Hysteroscopic morcellator system can be used for removal of a uterine septum

Mechanical hysteroscopic tissue removal or hysteroscopic morcellator: understanding the past to predict the future. A narrative review

Background

In recent years, the available evidence revealed that mechanical hysteroscopic tissue removal (mHTR) systems represent a safe and effective alternative to conventional operative resectoscopic hysteroscopy to treat a diverse spectrum of intrauterine pathology including endometrial polyps, uterine myomas, removal of placental remnants and to perform targeted endometrial biopsy under direct visualisation. This innovative technology simultaneously cuts and removes the tissue, allowing one to perform the procedure in a safer, faster and more effective way compared to conventional resectoscopic surgery.

Objective

To review currently available scientific evidence concerning the use of mechanical hysteroscopic morcellators and highlight relevant aspects of the technology.

Material and Methods

A narrative review was conducted analysing the available literature regarding hysteroscopic tissue removal systems.

Main outcome measures

Characteristics of available mHTR systems, procedures they are used for, their performance including safety aspects and their comparison.

Results

A total of 7 hysteroscopic morcellators were identified. The diameter of the external sheet ranged from 5.25 to 9.0 mm, optics ranged from 0.8 to 6.3 mm with 0o angle. The cutter device diameter ranged from 2.9 to 4.5 mm most of them with rotation and reciprocation.

Conclusion

We conclude that the adoption of mHTR has shown to reduce operating time, simultaneously cutting and suctioning tissue fragments avoiding the need for multiple removal and reinsertions of the device into the uterine cavity as well as reducing the volume of distension media required to complete the procedure compared to using the hysteroscopic resectoscope.

The Diagnosis and Surgical Approach of Uterine Septa

Uterine septa are a class of müllerian duct anomaly that, similar to other classes, are associated with poor reproductive outcomes; however, they are unique because these poor outcomes, particularly recurrent pregnancy loss, may be responsive to surgical correction. The current evidence regarding septoplasty is difficult to interpret because the definitions of a uterine septum, methods to diagnose it, and hysteroscopic techniques used for treatment are variable and generally of poor to moderate quality. Robust data on outcomes, particularly live births, after septoplasty are not available at this time. This review aims to examine the evidence on this contentious issue. A search of the literature was conducted using the MEDLINE, Embase, and Cochrane databases from 2002 to present with included articles reporting on clinical and/or imaging diagnosis of a uterine septum, operative techniques for uterine septoplasty, or clinical outcomes for women with uterine septa. The initial search revealed 4997 potentially relevant articles with 36 full-text articles included after the removal of nonrelevant titles, including 16 diagnostic studies, 17 surgical studies, and 3 studies on clinical outcomes. Where access to 3-dimensional transvaginal ultrasound or magnetic resonance imaging exists, these imaging modalities offer a highly sensitive and specific method of diagnosing a uterine septum without invasive diagnosis although this is operator dependent. Despite hysteroscopic septoplasty being described for over 40 years, there remains a lack of high-quality data to support hysteroscopic septoplasty and which women would most benefit from the procedure. There is no evidence for pre- or postoperative treatments nor has a single surgical approach been identified as superior than another although an important end point of live birth rates is largely unreported in these trials. Although several classification systems have been described, the diagnostic categorization of septal variants has limited a meaningful approach to this issue in both the clinical and research setting.

The techniques and outcomes of hysteroscopic metroplasty

PURPOSE OF REVIEW

To evaluate the reproductive outcomes and surgical techniques of the hysteroscopic metroplasty in women with septate uterus and recurrent abortions or primary unexplained infertility.

RECENT FINDINGS

Septate uterus is the most frequent congenital uterine anomaly caused by inadequate resorption of the Müllerian ducts. Hysteroscopic metroplasty has replaced the traditional laparotomy approach because of its positive and satisfactory outcomes in pregnancy and live-birth rates, and also many different postoperative benefits. The aim of metroplasty is to restore a normal anatomy of the uterine cavity as a prerequisite for a positive implantation and subsequent good obstetrical outcomes. This treatment clearly demonstrates its effectiveness both in recurrent abortion and in primary unexplained infertility.

SUMMARY

The hysteroscopic metroplasty with its simplicity, safety, and improved reproductive outcomes has liberalized the approach to treatment. Today, hysteroscopic metroplasty is a common practice to treat septate uterus with salutary effects both in infertile patients and in patients with recurrent pregnancy loss or premature labor, especially if in-vitro fertilization is being contemplated. Decisions on when to treat uterine septa are discussed in particular because of lack of prospective, randomized controlled trials.

Adenomyosis within a uterine septum in a patient with secondary infertility

BACKGROUND

Adenomyosis is a benign infiltration of endometrial stroma and glands into the myometrium. Until the advent and advancement of imaging techniques such as transvaginal ultrasound scan (TVUS) and magnetic resonance imaging (MRI), the diagnosis of adenomyosis could only be made with confidence using histology following hysterectomy.

CASE

The patient is a 37-year-old woman, with a long history of secondary infertility. A hysterosalpingogram (HSG) and a pelvic MRI showed two separate uterine cavities. The patient underwent laparoscopy and hysteroscopy revealing a bicornuate appearance of the uterus and a uterine septum. Resection of the septum showed adenomyosis on histologic examination.

COMMENT

Adenomyosis of uterine septum should be considered if MRI shows features of adenomyosis elsewhere in the uterus with thickened junctional zone. Further research is needed to investigate this association with the pathogenesis of adenomyosis.

Hysteroscopic metroplasty for the septate uterus: review and meta-analysis

The introduction of hysteroscopy to diagnose and treat intrauterine conditions, specifically to divide the uterine septum, or metroplasty, has replaced the traditional laparotomy approach, and objective results demonstrate its salutary effects in women treated. Hysteroscopic metroplasty averts the implications of major invasive abdominal surgery, with good and satisfactory results in pregnancy and live-birth rates, despite the lack of prospective, randomized, controlled studies. A careful review of the published results supports this type of treatment when the uterine septum adversely affects normal reproductive function.