A new method of transvaginal ultrasound-guided polypectomy: a feasibility study

Surgical Management of Abnormal Uterine Bleeding in Fertile Age Women

Abnormal uterine bleeding is a common gynecological disease and represents one of the most frequent reasons for hospital admission to a specialist unit, often requiring further surgical treatment. Following the so-called PALM-COEIN system we will attempt to further clarify the surgical treatments available today. The first group (PALM) is characterized by structural lesions, which may be more appropriately treated by means of surgical management. Although hysterectomy remains the definitive and decisive choice, there are many alternative techniques available. These minimally invasive procedures offer the opportunity for a more conservative approach. Precise and accurate counseling facilitates better patient selection, based on the patient's desires, age and disease type, allowing treatment to be individually tailored to each woman.

Saline infusion sonohysterography versus hysteroscopy for uterine cavity evaluation

BACKGROUND AND OBJECTIVES

The most frequent procedures performed on women with abnormal uterine bleeding are 2D and 3D ultrasound. The most common accepted approach for the management of abnormal uterine bleeding is 2D TV scan followed by therapeutic hysteroscopy. The purpose of this prospective study was to assess whether 3D saline infusion sonohysterography (3D SIS) could replace diagnostic hysteroscopy (DH) for the diagnosis of endometrial pathology, in patients with abnormal uterine bleeding.

DESIGN AND SETTING

A prospective study in the ultrasound department of the Women's Specialized Hospital, King Fahad Medical City, Riyadh, Saudi Arabia from January 2008 to February 2010.

PATIENTS AND METHODS

0One hundred and one patients with abnormal uterine bleeding, suspected to have endometrial abnormality by 2D and 3D transvaginal scan, were prospectively studied. Of these, 55 patients had undergone both 3D SIS and DH, followed by verification of results with histopathology.

RESULTS

Upon comparison of 3D SIS and DH individually with histopathology, specificity and sensitivity for 3D SIS were 67% and 100%, respectively, and for hysteroscopy 67% and 98%, respectively. In addition, the positive predictive value and negative predictive value were 98% and 100%, respectively, for 3D SIS, while for DH they were 98% and 67%, respectively.

CONCLUSION

3D SIS is a safe alternative to hysteroscopy. However, larger randomized controlled trials should be conducted to ascertain the validity and reliability of this advantageous, less-invasive procedure, for women with abnormal uterine bleeding, who require evaluation of the endometrial cavity.

Sonographic and magnetic resonance imaging findings of pelvic abscess following uterine perforation sustained during office endometrial sampling

Pipelle endometrial sampling, an outpatient, office-based procedure, provides comparative successful endometrial sampling in comparison with other techniques including conventional dilatation and curettage. We present an unusual occurrence in which office Pipelle endometrial sampling in a perimenopausal patient was complicated 10 days later by lower abdominal pain and intermittent fever. Sonography depicted findings consistent with a large pelvic abscess overriding the uterine fundus. Sonography and magnetic resonance imaging confirmed the presence of the unusual pelvic abscess and, in addition, noted findings consistent with perforation of the uterus during endometrial sampling.

Myomectomy through the uterine cervix using forceps under sonographic guidance

OBJECTIVES

To evaluate the feasibility of a novel method of forceps myomectomy under sonographic guidance.

METHODS

Between June 2005 and August 2006, we performed a prospective study to evaluate the feasibility of forceps myomectomy under sonographic guidance in patients with submucosal myomas. Patients were enrolled into the study if, on transvaginal sonographic or hysteroscopic examination, their myomas were found to have an intramural extension < 75%, absence of 'sinking' and a mean diameter < 8 cm.

RESULTS

There were 28 patients with submucosal myomas including Types 0 (n = 18), 1 (n = 6) and 2 (n = 4). In 26/28 (92.8%; 95% CI, 82.6-100) patients the myomas were removed completely. The mean operating time and intraoperative blood loss were 27.3 min and 33.5 mL, respectively. The median follow-up time was 15 months. There were no perioperative complications. No patient subsequently underwent myomectomy or hysterectomy.

CONCLUSIONS

In our experience, this novel method of forceps myomectomy is feasible for the removal of Type 0 and Type 1 submucosal myomas as well as selected Type 2 myomas.

Endometrial directed biopsy during sonohysterography using the NiGo device: prospective study in women with abnormal uterine bleeding

OBJECTIVE

To determine the accuracy of sonohysterography (SHG), combined with sonography-guided biopsies that are performed by using the NiGo device, in the diagnosis of endometrial pathologies in women with abnormal uterine bleeding (AUB).

DESIGN

Prospective study.

SETTING

Outpatient clinic.

PATIENT(S)

One hundred sixteen women with AUB (55 postmenopausal and 61 premenopausal).

INTERVENTION(S)

Patients underwent transvaginal sonography and SHG; when an endometrial condition needing a biopsy was diagnosed, the biopsy was performed both by using the NiGo device (ASL 1, Imperia, Italy) and by using Pipelle.

MAIN OUTCOME MEASURE(S)

Feasibility of SHG and endometrial biopsy by NiGo.

RESULT(S)

Sonohysterography was successfully performed by using the NiGo device in 87.4% of the cases (92.6% of premenopausal women and 81.5% of postmenopausal women). Seventy-eight (86.7%) women were judged to require endometrial biopsy; the NiGo device allowed obtaining an adequate biopsy for histological evaluation in 74 cases (94.9%). There was no statistically significant difference in efficacy between the NiGo and Pipelle in providing a specimen that was adequate for histological evaluation. Although no significant difference was observed in the histological diagnosis performed on the specimens obtained by the two techniques, NiGo allowed diagnosis of more focal lesions (simple hyperplasia, endometrial polyps, and myomas).

CONCLUSION(S)

The NiGo device allows an adequate biopsy for histological evaluation to be obtained during SHG in an outpatient setting.

Transvaginal sonographic findings of a large intramural uterine hematoma associated with iatrogenic injury sustained at termination of pregnancy

We report a case in which a patient presented with severe right lower abdominal pain associated with nausea and vomiting 3 days after termination of pregnancy. Transvaginal ultrasonography showed a large intramural mass in the anterior aspect of the lower segment of an acutely retroflexed uterus. Computed tomography and magnetic resonance imaging findings were consistent with an intramural hematoma as a result of iatrogenic injury sustained during the preceding termination of pregnancy. The patient was managed expectantly. Systematic review of the literature confirmed that this is the first report of sonographic findings associated with an intramural uterine hematoma some days after the injury sustained at termination of pregnancy. This case supports utilization of real-time ultrasound guidance during intrauterine surgery of selected cases to decrease procedure-related morbidity.

Saline infusion sonography in women with abnormal uterine bleeding: an update of recent findings

PURPOSE OF REVIEW

To inform about new developments concerning saline infusion sonography, especially in women suffering from abnormal uterine bleeding.

RECENT FINDINGS

The diagnostic accuracy of saline infusion sonography has been established before the period of this review; however, recent papers support the high diagnostic accuracy and conclude saline infusion sonography is able to replace diagnostic hysteroscopy in the evaluation of the uterine cavity. The use of gel instead of saline as distension medium and the introduction of new three-dimensional inversion rendering techniques enhances the visualization of the endometrium which may improve the diagnostic accuracy of saline infusion sonography. A simple, feasible and seemingly cost-effective method of saline infusion sonography-based guided endometrial biopsy has been developed. The technique may allow saline infusion sonography based polypectomy. A classification of submucous fibroids has been proposed in order to allow more accurate, saline infusion sonography-based, preoperative selection of fibroids suitable for hysteroscopic resection.

SUMMARY

The development of saline infusion sonography-based guided biopsies allows saline infusion sonography to compete with vaginoscopic operative hysteroscopy. Additional comparative trials are needed in order to finalize the decision about the proper method of the assessment of the uterine cavity.