D. Mavrelos, J. Naftalin, W. Hoo, J. Ben-Nagi, T. Holland, D. Jurkovic

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 irregularmenstrual bleeding • Early pregnancy loss • Subfertility Clevenger-Hoeft M et al., Obstet Gynecol 1999 Pritts EA, Obstet Gynecol Surv 2001

3. Type 1: <50% confined to the myometrium or protrusion ratio >50% Type 0: fibroid polyp 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: Three-dimensionalsalinecontrastsonohystero-graphy (3D-SCSH) This can help to determine the proportion of the fibroid that is confined to the myometrium Diagnostichysteroscopy This can visualize only the part of the fibroid that is visible within the uterine cavity 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 predictsuccessfulcompletesubmucousfibroidhysteroscopicresection Objective:

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

8. Methodology • Measurements taken: • Section of fibroidprotrudinginto the uterinecavity (A) • Intramuralcomponent (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 submucousfibroids Fibroidsclassifiedaccording to European Society of Hysteroscopy Location of the fibroid – anterior/ posterior/fundal

10. Univariateanalysis Comparison of demographic and ultrasound variables betweenwomen with complete and incompletefibroidresection • Multivariatelogistic regression analysis • Completeness of resection as response variable • Training set 60% of cases • 27 with completeresection • 12 with incompleteresection • Testing set 40% of cases • 22 with completeresection • 6 with incompleteresection

11. Comparison of variables: complete vs incomplete fibroid resection ParameterP-value Age 0.435 Nulliparous 0.141 Multiple fibroids 0.281 0.001 * Protrusionratio † 0.001 Diameter of fibroid † 0.001 Size of intramuralcomponent 0.472 Distance from fibroid to internal os Fundallocation 0.559 *Larger in cases with complete resection †Smaller in cases with complete resection Results of univariateanalysis. 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 0.002 (0.000–0.035) Parity 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 using a testing set ROC AUC Cut-off value Sensitivity Specificity Degree of protrusion 86% 0.777 43 % 67% Fibroid diameter 0.867 38 mm 86% 83% Size of intramuralcomponent 0.833 10 mm 59% 100% Testing set (n = 28)

14. 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 96% 36% 92% 9% Testing set 0.864 83% 86%

15. Complete submucous fibroid resection can be predicted by • Larger protrusion ratio of submucous fibroid into the uterine cavity • Smallerfibroid diameter • Smallersize of intramuralfibroidcomponent • Parity Unsuccessful fibroid resection is more common in cases with • Smallerprotrusionratio of submucous fibroidinto the uterinecavity • Largerfibroid diameter • Largersize of intramuralfibroidcomponent

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 calculateindividualprobability of complete hysteroscopic resection of submucous fibroid D. Mavrelos et al, UOG, 2011