Hysteroscopic resection is also known as Transcervical Resection of Fibroids (TCRF). It is a procedure of removing fibroids that occur on the inside of the womb (uterus), in the uterine lining via the vagina using an instrument called hysteroscope.
Key features of TCRF
- TCRF is suitable for fibroids that are within or bulging into the uterine cavity (submucosal) or fibroids that are less than 10 cm in diameter. Any fibroid tissue within the wall of the womb will not be removed.
- It aims to remove the fibroids that cause menstrual problems or that may be interfering with the ability to conceive.
- Hospital stay: one night’s stay or as a day-case.
- Anaesthetics: general anaesthetic as an inpatient or local anaesthetic as an outpatient.
- Duration of procedure: varied around 30 minutes to 1 hour, depending on the size of the fibroid.
- Recovery period: 1 - 2 weeks.
What can I expect from the procedure?
- If your reason for the operation is heavy periods or irregular menstrual bleeding, then your periods will be likely lighter and more regular afterwards. You will see improvements over the next 2-3 months.
If you received Endometrial Ablation at the same time of your hysteroscopic resection, reduction in bleeding will be even more pronounced.
- If your fibroids had made conceiving difficult then your chance of getting pregnant is improved after hysteroscopic resection. Please remember that the ability to conceive depends on many factors and therefore it is difficult to predict who will be successful after TCRF.
What are the alternatives?
If you no longer wish to become pregnant in the future, your alternatives may include uterine artery embolisation (UAE), MRgFUS, or a hysterectomy.
You may wish to consider endometrial ablation to control your heavy menstrual bleeding first and if this fails you may revisit the option of TCRF or UAE/UFE or hysterectomy.
What are the risks or complications of the procedure?
Like all operations, hysteroscopic resection carries some risks & complications, which include.
|Table 1. Risks & Complications of Hysteroscopic resection
||You may get adverse reaction with anaesthetics.
|Excessive bleeding during the operation
||If bleeding is not controlled by diathermy coagulation, it may be necessary to use pressure from an inflated catheter that is inserted into the womb.
|Infection of the womb
||Small risk and usually presented as offensive vaginal discharge.This is treatable with antibiotics.
||Risk of puncture of the uterus occurs in 1-2 per 1000 operations. Sometimes, when this happens, there is a small risk of bowel injury at the same time. It may be necessary to perform laparoscopy to check this out.
|Excessive fluid absorption
||Occurs in 1-5% operations. This managed by blood test monitoring and diuretics. Your hospital stay may prolonged as a result.
What are the risks of anaesthesia?
The risk of general anaesthetic (GA) depends very much on your general health. A fit, healthy 20 year old person would be at far less risk than an 80 year old person would with some serious disease. Possible risks of general anaesthesia include:
- Nausea and Vomiting. This does not always occur. May be caused by the surgical procedure or pain relief medication. Medications and fluids may be required to resolve it.
This may also be from a tube in the mouth or throat during anaesthetic and in this case, cough lozenges, gargle, and a simple pain killer may help.
- Muscle weakness. Muscle pain may be from spasm around the wound or the use of certain anaesthetics. Pain killers and rest usually settle it.
- Blurred or double vision. This usually settles down with rest.
- Allergic reactions. Your anaesthetist will avoid any known drugs that you know you are allergic to. In case of unexpected reaction, the team is well trained and qualified to deal with it.
- Damage to teeth. Once you are deeply asleep, tubes may be placed inside your mouth and throat. The shape of your mouth varies and different types of dental diseases, loose teeth, bridge and crowns may be present. The anaesthetist talks about the possible damage to you before the operation. If damage occurs, you will be told about it afterwards and repair is arranged.
What are pre-surgery treatments?
If you have large fibroid(s) you may be given a monthly injection to shrink them for 2-3 months before your TCRF procedure. This injection (a gonadotrophin releasing hormone analogue –GnRHa), reduces oestrogens that feed the fibroids. Examples of a GnRha include Zoladex, Decapeptyl.
Some women experience side effects similar to menopausal symptoms while on GnRHa injections, which include hot flushes and night sweats and may have cessation of their periods for a month or so.
Your hormone production should return to normal 4 to 6 weeks after stopping monthly GnRHa injection (e.g. Zoladex). The induced menopausal symptoms should disappear then.
In the case of large fibroids and you cannot tolerate GnRHa injections or you do not want to have them, you may be given a two stage surgical procedure, with the second operation to take place after 3 months of the first one. A two-stage procedure is also applicable if a significant portion of the fibroid lies within the muscle of your womb.
What other procedure am I likely to receive at the same time of TCRF?
If heavy menstrual bleeding is your main symptom and future pregnancy is not an issue, your gynaecologist may suggest a combination treatment of TCRF and Endometrial Ablation (EA) at the same time. EA is a procedure where the womb lining is destroyed. If you need EA your gynaecologist will discuss this fully with you what it is, risks and outcomes.
What happens BEFORE the procedure?
Pre-assessment usually takes place a week before the actual operation and lasts an hour. At pre-assessment, certain tests are carried out to make sure that you are fit for the procedure, which include:
- Physical examination.
- Pregnancy test.
- Check what medications you are taking regularly.
- Check your blood levels for haemoglobin to see if you are fit enough to go ahead.
- Check blood pressure, heart rate and ECG to see if the heart is fit.
- Possibly chest x-rays.
What happens ON THE DAY and BEFORE the operation?
- You will be taken to a waiting room where a nurse will check you in.
You will be seen by gynaecologist who will ask the date of your last menstrual period. You will also have the procedure explained to you and be asked to sign a written consent form.
- One hour before the operation, you will be given an anti-inflammatory & pain killers as well as anti-sickness/nausea medications. Also to soften the cervix to make resectoscope entry easier, you may be given medications to insert into the vagina.
- An anaesthetist will meet you to go though the type of anaesthesia applicable for your case and ask questions on previous operation(s) (if you've had any and also your family).
- If you choose to have GA, in the pre-op room, an intravenous line is inserted for drugs to be given. Then next 2 steps are applicable to you.
- You will be moved to the operating theatre where various monitors will be connected to help to care for you while you are anaesthetised.
- The anaesthetist will put you to sleep. Tube may be put into your mouth to help you to breathe and taken out at the end of the operation. She/he will stay with you throughout the surgery to make sure that you remain safe throughout.
What happens DURING the operation?
- Under general anaesthetics, the cervix is gently stretched by a number of gradually increased size dilators one after the other.
- When sufficient stretch is achieved, the surgeon inserts a resectoscope into the womb. The resectoscope is connected to the fluid system which is used to distend the womb to allow the surgeon a clearer view. The view of the inside of your womb is also aided by a camera system connected to the resectoscope and a monitor.
- Pictures are taken for comparison later.
- The surgeon starts to shave off the fibroid by passing an electrical current through the cutting loop attached to the resectoscope and remove it bits by bits (piecemeal) if it is larger than 5 cm. The electrical current in the cutting loop helps to ensure a cleaner cut and seal the blood vessels at the same time.
- Pictures are taken to see the effects of the treatment.
- A sample of the removed fibroid(s) is taken to send to the labs to check for abnormality.
- Endometrial ablation may also be carried out at the same time to thin the lining of the womb to make your periods lighter. This is ONLY done if you have consented to it and suitable when you have completed your family or do NOT wish to become pregnant later.
- A dose of antibiotics is given during the procedure.
- During and at the end of the operation, all fluid used is collected and checked for fluid balance.
- The whole procedure takes about 30 minutes to complete but may take a little longer for larger fibroids.
What happens AFTER surgery?
- You will be moved to the recovery room to be cared for by a specialist nurse until you are stable and then transferred to the ward.
- You may have some cramping abdominal pains and pain relief is given for this.
- Some vaginal blood loss may occur but not too much to cause concern.
- Once you are fully recovered, you will be given a drink and a light meal.
You will be discharged home either later on the same day of your operation or early the next day.
Care at home guide
- You may feel drowsy in the first 24 hours and it is advisable that you do not drive or operate machinery.
- To prevent infection, you are prescribed antibiotics.
- You may experience cramping symptoms. If this is the case, you can take paracetamol (e.g. Panadol) or ibuprofen such as Nurofen (only if you are not allergic to it, or asthmatic or have history of stomach ulcers). If you are in doubt, ask your pharmacist.
- Rest for a couple of days then gradually resume your normal activities.
- You may get vaginal bleeding lasting 2-4 weeks and it should settle after that. Do not use tampons, only use sanitary towels.
- You may still see a pinkish/brown/yellow or clear vaginal discharge in the first 2-4 weeks which is common as the womb heals.
- Don’t use tampons until the blood stained discharge has stopped as this could introduce infection.
- Use the shower instead of the bath in the first 2 weeks.
- You can have sex again as soon as the discharge stops. Do continue contraception as before, unless you are wanting to get pregnant.
- Depending on your speed of recovery, you can go back to work and continue with normal activities within about one week.
When should I seek emergency medical attention?
While it is unusual to have problems once you are at home, seek immediate medical attention if any of the following occurs:
- Fever with temperature above 38 ºC or chills.
- Increased abdominal pain which is not relieved by pain medications.
- Increased/prolonged bleeding.
- Unusual foul-smelling vaginal discharge (yellow/green colour).
- Discharge from wound or wound opening.
- Frequent urination or burning sensation when passing urine.
- Difficulty or unable to pass urine.