1. UOG Journal Club: September 2011
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)

2. Submucous fibroids can be a cause of:
Heavy and irregular menstrual bleeding
Early pregnancy loss
Subfertility
Clevenger-Hoeft M et al., Obstet Gynecol 1999
Pritts EA, Obstet Gynecol Surv 2001

3. Type 0:
fibroid polyp
Type 1:
<50% confined to the myometrium or
protrusion ratio >50%
Type 2:
≥50% confined to the myometrium or protrusion ratio ≤50%
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?
Wamsteker K et al.
Obstet Gynecol 1993

4. Submucous fibroids can be assessed by:
Diagnostic hysteroscopy
This 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
Ultrasonography
This allows accurate measurement of fibroid size
Saline contrast sonohysterography
This facilitates detection
of submucous fibroids
and improves diagnostic accuracy
Leone FP et al., Fertil Steril 2003
Lee C et al., UOG 2006
Salim R et al., Hum Reprod 2005

5. Transcervical resection of fibroid (TCRF) introduced into clinical practice
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

6. 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:

7. Prospective observational study of 61 symptomatic women, 2006–2008
Inclusion criteria:
Heavy and/or irregular periods
AND
Submucous fibroid diagnosed by two-dimensional transvaginal ultrasound
Exclusion criteria:
Use of hormonal contraception
Previous operation for fibroids
3D saline contrast sonohysterography
with 5–10 mL sterile saline solution

8. Widest diameter of the fibroid, plane perpendicular to the endometrium
Methodology
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

9. Additionally recorded variables:
Number of submucous fibroids
Fibroids classified according to European Society of Hysteroscopy
Location of the fibroid – anterior/ posterior/fundal

10. Multivariate logistic regression analysis
Univariate analysis
Comparison of demographic and ultrasound variables between women with complete and incomplete fibroid resection
Multivariate logistic regression analysis
Completeness of resection as response variable
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

11. Comparison of variables: complete vs incomplete fibroid resection
Parameter P-value
Age
0.435
Nulliparous
0.141
Multiple fibroids
0.281
Protrusion ratio
0.001 * †
Diameter of fibroid
0.001 †
Size of intramural component
0.001
0.472
Distance from fibroid to internal os
Fundal location
0.559
*Larger in cases with complete resection
†Smaller in cases with complete resection
Results of univariate analysis. Women with complete (n = 49) vs incomplete resection (n = 18) (n = 61 women, 67 fibroids)

12. Predicting complete resection of submucous fibroid: multivariate logistic regression model
Variables in the model:
OR (95% CI)
P-value
Parity
0.002 (0.000–0.035)
0.035
Size of intramural component (mm)
0.511 (0.277–0.943)
0.032
Fibroid diameter (mm)
0.843 (0.655–1.000)
0.050
Training set (n = 39)

13. Analysis of single variables Size of intramural component
using a testing set
ROC AUC Cut-off value Sensitivity Specificity
Degree of protrusion
0.777
43 %
86%
67%
Fibroid diameter
0.867
38 mm
86%
83%
Size of intramural component
0.833
10 mm
59%
100%
Testing set (n = 28)

14. AUC Cut-off value Sensitivity Specificity
Prediction of complete hysteroscopic submucous fibroid resection using logistic regression model
Training set n = 39
Sensitivity
Testing set n = 28
1 – Specificity
ROC curves
AUC Cut-off value Sensitivity Specificity
Training set
0.975
36%
96%
92%
Testing set
0.864 9%
86%
83%

15. Complete submucous fibroid resection can be predicted by
Larger protrusion ratio of submucous fibroid into the uterine cavity
Smaller fibroid diameter
Smaller size of intramural fibroid component
Parity
Unsuccessful fibroid resection is more common in cases with
Smaller protrusion ratio of submucous fibroid into the uterine cavity
Larger fibroid diameter
Larger size of intramural fibroid component

16. Conclusions
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 component
can be used to calculate individual probability of complete hysteroscopic resection of submucous fibroid
D. Mavrelos et al, UOG, 2011