Hysteroscopic myomectomy for FIGO type 3 uterine fibroids with diameter not less than 5 cm: a retrospective, single-center study of eighteen cases

BACKGROUND: Hysteroscopic myomectomy is a preferred treatment for women requiring future fertility. While it was difficult to manage large submucosal fibroids or deep intramural invasion myomas with hysteroscopic approaches. We conducted this study to explore the feasibility of hysteroscopic removal of large sized (≥ 5 cm) FIGO type 3 fibroids with deep intramural invasion that are difficult to manage with one-step hysteroscopy by "downgrading" technique. METHODS: This retrospective study included of hysteroscopic myomectomy from February 2023 to September 2025 in an academic university hospital. The removal of large type 3 myomas was typically not less than 5 cm in maximum diameter. The clinical characteristics, details of the surgery and postoperative follow-up were collected for retrospective analysis. RESULTS: A total of eighteen patients were included. The primary maximum diameter of fibroids ranges from 5 to 9.5 cm (median size was 6.5 cm) and ten of them was 6 cm or larger. 77.8% cases scored above 6 according to the classification of the STEPW classifications. Mean hysteroscopic operating time was 41.7 min. The perfusion fluid deficit was between 300 and 2,500 mL. The lowest blood potassium levels ranged from 2.11 to 3.82 mmol/ml. The One-step Hysteroscopic resection was performed in sixteen cases, 88.9% of patients. One case had successfully removed the residual fibroid through another hysteroscopic surgery six weeks after surgery, and another patient refused to receive a reoperation. All patients exhibited stable vital signs intraoperatively and postoperatively. The menstruation was recovered in all patients after the procedure. After 3 to 34 months of follow-up, there was no evidence of the recurrence in all but one patient who lost to follow-up at 1 year postoperatively. Notably, three patient achieved pregnancy spontaneously and two of them successfully delivered a healthy baby. CONCLUSIONS: Hysteroscopic resection with "downgrading" technique is a potential alternative approach for women with large (≥ 5 cm) FIGO type 3 fibroids. However, careful execution in a proficient hysteroscopic center is essential.