The Blooming phenomenon: a rarity, but a dilemma in hysteroscopic resection of myomas

Abstract

Modern surgical technologies allow gynecologists to treat most submucosal myomas hysteroscopically by some form of resection. What appears on imaging or direct visualization to be a submucosal myoma can be a single tumor, or may represent multiple smaller myomas appearing as one, compacted together in a typical pseudo capsule. During myoma resection, the effect of the media used to induce distension can vary, depending on the morphology of the myomas. After starting resection, the pressure of the distending media can push truly solitary myomas to somewhat flatten against the uterine wall. However, in the second type of myoma, the fluid can displace the myomas into the uterine cavity, an appearance similar to the blooming of a flower. The tip of the hysteroscope may enter the dissected spaces between the myomas, which impairs the panoramic view. This phenomenon may cause inadequate treatment of the myomas encountered during hysteroscopic myomectomy. In this study, the “Blooming phenomenon” is introduced, and the problems created by this phenomenon and solutions for its management are considered.

Keywords: fibroid; hysteroscopy; submucosal myoma resection; Leiomyoma.

Figure 1

(A) Solitary submucosal myoma; and (B) apparently solitary, but actually multiple submucosal myomas

Figure 2

(A) Solitary submucosal myoma; (A₁) arrows show the pressure of the distending media on the myoma; (A₂) pressing and flattening of the true solitary myoma; and (A₃) flattened solitary myoma due to pressure of distending media

Figure 3

(B) resection of false solitary myoma; (B₁) pseudo capsule opened due to resection; (B₂) fluid entering the spaces between the myomas; and (B₃) release of intracapsular compression leading to extrusion of the multiple small myomas by fluid displacement

Figure 4

(A) schematic view of dissected spaces between the myomas; and (B) real hysteroscopic view of dissected myoma showing an inadvertent resection of the deeper areas of the myometrium

Figure 5

Hysterectomy of the same patient in Figure 4B with failed hysteroscopic myomectomy. (A) the yellow dotted line represents the pseudo capsule of the myoma; (B) blue arrows indicate the directions of protrusions of the myomas after partial resection of pseudo capsule; (C) blue arrow indicates the distance between tip of hysteroscope and myoma before dissection of pseudo capsule, while the yellow arrow demonstrates the reduction of this distance after dissection of pseudo capsule; (D) vertical and transverse resection direction of myoma which should be avoided; and (E) black arrow represents the correct direction of the resection