Hysteroscopic treatments for endometrial malignancies and premalignancies: state of the art

Endometrioid endometrial cancer (EEC) is the most common gynecologic malignancy worldwide. One in four cases will be diagnosed before menopause. Endometrial atypical hyperplasia (EAH) is a precursor of endometrial cancer and tends to occur at a young age. Those who have early stage, grade 1 EEC or EAH and wish to preserve their fertility can be managed with hormonal therapy. Hysteroscopic treatment in addition to progestin therapy has been used more commonly in the last decade. Herein, a review of available data on hysteroscopic treatment in EEC and EAH is presented.

Hysteroscopic treatment and reproductive outcomes in cesarean scar pregnancy: experience at a single institution

OBJECTIVE

To study the risk factors leading to type II/III cesarean scar pregnancy and evaluate the efficacy of hysteroscopic treatment and subsequent reproductive outcomes.

DESIGN

Retrospective study from 2013 to 2018.

SETTING

Inpatient samples.

PATIENT(S)

A total of 439 patients with cesarean scar pregnancy received hysteroscopic treatment. They were grouped according to the type of surgery as hysteroscopy combined with dilation and curettage, systemic methotrexate followed by hysteroscopy combined with dilation and curettage, and uterine artery embolization or laparoscopic ligation of bilateral uterine arteries followed by hysteroscopy combined with dilation and curettage. Cesarean scar pregnancy was classified as types I, II, and III on the basis of the relationship between the gestational sac and myometrial thickness by ultrasound.

INTERVENTION(S)

Not applicable.

MAIN OUTCOME MEASURE(S)

Risk factors leading to type II/III cesarean scar pregnancy. The success of hysteroscopic treatment as well as favorable reproductive outcomes.

RESULT(S)

The significant variables were multiple parity, prior cesarean section (CS), hysteroscopic therapy, and dilation and curettage after the last CS between type I and type II/III. There were significant differences among the three groups in symptoms, largest diameter of the gestational sac, presence of fetal heartbeat, myometrial thickness, type of cesarean scar pregnancy, blood loss, length of hospital stay, and expense. The rates of complications and success were 8.2% and 93.6%, respectively. Thirty-seven women conceived again, and 22 women completed a term pregnancy with no uterine rupture. The recurrence rate of cesarean scar pregnancy was 10.8%.

CONCLUSIONS

The type of cesarean scar pregnancy is related to the rates of multiple parity, cesarean deliveries, and dilation and curettage procedures after the last CS. Hysteroscopic therapy is a safe and effective surgical approach with a low risk of subsequent ectopic pregnancy.

Conservative cesarean scar pregnancy treatment: local methotrexate injection followed by hysteroscopic removal with hysteroscopic tissue removal system

OBJECTIVE

To describe a conservative cesarean scar pregnancy (CSP) treatment in a patient with the desire for future pregnancy. To date, there is no gold standard for the management of a viable CSP. There is a wide range of treatment options that include major surgery and minimally invasive procedures. Moreover, after a minimally invasive treatment, the gestational sac may be visible at ultrasound for >6 months. The described technique may be useful to avoid complications related to the use of energy with a large reduction in operative times.

DESIGN

Description of the technique with narrated video footage.

SETTING

Academic tertiary hospital.

PATIENT(S)

A 31-year-old woman with a previous cesarean section was referred to our clinic with lower abdominal pain. Transvaginal ultrasound revealed a gestational sac with a viable embryo located in the anterior isthmic region, suggestive of CSP at 9 weeks of gestation. Appropriate counseling describing the two diametrically opposite clinical management options was performed, and the patient decided to terminate the pregnancy. Informed consent was obtained from the patient.

INTERVENTION(S)

Hysteroscopy was performed under local anesthesia in an outpatient setting, using a 2.9-mm Hopkins II Forward-Oblique Telescope 30° endoscope (Karl Storz, Tuttlingen, Germany) with a 4.3-mm inner sheath and 5F instruments. A 3.7F needle (Deflux metal needle; Oceana Therapeutics, Edison, NJ) was pushed into the myometrial tissue surrounding the implantation site of the gestational sac at four different points. Six additional injections were performed into the gestational sac, and 50-mg methotrexate was injected. The appropriate follow-up was performed to determine the success of the procedure. β-Human chorionic gonadotropin was dosed weekly until negative. After 6 weeks, to remove the avascular trophoblastic remnants found at ultrasound evaluation, the patient underwent hysteroscopic removal with a 6-mm TruClear hysteroscopic tissue removal system (Medtronic Parkway, Minneapolis, MN). A contemporary transabdominal ultrasound was performed to minimize surgical risks.

MAIN OUTCOME MEASURE(S)

Complete and conservative CSP treatment with the absence of surgical complications.

RESULT(S)

Conservative cesarean scar pregnancy treatment was performed successfully with primary local methotrexate injection followed, after 6 weeks, by hysteroscopic removal of the CSP remnants with the TruClear hysteroscopic tissue removal system. The first procedure lasted 6 minutes, whereas hysteroscopic removal of the CSP lasted 5 minutes. Both procedures were performed in an outpatient setting, and no complications were detected during and after the treatments. The patient reported good health at the 1-month follow-up visit, and the ultrasound showed an empty isthmocele (Fig. 1).

CONCLUSION(S)

Primary local methotrexate injection followed by hysteroscopic removal of the CSP remnants with the hysteroscopic tissue removal system may be a valuable treatment for women who desire pregnancy in the near future. This combined technique may avoid potential complications, such as thermal-induced myometrial injuries or uterine perforation. Moreover, the operator has the possibility to perform an under-vision procedure with a lower incidence of intraoperative and postoperative bleeding. Because it does not reduce fertility/pregnancy rate, this technique should be a valid option in patients who desire future pregnancy.

Quality of life and sexuality of postmenopausal women with intrauterine pathologies: a recommended three-step multidisciplinary approach focusing on the role of hysteroscopy

Intrauterine pathologies are common in postmenopausal women and clinicians must identify signs and symptoms accurately to provide the adequate diagnosis and treatment. The quality of life (QoL) and sexuality of women are important outcomes to be considered to provide adequate clinical management of the postmenopausal patient with gynecologic pathologies. The aim of this paper is to propose a simple and replicable three-step multidisciplinary approach to evaluate the psychological outcomes of postmenopausal women with intrauterine pathologies, focusing on the role of hysteroscopy. In particular, the article describes three evaluation steps of those psychological outcomes corresponding to three fundamental moments of the patient's diagnostic and therapeutic path: the initial symptoms, diagnosis, and treatment. In our viewpoint, the standard use of such a protocol might considerably improve the QoL of postmenopausal patients undergoing hysteroscopic procedures due to intrauterine pathologies.

HE4 in the Diagnostic Approach of Endometrial Cancer in Patients with Postmenopausal Bleeding, the METRODEC Protocol: Protocol for a Multicenter Prospective Study

Background: Endometrial cancer is the most common pelvic gynecological cancer in France. The most frequent symptom is post-menopausal bleeding and is one of the primary reasons for consultation in gynecological emergencies. The treatment is very codified and consists of a surgical intervention for anatomopathological analysis. The latter is frequently reassuring. These interventions are often performed in mild situations and there is currently no element to be sufficiently reassuring to avoid surgery. This study aims to explore the sensitivity of an innovative marker: Human Epididymis 4 (HE4) in the diagnosis approach of endometrial cancer in case of postmenopausal bleedings. Methods: This is a prospective multicenter diagnostic study with three centers involved. Inclusion criteria are any patient with post-menopausal bleeding who is to undergo hysteroscopy, endometrial biopsy, or endometrial resection. In accordance with the recommendations for the management of post-menopausal bleedings, the medical conduct consists of performing a clinical examination, an ultrasound and, in general, even in case of paraclinical examination reassuring, an anatomopathological analysis. This pathological analysis can be obtained in several ways: biopsy, hysteroscopy-curettage (which is the most frequently performed surgery), and hysterectomy. Our protocol consists of taking a blood sample from each woman who will undergo one of the interventions mentioned above. The dosage of HE4 and CA125 requires the withdrawal of an additional heparinized tube during the preoperative assessment usually performed. This research is therefore classified as non-interventional. The primary outcome is to evaluate the sensitivity of the HE4 marker in patients with postmenopausal bleeding in the diagnosis of endometrial cancer. The secondary outcomes are other parameters (specificity, VPP, VPN) of HE4, Evaluating the diagnostic capabilities of the CA125 marker alone and associated with HE4, as well as those of the REM and REM-B algorithms. We aim to include 100 patients over a period of one year in three centers. Discussion: As of now, there is no biological marker used in routine practice in the diagnosis of endometrial cancer. The ultimate goal of HE4 in endometrial cancer is to avoid surgery for those who are identified as non-sick. This study is the precursor of others for use in routine practice, HE4 would represent a great help to diagnosis if our study demonstrates it as reliable in the management of these patients and avoid many unnecessary and risky surgeries.

The use of hysteroscopy in endometrial cancer: old questions and novel challenges

Endometrial cancer is the most common gynecological malignancy with a relatively good overall prognosis. It traditionally has two subtypes: type 1 (endometrioid carcinoma) and type 2 (non-endometrioid carcinoma). The prognosis is excellent for stage I endometrioid cancer, with a 5-year survival rate of 96%. However, the prognosis is much worse for women with high-risk endometrial cancer. Effective preoperative staging is important in order to tailor treatment and achieve optimal long-term survival. The majority of asymptomatic polyps detected by ultrasound are treated surgically. Conventionally, dilatation and curettage was performed to obtain a histological diagnosis, but nowadays hysteroscopy with biopsy is starting to be considered as the gold standard. Hysteroscopic resection seems to reduce the risk of underdiagnosed (atypical endometrial hyperplasia) endometrial cancer. To avoid the spread of malignant cells, hysteroscopy should be performed with concern to keep intrauterine pressure low. In comparison with cervical injection, the hysteroscopic method has a better detection rate in the para-aortic area during sentinel lymph node mapping. In the assessment of cervical involvement, the accuracy of magnetic resonance imaging is significantly higher than the accuracy of hysteroscopy. In fertility-sparing cases, hysteroscopic endometrium resection with progesterone therapy is an acceptable option.

Removal of uterine polyps: clinical management and surgical approach

Endometrial polyps have a reported prevalence from 7.8% up to 30% and are one of the most cost-consuming gynecological conditions for our specialty. There are strong practitioner beliefs that surgical removal of endometrial polyps is highly beneficial, particularly for those with abnormal uterine bleeding and infertility. Additionally, polypectomy is indicated to reduce the risk of malignancy. Transvaginal ultrasound is the first-line diagnostic option for detection of endometrial polyps, while sonohysterography has similar accuracy as hysteroscopy in the diagnostic confirmation. Blind dilatation and curettage is not recommended for polyp removal; rather, hysteroscopy in the operating room and office setting using small-diameter hysteroscopic equipment is the standard approach. This can be performed without anesthesia in most women. While hysteroscopy is an effective method for polypectomy with a low complication rate, it is unknown whether this is truly beneficial for reproductive-age women with infertility and prior assisted reproduction therapy. The risk of malignancy in women with postmenopausal bleeding justifies the necessity of polypectomy with histologic tissue examination. In asymptomatic women, the risk of malignancy is low, and there are no known benefits of polyp removal in the prevention of malignant transformation. Cost-effective studies remain to be done to provide us with the optimal approach to endometrial polyps including the management of asymptomatic and/or infertile women, ideal location including office-based or the operating room setting, complication prevention including intrauterine adhesions, and recurrence issues.

Effectiveness of different methods for polypectomy in the menopause: a retrospective study

Introduction: Most endometrial polyps represent focal hyperplasia of the endometrium. Endometrial polyps can be diagnosed by ultrasound, hysterocontrast sonography, hysterosalpingography, endometrial biopsy, and uterine curettage, but diagnostic hysteroscopy is considered the gold-standard method, with the greatest sensitivity and specificity and also with the opportunity for treatment at the same time.Study design: A retrospective study was conducted on 424 patients between 2006 and 2018. The polyps were verified during diagnostic hysteroscopy and were removed by resectoscopy or curettage. All samples underwent histological examination. The effectivity of the type of resection and the recurrence rate were evaluated.Results: The average age of the patients was 60.2 ± 9.3 years. Polyps were excised in 62.97% by resectoscopic polypectomy and in 37.03% by curettage. Malignancy was confirmed in 4.24% of cases. Histological verification of polyps was 79.4% in the resectoscopy group and 69.04% in the curettage group; the difference was significant (p < 0.01). The recurrence rate was 20.47% after resectoscopy and 27.12% following curettage.Conclusion: Hysteroscopy remains the best option and the gold-standard method among diagnostic procedures of endometrial pathology. In this study, there was a significant difference in matching hysteroscopic and histological findings in the two methods of polypectomy. The recurrence rate is also lower following resectoscopy.

The feasibility of laparoscopically assisted, hysteroscopic removal of interstitial pregnancies: A case series

OBJECTIVE

The study objective was to assess the feasibility of the management of interstitial pregnancy by laparoscopically assisted hysteroscopic removal.

METHODS

This retrospective study included a case series of 17 patients who were diagnosed interstitial pregnancy with dilated proximal tubal ostium by transvaginal ultrasonography at the Women's hospital, School of Medicine, Zhejiang University between August 2017 and October 2020. Laparoscopically assisted hysteroscopic removals of the products of conception were performed. Various data were collected including age, surgical and obstetric history, gestational age, preoperative symptoms, human chorionic gonadotropin level and ultrasonography results. The outcomes measured were intraoperative bleeding, pathologic findings, conversions.

RESULTS

Eleven cases were successfully resected the interstitial gestational products with laparoscopically assisted hysteroscopy. There were four cases failed of hysteroscopic removal, for the proximal tubal ostia were too small for the surgical instruments to enter. Then cornual wedge resections were performed. Two cases were identified as intramural pregnancy by hysteroscopic and laparoscopic view. Most of the intramural pregnancy tissue of one patient was removed by hysteroscopy. The other one converted to laparoscopy.

CONCLUSION

Laparoscopically assisted hysteroscopic management could be a feasible surgical option to interstitial pregnancies. Further clinical studies are needed to establish detailed criteria to select the appropriate cases for hysteroscopic management.

Novel diagnostic approaches to intrauterine neoplasm in fertile age: sonography and hysteroscopy

Endometrial carcinoma (EC) is the most common gynecological malignancy in the world. It is mostly detected in postmenopausal women, but it can also occur in women of fertile age who need fertility-sparing therapy. An early diagnosis is the main objective for the correct management of these patients, making it possible to use a fertility-sparing treatment approach without exposing the patients to the risk of cancer progression. In this review, we discuss the role of sonography and hysteroscopy in the detection of intrauterine neoplasm in women of childbearing age.

Prediction of Myometrial Invasion in Stage I Endometrial Cancer by MRI: The Influence of Surgical Diagnostic Procedure

Simple Summary

Fertility sparing treatment can be considered for young women with clinical stage 1A endometrial cancer (EC) without myometrial invasion (MI). Surgical diagnostic procedures (SDP) were needed to make diagnosis of EC, but different extents of SDP including diagnostic hysteroscopic biopsy (DHB, group 1), operative hysteroscopic partial resection (OHPR, group 2), operative hysteroscopic complete resection (OHCR, group 3), and cervical dilatation and fractional curettage (D&C, group 4) may affect the accuracy of MI assessment by magnetic resonance imaging (MRI) after SDP. Here, we retrospectively review those initially diagnosed with stage 1A EC and compare MI status on MRI reports and final histopathology of hysterectomy. We found that the MRI accuracy of MI was better in patients with EC diagnosed with D&C. Three diagnostic procedures using hysteroscopy might interfere with the diagnostic power of MI on MRI. Thus, D&C for diagnosis of EC and further hysteroscopic complete resection with hormone as a fertility sparing treatment for those confirmed as stage 1A without MI from MRI may be a choice in the future.

Abstract

Young women with endometrial cancer (EC) can choose fertility-sparing treatment for stage 1A disease without myometrial invasion (MI). The surgical diagnostic procedure (SDP) may affect the accuracy of magnetic resonance imaging (MRI) to assess MI. Here, we evaluated different SDP and compared the MI on MRI results with further pathologic results after hysterectomy. We retrospectively collected data on 263 patients with clinical stage IA EC diagnosed between January 2013 and December 2015. Patients were classified into four groups based on SDP, including diagnostic hysteroscopic biopsy (DHB, group 1), operative hysteroscopic partial resection (OHPR, group 2), operative hysteroscopic complete resection (OHCR, group 3), and cervical dilatation and fractional curettage (D&C, group 4). The sensitivity, specificity, diagnostic accuracy, positive predictive value, and negative predictive value of MRI to assess MI were 73.1%, 46.7%, 63.9%, 71.8%, and 48.3%, respectively. Three hysteroscopic procedures (groups 1 to 3) had a trend with a higher odds ratio of discrepancy between MRI and histopathology (p = 0.068), especially in group 2 (odds ratio 2.268, p = 0.032). Here, we found MRI accuracy of MI was better in patients with EC diagnosed with D&C. Three diagnostic procedures using hysteroscopy might interfere with the diagnostic power of MI on MRI.

Symptoms and Quality of Life Changes after Hysteroscopic Treatment in Patients with Symptomatic Isthmocele-Preliminary Results

Due to an increasing number of cesarean section deliveries, the common consequences of that surgery are observed more often in the population. One of them is the uterine cesarean scar defect known as niche or isthmocele. Most patients with that aliment are asymptomatic, but some of them can report abnormal uterine bleeding, pelvic pain, subfertility which can be the reason for reduced quality of life (QoL) of the patients. In our study, we analyzed the subjective feelings of changes in the severity of symptoms and quality of life of women with niche after diagnostic and operative hysteroscopy. The patients n = 85 included in the study group completed a follow up questionnaire six months after the procedure. Patients after operative hysteroscopy in comparison to patients after diagnostic procedure reported statistically significant reduction in post-menstruation bleeding/spotting and improvement in the quality of sexual activity. We have also noticed a higher pregnancy rate in the operative group, however, the difference was not statistically significant. According to our study, most women reported a positive effect of hysteroscopy on their QoL in social, psychological, environmental, and health domains.

Distending Media Used During Hysteroscopy: Perioperative Nursing Implications

Hysteroscopy is a gynecological procedure that may be indicated for abnormal uterine bleeding, diagnosis and management of infertility, contraception, or sterilization. Surgeons use distending media during hysteroscopy to view the uterine cavity. Media options include carbon dioxide gas and both electrolytic and nonelectrolytic fluids. All distending media is absorbed by the patient's body, but the manner in which each media is absorbed is unique to its chemical composition. Understanding the properties of each distending medium and the risks involved with its use is critical to safe perioperative nursing care for patients undergoing hysteroscopy. This article provides perioperative nurses with a review of uterine anatomy and evidence-based information on the types of distending media used during hysteroscopy and the corresponding perioperative nursing implications.

Increasing the adoption of ambulatory hysteroscopy in Australia - cost comparisons and patient satisfaction

We present the findings of a prospective cohort study in a single tertiary hospital to review the patient experience and economic benefit of ambulatory hysteroscopy (AH). Data were collected between May 2017 and February 2020. Patient satisfaction was measured with qualitative survey. Hospital level financial data were obtained over two financial years (2017/18 and 2018/19) to identify seasonal variation. The primary outcome was patient satisfaction and the secondary outcome was cost of AH compared to hysteroscopy under GA. Three hundred and twenty-nine patients underwent AH. Two hundred and ninety-eight responses (91%) were collected. Ninety-five percent of procedures were successful. Median pain score was five out of 10. Despite pain, 94% of patients would undergo AH again and 97% would recommend it. The average hospital cost for AH was $259 compared with $3098 for hysteroscopy under GA. These findings support AH as a safe, well-tolerated and economically viable alternative to hysteroscopy under GA.Impact StatementWhat is already known on this subject? Hysteroscopy is traditionally performed in an operating theatre under general anaesthesia (GA). Technological advancements allow for the procedure to be performed in an outpatient setting. Despite advantages of ambulatory hysteroscopy (AH), GA hysteroscopy is still the predominant intervention in Australia.What the results of this study add? Patient satisfaction in AH was assessed. The median pain score was five out of 10. Despite pain, 94% of patients would undergo AH again and 97% would recommend it.What the implications are of these findings for clinical practice and/or further research? AH is a well-tolerated alternative to hysteroscopy under GA with significant cost benefits to the hospital and high patient satisfaction. Further research should focus on direct comparison of the two procedure approaches using randomised controlled trials.

COVID 19 pandemic and minimally invasive gynecology: consequences and future perspectives

The extent of the 2020 pandemic not only extends to the infected patients but also to patients who have been waiting for medical procedures. Reevaluation of the healthcare system is important in order to help assist the needs of intensive care units. The urgency of the gynaecological cases should be aligned based on surgical interventions and minimally invasive methods should be preferred. This will not endanger professional and other resource demands of ICUs. In acute cases, laparoscopy or hysteroscopy (preferring office hysteroscopy) should be chosen, that require no or only short period of hospitalization. Postponing non-acute surgeries is recommended to the post-pandemic period. Abbreviations: ICU: intensive care unit; COVID-19: coronavirus disease; SARS-CoV-2: severe acute respiratory syndrome Coronaviruses; IgM-IgG: immunoglobulin M; GAGP: aerosol generating procedures; PPE: personal protective equipment; ERAS: early recovery after surgery; mESAS: modified elective surgery acuity scale; RPOC: retained product of concept; PMB: postmenopausal bleeding.

Whether preoperative hysteroscopy increases the dissemination of endometrial cancer cells: A systematic review and meta-analysis

AIM

To determine whether hysteroscopy (HSC) increases the risk of intraperitoneal dissemination in endometrial cancer patients.

METHODS

We conducted a comprehensive review of multiple databases. Quality assessments of eligible studies were performed using the Newcastle-Ottawa and Jadad scales. Positive peritoneal cytology (PPC) as the outcome of interest was compared between endometrial cancer patients with and without HSC. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated as a measure of effects.

RESULTS

Three case-control studies and eight retrospective cohort studies included 3364 patients, of whom 1116 underwent preoperative HSC, which resulted in a significantly higher PPC rate (OR, 1.82; 95% CI, 1.31-2.54; p = 0.0004). I² was 11%, and the heterogeneity was acceptable. The difference between the groups with stages I-II was statistically insignificant (OR, 1.50; 95% CI, 0.75-2.99; p = 0.25). When liquid was used as the uterine distension medium during HSC and the intrauterine pressure was controlled under 80 mmHg, the difference between the two groups was also insignificant (OR, 1.18; 95% CI, 0.50-2.79; p = 0.71). However, when the intrauterine pressure exceeded 80 mmHg, the difference between the two groups was statistically significant (OR, 2.18; 95% CI, 1.28-3.73; p = 0.004).

CONCLUSION

This meta-analysis indicates that preoperative HSC in patients with endometrial cancer may increase the risk of intraperitoneal dissemination of malignant cells, which may be associated with intrauterine pressure >80 mmHg but not with stages I-II. There is no reason to avoid HSC for the diagnosis of endometrial cancer, especially in early stages, but intrauterine pressure should possibly be controlled below 80 mmHg.

Live births after Asherman syndrome treatment

OBJECTIVE

To study the reproductive outcomes after surgical management of women with Asherman syndrome (AS).

DESIGN

Cohort study.

SETTING

International referral hospital for women with AS.

PATIENT(S)

A total of 500 women who were diagnosed with and treated for AS between January 2003 and December 2016 and followed for a minimum of 2 years.

INTERVENTION(S)

Hysteroscopic adhesiolysis using conventional instruments with concomitant fluoroscopy as a guidance method.

MAIN OUTCOME MEASURE(S)

Live birth rate.

RESULT(S)

Of the 500 women included in the cohort, 569 pregnancies were achieved within 3 years after surgery. The miscarriage rate was 33.0%, and the live birth rate was 67.4%. Age, the causal procedure, and at least one miscarriage after adhesiolysis strongly predicted the outcome of a live birth.

CONCLUSION(S)

The overall take-home newborn rate was 67.4% after adhesiolysis in women with AS. Women with AS who are relatively young, with a first-trimester procedure preceding AS, and with low grades of adhesions and no miscarriage after adhesiolysis have the best chance of a newborn delivery.

Hysteroscopy Findings in Women with Thin Endometrium Scheduled for In Vitro fertilization in Niger Delta Region, Nigeria

The effect of endometrial thickness on in vitro fertilization (IVF) outcome is still a subject of debate. It is unclear why a thin endometrium reduces IVF success rates. Our objective was to analyze the hysteroscopic findings in women scheduled for IVF who had an endometrial thickness less than 7 mm. Relevant data of patients scheduled for IVF cycles and found to have an endometrial thickness (ET) of <7 mm on transvaginal ultrasound scan (TVS) between April 1, 2010 and March 31, 2017, at a private fertility and minimal access surgery unit in the Niger-Delta region of Nigeria, were retrieved and documented. A total of 41 patients had ET <7 mm during the study period. These patients accounted for 2.8% of the 1487 IVF cycles performed during the same period. All 41 patients had office hysteroscopies performed, constituting 4.1% of the 1,002 hysteroscopies performed during the study period. The age range of the patients was 23 - 50 years with a mean of 39.9 ± 6.9 years, and the duration of infertility ranged from 3 to 13 years with a mean of 7.2 ± 2.5 years. Most of the patients (32, 78.1%) had secondary infertility. Sixteen patients (39.0%) had intrauterine adhesions. A thin endometrium, though infrequent during IVF treatment cycles, might be associated with undiagnosed intrauterine adhesions.

Hysteroscopy-assisted laparoscopic salpingectomy for interstitial pregnancy without cornual resection

OBJECTIVE

To illustrate a novel surgical management technique for interstitial ectopic pregnancies (IP).

DESIGN

Video description of the case, demonstration of the surgical technique, reevaluation at the 6-week postoperative follow-up, and review of the advantages of this surgical technique for IP.

SETTING

Tertiary referral center.

PATIENT(S)

A 42-year-old gravida 2 para 1-0-0-1, underwent a successful in vitro fertilization (IVF) cycle with a single embryo transfer and had an early ultrasound diagnosis of IP with cardiac activity. After failed medical management with a single dose of methotrexate, she was referred to us for surgical management. Transvaginal ultrasound revealed fluid in the cul-de-sac and confirmed a right interstitial ectopic pregnancy with an estimated gestational age of 6 weeks. The myometrium at the periphery of the implantation site was 1-1.5 mm, and the "interstitial line sign" was seen. After counseling for possible treatment modalities, the patient opted for surgical management, planning for further IVF treatment. Her preoperative β-human chorionic gonadotropin level (β-hCG) was 3241 IU/L. Her surgical history was significant for a previous myomectomy via laparotomy and an elective lower transverse C-section.

INTERVENTION(S)

Hysteroscopy assisted by multipuncture video laparoscopy surgery was performed. Hysteroscopic resection was not feasible as the ectopic was not visualized as described previously. Using normal saline as the distension media and with the hysteroscope aimed at the right ostium, the hydrostatic pressure was increased transiently to dissect the ectopic pregnancy and facilitate the next surgical step. Laparoscopically, the ectopic pregnancy was milked with atraumatic graspers and mobilized from the cornua into the tube creating enough proximal length for salpingectomy. Right salpingectomy was achieved using high-frequency bipolar with no complications.

MAIN OUTCOME MEASURE(S)

Hysteroscopy-assisted laparoscopy technique allows for several advantages, including a short operative time and minimal blood loss. No sutures were required and the myometrial architecture was left undisrupted.

RESULT(S)

The postoperative course was uncomplicated, and the patient was discharged on the same day of surgery. The patient's β-hCG level dropped from 3,241 to 139 IU/L after 48 hours. Two weeks later, the β-hCG level was 3 IU/L. A follow-up ultrasound was performed six weeks postoperatively confirming the integrity of the myometrium without defects and proportional wall thickness on both sides. The patient was referred back to her infertility specialist to resume IVF treatment with no remarkable delay.

CONCLUSION(S)

In select cases and the presence of a proficient laparoscopic surgeon, early diagnosed IP can be removed safely using the described novel technique. While an interval conception of 3-6 months is recommended after conventional surgical procedures for IP, this technique can be comparable to salpingectomy.

The blooming phenomenon: a rare but a dilemma in hysteroscopic resection of myomas

Modern surgical technologies allow gynecologists to treat most submucosal myomas hysteroscopically by some form of resection. What appears on imaging or direct visualization to be a submucosal myoma can be a single tumor, or may represent multiple smaller myomas appearing as one, compacted together in a typical pseudo capsule. During myoma resection, the effect of the media used to induce distension can vary, depending on the morphology of the myomas. After starting resection, the pressure of the distending media can push truly solitary myomas to somewhat flatten against the uterine wall. However, in the second type of myoma, the fluid can displace the myomas into the uterine cavity, an appearance similar to the blooming of a flower. The tip of the hysteroscope may enter the dissected spaces between the myomas, which impairs the panoramic view. This phenomenon may cause inadequate treatment of the myomas encountered during hysteroscopic myomectomy. In this study, the “Blooming phenomenon” is introduced, and the problems created by this phenomenon and solutions for its management are considered.

Transcervical microwave ablation in type 2 uterine fibroids via a hysteroscopic approach: analysis of ablation profiles

Type 2 uterine fibroids are challenging to resect surgically as ≥ 50% volume of myoma lies within the myometrium. A hysteroscopic approach for ablating fibroids is minimally-invasive, but places a considerable burden on the operator to accurately place the ablation applicator within the target. We investigated the sensitivity of transcervical microwave ablation outcome with respect to position of the ablation applicator within 1 - 3 cm type 2 fibroids.Methods:A finite element computer model was developed to simulate 5.8 GHz microwave ablation of fibroids and validated with experiments inex vivotissue. The ablation outcome was evaluated with respect to applicator insertion angles (30°, 45°, 60°) , depth and offset from the fibroid center (±2 mm for 3 cm fibroid and ±1 mm for 1 cm fibroid) with 35 W and 15 W applied power for 3 cm and 1 cm fibroids, respectively. Power deposition was stopped when thermal dose of 40 cumulative equivalent minutes at 43 °C (CEM43) was accrued in adjacent myometrium.Results:Within the range of all evaluated insertion angles, depths and offsets, the ablation coverage was less sensitive to variation in angle as compared to depth and offset, and ranged from 34.9 - 83.6% for 3 cm fibroid in 140 - 400 s and 34.1 - 67.9% for 1 cm fibroid in 30 - 50 s of heating duration. Maximum achievable ablation coverage in both fibroid cases reach ∼ 90% if thermal dose is allowed to exceed 40 CEM43 in myometrium.Conclusion:The study demonstrates the technical feasibility of transcervical microwave ablation for fibroid treatment and the relationship between applicator position within the fibroid and fraction of fibroid that can be ablated while limiting thermal dose in adjacent myometrium.

Transvaginal Sonography Post-Office Hysteroscopy as a Screening Tool for Tubal Patency: A Reliable and Feasible Technique in an Outpatient Setting

OBJECTIVE

To determine feasibility and accuracy of post-hysteroscopic transvaginal ultrasonography (TVUS) measurement of pelvic fluid accumulation as a screening method for tubal patency (TP).

METHODS

We conducted a retrospective cohort study of 85 patients who underwent uterine cavity assessment by office hysteroscopy at our university-affiliated fertility centre from November 2019 to October 2020. During the study period, two-dimensional (2D) TVUS was performed pre- and post-hysteroscopy to evaluate TP. Patient records were reviewed for demographics, diagnosis, and prior/subsequent TP testing. Predictive values for TP were calculated.

RESULTS

Pelvic fluid accumulation post-hysteroscopy was found in 65.9% of patients (56). Accumulation of fluid was seen with the use of as little as 10-50 mL of saline. Using more fluid did not increase the likelihood of demonstrating TP (P = 0.17). A trend towards more false-negative results for TP was observed when less fluid was used (7.7% with 10-50 mL vs. 3.8% with 60-190 mL and 1.3% with 200-760 mL; P = 0.10). The positive predictive value (PPV) of TVUS post-hysteroscopy in comparison to known patency/occlusion was 100%; negative predictive value (NPV) was 33%; sensitivity was 82.8%; and specificity was 100%. Similar values were seen in a second analysis that included patients with highly suspected patent or occluded tubes (n = 60); presumed predictive values were: PPV 100%, NPV 42%, sensitivity 78.8%, and specificity 100%. The use of more fluid did not increase pain (P = 0.75). This finding remains after accounting for confounders (e.g., pre-medication, endometrial biopsy).

CONCLUSION

TVUS pre- and post-hysteroscopy is feasible in an outpatient setting, and can serve as a reliable screening tool for TP. When hysteroscopy is performed and TP is not known, TVUS can be added for screening, potentially omitting the need for more invasive examinations. With limited non-urgent ambulatory services, it is of upmost importance to maximize information from a single procedure.

Identification and treatment of a cervical sinus tract in a patient with 10 years of infertility

OBJECTIVE

To introduce a special case of endometrial cavity fluid (ECF), highlighting the application of hysteroscopy and laparoscopic surgical techniques in the treatment of cervical sinus tract.

DESIGN

Narrated video featuring the diagnosis and surgical management of a case of recurrent ECF. Informed consent was obtained from the patient, and approval was granted by the ethics committee of the First Affiliated Hospital of the Wenzhou Medical University.

SETTING

Academic tertiary hospital.

PATIENT(S)

A 36-year-old woman, gravida 0, had menstrual spotting for 13 years after abdominal myomectomy of a 104 × 86 × 111-mm myoma on the posterior uterine wall near the cervix. She failed to conceive after her marriage for 10 years, and 5 operations, including hysteroscopy and laparoscopy, were performed to increase pregnancy opportunities. She also underwent in vitro fertilization and embryo transfer procedures many times, but failed. Transvaginal sonography preoperatively suggested that ECF sometimes appeared and sometimes disappeared. The local echo of the posterior wall of the cervix was enhanced. A 40-mm cystic dark area was found beside the right ovary, which seemed to connect with the cervical hyperechoic part. Additionally, a solid mass of the right adnexa with abundant blood supply was detected.

INTERVENTION(S)

First, hysteroscopy was performed to explore the ECF. A deep and narrow cervical sinus with a steady stream of accumulated blood overflowed in the lower part of the cervix, and a normal uterine cavity was found. Laparoscopic adhesiolysis and enucleation of the cystic structure that connected to the sinus tract then were performed. Hysteroscopy was repeated to determine the thinnest cervical region by the light transmission test. A horizontal incision was made on the thinnest layer. Scar tissues were removed. The incision was sutured in full layer intermittently and continuously under laparoscopy. The postoperative thickness of the muscular layer in the sinus was confirmed by light transmission test of hysteroscopy. The patient was discharged on the third day after operation, uneventfully. Histopathologic examination showed that the cystic structure and scar tissue contained smooth muscle tissue and were covered by both mucinous columnar epithelium of the cervical canal and endometrial glandular epithelium.

MAIN OUTCOME MEASURE(S)

Restoration of normal anatomy, removal of uterine effusion, and symptomatic relief.

RESULT(S)

At the 6-month follow-up, the patient's menstrual cycles returned to normal without the recurrence of menstrual spotting. The ultrasound scan also showed a symmetrical uterus without ECF.

CONCLUSION(S)

Patients with ECF who underwent assisted reproductive surgeries were related to the poor prognosis. However, the treatment should be different according to the causes, appearance time, and accumulation amount, including expectant treatment, postponement of embryo transfer, transvaginal aspiration, laparoscopic salpingectomy, or proximal tubal occlusion. For patients with recurrent ECF and/or special appearance on ultrasound, endoscopic examination is necessary. In addition, patients with large myomas at difficult locations required a uniform strategy to reduce the intraoperative and postoperative complications, especially for the nulligravida women.

Reproductive outcomes in women with mild intrauterine adhesions; a systematic review and meta-analysis

BACKGROUND

Moderate to severe intrauterine adhesions (IUAs) may greatly impact fertility, predisposing to pregnancy and obstetric complications. The impact of mild IUAs on reproductive performance remains unclear. A systematic review and meta-analysis was performed to examine the long-term reproductive outcomes in women with hysteroscopic identified and treated mild IUAs mild intrauterine adhesions (IUAs).

METHODS

An electronic literature search was conducted using MEDLINE and EMBASE from inception to June 2019. All prospective cohort, cross-sectional studies or randomized controlled trials Clinical trials in which reproductive outcomes of women with mild IUAs, were reported were included.

RESULTS

Five studies, reporting on reproductive outcomes of 229 women with hysteroscopic identified and treated mild IUAs, were included. The pregnancy rate was 62.3% (142 of 228; 95% CI: 0.55-0.72, I² 25%, p = .21) and in 86.6% (123 of 142) a live birth was encountered (95% CI: 0.71-0.97) with 83.1% (108 out of 130) term deliveries (95% CI: 0.53-0.95). A miscarriage was reported in 10% (13 of 130; 95% CI: 0.02-0.26). Due to the lack of a control group, reproductive outcomes were compared to a general population. Pregnancy and live birth rates were significantly lower in women with identified and treated mild IUAs, 90% versus 62.3% and respectively 99.5% versus 86.6%. The miscarriage rate was similar. Data on obstetric and neonatal outcomes are lacking.

CONCLUSIONS

Women with hysteroscopic identified and treated mild IUAs seem to have lower pregnancy and live birth rate compared to the general population. Future studies consisting of a large cohort of women with hysteroscopic identified and treated IUAs with structural follow-up and a control group are needed to confirm our findings.

Temporary Ligation of the Bilateral Uterine Arteries During Laparoscopy Combined with Hysteroscopy in the Treatment of Caesarean Scar Pregnancy: Experience at a Chinese Teaching Hospital

Purpose

This study aimed to investigate the clinical efficacy of temporary ligation of the bilateral uterine arteries during laparoscopy combined with hysteroscopy in the treatment of caesarean scar pregnancy (CSP).

Patients and Methods

This study was a retrospective analysis of 83 patients who had initially undergone laparoscopy combined with hysteroscopy for CSP between 2012 and 2018 at Xiamen Women and Children’s Hospital. Patients were assigned to the ligation group or the no ligation group according to whether they underwent temporary ligation of the bilateral uterine arteries. Factors extracted from the database included general preoperative information, surgical indicators (intraoperative blood loss, operation time, and blood transfusion), postoperative recovery indicators (β-hCG on day 3 after surgery, time to β-hCG normalization), and postoperative complications (decrease in menstrual bleeding, alteration in the menstrual cycle) and were compared between the two groups.

Results

The intraoperative blood loss of patients in the ligation group was significantly less than that of patients in the no ligation group (P=0.027), especially in patients with higher serum β-hCG level (P=0.030). No significant differences in the operation time, blood transfusion, decline ratio of hCG on day 3 after surgery, reduction in haemoglobin and haematocrit value, decrease in menstrual bleeding, or alteration in the menstrual cycle were observed between the two groups (P>0.05).

Conclusion

For CSP patients, temporary ligation of the bilateral uterine arteries during laparoscopy combined with hysteroscopy achieved better clinical outcomes than laparoscopy combined with hysteroscopy without ligation with respect to intraoperative blood loss. This approach offers effective and safe surgical management for CSP in clinical practice.

Three degrees of separation: complete uterine and cervical septa

OBJECTIVE

To review the diagnosis and management of 3 variations of incomplete müllerian duct fusion and reabsorption.

DESIGN

Narrated video delineating the surgical management of 3 müllerian anomalies; this video was deemed exempt from review by the institutional review board of the Mayo Clinic.

SETTING

Tertiary care academic medical center.

PATIENT(S)

This video focuses on 3 müllerian anomalies: complete septate uterus with a single septate cervix (septate uterus unicollis); complete septate uterus with duplicated cervix (septate uterus bicollis); and complete duplication of the uterus and cervix (uterine didelphys).

INTERVENTION(S)

Magnetic resonance imaging (MRI), cervical septoplasty, operative hysteroscopy, and uterine septoplasty.

MAIN OUTCOME MEASURE(S)

Several variations of uterine malformations exist. In our practice, we differentiate complete septate uteri as either unicollis or bicollis via MRI and vaginal examination. The bicollis presentation can be identified on MRI by the "lambda sign," which is seen as the 2 cervices that diverge as they enter the vagina. This is in comparison with the unicollis presentation when the single septate cervix can be traced with parallel lines as it enters the vagina. The circle method is described in this video to help distinguish between a single and duplicated cervix on examination.

RESULT(S)

The cervical and uterine septa were resected completely in the patient with a complete septate uterus unicollis. In contrast, the uterine septum was resected completely and the 2 cervical canals were not incised in the case of the complete septate uterus bicollis. Although uterine and cervical septa resection is controversial, our practice is to avoid the incision of the 2 cervical canals in cases that are more clearly consistent with a bicollis classification.

CONCLUSION(S)

Müllerian anomalies represent a continuum of disorders caused by different degrees of disruption in embryogenesis. MRI with vaginal gel and vaginal examination are tools to help classify the anomaly and guide surgical management.

The Addition of Endometrial Injury to Freeze-All Strategy in Women with Repeated Implantation Failures

(1) Background: Recurrent implantation failure (RIF) after IVF remains a challenging topic for fertility specialists and a frustrating reality for patients with infertility. Various approaches have been investigated and applied towards the improvement of clinical outcomes. Through a nonrandomized clinical trial, we evaluated the effect of the combination of hysteroscopic endometrial injury and the freeze-all technique on pregnancy parameters in a cohort of RIF patients; (2) Methods: The study group comprised of 30 patients with RIF that underwent a hysteroscopic endometrial injury prior to a frozen embryo transfer cycle; another 30 patients with RIF, comprising the control group, underwent a standard frozen cycle with no adjuvant treatment before. Live birth comprised the primary outcome. Logistic and Poisson regression analyses were implemented to reveal potential independent predictors for all outcomes. (3) Results: Live birth rates were similar between groups (8/30 vs. 3/30, p = 0.0876). Biochemical and clinical pregnancy and miscarriages were also independent of the procedure (p = 0.7812, p = 0.3436 and p = 0.1213, respectively). The only confounding factor that contributed to biochemical pregnancy was the number of retrieved oocytes (0.1618 ± 0.0819, p = 0.0481); (4) Conclusions: The addition of endometrial injury to the freeze-all strategy in infertile women with RIF does not significantly improve pregnancy rates, including live birth. A properly conducted RCT with adequate sample size could give a robust answer.

Histopathology of women with non-uniform endometrial echogenicity and risk factors for atypical endometrial hyperplasia and carcinoma

OBJECTIVE

In sonography, homogeneous endometrium is defined as uniform endometrial echogenicity and heterogeneous, asymmetrical or cystic endometrium is defined as non-uniform. However, the relationship between the non-uniform endometrial echogenicity and the presence or absence of pathology is not known. A retrospective study of the patients with ultrasound non-uniform endometrium who underwent hysteroscopy-directed biopsy was performed to explore its clinical meaning in the diagnosis of endometrial lesions.

MATERIALS AND METHODS

Patients with non-uniform endometrial echogenicity who underwent hysteroscopy-directed biopsy were enrolled in the Obstetrics and Gynecology Hospital of Fudan University from January 2015 to May 2018 as the primary cohort. In total, 692 patients with non-uniform endometrial echogenicity were diagnosed and underwent hysteroscopy-directed biopsy. Characteristics were assessed using univariate logistic regression between patients with and without atypical endometrial hyperplasia and carcinoma (atypical EH+). Multivariate analyses were used to develop the predicting model. We incorporated statistically significant variables and presented with nomogram. Internal validation was assessed. An independent validation cohort consisted of 237 consecutive patients from June 2018 to February 2019.

RESULTS

Hysteroscopy-directed biopsy showed that 55.20% (382/692) of the patients with non-uniform endometrium had normal endometrium, while 44.80% (310/692) had endometrial lesions, including 39.31% (272/692) benign lesions and 5.49% (38/692) atypical EH+. Univariate logistic analysis showed that older age (P=0.027), abnormal uterine bleeding (AUB) before menopause (P=0.011), postmenopausal bleeding (P<0.001) and endometrial thickness ≥7 mm (P=0.013) were statistically significant for atypical EH+. Multivariate logistic regression analysis showed that age ≥50 years old (OR: 3.97, 95% CI: 1.17-13.43, P=0.027), endometrial thickness ≥7 mm (OR: 8.08, 95% CI: 1.86-35.08, P=0.005) and postmenopausal bleeding (OR: 8.98, 95% CI: 3.26-24.76, P<0.001) were risk factors for atypical EH+. Predictors in the individualized predicted nomogram included age ≥50 years old, AUB before menopause, postmenopausal bleeding and endometrial thickness ≥7 mm. The model showed good discrimination with area under curve (AUC) of 77.09%. With cutoff value of 0.0089267, the recall of atypical EH+ is 100% with precision 6.52% and 6.22% in both primary and validation cohort, respectively. Conclusion Non-uniform endometrial echogenicity is clinically meaningful in assessment of atypical EH+ with risk factors of age ≥50 years old, postmenopausal bleeding and endometrial thickness ≥7 mm. The model can help clinician to predicate the probability of atypical EH+ and make clinical decision.

Four cases of heterotopia of an intrauterine device embedded in the bladder muscular layer causing cystolithiasis: case report and review of the literature

Family planning is a basic national policy in China. An intrauterine device (IUD) is an important method of achieving family planning owing to its high safety, low cost, and convenient use. The indwelling birth control ring has no obvious adverse effects on the sexual life of women after the operation, and the process is reversible. This ring can be removed for women who want to have children again. There are approximately 100 million women with IUDs worldwide, with approximately 80 million in China. This finding accounts for approximately 40% of women of childbearing age in China. Although an IUD is safe, the invasive operation inevitably leads to complications, such as pelvic infection, abnormal menstruation, and damage to adjacent organs. Among them, ectopic bladder stone formation is a rare complication, but several related cases have been reported. We report four cases of heterotopia of an IUD and cystolithiasis, with diagnosis based on the medical history, clinical manifestations, imaging, and cystoscopic findings. The four patients with ectopic IUDs were treated with cystoscopy combined with laparoscopy (or hysteroscopy). We describe the process of diagnosis and treatment of our patients, and the related literature on an ectopic IUD is reviewed.

[Management of side effects under hormonal replacement therapy in menopausal women: Abnormal uterine bleeding. Postmenopausal women management: CNGOF and GEMVi clinical practice guidelines]

OBJECTIVES

To publish, under the aegis of the French National College of Gynecologists and Obstetricians (CNGOF) and the Study Group on Menopause and Hormonal Aging (GEMVi), recommendations based on the evidence available in the literature for the management of abnormal uterine bleeding (AUB) in women taking hormonal replacement therapy (HRT). A review of the literature was performed by consulting Medline, Cochrane Library data as well as international recommendations in French and English up to September 1, 2020.

RESULTS

AUB occurring in a woman taking HRT (FIGO 2011) is one of the main factors of poor adherence to the HRT. AUB must seek an organic cause including endometrial cancer. The main functional causes of AUB in a woman taking HRT are resumption of ovarian activity, poor compliance, and trophic disorders of the endometrium. AUB are dependent on the type of HRT. In the event of AUB under HRT, it is suggested to perform a pelvic ultrasound at the end of the progestational sequence in the event of sequential HRT. In a single episode of AUB and when the ultrasound estimates the endometrial thickness less than or equal to 4mm, it is possible to postpone further uterine exploration. In case of recurrent AUB or when the endometrium thickness is greater than 4mm in a postmenopausal woman, additional uterine investigations (hysteroscopy and histology) are recommended.

CONCLUSION

AUB under HRT must seek an organic cause. The measurement of endometrial thickness by pelvic ultrasound is relevant for screening for endometrial cancer.

Cold scissors versus electrosurgery for hysteroscopic adhesiolysis: A meta-analysis

BACKGROUND

Intrauterine adhesion seriously affects reproductive health in women. Hysteroscopic adhesiolysis using cold scissors or electrosurgery is the main treatment, although there is no consensus on the preferable method. This review aimed to compare the efficacy and safety of these methods for treating moderate to severe intrauterine adhesion.

METHODS

PubMed, EMBASE, MEDLINE, Cochrane Database of Systematic Reviews, Web of Science, Chinese Biomedical Literature Database, and China National Knowledge Infrastructure were searched on April 30, 2020. Randomized controlled trials and observational studies that were published in all languages (must contain English abstracts) and compared hysteroscopic cold scissors with electrosurgery for the treatment of intrauterine adhesion were included. Mean differences, odds ratios, and 95% confidence intervals (CIs) were reported. Bias was evaluated using the Cochrane Risk of Bias assessment tool for randomized controlled trials and the Newcastle-Ottawa Scale for observational studies. Data were analyzed using RevMan software (Review Manager version 5.3, The Cochrane Collaboration, 2014). Two researchers independently extracted data and assessed the quality of the included studies. If a consensus was not reached, a third researcher was consulted.

RESULTS

Nine studies (n = 761; 6 randomized controlled trials and 3 retrospective studies) were included. The intrauterine adhesion recurrence rate with second look hysteroscopy was significantly lower (odds ratio = 0.30, 95% CI = 0.16-0.56; P = .0002) with hysteroscopic cold scissors than with electrosurgery. The total operation time was significantly shorter (mean difference = -7.78, 95% confidence interval = -8.50 to -7.07; P < .00001), intraoperative blood loss was significantly lower (mean difference = -9.88, 95% CI = -11.25 to -8.51; P < .00001), and the menstrual flow rate was significantly higher (odds ratio = 4.36, 95% confidence interval = 2.56-7.43; P < .00001) with hysteroscopic cold scissors than with electrosurgery. There were no significant differences in the pregnancy rate. One complication (1 perforation case, hysteroscopic cold scissors group) was reported.

CONCLUSIONS

Hysteroscopic cold scissors is more efficient in preventing intrauterine adhesion recurrence, increasing the menstrual flow, reducing intraoperative blood loss, and shortening the operation time.

Cesarean Scar Pregnancy Treated by Artery Embolization Combined with Diode Laser: A Novel Approach for a Rare Disease

Cesarean scar pregnancy (CSP) is a rare form of ectopic pregnancy which represents a consequence of a previous cesarean section. It is associated with major maternal morbidity and mortality and has potential implications on future fertility. Because of possible serious complications, CSP should be swiftly diagnosed and treated. There is no management protocol for this rare, life-threatening condition, and each patient should be evaluated individually. Several types of conservative treatment have been used to treat cesarean scar pregnancy: dilation and curettage (D&C), excision of trophoblastic tissues, local or systemic administration of methotrexate, bilateral hypogastric artery ligation, and selective uterine artery embolization with curettage and/or methotrexate administration. In our study we present a cesarean scar pregnancy of a 40-year-old woman who was treated with angiographic uterine artery embolization (UAE) followed by hysteroscopic diode laser resection. Our combined UAE–hysteroscopic laser surgery appears to offer an effective, safe, and minimally invasive surgical treatment.

Postpartum retained products of conception: Is it possible to avoid postpartum curettage?

OBJECTIVE

Removal of retained products of conception (RPOC) by suction curettage or hysteroscopy may be required in the postpartum period, possibly causing intrauterine adhesions. We investigated whether rates of suction curettage, hysteroscopy, and postoperative intrauterine adhesions have changed over time.

METHODS

Parturients considered at risk for RPOC were followed in a specialized postpartum clinic with sequential ultrasound scans. We compared the rates of women requiring surgical procedures for RPOC removal and rates of postoperative intrauterine adhesions between two 2-years periods: 2011-2012 ("early period") and 2016-2017 ("late period").

RESULTS

The overall rates of women requiring a surgical procedure for removal of RPOC did not differ between the early and late periods (38/762 [5.0%] vs 41/732 [5.6%], respectively, P = 0.595). However, removal of RPOC by suction curettage decreased significantly over time whereas removal by hysteroscopy increased (P = 0.022). Intrauterine adhesions were diagnosed in 7 of 38 women (18.4%) who underwent a surgical procedure for RPOC removal in the early period, but none of the patients operated on in the late period developed intrauterine adhesions (P = 0.004).

CONCLUSION

Removal of RPOC in postpartum women may be completed by hysteroscopy in most cases, significantly reducing the need for postpartum curettage and the rates of postoperative intrauterine adhesions.

Methotrexate injection for interstitial pregnancy: Hysteroscopic conservative mini-invasive approach

Background

Interstitial localisation of ectopic pregnancy is associated with high rates of maternal morbidity and mortality. Considering the rarity of interstitial pregnancy, the optimal treatment regimen remains unclear. We propose the management of interstitial pregnancy with local methotrexate injection using a combined hysteroscopic and ultrasonographic approach.

Technique

Hysteroscopy was performed under local anaesthesia in the operating room, using a 2.9-mm Hopkins II Forward-Oblique Telescope 30° endoscope with a 4.3-mm inner sheath and 5 FR instruments. A needle was pushed into the cornual region injecting methotrexate solution directly into the gestational sac and into the myometrial tissue tangentially at the four cardinal points. A contemporary transabdominal ultrasound (US) was performed in order to reduce risks of complications.

Experience

Five patients with an US diagnosis of interstitial ectopic pregnancy admitted to our department between January 2016 and September 2019 were managed with a local hysteroscopic injection of methotrexate. The technique was effective in all patients and no surgical complications occurred during or after the procedure. Three patients were evaluated for tubal patency with contrast ultrasonography confirming bilateral tubal patency 9 months from treatment, while one patient had a spontaneous birth 22 months from their initial surgery.

Conclusion

The hysteroscopic ultrasound-guided approach combined with the local injection of methotrexate is a minimally invasive conservative approach that seems to be promising in the management of interstitial ectopic pregnancy.

Critical Role of 3D ultrasound in the diagnosis and management of Robert's uterus: a single-centre case series and a review

A septate uterus with a non-communicating hemicavity was first described by Robert in 1969/70 as a specific malformation of the uterus. The condition is commonly associated with a blind uterine hemicavity, unilateral haematometra, a contralateral unicornuate uterine cavity and a normal external uterine fundus. The main symptoms are repetitive attacks of pain at four-weekly intervals around menarche, repeated dysmenorrhea, recurrent pregnancy loss and infertility. In this report, we review the disease, its diagnosis and treatment, and describe five cases of Robert's uterus. Three dimensional (3D) ultrasound (US) imaging was performed by the transvaginal route in four cases. In the fifth case of a 13-year-old girl, we avoided the vaginal route and magnetic resonance imaging (MRI) and 3D transrectal US yielded the correct diagnosis. The following treatment procedures were undertaken: laparoscopic endometrectomy, hysteroscopic septum resection, laparoscopic uterine hemicavity resection and total laparoscopic hysterectomy (TLH). The diagnosis and optimum treatment of Robert's uterus remains difficult for clinicians because of its rarity. A detailed and careful assessment by 3D US should be performed, followed by hysteroscopy in combination with laparoscopy, to confirm the diagnosis.

Power Doppler sonography - A supplement to hysteroscopy in abnormal uterine bleeding: Redefining diagnostic strategies

Background

Abnormal Uterine Bleeding (AUB) is a very frequent cause of gynecological visits in women of all age groups. Ultrasound pelvis with or without endometrial sampling have been conventionally used to make diagnosis. Power Doppler is a comparatively recent modality which can be used to screen patients who will need endometrial biopsy/ curretage. We hereby conducted a study to compare the diagnostic accuracy of power Doppler sonography and hysteroscopy with histopathology associated with abnormal uterine bleeding. We also calculated the incidence of uterine pathology in AUB by power Doppler ultrasound and hysteroscopy and compared it with histopathology.

Methods

This prospective cohort study was conducted at the Department of Obstetrics and Gynaecology, Institute of Medical Sciences, Banaras Hindu University. After excluding 42 women, a total of 100 women fulfilling the inclusion criteria contributed to our study. Selected women underwent power Doppler ultrasound and hysteroscopy with guided biopsy. Results were compared with histopathology as per the gold standard. Evaluation of sensitivity, specificity, positive and negative predictive values were performed for each modality. All statistical analyses were performed using the SPSS 11.0 statistical package. P value ≤0.05 was considered statistically significant for all tests used.

Results

Sensitivity and specificity of power Doppler are 75% and 100% for carcinoma endometrium, 72.72% and 98.9% for endometrial hyperplasia, and 81.81% and 100% for endometrial polyp, respectively.

Conclusion

Power Doppler sonography can be used to screen outpatients who do not need an endometrial biopsy for abnormal uterine bleeding. This will avoid unnecessary hysteroscopy in definitive benign cases, and watchful hysteroscopy in suspected premalignant and malignant cases. Irregular branching vessels and color splashes were found to be the best parameters for diagnosing endometrial carcinoma. Power Doppler should be done along with transvaginal sonography in all cases of abnormal uterine bleeding.

Antibiotic therapy versus no treatment for chronic endometritis: a case-control study

OBJECTIVE

To demonstrate the infectious nature of chronic endometritis (CE) in an inductive way by comparing the results of germ-oriented antibiotic therapy vs. no treatment in women with CE.

DESIGN

Retrospective, nonconcurrent case-control study.

SETTING

Tertiary hysteroscopic center in a university teaching hospital.

PATIENT(S)

Sixty-four consecutive women with CE who received antibiotic therapy (Group A) compared with a historical group of 64 patients with CE who refused antibiotic therapy (Group B).

INTERVENTIONS(S)

CE was diagnosed through hysteroscopy, histology, and immunohistochemistry for CD138. Patients in both groups were tested for CE twice to evaluate the cure rate after antibiotic therapy (Group A) or no treatment (Group B). For patients with persistent disease, antibiotic therapy was repeated up to 3 times. Antibiotics were chosen based on endometrial culture (with antibiogram).

MAIN OUTCOME MEASURE(S)

The primary outcome was to compare the cumulative cure rate of CE (defined as the percentage of patients without CE at the test of cure) between groups.

RESULT(S)

Among Group A, 20 patients (31.25%) experienced CE resolution after 1 antibiotic cycle, an additional 20 patients (31.25%) after 2 antibiotic cycles, and 12 patients (19.35%) after 3 antibiotic cycles. In 12 cases (18.75%), CE was persistent after 3 cycles of antibiotics. The cure rate of CE in Group A after 1 cycle of antibiotics was significantly higher than that of Group B (32.25% vs. 6%). Similarly, the cumulative cure rate was considerably higher in Group A vs. Group B (81.3% vs. 6%). Notably, the number of positive cases decreased significantly with all techniques between the first and second evaluation, whereas at the third evaluation, there was a statistical decrease only with hysteroscopy and CD138⁺ cell count but not with histology. The cumulative number of cases of CE diagnosed at hysteroscopy was significantly higher than histology and immunohistochemistry.

CONCLUSION(S)

Our study demonstrated the superiority of antibiotic therapy compared with no treatment for CE cure. Accordingly, the infectious nature of CE is inferred.

Nitrous oxide versus lidocaine versus no analgesic for in-office hysteroscopy: a randomised clinical trial

OBJECTIVE

To compare the effect of inhaled nitrous oxide (INO) on pain control during in-office hysteroscopy with 1% lidocaine paracervical infiltration and no analgesic.

DESIGN

Single-blind stratified randomised clinical trial with masked assessment by a third party.

SETTING

Department of Obstetrics and Gynaecology in a Spanish hospital.

POPULATION

Women who underwent hysteroscopy.

METHODS

Patients were stratified into three groups according to the purpose of the hysteroscopy (biopsy, polypectomy or tubal sterilisation) and then assigned to different treatment groups through a permuted-blocks randomisation within strata. Pain scale was provided by a gynaecologist totally blinded to procedures and treatments. Effects were assessed using a one-way analysis of variance following an intention-to-treat approach.

MAIN OUTCOME MEASURES

Visual analogue scale (VAS) from 0 to 100 mm.

RESULTS

A total of 314 women were included: 105 to INO, 104 to 1% lidocaine and 105 to no analgesic. Baseline characteristics were comparable. Mean VAS score after the procedure was 34.7 ± 25.8 mm, 36.1 ± 22.9 mm (P = 1.0) and 47.3 ± 28.2 mm (P = 0.001) for INO, 1% lidocaine and no analgesic, respectively. No adverse events were reported in 91 (86.7%) patients in the INO group compared with 79 (76%) in the 1%-lidocaine group (P = 0.04) and 85 (81%) in the no-analgesic group (P = 0.26).

CONCLUSION

INO was as effective as 1% lidocaine in pain control for in-office hysteroscopy and was better tolerated. The no-analgesic group presented the poorer results, so was the least recommended clinical option.

Comparison of three biopsy forceps for hysteroscopic endometrial biopsy in postmenopausal patients (HYGREB-1): A multicenter, single-blind randomized clinical trial

OBJECTIVE

To compare three types of biopsy forceps for hysteroscopic endometrial biopsy in postmenopausal women.

METHODS

Postmenopausal women undergoing operative hysteroscopy with endometrial biopsy for abnormal uterine bleeding or endometrial thickness (≥5 mm) were included. Operative hysteroscopy with endometrial biopsy was performed by hysteroscopic forceps. Women were randomized (1:1:1 ratio) in three groups and allocated to undergo endometrial biopsy by hysteroscopy using spoon, alligator, or snake forceps.

RESULTS

Seventy-five women were included in the study, 25 in each group. The duration of the biopsy was comparable between the three groups (P = 0.334) with a median of 180 seconds (range 20-480 seconds). No differences were observed about the number of attempts (P = 0.602), the use of another instrument (P = 0.276), and the biopsy appropriateness (P = 0.592). The spoon forceps group reported higher levels of pain compared to the alligator and snake forceps groups (P < 0.001). The spoon forceps received significantly lower scores by the operator compared to the alligator and snake forceps (P < 0.001). The alligator and snake forceps reported wider biopsy than the spoon forceps (P < 0.001).

CONCLUSION

Snake and alligator hysteroscopic forceps may be considered the first choice to perform an endometrial biopsy in postmenopausal women. ClinicalTrials.gov: NCT03427957.

Classification systems of Asherman's syndrome. An old problem with new directions

Intrauterine adhesion (IUA) formation and the resulting Asherman's syndrome (AS) is an unfortunate clinical condition that occurs when the endometrium is damaged as a consequence of trauma, such as vigorous curettage, infection, or some Müllerian anomaly. The most frequent symptoms include hypo/amenorrhea, infertility, and adverse reproductive outcomes. Prevention of IUA formation is essential; however, when present, accurate diagnosis and surgical intervention (hysteroscopic adhesiolysis) are required. The outcome of this treatment is based on the technique and the extent of surgery performed which depends on the severity and complexity of the disease. Hence its classification becomes particularly important to determine a standardized therapy for each case and patient counseling regarding the prognosis. In this article, we aim to describe the IUAs classification systems that have been proposed comparing the merits and demerits of each one.

Ultrasonographic technique to differentiate enhanced myometrial vascularity/arteriovenous malformation from retained products of conception

PURPOSE

To objective of this study is to discuss the ultrasonographic technique to diagnose uterine enhanced myometrial vascularity/arteriovenous malformation (EMV/AVM) and differentiate it from retained products of conception. The study also reviews the management and outcome of EMV/AVM.

METHODS

We present a series of three women who developed EMV after early pregnancy loss and a control case of incomplete abortion, where colour Doppler ultrasound was used to distinguish retained products of conception from features of EMV. Clinical status and imaging findings, including peak systolic velocity (PSV), were used for the initial risk stratification of the patients. All cases with EMV/AVM were managed expectantly with serial ultrasound imaging and trending human chorionic gonadotropin levels. The patient with retained products of conception was managed by hysteroscopy and curettage.

RESULTS

In all cases, presentation was suggestive of incomplete abortion with retained products of conception. However, colour Doppler ultrasound demonstrated hypoechoic areas within the endometrium extending into the myometrium with a high maximum PSV. In the control case, colour Doppler ultrasound noted a heterogeneous area in the left uterine cavity; however, vascular flow in this area was distinct from the endometrium, suggesting retained products of conception. All three women with EMV were managed expectantly with close monitoring and good outcomes.

CONCLUSION

In patients with early pregnancy loss and bleeding or persistently elevated human chorionic gonadotropin levels, clinical status and appropriate use of ultrasound imaging with colour Doppler, including PSV measurement, can assist in recognition of EMV/AVM. Expectant management with serial ultrasound evaluation is a safe treatment option for EMV/AVM with low PSV and can minimise complications such as need for blood transfusion, uterine artery embolization, and hysterectomy.

Successful endoscopic management of 3 cases of translocated intrauterine devices: a case report

Intrauterine devices (IUDs) are the most popular form of contraception globally; however, the use of IUDs carries some risks. IUD migration is a rare but serious complication that occurs after insertion, sometimes years later. Herein, we report 3 cases of translocated IUDs removed by endoscopy and describe the clinical characteristics and intraoperative findings of these patients. Case 1 was a 46-year-old woman who presented with upper abdominal pain. Gastroscopy showed the presence of an IUD inside the stomach. Digestive endoscopy performed at our hospital showed a T-shaped foreign body embedded in the gastric wall at the junction between the gastric antrum and the gastric body. The IUD was removed endoscopically without complications. Case 2 was a 36-year-old woman who had twice undergone cesarean section. Two months before presenting at our hospital, the patient experienced external hemorrhoid. During anal suppository treatment, she felt a lump inside the rectum. Pelvic computed tomography revealed a small, circular dense shadow with an approximate diameter of 0.4 cm in the upper intestinal cavity of the rectum. Subsequently, the patient received transanal endoscopy and rectal foreign-body removal surgery. Case 3 was a 40-year-old woman. She had failed to remove an IUD in other 2 hospitals. On the basis of pelvic computed tomography, the IUD was suspected to have perforated the bladder. Cystoscopy showed that part of the IUD was surrounded by stones. Laser lithotripsy was performed to expose the IUD completely. Under hysteroscopy, the IUD could be seen in the middle of the uterine cavity; 1 end was located on the right uterine horn, and the other was protruding out of the uterus. During the operation, the IUD was broken into two parts and one part was removed through the vagina. The cystoscope was placed again, and the remaining part of the IUD was smoothly removed. Although IUD migration has a low incidence, it can have a huge impact on patients' physical and emotional health. Migrated IUDs must be removed immediately. Hysteroscopy and digestive endoscopy are effective approaches for removing migrated IUDs.

Endometriosis presenting as vaginal polyps: outpatient vaginoscopic treatment

OBJECTIVE

To demonstrate an outpatient vaginoscopic technique for treating multiple vaginal polyps.

DESIGN

Demonstration of surgical technique using slides, pictures, and video.

SETTING

Private hospital.

PATIENT(S)

Thirty-two-year-old nulligravid woman presenting to the gynecology clinic with one episode of intermenstrual bleeding, regular menstrual cycles with normal flow, and no history of dysmenorrhoea or dyspareunia. The genital local examination was normal, and speculum examination showed multiple vaginal lesions like polyps in the proximal posterior two-thirds and right lateral vaginal walls. Her transvaginal ultrasound read a normal uterus with a right ovarian simple cyst.

INTERVENTION(S)

The surgeon performed an outpatient operative vaginoscopy using a 5-mm continuous flow office hysteroscope with a 2.9-mm rod lens optical system and a 5F working channel. Distension of the vagina was achieved with a normal saline solution, and an intrauterine pressure of 50 to 60 mm Hg was maintained by an irrigation and aspiration electronic pump. An inspection of the vaginal walls, fornices, and the external cervical os (Fig. 1) revealed 10 vaginal lesions like polyps in the proximal two-thirds of the posterior and right lateral vaginal wall. The vaginal lesions (Fig. 2) varied in size from 0.5 cm to 4 cm. An excisional biopsy was performed and the sample sent for histopathologic evaluation. The vaginal lesions <2 cm in length were excised by cutting the base with scissors or using a bipolar vaporization electrode, which was connected to an electrocautery unit by a bipolar high-frequency cord. Vaginal lesions >2 cm were excised with the TruClear 5C Hysteroscopic Tissue Removal System (HTRS) with a zero-degree scope using the 2.9-mm incisor with a 5-mm cutting window at one end attached to a reusable handpiece with two connectors-one to the motor unit and second to the suction bottle with a collection bag. The overall diameter of TruClear 5C is 5.7 mm, and the optic size is 0.8 mm. The same irrigation pump is compatible with HTRS, and the pressure was increased to 150 mm Hg to maintain vaginal distension. Three factors influenced our decision to use the HTRS intraoperatively: the number and size of the vaginal lesions and the surgical time in the outpatient setting. A mechanical system that works on the principle of excising and aspirating tissue, the HTRS incisor has a rotatory action with the excising window placed against the most distal part of the vaginal lesions. The cutting action is controlled via a foot pedal attached to a motor control with 800 rotations per minute. The handpiece remains stationary while the polyp is excised and aspirated through the window into the collection bag. Minimal bleeding occurred and stopped spontaneously. The institutional ethics committee exempted this case report from review, and we obtained informed written consent from the patient.

MAIN OUTCOME MEASURE(S)

All vaginal lesions excised in an outpatient setting via vaginoscopy technique without anesthesia.

RESULT(S)

The operative time with the Bettocchi hysteroscope was 14 minutes, and HTRS was 6 minutes. The patient did not complain of pain but did describe minimal discomfort, rated on the visual analog scale as 2 (where ≥5 is severe pain). She was discharged 1 hour later. The histopathology was reported as vaginal endometriosis (ectopic presentation of endometriosis is rare, accounting for 0.02% of cases). After surgery, she was started on cyclical oral contraceptive pills (OCP) in the combination of 30 mg of ethinyl estradiol + 2 mg of dienogest because she desired to delay pregnancy by 1 year. She remained asymptomatic for 6 months. These contraceptive hormones are available in the form of oral pills, vaginal rings, and transdermal patches, and a physician can provide OCP continuously or cyclically. Continuous OCP is more efficacious for control of dysmenorrhoea, but cyclical OCP is preferred because it is affordable, tolerable, effective, produces no unpredictable bleeding, and slows the progression of the disease. (A cohort study found the contraceptive vaginal ring to be more effective for symptom-control in rectovaginal endometriosis with higher patient satisfaction than the transdermal patch; vaginal rings or transdermal patches are not available in some countries.) CONCLUSION(S): Vaginoscopy allows a more in-depth visualization of the vagina with complete inspection and removal of all polyps. Vaginoscopy is feasible in the outpatient setting and allows a comfortable, ergonomic position for the surgeon. Vaginoscopy or no-touch technique avoids the use of a speculum or tenaculum and results in minimal pain during the outpatient procedure.

Atypical vessels in hysteroscopy: Usefulness in prediction of malignant diseases in patients treated with tamoxifen

AIM

Tamoxifen (TAM) is widely used in adjuvant endocrine therapy for invasive breast cancer as a selective estrogen modulator, but this treatment has a risk of developing endometrial malignancy. However, hysteroscopic findings during or after TAM treatment are unclear. The aim of this study is to examine the association between hysteroscopic patterns and malignant histological findings during or after treatment with TAM.

METHODS

The subjects were patients who received TAM after surgery for breast cancer and underwent hysteroscopy at our institution from January 2016 to December 2019. Clinicopathological factors and hysteroscopic findings were collected from medical records and investigated retrospectively. Histologically, atypical endometrial hyperplasia, endometrial cancer, and carcinosarcoma were classified as malignant diseases.

RESULTS

A total of 26 patients were eligible for the study. Hysteroscopic findings included an irregular surface of the endometrium (n = 3, 11.5%), atypical vessels (n = 10, 38.5%), papillary structure (n = 3, 11.5%), and polypoid structure (n = 18, 69.2%). Histological examination revealed malignancy in six patients (23.0%). The percentage of atypical vessels in patients with malignancies was significantly higher than that in patients with a normal endometrium or benign lesion (100% vs. 20%, p = 0.0009). The sensitivity and specificity of atypical vessels in hysteroscopy for diagnosis of malignant diseases were 100% and 80%, respectively.

CONCLUSIONS

Hysteroscopic findings of atypical vessels may be useful for prediction of malignant diseases in patients treated with TAM.

Analysis of the therapeutic effects of hysteroscopic polypectomy with and without doxycycline treatment on chronic endometritis with endometrial polyps

PROBLEM

We aimed to compare the therapeutic effects of hysteroscopic polypectomy with and without doxycycline treatment on chronic endometritis (CE) with endometrial polyps.

METHOD OF STUDY

DESIGN: A cross-sectional study was conducted on 267 infertile patients, of whom 243 were recruited, who underwent hysteroscopic polypectomy between March 2019 and March 2020. During surgery, the endometrial specimens for the immunohistochemistry analysis of the plasma cell marker CD138 and for the intrauterine bacterial culture were obtained to diagnose CE, and the prevalence of CE was analyzed. Of the 222 women who were diagnosed with CE after polypectomy, we treated 62 women with doxycycline (antibiotic group) and did not provide antibiotics in 160 women (non-antibiotic group).

RESULTS

Most of the infertile patients with endometrial polyps had CE (92.6%). The recovery rate from CE by hysteroscopic polypectomy was significantly higher in the non-antibiotic group than in the antibiotic group (88.8% and 58.1%, respectively, p < 0.0001). The duration of recovery from CE in the non-antibiotic group was shorter than that in the antibiotic group (42.6 ± 41.0 and 56.5 ± 32.3 days, respectively, p < 0.0001). The clinical pregnancy rate within 6 months in non-antibiotic group was higher than that in the antibiotic group (63.2% and 43.8%, respectively, p = 0.034).

CONCLUSION

Endometrial polyps are significantly associated with CE. Most CE patients with endometrial polyps had been cured by polypectomy without doxycycline. Inappropriate antibiotic therapy may delay recovery from CE and decrease the efficacy of polypectomy on CE and pregnancy rates.

Uterine Fundus Remodeling after Hysteroscopic Metroplasty: A Prospective Pilot Study

The septate uterus is the most common congenital uterine malformation and is treated by hysteroscopic metroplasty. There are few studies on the fundal uterine changes that occur after surgery. We designed a pilot prospective observational study to evaluate by three-dimensional transvaginal ultrasound (3D-TVS) the changes not only of the internal fundal uterine profile, but also of the external one, after hysteroscopic metroplasty. Sixty women who underwent hysteroscopic metroplasty for partial or complete uterine septum (U2a and U2b subclasses of ESHRE/ESGE classification) were enrolled. We performed 3D-TVS after surgery confirming optimal removal of the septum. However, at ultrasound follow-up after three months, we observed a significant increase (p < 0.001) in the residual septum (Zr) (3.7 mm (95% CI: 3.1-4.4)), the myometrial wall thickness (Y) (2.5 mm (95% CI: 2.0-3.0)) and the total fundal wall thickness (Y + Zr) (6.2 mm (95% CI: 5.5-6.9)). Forty-three patients (72%) required a second step of hysteroscopic metroplasty. Moreover, the shape of uterine fundus changed in 58% of cases. We actually observed a remodeling of the uterine fundus with modifications of its external and internal profiles. Therefore, we propose to always perform a second ultrasound look at least three months after the metroplasty to identify cases that require a second- step metroplasty.

Patient-reported menstrual and obstetric outcomes following hysteroscopic adhesiolysis for Asherman syndrome

Objective

Review the menstrual and obstetric outcomes among Asherman syndrome patients when stratified by disease severity.

Design

Retrospective cohort study.

Setting

A community teaching hospital affiliated with a large academic medical center.

Patients

A total of 355 Asherman syndrome patients stratified by March classification who underwent hysteroscopic adhesiolysis.

Interventions

Telephone survey, analyzed with multivariable analysis.

Main Outcome Measures

Return of menstruation. Pregnancy, miscarriage, and live birth rate.

Results

A total of 355 patients underwent hysteroscopic adhesiolysis. Of these, 150 (42.3%) patients completed the telephone survey with a mean follow-up of 2.21 years. Additionally, 40.7% had mild, 52.7% had moderate, and 6.6% had severe disease. Furthermore, 25.3% of patients reported amenorrhea at presentation, with mild disease patients having the highest rate of returning menstruation (93.8%) following treatment. The cumulative pregnancy rate was 81.9%, and the cumulative live birth rate was 51.2%, with no statistical differences identified by the classification group.

Conclusion

Asherman syndrome disease severity predicted returning menstruation but not pregnancy or live birth rate.

Hysteroscopic management of endometrial polyps and submucous leiomyomas in women using a levonorgestrel-releasing intrauterine system

INTRODUCTION

This study was designed to evaluate the feasibility and effectiveness of hysteroscopy in the management of symptoms related to endometrial polyps and submucous leiomyomas in women using a levonorgestrel-releasing intrauterine system (LNG-IUS).

MATERIAL AND METHODS

Twenty-three LNG-IUS users presenting with endometrial polyps and/or submucous leiomyomas and irregular uterine bleeding were recruited for hysteroscopic examination and surgery. Intrauterine pathology was investigated and treated by hysteroscopic resection with the LNG-IUS in situ, and the effect of the procedure on symptoms was evaluated after three to six months.

RESULTS

Intrauterine pathology was successfully resected by hysteroscopy in 23 (100.0%) out of 23 cases. Following hysteroscopy, 18 (78.3%) women reported amenorrhea, one (4.3%) regular spotting, three (13.0%) irregular spotting and one (4.3%) patient resumed normal menstrual cycle. We conclude that 19 (82.6%) patients were postoperatively asymptomatic. All procedures were uncomplicated and 4 (17.4%) were carried out without general anesthesia as office procedures.

CONCLUSION

Endometrial polyps and submucous leiomyomas can develop in LNG-IUS users, and this can cause irregular uterine bleeding. Hysteroscopic resection of these pathologies is a feasible method in the clinical management of symptoms.

Sepsis following hysteroscopic myomectomy

Hysteroscopy and hysteroscopic myomectomy in general have low complication rates. Two patients underwent hysteroscopic myomectomy for prolapsing submucous myomas after UAE. The onset of prolapsing myoma occurred at varying times between completion of UAE and myomectomy, resulting in bacteremia for both patients. In Case 1, the patient recovered with intravenous antibiotic treatment. However, the patient in Case 2 had status improvement after undergoing an abdominal myomectomy, explorative laparotomy for removal of a necrotic myoma. Our two patient cases serve as a caution to clinicians regarding the rare incidence of septicemia occurring in patients undergoing hysteroscopic myomectomy with prior UAE treatment for prolapsing myomas.