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From the standpoint of GnRH analogs and endometrial ablation and even preparation for myomectomy, that is the kind of endometrium you would like to see. The perfect patient is the postmenopausal patient, in terms of the endometrium. It is very low, very thin and very avascular. I have seen patients walk in with submucous fibroids that have had hemoglobins in the 2 to 3 range that were still out walking and talking and they had just chronically brought their hemoglobins down. The one that I can think about most recently had nothing more than a 1-cm submucous fibroid and that was the sole source of her bleeding and she was in the low 3’s with her hemoglobin. We know that we can significantly increase patient’s hematocrit on GnRH analogs and iron. This was just one of the original studies looking at the use of GnRH analog versus iron alone. There is no question that the to of them together are better. We can reduce myoma volume. I find this to be less of an issue when I am doing a laparotomy/myomectomy. I find it to be helpful when I am doing a resectoscopic myomectomy. Doing a 1.5 to 2.0 cm myoma is incredibly simpler than doing a 3 to 4 cm myoma. There is not that much difference in size, if you were to take it out, put it on a table and look at it, but the difference from a standpoint of difficulty hysteroscopically, where you have minimal ability to distend and that cavity is only so big, is tremendous. In these situations, if you can get just a small bit of shrinkage, that may help facilitate surgery.
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The most common use of the resectoscope is removal of intrauterine lesions. Using unipolar or bipolar, you are going to create open vessels. With the pressure head that you have to create uterine distention, there is going to be enough force to be able to drive fluid into these vessels. How long does it take with a 20-gauge IV in a patient and a bag on pressure to go through one liter of fluid? It doesn’t take very long at all. That is why you have to watch patients like a hawk and you have to be constantly vigilant about the I&O’s. You can go from being 500 behind, 500 behind, 500 behind – and you are 1500 behind. If you are using normal saline, that is not a big deal, but if you are using glycine or sorbitol that has absolutely no saline in it, it can be a huge deal.
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All of the instruments that you use, whether it is a diagnostic hysteroscope, an operative hysteroscope or a resectoscope, ought to have continuous flow. You have to have this ability to put your media through an inner channel and then through a separate channel, create a current. Ten years ago, this did not exist. It now exits for all of our hysteroscopic instrumentation. It allows us to be able to work in bloody cavities fairly quickly. We can clean out those cavities and get good visualization.