Operative hysteroscopy is a safe surgical technique to treat intra-cavity uterine pathologies [1-3]. The resectoscopes currently on the market are between 180 and 200 mm long. We are more and more confronted with technical difficulties and incomplete surgeries due to a too short length of resectoscopes. Indeed, due to the increase of the average BMI in the population, we are regularly confronted with patients with a BMI > 35 [4,5]. Their peri-perineal excess fat does not allow us to work easily, with a surgical handle in contact with the patient, limiting the procedure and access to the fundic wall and the anterior part of the uterine cavity.

Also, in the context of polyfibroid uterus, patients could have a large cavity with a hysterometry more than 12cm. Actual resectoscopes does not allow to reach the pathologies of the uterine fundus. Fibroids affect 20 to 50% of women of childbearing age and their incidence increases with age, affecting more than one woman in two from the age of 35 years old [6]. With the advancement of the age of first pregnancy and the possibility of gamete donation , we are faced with an increase in the management of these polyfibroid uteri with large cavities and the presence of intra-cavity myomas [7,8].

In order to remedy these technical difficulties, Delmont Imaging (Avenue du Mistral 13 600 La Ciotat / France) has developed a new surgical hysteroscope "XXL Resecare" to respond to these more frequent difficulties (Figure 1). They have developed a hysteroscope with a diameter of 6.9mm (18 French) and a length of 287mm with bipolar electrodes adapted to the size of the hysteroscope: curved loop, roller ball and knife. This resectoscope allows to reach the pathology of the uterine fundus and an optimal position of the surgeon (Figures 2 and 3). With an experience of 42 patients treated, we were able to perform a complete hysteroscopic treatment in those patients who could not be treated entirely with a standard-size hysteroscope.

Figure 1: Comparison of the size of the two resectoscopes

1. XXL Resecare, diameter of 6.9mm (18 French) and a length of 287mm, with electrods, Delmont Imaging (La Ciotat/ France)
2. Resecare, diameter of 6.9mm (18 French) and a length of 187mm, with electrods Delmont Imaging (La Ciotat/ France)

Figure 2: Comparison of the surgeon's position between the two hysteroscopes on a patient with BMI > 35

1. XXL Resecare, length of 287mm (18 French) Delmont Imaging (La Ciotat/ France)
2. Resecare, length of 187mm (18 French), Delmont Imaging (La Ciotat/ France)

Figure 3: Comparison of accessibility to fundic pathology, loop maximally extended, between the two hysteroscopes

1. XXL Resecare, length of 287mm (18 French), Delmont Imaging (La Ciotat/ France)
2. Resecare, length of 187mm (18 French), Delmont Imaging (La Ciotat/ France)

References

1. American Association of Gynecologic Laparoscopists (AAGL): Advancing Minimally Invasive Gynecology Worldwide. AAGL practice report: practice guidelines for the diagnosis and management of submucous leiomyomas. J Minim Invasive Gynecol 19 (2012): 152-171.
2. American Association of Gynecologic Laparoscopists. AAGL practice report: practice guidelines for the diagnosis and management of endometrial polyps. J Minim Invasive Gynecol 19 (2012): 3-10.
3. AAGL Elevating Gynecologic Surgery. AAGL practice report: practice guidelines on intrauterine adhesions developed in collaboration with the European Society of Gynaecological Endoscopy (ESGE). Gynecol Surg 14 (2017): 6.
4. De Saint Pol T. Evolution of obesity by social status in France, 1981-2003. Economics & Human Biology 7 (2009): 398-404.
5. Organization WH. Obesity: Preventing and Managing the Global Epidemic: Report of a WHO Consultation. World Health Organization (2000).
6. Parker WH. Etiology, symptomatology, and diagnosis of uterine myomas. Fertil Steril 87 (2007): 725-736.
7. Kohler HP, Billari FC, Ortega JA. The Emergence of Lowest-Low Fertility in Europe During the 1990s. Population and Development Review 28 (2002): 641-680.
8. Sobotka T. Is Lowest-Low Fertility in Europe Explained by the Postponement of Childbearing? Population and Development Review 30 (2004): 195-220.