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Ferreira de Castro L, Santos I, Laganà AS, de Vree B, van Herendael BJ, Djokovic D. Enhancing precision in hysteroscopic surgery: The role of intraoperative ultrasound. Eur J Obstet Gynecol Reprod Biol 2024; 302:306-309. [PMID: 39357384 DOI: 10.1016/j.ejogrb.2024.09.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Revised: 09/14/2024] [Accepted: 09/17/2024] [Indexed: 10/04/2024]
Abstract
Hysteroscopy stands as the gold-standard approach for managing intrauterine pathology. However, in complex clinical cases, hysteroscopic evaluation alone may prove insufficient for the safest and successful patient management. Intraoperative ultrasound (IOUS) has emerged as a valuable adjunct to hysteroscopic surgery, offering real-time visualization of endometrial cavity, uterine walls and instruments within the uterine cavity, enabling precise delineation of anatomical structures, and helping to assess the extent of pathology during intricate interventions. This review aims to comprehensively assess the applications, efficacy and utility of IOUS in hysteroscopic surgery. Available evidence indicates that in hysteroscopic myomectomy, IOUS significantly reduces the risk of uterine perforation, particularly in submucosal FIGO 2 myomas, and enhances the likelihood of a single-step procedure. During hysteroscopic metroplasty, ultrasound guidance decreases the chance of incomplete uterine septum resection. In the hysteroscopic management of severe Asherman syndrome, IOUS reduces the risk of uterine perforation or false passage. For cesarean scar pregnancy (CSP), ultrasound is crucial in defining the most appropriate surgical approach and is effective in guiding the hysteroscopic treatment of endogenic CSP. The use of IOUS in hysteroscopy proves valuable in complex cases where the risk of uterine perforation or incomplete procedure is increased.
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Affiliation(s)
- Luís Ferreira de Castro
- Department of Obstetrics and Gynecology, Centro Materno Infantil do Norte Albino Aroso, Unidade Local de Saúde de Santo António, Porto, Portugal; Instituto de Ciências Biomédicas Abel Salazar, University of Porto, Porto, Portugal.
| | - Inês Santos
- Gynecology Department, Hospital Professor Doutor Fernando Fonseca, Unidade Local de Saúde de Amadora/Sintra, Lisbon, Portugal
| | - Antonio Simone Laganà
- Unit of Obstetrics and Gynecology, "Paolo Giaccone" Hospital, Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Palermo, Italy
| | - Bart de Vree
- Department of Obstetrics and Gynecology - Ziekenhuis Aan de Stroom (ZAS), Antwerpen, Belgium; Department of Obstetrics and Gynecology - University Hospital Antwerp (UZA), Edegem, Belgium; Endoscopic Training Center Antwerp (ETCA), Antwerp, Belgium
| | - Bruno J van Herendael
- Department of Obstetrics and Gynecology - Ziekenhuis Aan de Stroom (ZAS), Antwerpen, Belgium; Endoscopic Training Center Antwerp (ETCA), Antwerp, Belgium; Università degli Studi dell'Insubria, Varese, Italy
| | - Dusan Djokovic
- Department of Obstetrics and Gynecology, Hospital CUF Descobertas, Lisbon, Portugal; Department of Obstetrics and Gynecology, NOVA Medical School/Faculdade de Ciências Médicas, NOVA University of Lisbon, Lisbon, Portugal
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Dreessen JRJ, van der Meulen JF, Bongers MY, Mol BWJ, Langenveld J. Publication trends and usefulness of research in hysteroscopic myomectomy for heavy menstrual bleeding: A review of the published literature. Int J Gynaecol Obstet 2022; 161:692-701. [PMID: 36495222 DOI: 10.1002/ijgo.14613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 12/07/2022] [Indexed: 12/14/2022]
Abstract
Despite the amount of research into hysteroscopic myomectomy, questions about the optimal treatment of heavy menstrual bleeding remain. This study reviewed publication trends on this topic from 2002 to 2019 and assessed the usefulness of studies. A total of 580 articles were published on PubMed in this time frame, in 15 different languages. There were meta-analyses (1.6%), systematic reviews (12%), and randomized controlled trials (4.2%). Twelve percent were published in high impact factor journals. After applying our selection criteria, the usefulness of 37 articles was assessed: one article scored high, 31 scored moderate, and five scored low. The costs of these studies were estimated at US$ 971 700.
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Affiliation(s)
- Janique R J Dreessen
- Department of Obstetrics and Gynecology, Zuyderland Medical Centre, Heerlen, The Netherlands
| | - Julia F van der Meulen
- Department of Obstetrics and Gynecology, Maxima Medical Centre, Veldhoven, The Netherlands.,Grow School of Oncology and Developmental Biology, MUMC, Maastricht, The Netherlands
| | - Marlies Y Bongers
- Department of Obstetrics and Gynecology, Maxima Medical Centre, Veldhoven, The Netherlands.,Grow School of Oncology and Developmental Biology, MUMC, Maastricht, The Netherlands
| | - Ben W J Mol
- Department of Obstetrics and Gynecology, Monash University, Clayton, Victoria, Australia
| | - Josje Langenveld
- Department of Obstetrics and Gynecology, Zuyderland Medical Centre, Heerlen, The Netherlands
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3
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Moawad NS, Palin H. Hysteroscopic Myomectomy. Obstet Gynecol Clin North Am 2022; 49:329-353. [DOI: 10.1016/j.ogc.2022.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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4
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Loddo A, Djokovic D, Drizi A, De Vree BP, Sedrati A, van Herendael BJ. Hysteroscopic myomectomy: The guidelines of the International Society for Gynecologic Endoscopy (ISGE). Eur J Obstet Gynecol Reprod Biol 2021; 268:121-128. [PMID: 34902749 DOI: 10.1016/j.ejogrb.2021.11.434] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 11/11/2021] [Accepted: 11/27/2021] [Indexed: 11/16/2022]
Abstract
OBJECTIVE With this publication, the International Society for Gynecologic Endoscopy (ISGE) aims to provide the clinicians with the recommendations arising from the best evidence currently available on hysteroscopic myomectomy (HM). STUDY DESIGN The ISGE Task Force for HM defined key clinical questions, which led the search of Medline/PubMed and the Cochrane Database. We selected and analyzed relevant English-language articles, published from January 2005 to June 2021, including original works, reviews and the guidelines previously published by the European Society for Gynecological Endoscopy (ESGE) and the American Association of Gynecologic Laparoscopists (AAGL), in which bibliographies were also checked in order to identify additional references, using the medical subject heading (MeSH) term "Uterine Myomectomy" (MeSH Unique ID: D063186) in combination with ''Myoma" (MeSH Unique ID: D009214) and ''Hysteroscopy" (MeSH Unique ID: D015907). We developed the recommendations through multiple cycles of literature analysis and expert discussion. RESULTS The ISGE Task Force did develop 10 grade 1A-C and 4 grade 2A-C recommendations. For planning HM, evaluation of the uterus with saline infusion sonohysterography (SIS) or combined assessment by transvaginal ultrasound (TVUS) and diagnostic hysteroscopy is recommended (Grade 1A). The use of STEPW (Size, Topography, Extension of the base, Penetration and lateral Wall position) classification system of submucosal leiomyoma (LM) is recommended to predict the complex surgeries, incomplete removal of the LM, long operative time, fluid overload and other major complications (grade 1B). For type 0 LMs, in addition to resectoscopy (slicing technique), morcellation is recommended, being faster and having a shorter learning curve with respect to resectoscopy (grade 1C). For type 1-2 LMs, slicing technique is currently recommended (grade 1C). A fluid deficit of 1000 mL also in case of bipolar myomectomy with saline solution, in healthy women of reproductive age, contains low risk for major complications. Lower thresholds (750 mL) for fluid deficit should be considered in the elderly and in women with cardiovascular, renal or other co-morbidities (Grade 1B). CONCLUSION HM is the most effective conservative minimally invasive gynecologic intervention for submucous LM. The set of 14 ISGE recommendations can significantly contribute to the success of HM and the safety of patients for whom the choice of appropriate surgical technique, as well as the surgeon's awareness and measures to prevent complications are of the utmost importance.
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Affiliation(s)
- Alessandro Loddo
- Clinica Ostetrica e Ginecologica Azienda Ospedaliero-Universitaria di Cagliari, Policlinico Duilio Casula, Monserrato, CA, Italy
| | - Dusan Djokovic
- Maternidade Dr. Alfredo da Costa, Centro Hospitalar Universitário Lisboa Central (CHULC), Lisbon, Portugal; Department of Obstetrics and Gynecology, NOVA Medical School - Faculdade de Ciências Médicas, NOVA University of Lisbon, Lisbon, Portugal; Department of Obstetrics and Gynecology, Hospital CUF Descobertas, Lisbon, Portugal
| | - Amal Drizi
- Independent Consultant in Obstetrics and Gynecology, Algiers, Algeria
| | - Bart Paul De Vree
- Department of Obstetrics & Gynecology, Ziekenhuis Netwerk Antwerpen (ZNA), Campus Middelheim, Antwerp, Belgium; Department of Obstetrics & Gynecology, Universitair Ziekenhuis Antwerpen (UZA), Edegem, Belgium
| | - Adel Sedrati
- Independent Consultant in Gynecology Obstetrics and Gynecology, Constantine, Algeria
| | - Bruno J van Herendael
- Endoscopic Training Center Antwerp (ETCA), Stuivenberg General Hospital, Ziekenhuis Netwerk Antwerpen (ZNA), Antwerp, Belgium; Università degli Studi dell'Insubria, Varese, Italy
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Galazis N, Mappouridou S, Saso S, Lathouras K, Yazbek J. Applying the vaginal approach for benign ovarian cystectomy: current evidence and future applications. Future Sci OA 2020; 6:FSO470. [PMID: 32518685 PMCID: PMC7273401 DOI: 10.2144/fsoa-2019-0138] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Vaginal ovarian cystectomy has not gained wide acceptance owing to the potential difficulty in entering the cul-de-sac. We review the current evidence on vaginal approaches to benign ovarian cysts. Outcome measures of interest included time to return to work, patient satisfaction, surgical complications and length of hospital stay. Ten studies were included in this review and involving 525 patients. Vaginal ovarian cystectomy is overall safe and feasible in appropriately selected cases with no evidence of intrapelvic adhesions or endometriosis. These findings will need to be validated in appropriately powered studies, before reliable conclusions can be drawn. Furthermore, we emphasize the importance of ultrasound both preoperatively for case selection optimization and intraoperatively, as a means of guidance during posterior culdotomy. The management of benign ovarian cysts through the vagina (VOC) has not gained wide acceptance by gynecologists worldwide owing to the potential difficulty in accessing the pelvic organs through an incision at the top of the vagina that may cause injury to adjacent structures such as the rectum. This is a review of the literature on the effectiveness of VOC. Various techniques have been described. Overall, VOC is safe and effective in appropriately selected cases. Larger studies will need to be conducted to validate these results. We also emphasize the importance of ultrasound both preoperatively as a tool to select the right patients for VOC as well as during surgery as an adjunct to guide the surgeon.
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Affiliation(s)
- Nicolas Galazis
- West London Gynaecological Cancer Centre, Queen Charlotte's Hospital, Hammersmith Hospital Campus, Imperial College London, Du Cane Road, London W12 0HS, UK
| | - Stephanie Mappouridou
- West London Gynaecological Cancer Centre, Queen Charlotte's Hospital, Hammersmith Hospital Campus, Imperial College London, Du Cane Road, London W12 0HS, UK
| | - Srdjan Saso
- West London Gynaecological Cancer Centre, Queen Charlotte's Hospital, Hammersmith Hospital Campus, Imperial College London, Du Cane Road, London W12 0HS, UK.,Division of Surgery & Cancer, Institute of Reproductive & Developmental Biology, Imperial College London, Hammersmith Hospital Campus, Du Cane Road, London W12 0HS, UK
| | - Konstantinos Lathouras
- West London Gynaecological Cancer Centre, Queen Charlotte's Hospital, Hammersmith Hospital Campus, Imperial College London, Du Cane Road, London W12 0HS, UK
| | - Joseph Yazbek
- West London Gynaecological Cancer Centre, Queen Charlotte's Hospital, Hammersmith Hospital Campus, Imperial College London, Du Cane Road, London W12 0HS, UK
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Vitale SG, Ferrero S, Caruso S, Barra F, Marín-Buck A, Vilos GA, Vitagliano A, Török P, Ciebiera M, Cianci A. Ulipristal Acetate Before Hysteroscopic Myomectomy: A Systematic Review. Obstet Gynecol Surv 2020; 75:127-135. [DOI: 10.1097/ogx.0000000000000764] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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Indraccolo U, Bini V, Favilli A. Likelihood of Accomplishing an In-Patient Hysteroscopic Myomectomy in a One-Step Procedure: A Systematic Review and Meta-Analysis. BIOMED RESEARCH INTERNATIONAL 2020; 2020:4208497. [PMID: 32090092 PMCID: PMC7015183 DOI: 10.1155/2020/4208497] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 11/20/2019] [Indexed: 11/17/2022]
Abstract
PURPOSE To assess the feasibility rate of one-step hysteroscopic myomectomy according to the technique adopted. METHODS In July 2016, PubMed, ClinicalTrials.gov, SCOPUS, Scielo, and AJOL databases were used for searching references. Series of in-patient hysteroscopic myomectomies reporting success rate in only one-step procedure, categorization of submucous fibroids, explanation of the surgical technique, and description of patients were considered eligible for meta-analysis (retrospective, prospective randomized studies). Two authors extracted the data. Rate of myomectomies accomplished in only a surgical step and rate of intraoperative complications were extracted per protocol. A modified GRADE score was used for quality assessment. Random-effect models were already assumed. Mean rates were compared among subgroups. RESULTS One thousand two hundred and fifty-seven studies were screened and 241 of these were read for eligibility. Seventy-eight series were included in qualitative synthesis and 24 series were included in quantitative synthesis. Wide heterogeneity was found. In series with <50% of G2 myomas treated, the slicing technique feasibility rate was 86.5% while techniques for enucleating the deep portion of the myomas showed a feasibility rate of 92.3% (p < 0.001). In series with ≥50% of G2 myomas treated, the slicing technique feasibility rate was 70.6% while techniques for enucleating the deep portion of myomas showed a feasibility rate of 88.4% (p < 0.001). In series with ≥50% of G2 myomas treated, the slicing technique feasibility rate was 70.6% while techniques for enucleating the deep portion of myomas showed a feasibility rate of 88.4% (. CONCLUSION In case of submucous myomas with intramural development, the slicing technique was correlated with a lower rate of in-patient hysteroscopic myomectomies accomplished in a one-step procedure and a higher complications rate.
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Affiliation(s)
- Ugo Indraccolo
- Department of Obstetrics and Gynaecology, USL Umbria 1, Alta Valle del Tevere Hospital, Città di Castello (PG), Umbria, Italy
| | - Vittorio Bini
- Department of Medicine, University of Perugia, Perugia, Italy
| | - Alessandro Favilli
- Department of Obstetrics and Gynaecology, USL Umbria 1, Alta Valle del Tevere Hospital, Città di Castello (PG), Umbria, Italy
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Tinelli A, Favilli A, Lasmar RB, Mazzon I, Gerli S, Xue X, Malvasi A. The importance of pseudocapsule preservation during hysteroscopic myomectomy. Eur J Obstet Gynecol Reprod Biol 2019; 243:179-184. [DOI: 10.1016/j.ejogrb.2019.09.008] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2019] [Revised: 09/08/2019] [Accepted: 09/16/2019] [Indexed: 11/29/2022]
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Ultrasound guidance in reproductive surgery. Best Pract Res Clin Obstet Gynaecol 2019; 59:12-24. [PMID: 31279764 DOI: 10.1016/j.bpobgyn.2019.05.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 05/24/2019] [Accepted: 05/24/2019] [Indexed: 11/22/2022]
Abstract
Ultrasound plays a key role in diagnosis and guidance in reproductive medicine and surgery. In the field of reproductive surgery, some of the interventions, especially intrauterine procedures, are regularly conducted without imaging guidance but instead performed based on clinical skills and experience alone. Operative real-time US provides concurrent visualisation of the structures, contents and planes and operating instruments and, therefore, has the potential to improve efficacy and safety of the operative interventions. Ultrasound should be used in our operating theatres more often to guide various intrauterine procedures to reduce the intra-operative risks and complications including uterine perforations and visceral injury. The use of ultrasound necessitates an additional assistant experienced in ultrasound in the theatre, but regular use of ultrasound improves the training opportunities of the trainees and clinicians.
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10
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Zhao H, Yang B, Li H, Xu Y, Feng L. Successful Pregnancies in Women with Diffuse Uterine Leiomyomatosis after Hysteroscopic Management Using the Hysteroscopy Endo Operative System. J Minim Invasive Gynecol 2018; 26:960-967. [PMID: 30308306 DOI: 10.1016/j.jmig.2018.10.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 10/02/2018] [Accepted: 10/04/2018] [Indexed: 02/06/2023]
Abstract
STUDY OBJECTIVE To evaluate the feasibility, effectiveness, and reproductive outcome of hysteroscopic management using the Hysteroscopy Endo Operative system (HEOS) in patients with diffuse uterine leiomyomatosis (DUL). DESIGN Retrospective study (Canadian Task Force classification III). SETTING Beijing Tiantan Hospital, Capital Medical University, Beijing, China. PATIENTS Eight women of reproductive age suffering from menorrhagia and anemia or infertility diagnosed with DUL by ultrasonography and hysteroscopy. INTERVENTIONS Hysteroscopic surgery using cold graspers combined with electric loop by the HEOS was performed to excise submucous myomas (including types 0, I, and II), leaving other intramural myomas in place. The fenestration method is used in electrical hysteroscopic myomectomy. Postoperative endometrial repair and synechiae, menstrual improvement, conception, and pregnancy were recorded. MEASUREMENTS AND MAIN RESULTS Two patients underwent a single hysteroscopic myomectomy, whereas 6 patients underwent 2 to 3 myomectomies. No complications were observed. The mean follow-up period was 39.13 ± 17.01 months (range, 21-67). The endometrium recovered 2 to 3 months after the initial surgery, and 100% improvement in menstruation was observed. Two patients had mild synechia after the first hysteroscopic surgery. Seven patients conceived spontaneously (postoperative pregnancy rate, 87.5%), 6 of whom had a full-term pregnancy. One patient suffered a miscarriage in the second trimester (live birth rate, 75%). CONCLUSION Hysteroscopic surgery using cold graspers combined with electric loop by the HEOS is a feasible and effective for treatment of DUL because it preserves the uterus and yields favorable reproductive outcomes. The cold surgery and fenestration method minimizes electrical and thermal damage to the endometrium surrounding the myoma, consequently reducing surgical risks.
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Affiliation(s)
- Hui Zhao
- Department of Obstetrics and Gynecology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (all authors)
| | - Baojun Yang
- Department of Obstetrics and Gynecology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (all authors)
| | - Haixia Li
- Department of Obstetrics and Gynecology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (all authors)
| | - Yun Xu
- Department of Obstetrics and Gynecology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (all authors)
| | - Limin Feng
- Department of Obstetrics and Gynecology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (all authors)..
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Chase T, Estes SJ. Hysteroscopic Myomectomy of a Large Submucosal Leiomyoma with Novel Use of Fluid Warming. J Minim Invasive Gynecol 2018; 25:1289-1294. [PMID: 29772408 DOI: 10.1016/j.jmig.2018.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Revised: 04/30/2018] [Accepted: 05/02/2018] [Indexed: 10/16/2022]
Abstract
Uterine myoma size is often considered a limiting factor when choosing the surgical approach to myomectomy. In this case, a 35-year-old woman presented with heavy menstrual bleeding and desire for fertility. Ultrasound performed 3 months earlier could not assess the endometrium and suggested leiomyoma. Magnetic resonance imaging of the pelvis identified a fundal submucosal myoma measuring 6.8 × 7.1 × 3.5cm. A planned staged hysteroscopic resection of the large submucosal myoma with intramural component was achieved. Unassisted conception occurred 2 months later. She delivered by cesarean section at term without complications. This case demonstrates that hysteroscopic mechanical tissue removal device combined with ultrasound guidance and a fluid warming system can complete myomectomy for very large uterine myomas without the need for laparoscopy or laparotomy.
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Affiliation(s)
- Tess Chase
- Department of Obstetrics and Gynecology, Penn State Health, Hershey, Pennsylvania
| | - Stephanie J Estes
- Department of Obstetrics and Gynecology, Penn State Health, Hershey, Pennsylvania.
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Rodríguez-Mías NRL, Cubo-Abert M, Fernandez-Oliva A, Poza-Barrasus JL, Gil Moreno A. Abdominal Ultrasound Assessment During Operative Hysteroscopy: A Case Series. J Gynecol Surg 2018. [DOI: 10.1089/gyn.2017.0095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
| | - Montserrat Cubo-Abert
- Department of Gynecology, Hospital Vall d'Hebrón, Autonomous University of Barcelona, Barcelona, Spain
| | - Antonio Fernandez-Oliva
- Department of Gynecology, Hospital Vall d'Hebrón, Autonomous University of Barcelona, Barcelona, Spain
| | - Jose Luis Poza-Barrasus
- Department of Gynecology, Hospital Vall d'Hebrón, Autonomous University of Barcelona, Barcelona, Spain
| | - Antonio Gil Moreno
- Department of Gynecology, Hospital Vall d'Hebrón, Autonomous University of Barcelona, Barcelona, Spain
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