Is the Distance Between Myoma and Serosa a Limiting Factor

Even if uterine myomas are often asymptomatic, they have been associated with a number of clinical issues such as abnormal uterine bleeding (AUB), heavy menstrual bleeding (HMB), infertility, and recurrent pregnancy loss, especially when these masses are submucous. Gold standard treatment for symptomatic submucous fibroids has long been considered their laparotomic removal or a total hysterectomy. The development of endoscopy has made these fibroids accessible and removable from the inner surface of uterus. The development of different and new techniques allows to overcome the initial limitations of the traditional resectoscopic myomectomy. For a long time several authors have considered the myometrial free margin as a limiting factor when it is lower than 5–10 mm. The onset of the “cold loop technique” has made possible to treat safely G2 submucous myomas even when the thickness of the myometrium is considerably thin. It is feasible because the myometrial free margin can undergo dynamic changes after the various phases of hysteroscopic resection performed with cold handles. It decreases after the distension of the uterine cavity and then increases progressively after the various phases of resection reaching the maximum value at the end of the procedure. Not applying electric energy the cold loop technique does not damage muscle fibers allowing the myometrium separating the myoma from serosa to be a dynamic factor. Thus the myometrial free margin should not longer be considered a selection criteria for the resectoscopic myomectomy.