1. Ricardo Lasmar MD, PhD GINENDO UNESP - UERJ ricardo@lasmar.com.br Lasmar Hysteroscopic Myomectomy

2. New Submucous Fibroids Classification STEP-W classification AAGL 35 th Annual Meeting AAGL 35 th Annual Meeting www.ginendo.com Lasmar Hysteroscopic Myomectomy

3. www.ginendo.com Lasmar Classification (ESGE)  0 - Fibroids totally in cavity  1 - More than 50% in cavity  2 - Less than 50% in cavity Wamsteker K, 1993 Hysteroscopic Myomectomy

4. Lasmar New Classification Target More Correlation with Difficulty and Complexity of Hysteroscopic Myomectomy

5. www.ginendo.com Lasmar New Classification Including more 4 parameters: Penetration Penetration Size Size Topography Topography Extension of the base Extension of the base Wall Wall Hysteroscopic Myomectomy

6. STEP-W Classification Size (cm) Topography Extension Base Penetration Lateral Wall TOTAL 0 ≤ 2 Low ≤ 1/3 0+1 1 > 2 to 5 Middle >1/3 - 2/3 ≤ 50% 2 > 5 Upper > 2/3 > 50% = Lasmar.RB.et al., J Minim Invasive Gynecol. 2005 Jul-Aug;12(4):308-11 Hysteroscopic Myomectomy

7. 0202 1 >2 to 5 2 > 5 STEP-W CLASSIFICATION Size (cm) Lasmar ricardo@lasmar.com.br Hysteroscopic Myomectomy

8. 0 1 2 STEP-W CLASSIFICATION Topography Lasmar ricardo@lasmar.com.br upper middle low Hysteroscopic Myomectomy

9. 0  1/3 1 >1/3 to 2/3 2 > 2/3 STEP-W CLASSIFICATION Extension of the base Lasmar www.ginendo.com Hysteroscopic Myomectomy

10. 0 12 STEP-W CLASSIFICATION Penetration Lasmar www.ginendo.com Hysteroscopic Myomectomy

11. 0 A or P 1L1L STEP-W CLASSIFICATION Wall Lasmar www.ginendo.com Hysteroscopic Myomectomy

12. Size (cm) Topography Ext. Base PenetrationLat.WalTotal0 ≤ 2 Low ≤ 1/3 0+1 1 > 2 to 5 Middle >1/3 - 2/3 ≤ 50% 2 > 5 Upper > 2/3 > 50% Score + + + + = T. Score Group Indication Indication 0 to 4 I Low complexity hysteroscopic myomectomy. 5 to 6 II High complexity hysteroscopic myomectomy. GnRH? Two-step hysteroscopic myomectomy. 7 to 9 III Hysteroscopic myomectomy is not indicate. Lasmar.RB.et al., J Minim Invasive Gynecol. 2005 Jul-Aug;12(4):308-11

13. Mean Operative Time (min) –62 ESGE STEP-W T 0 = 11 = 5:4 Group I = 50 = 8:2 T 1 = 32 = 9:1 Group II = 12 = 23:2 (p<0,001) T 2 = 19 = 18:1 (p=0,02) www.ginendo.com Hysteroscopic Myomectomy Lasmar

14. Average Fluid Balance (ml) = 62 ESGE STEP-W T 0 = 11 = 56.2 Group I = 50 = 89.8 T 1 = 32 = 123.2 Group II = 12 = 355.0 (p=0,02) T 2 = 19 = 222.0 (p=0,17) www.ginendo.com Hysteroscopic Myomectomy Lasmar

15. Incomplete Myomectomy 05 (62) ESGE STEP- W T 1 = 1 (20%) Group II = 05 T 2 = 4 (80%) (100%) ricardo@lasmar.com.br Hysteroscopic Myomectomy Lasmar ricardo@lasmar.com.br

16. % Complete Hysteroscopic Myomectomy - 62 ESGE STEP-W T 0 = 11/11 (100%) Group I = 50/50 (100%) T 1 = 31/32 (97%) Group II= 07/12 (58%) (p<0,001) T 2 = 15/19 (79%) (p=0,07) www.ginendo.com Hysteroscopic Myomectomy Lasmar

17. Conclusion STEP-W Classification has a bigger Correlation with the Difficulty and Complexity of Hysteroscopic Myomectomy

18. Thank you Obrigado Ricardo Lasmar ricardo@lasmar.com.br Lasmar Hysteroscopic Myomectomy

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