Prevention, diagnosis, and management of complications in hysteroscopic myomectomy: a literature review

Background and Objectives: Submucous myomas, even if representing only 5.5-15% of all uterine myomas, are usually those related to the most severe symptoms. Hysteroscopy is considered the gold standard for removing submucous leiomyomas and is associated with a low incidence of adverse events. Nevertheless, hysteroscopic myomectomy (HM) can be complex and complicated. This article aims to review the potential complications of HM to help surgeons prevent and manage them appropriately. Methods: A review of the literature from November 1993 to July 2023 was conducted on PubMed and Embase databases, searching for keywords which were then combined into pairs. Other articles from other databases were included when relevant. Only articles published in English were included in this review. Key Content and Findings: Complications during hysteroscopy are rare. More than 50% of complications are due to mechanical trauma. Cervical trauma and cervical or uterine perforation can occur during cervical dilation, with the introduction of the scope, or with excessive resection of the myoma. The distance between the myoma and the uterine serosa [free myometrial margin (FMM)] is crucial to assess the risk of uterine wall perforation during the procedure. However, it has been demonstrated that FMM is a parameter that tends to increase during the hysteroscopic excision of the myoma. Other potential severe complications are fluid overload and venous gas embolism. Scrupulous supervision of fluid balance during the procedure is crucial to minimize this rare but possible event. Deficits of 1,000-2,500 mL with saline solution as a medium require careful monitoring and surgery must be stopped at the first sign of possible embolism. Surgery must be stopped immediately with a deficit of 2,500 mL or more (Grade 1C evidence). When dealing with older women and patients with cardiovascular, renal, or other comorbidities, the threshold for fluid deficit must be lowered to 750 mL (Grade 1B evidence). The complication rates mainly depend on the technique used, the surgeon's expertise, the patient's characteristics, and the overall complexity of the procedure. Conclusions: Preoperative planning and diagnostic assessment are crucial for minimizing the complication rate as well as a conscious choice of the most adequate and suitable hysteroscopic technique, with a personalized approach for each patient.