar
  49. 49.
    Walocha JA, Litwin JA, Miodonski AJ. Vascular system of intramural leiomyomata revealed by corrosion casting and scanning electron microscopy. Hum Reprod. 2003;18(5):1088–93.CrossRefPubMedGoogle Scholar
  50. 50.
    Emanuel MH, Wamsteker K, Hart AA, Metz G, Lammes FB. Long-term results of hysteroscopic myomectomy for abnormal uterine bleeding. Obstet Gynecol. 1999;93(5 Pt 1):743–8.PubMedGoogle Scholar
  51. 51.
    Mazzon I, Favilli A, Grasso M, Morricone D, Di Renzo GC, Gerli SI. cold loop' hysteroscopic myomectomy a better option for reproduction in women with diffuse uterine leiomyomatosis? A case report of successful repeated pregnancies. J Obstet Gynaecol Res. 2015;41(3):474–7.CrossRefPubMedGoogle Scholar
  52. 52.
    Leone FPCS, Marciante C, Cetin I, Ferrazzi E. Feasibility and long-term efficacy of hysteroscopic myomectomy for myomas with intramural development by the use of non-electrical “cold” loops. Gynecol Surg. 2012;9:155–61.CrossRefGoogle Scholar
  53. 53.
    Camanni M, Bonino L, Delpiano EM, Ferrero B, Migliaretti G, Deltetto F. Hysteroscopic management of large symptomatic submucous uterine myomas. J Minim Invasive Gynecol. 2010;17(1):59–65.CrossRefPubMedGoogle Scholar
  54. 54.
    Taskin O, Sadik S, Onoglu A, Gokdeniz R, Erturan E, Burak F, et al. Role of endometrial suppression on the frequency of intrauterine adhesions after resectoscopic surgery. J Am Assoc Gynecol Laparosc. 2000;7(3):351–4.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing AG 2018

Authors and Affiliations

  • Ivan Mazzon
    • 1
  • Alessandro Favilli
    • 2
  • Vittorio Villani
    • 1
  • Sandro Gerli
    • 3
  1. 1.“Arbor Vitae” CentreClinica Nuova Villa ClaudiaRomeItaly
  2. 2.Department of Surgical and Biomedical Sciences, Translational Medicine and Surgery Research Doctoral ProgramUniversity of PerugiaPerugiaItaly
  3. 3.Department of Surgical and Biomedical Sciences, Section of Obstetrics and gynecology, Centre of Reproductive MedicineUniversity of PerugiaPerugiaItaly

Personalised recommendations