Preoperative assessment of submucous fibroids by three-dimensional saline

contrast sonohysterography D. Mavrelos, J. Naftalin, W. Hoo, J. Ben-Nagi, T. Holland, D. Jurkovic

Volume 38, Issue 3, Date: September 2011, pages 350–354

Journal Club slides prepared by Ligita Jokubkiene(UOG Editor for Trainees)

UOG Journal Club: September 2011

Clevenger-Hoeft M et al., Obstet Gynecol 1999Pritts EA, Obstet Gynecol Surv 2001

Early pregnancy loss

Subfertility

Submucous fibroidscan be a cause of:

Type 2:≥50% confined to the

myometrium or protrusion ratio ≤50%

Type 1:<50% confined to the

myometrium orprotrusion ratio >50%

Type 0:fibroid polyp

Wamsteker K et al.Obstet Gynecol 1993

Classification is widely used in clinical practice but not very accurate in predicting the success of hysteroscopic resection

What are the other factors that are important in determining the success of hysteroscopic surgery?

Submucous fibroids can be assessed by:Submucous fibroids can be assessed by:

Diagnostic hysteroscopyThis can visualize only the part of the fibroid that is visible within the uterine cavity

Three-dimensional saline contrast sonohystero-graphy (3D-SCSH)This can help to determine the proportion of the fibroid that is confined to the myometrium

UltrasonographyThis allows accurate measurement of fibroid size

Leone FP et al., Fertil Steril 2003Lee C et al., UOG 2006

Salim R et al., Hum Reprod 2005

Saline contrast sonohysterographyThis facilitates detection of submucous fibroids and improves diagnostic accuracy

Not all submucous fibroids can be successfully removed at hysteroscopic surgery

A critical aspect of the procedure is careful selection of patients to avoid treatment failure

Emanuel MH et al., Obstet Gynecol 1999

Transcervical resection of fibroid (TCRF) introduced into clinical practice

Preoperative assessment of submucous fibroids by three-dimensional saline contrast

sonohysterography

D. Mavrelos et al, UOG, 2011

To identify variables that can be used to predict successful complete submucous

fibroid hysteroscopic resection

Objective:

Inclusion criteria:Heavy and/or irregular periodsANDSubmucous fibroid diagnosed by two-dimensional transvaginal ultrasound

Exclusion criteria:Use of hormonal contraceptionPrevious operation for fibroids

3D saline contrast sonohysterographywith 5–10 mL sterile saline solution

Prospective observational study of61 symptomatic women, 2006–2008

Measurements taken:•Section of fibroid protruding into the uterine cavity (A)•Intramural component (B)•Distance between lowermost part of the fibroid and internal cervical os (C)

Calculated:•Protrusion ratio (A/(A+B))x100•Fibroid diameter A+B

Widest diameter of the fibroid, plane perpendicular to the endometrium

Methodology

Number of submucous

fibroids

Fibroids classified

according to European Society of

Hysteroscopy

Location of the fibroid – anterior/ posterior/fundal

Additionally recorded variables:

Training set 60% of cases•27 with complete resection•12 with incomplete resection

Testing set 40% of cases•22 with complete resection•6 with incomplete resection

Univariate analysisUnivariate analysisComparison of demographic and ultrasound variables between

women with complete and incomplete fibroid resection

Multivariate logistic regression analysisMultivariate logistic regression analysisCompleteness of resection as response variable

Age

Results of univariate analysis. Women with complete (n = 49) vs incomplete resection (n = 18) (n = 61 women, 67 fibroids)

Parameter P-value

Multiple fibroids

Nulliparous

Diameter of fibroid

Fundal location

Size of intramural component

Distance from fibroid to internal os

Protrusion ratio

0.435

0.141

0.281

0.001

0.001

0.0010.472

0.559

Comparison of variables:complete vs incomplete fibroid resection

*†

†

*Larger in cases with complete resection†Smaller in cases with complete resection

Training set (n = 39)

Parity

OR (95% CI) P-value

Size of intramural component (mm)

Fibroid diameter (mm)

0.002 (0.000–0.035)

0.511 (0.277–0.943)

0.843 (0.655–1.000)

0.035

0.032

0.050

Variables in the model:

Predicting complete resection of submucous fibroid: multivariate logistic regression model

Fibroid diameter

Degree of protrusion

Size of intramural component

0.777

59%

86%

86%

100%

83%

67%

ROC AUC Cut-off value Sensitivity Specificity

0.833

0.867

10 mm

38 mm

43 %

Analysis of single variablesusing a testing set

Testing set (n = 28)

Training set n = 39

Testing set n = 28

Training set

Testing set

0.975

0.864 86%

92%

9%

36%

AUC Cut-off value Sensitivity Specificity

96%

83%

ROC curvesROC curves

Prediction of complete hysteroscopic submucous fibroid resection using logistic regression model

1 – Specificity

•Larger protrusion ratio of submucous fibroid into the uterine cavity•Smaller fibroid diameter•Smaller size of intramural fibroid component•Parity

•Smaller protrusion ratio of submucous fibroid into the uterine cavity•Larger fibroid diameter•Larger size of intramural fibroid component

Complete submucous fibroid resection can be predicted by

Unsuccessful fibroid resection is more common in cases with

Larger submucous fibroid protrusion ratio, smaller fibroid diameter and smaller size of intramural component are

associated with successful fibroid resection

Logistic regression model, including:1. parity, 2. fibroid diameter, 3. size of intramural componentcan be used to calculate individual probability of complete

hysteroscopic resection of submucous fibroid

D. Mavrelos et al, UOG, 2011

Conclusions