Hysteroscopic Polypectomy

1. Proliferative/hyperplastic 

2. Functional

3. Atrophic

4. Mixed (endometrial-endocervical)

5. Adenomyomatous

6. Malignant

One of the challenges when we start imaging individuals and finding abnormalities like polyps is that we don’t know their natural history, which for polyps has been studied only in a limited manner. However, the investigators that did look at this in the context of a small prospective study identified a spontaneous regression of about 27% with polyp size being a major determinant (32). More than one group of investigators has shown that when polyps are at least 1.5 cm in maximum diameter they are less likely to regress than smaller polyps(32, 33) and episodes of heavy bleeding may be a predictor for the passage of polyps(33).  

When endometrial or endocervical polyps cause abnormal bleeding one mechanism is suspected to be related to stromal congestion within the polyp, a circumstance that leads to venous stasis and necrosis, typically at the apex of the lesion (34). Another theory postulates theories variable expression of gonadal steroid hormone receptors that contribute to an altered response that results in tissue breakdown and related bleeding (6). The available evidence shows no relationship between the number, size or location of the polyps and presence of AUB(51)(35). 

Endometrial polyps are commonly found in women with infertility(39, 40) with a reported prevalence that is as high as 32%(41). While this sounds high, some studies show a similar prevalence of endometrial polyps in women without infertility, a circumstance that begs determine what, if any, relationship there between endometrial polyps and infertility.

The overwhelming majority of endometrial polyps are benign, but hyperplasia and malignancy occur in up to 13% (2, 44-49). It appears that the risk of malignancy is highest in those postmenopausal women who have symptoms, particularly postmenopausal bleeding and is much lower in premenopausal women (50). In addition to the risks of increasing age and menopausal status there are other correlates including polyp size > 15mm(46, 47) and a record of tamoxifen use(19, 22, 51). Both atypical hyperplasia and endometrial carcinoma may originate from endometrial polyps, with the two most common pathological categories being endometrioid and serous papillary carcinoma (52, 53). 

As imaging techniques are applied to more and more individuals, including those without symptoms, the chance of identifying lesions that may not have clinical significance rises, and the chance for adverse events becomes a consideration. Consequently, there is a role for expectant management of endometrial polyps in the presence of one or more of three circumstances. First, and as described previously in this section, women with a polyp less than 10mm in diameter on sonographic assessment have a chance of spontaneous regression that is almost 27% over a period of 12 months. Second, the chance of malignancy is low in premenopausal women and in asymptomatic postmenopausal individuals who have an TVUS based EEC <11 mm. Third, those with minimal or no symptoms will not benefit symptomatically from polypectomy, so if they also fit the other criteria they as well are candidates. Some clinicians will suggest that small polyps be followed for up to a year, reassessing the value of removal at that time.

The evidence supporting medical management of endometrial polyps is somewhat tenuous. The use of GnRH agonists has been evaluated but while symptoms are suppressed while on therapy, they tend to return following discontinuation [Vercellini, 1994 #105]. The intrauterine system containing 52 mg of levonorgestrel (LNG-IUS52) has been evaluated in a well-designed comparative trial in women that lasted over four years that demonstrated fewer polyps in the LNG-IUS treated group(74). While this is a preventative trial, it didn’t demonstrate activity in patients with known polyps.

Given the availability of hysteroscopy, including the opportunity to perform many procedures in an office or clinic environment, there is no longer a role for blind polypectomy. This includes the process of making the diagnosis hysteroscopically and using blind techniques to remove the polyp. Not only is blind excision frequently ineffective there is documented perforation rate of about 1%, sometimes with disastrous consequences when there is related bowel or vascular injury. Available evidence suggests that blind techniques such as “D & C” result in complete removal of endometrial polyps in about 15% of women, a number that reaches about 40% if polyp forceps are used blindly (76-80). Hysteroscopically directed polypectomy, on the other hand, is associated with low complication rates and much higher rates of complete excision (12, 81-84). Collectively the intrauterine endoscopic approaches to endometrial polypectomy are the recommended surgical techniques for this pathology.

Simple transaction and extraction is generally the most cost effective technique for relatively small or pedunculated and soft polyps that have a minimum diameter comparable with the inside diameter of the cervical canal. Most small, and many larger polyps can be transected at their base with sharp scissors and then removed using tenacious grasping forceps. The diameter of the polyp or polyp fragment should be such that it is extractable through the cervix considering its dilation. Care should be taken to transect the polyps as close to the basalis as possible to minimize the risk of recurrence, a risk that may be lower with electrosurgical technique(86).  

Once the hysteroscope is positioned, and the scissors advanced into the endometrial cavity, a useful technique is partial transaction, leaving the polyp attached to the cervical canal or endometrium by a small strand. This allows the instruments to be switched so that the polyp can be easily detached with appropriate grasping forceps. Then, the polyp is brought into proximity with the distal tip of the hysteroscopic system and the entire assembly extracted from the endometrial cavity through the cervical canal. It can help to turn off the inflow of distension media for extraction, one method to reduce the chance of dislodgement from the forceps. If there are more than one polyp this technique can be compromised if small transected vessels bleed rendering the distending media opaque. In such instances other techniques should be considered or the procedure can be completed at a later date.

A monopolar, or, preferably, a bipolar radiofrequency (RF) resectoscope can be fitted with a loop electrode and used to transect polyps at their base. The ESU settings will vary based upon the system used and the diameter of the loop electrode. So, the surgeon should be familiar with the specifics of the system in use. 

Once transected, the lesions can be captured between the resectoscope’s distal end and the retracted electrode whereupon the entire system, including the polyp, can be removed turning down the media inflow to minimize the risk of dislodgement. Alternatively, a separate grasping instrument can be used to remove each piece, but this generally involves refitting the system with a bridge or using another assembly, a circumstance that can increase procedure time and patient discomfort if performed under local anesthesia. 

A potential advantage of this technique is the ability to use the loop electrode to deeply transect the base of the polyp, an approach that may reduce the risk of recurrence. Indeed there is evidence from a comparative study of 240 women that the use of energy does reduces the risk of recurrence; 0% in the RF group and 15% in the women who had scissors and grasping forceps technique for removal of their polyps (86).  There are also disadvantages with the use of the resectoscope, that is generally of a larger diameter than operative hysteroscopes or many electromechanical systems – although the OD of some systems is now down to 15 French. The use of monopolar RF resectoscopes offers a greater risk of complications related to media and current diversion that have fortunately been eliminated with bipolar systems that function in saline media. With this and other RF techniques it is important to minimize electrosurgical injury a circumstance that has particular importance with multiple polyps. In such instances, either a staged procedure (multiple sessions) or mechanical techniques may be more appropriate options.

Another RF approach is the use of bipolar needles that can be used with the 5 Fr operative channel hysteroscopic systems that are generally of smaller OD than resectoscopes. The needle can be used to dissect, transect and even morcellate the polyp, but like scissors-based dissection requires grasping forceps for removal of polyps. The electrosurgical unit settings are generally specific to the instrument so one cannot provide specific guidance in this regard. Because bipolar instruments function in – even require - saline as distension media, there is a decreased risk of hyponatremia and its sequellae compared to systems that use electrolyte free media (30, 88). The advantage of these bipolar needles is that they can relatively easily bivalve or trivalve a polyp otherwise too large to remove through the cervix and do so in a relatively bloodless fashion because of the electrocoagulation effect. Disadvantages of these systems are the cost – not only of the base unit, but also of the needles that are typically, not always single use designs. 

The endoscopic electromechanical morcellator and extraction systems were originally designed for use in orthopedics and were modified for use in hysteroscopic surgery in the last 20 years. Their utility for endometrial polypectomy is grounded in the relatively easy learning curve and short operating time because the design is somewhat agnostic to polyp size and number. The devices largely eliminate the need for switching instruments and, consequently, at least for larger or multiple polyps results in fewer removals and reinsertions of instruments through the cervix and decreased risk of cervical laceration and systemic fluid absorption (88, 89).  

Their general use and function is described in the section on equipment and supplies. Once the device is positioned in the endometrial cavity, the “window” or fenestration is brought into proximity with the polyp and activated. This usually results in the polyp being quickly morcellated and aspirated. The specimen is captured in a tissue trap that is in line with the aspiration/extraction channel of the system. There may be value in gently pushing fenestration against the attachment of the polyp to the endometrium to resect the stalk or base as close as possible to the basalis of the endometrium. 

There is comparative evidence regarding this technique. A multicenter randomized trial allocated 121 women with polyps to either hysteroscopic electromechanical morcellation and extraction or RF resectoscopic resection in an ambulatory setting. The electromechanical technique was associated with a shorter operative time, removal of a greater proportion of polyps, reduced procedure-related pain and greater acceptability to patients than resectoscopic polypectomy (90). Another randomized trial designed to evaluate resident training randomized 60 women to either hysteroscopic electromechanical morcellation or RF electrosurgical resection demonstrating reduced operating time with the electromechanical technique, and, again a minimal apparent learning curve (91). 

One of the major issues with these devices is their cost. In most instances they have been developed as single use instruments with exorbitant costs set to facilitate office surgery in otherwise expensive hospital environments. Fortunately, less expensive manually activated systems are becoming available and reusable systems promise to substantially reduce the per case costs while maintaining the other advantages of the technique.