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Van Geyte M, de Frenne A, Weyers B, Weyers S, van Vliet H, Hamerlynck T, van Wessel S. Manually driven versus motor driven hysteroscopic tissue removal system for polypectomy: Long-term results. Eur J Obstet Gynecol Reprod Biol 2024; 296:270-274. [PMID: 38492506 DOI: 10.1016/j.ejogrb.2024.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 03/06/2024] [Accepted: 03/10/2024] [Indexed: 03/18/2024]
Abstract
OBJECTIVE The aim of this follow-up study is to compare a manually driven hysteroscopic tissue removal system (ResectrTM 9 Fr) with a motor driven system (TruclearTM) in terms of long-term clinical outcomes such as abnormal uterine bleeding and polyp recurrence. STUDY DESIGN This is a follow-up of a multicenter randomized controlled trial comparing a manually and motor driven hysteroscopic tissue removal system for polypectomy. This prospective cohort study was performed at Ghent University Hospital (Ghent, Belgium) and Catharina Hospital Eindhoven (Eindhoven, the Netherlands). The trial was registered at Clinicaltrials.gov (Trial ID = NCT05337605, April 2022). Seventy-five women with abnormal uterine bleeding who participated in the randomized controlled trial and had pathological confirmation of the diagnosis of an endometrial polyp, were contacted. Fifty-five women (70.67 %) were willing to participate in this follow-up study. The primary outcome was the recurrence and/or persistence of abnormal uterine bleeding and the time to the recurrence of abnormal uterine bleeding. Secondary outcomes were polyp recurrence and time to polyp recurrence, symptom relief, satisfaction score regarding symptom relief and general satisfaction score regarding the surgical procedure. RESULTS In the manually driven group, the mean time to the recurrence or persistence of abnormal uterine bleeding was 26 months (95 % CI 20 - 32). In the motor driven group, the mean time to the recurrence or persistence of abnormal uterine bleeding was 29 months (95 % CI 23- 34). A log-rank test showed a non-significant difference between both groups (P =.77). There was no significant difference in polyp recurrence (P =.22) or symptom relief between the two groups (P =.67). Additionally, the groups did not differ in satisfaction scores regarding symptoms or polypectomy (P =.16 and P =.61, respectively). CONCLUSION This long-term follow-up study showed no statistically significant difference in the recurrence and persistence of abnormal uterine bleeding between a manually and motor driven hysteroscopic tissue removal system for polypectomy.
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Affiliation(s)
- Margot Van Geyte
- Ghent University, Faculty of Medicine and Health Sciences, Corneel Heymanslaan 10, 9000 Ghent, Belgium
| | - Alejandra de Frenne
- Ghent University, Faculty of Medicine and Health Sciences, Corneel Heymanslaan 10, 9000 Ghent, Belgium
| | - Basiel Weyers
- Women's Clinic, Ghent University Hospital, Corneel Heymanslaan 10, 9000 Ghent, Belgium
| | - Steven Weyers
- Women's Clinic, Ghent University Hospital, Corneel Heymanslaan 10, 9000 Ghent, Belgium
| | - Huib van Vliet
- Women's Clinic, Ghent University Hospital, Corneel Heymanslaan 10, 9000 Ghent, Belgium; Department of Obstetrics and Gynecology, Catharina Hospital, Michelangelolaan 2, 5623 EJ Eindhoven, the Netherlands
| | - Tjalina Hamerlynck
- Women's Clinic, Ghent University Hospital, Corneel Heymanslaan 10, 9000 Ghent, Belgium
| | - Steffi van Wessel
- Women's Clinic, Ghent University Hospital, Corneel Heymanslaan 10, 9000 Ghent, Belgium.
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Sivas MC, Ohanoglu Cetinel K, Arslan HS. Evaluation of whether there is residual polyp tissue after hysteroscopic morcellation at Cam and Sakura City Hospital: a retrospective cohort study. BMC Womens Health 2024; 24:133. [PMID: 38378558 PMCID: PMC10877796 DOI: 10.1186/s12905-024-02978-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 02/17/2024] [Indexed: 02/22/2024] Open
Abstract
BACKGROUND In polypectomy with mechanical hysteroscopic morcellators, the tissue removal procedure continues until no polyp tissue remains. The decision that the polypoid tissues were removed completely is made based on visual evaluation. In a situation where the polyp tissue was visually completely removed and no doubt that the polyp has been completely removed, short spindle-like tissue fragments on the polyp floor continue in most patients. There are no studies in the literature on whether visual evaluation provides adequate information at the cellular level in many patients in whom polypoid tissues have been determined to be completely removed. The aim of the present study was to analyze the pathological results of the curettage procedure, which was applied following the completion of polyp removal with operative hysteroscopy, and to evaluate whether there was residual polyp tissue in the short spindle-like tissue fragments that the mechanical hysteroscopic morcellator could not remove. The secondary aims of this study were to compare conventional loop resection hysteroscopy with hysteroscopic morcellation for the removal of endometrial polyps in terms of hemoglobin/hematocrit changes, polypectomy time and the amount of medium deficit. METHODS A total of 70 patients with a single pedunculate polypoid image of 1.5-2 cm, which was primarily visualized by office hysteroscopy, were included in the study. Patients who had undergone hysteroscopic polypectomy were divided into two groups according to the surgical device used: the morcellator group (n = 35, Group M) and the resectoscope group (n = 35, Group R). The histopathological results of hysteroscopic specimens and curettage materials of patients who had undergone curettage at the end of operative hysteroscopy were evaluated. In addition, the postoperative 24th hour Hb/HCT decrease amounts in percentage, the polypectomy time which was measured from the start of morcellation, and deficit differences were compared between groups. RESULTS In total, 7 patients in the morcellator group had residual polyp tissue detected in the full curettage material. The blood loss was lower in the morcellator group than in the resectoscope group (M, R; (-0.07 ± 0.08), (-0,11 ± 0.06), (p < 0.05), respectively). The deficit value of the morcellator group were higher (M, R; (500 ml), (300 ml), (p < 0.05), respectively). The polypectomy time was shorter in the morcellator group (M, R; mean (2.30 min), (4.6 min), (p < 0.05)). CONCLUSIONS Even if the lesion is completely visibly removed during hysteroscopic morcellation, extra caution should be taken regarding the possibility of residual tissue. There is a need for new studies investigating the presence of residual polyp tissue.
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Affiliation(s)
- Mustafa Can Sivas
- Department of Obstetrics and Gynecology, Republic of Türkiye Ministry of Health, Basaksehir Cam and Sakura City Hospital, Basaksehir Neighborhood, G-434 Street, No: 2L, Basaksehir, Istanbul, Türkiye.
| | - Karolin Ohanoglu Cetinel
- Department of Obstetrics and Gynecology, Republic of Türkiye Ministry of Health, Basaksehir Cam and Sakura City Hospital, Basaksehir Neighborhood, G-434 Street, No: 2L, Basaksehir, Istanbul, Türkiye
| | - Hilal Serap Arslan
- Department of Pathology, Republic of Türkiye Ministry of Health, Basaksehir Cam and Sakura City Hospital, Istanbul, Türkiye
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Mak KS, Huang YT, Su YY, Pan YB, Lin YS, Weng CH, Wu KY, Chao AS, Wang CJ. Clinical outcomes in women with endometrial polyps underwent conservative management. Taiwan J Obstet Gynecol 2023; 62:553-558. [PMID: 37407193 DOI: 10.1016/j.tjog.2022.08.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/03/2022] [Indexed: 07/07/2023] Open
Abstract
OBJECTIVE To evaluate the regression rate of endometrial polyps (EPs) in a cohort of asymmetric women after conservative follow-up. MATERIALS AND METHODS In this retrospective cohort study, a total of 1006 women with asymptomatic EPs were treated with expectant management or hormonal drugs between June 1999 and May 2018. Four hundred forty-eight women (44.5%) were administered with hormonal medications and 558 women were managed expectantly (55.5%). Office hysteroscopy was performed to confirm the diagnosis and regression of EPs. Hormonal administration included oral contraceptives, progestin and cyclic estrogen/progestin regimen according to physicians' preferences. Clinical characteristics, including the patient's age, body mass index, parity, and type of conservative management were collected. RESULTS The mean observation time was 14.1 ± 18.5 months (range, 1-162 months). The overall regression rate of EPs in this cohort was 33.5%, 24.6% occurred after medication and 8.9% after expectant management. Patient age (<50 years) (p < 0.001), follow-up period (p = 0.005) and hormonal drugs used (p < 0.001) were significantly associated with EP regression. Twenty-four (7.1%) of the 337 EP regression patients later developed recurrent disease. Follow-up period (p < 0.001) and hormonal drugs used (p = 0.032) were closely related to polyp recurrence after initial regression. Nevertheless, multivariate logistic regression analysis revealed that hormonal drugs used was significantly associated with the regression (p < 0.001) and recurrence (p = 0.016) of EPs. CONCLUSION Women aged 50 or less are more suitable for conservative treatment for EPs. Hormonal drugs used could increase the incidence of EP regression.
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Affiliation(s)
- Kit-Sum Mak
- Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital at Linkou, Kweishan, Taoyuan, Taiwan
| | - Yi-Ting Huang
- Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital at Linkou, Kweishan, Taoyuan, Taiwan
| | - Yu-Ying Su
- Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital at Linkou, Kweishan, Taoyuan, Taiwan
| | - Yu-Bin Pan
- Biostatistics Unit, Clinical Trial Center, Chang Gung Memorial Hospital, Kweishan, Taoyuan, Taiwan; Gynecologic Cancer Research Center, Chang Gung Memorial Hospital, Kweishan, Taoyuan, Taiwan
| | - Yu-Shan Lin
- Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital at Linkou, Kweishan, Taoyuan, Taiwan
| | - Cindy Hsuan Weng
- Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital at Linkou, Kweishan, Taoyuan, Taiwan
| | - Kai-Yun Wu
- Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital at Linkou, Kweishan, Taoyuan, Taiwan; Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - An-Shine Chao
- Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital at Linkou, Kweishan, Taoyuan, Taiwan; Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Chin-Jung Wang
- Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital at Linkou, Kweishan, Taoyuan, Taiwan; Chang Gung University College of Medicine, Taoyuan, Taiwan.
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Multivariate Analysis of Recurrence after Hysteroscopic Diagnosis and Treatment of Endometrial Polyps following IVF-ET Failure. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2022; 2022:4140022. [PMID: 36159570 PMCID: PMC9492378 DOI: 10.1155/2022/4140022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 08/02/2022] [Accepted: 08/09/2022] [Indexed: 11/20/2022]
Abstract
Objective To explore the risk factors affecting the recurrence of endometrial polyps (EPs) after hysteroscopic diagnosis and treatment of EPs following in vitro fertilization-embryo transfer (IVF-ET) failure by multivariate analysis. Methods The clinical data of 369 patients with EPs hysteroscopically treated in our department due to IVF-ET failure from January 2017 to January 2020 were retrospectively analyzed, including the number and size of polyps, postoperative treatment, endometriosis (EM), hydrosalpinx (HSP), and polycystic ovarian syndrome (PCOS), and the effects of these factors on EP recurrence were observed. Results Of the patients enrolled, 184 cases (49.9%) were treated by curettage, and 185 cases (50.1%) by electrotomy. A total of 72 cases (19.5%) of postoperative recurrence were determined, including 34 cases (9.2%) without postoperative medication, 31 cases (8.4%) with one month of postoperative Didroxyprogesterone (DG) administration, and 7 cases (1.9%) with three months of postoperative DG administration. Surgical methods, 3 months of postoperative medication, PCOS, and polyp number and size significantly influence the recurrence of EPs, which were all the influencing factors of polyp recurrence. After controlling for other factors, the risk of EP recurrence after electrotomy was found to be lower than that after curettage, with an odds ratio (OR) (95% confidence interval (CI)) of 0.354 (0.163–0.767); the risk of EP recurrence after 3 months of postoperative medication was lower than that without postoperative medication, with an OR (95% CI) of 0.024 (0.005–0.104); the risk of EP recurrence in patients with PCOS was higher than that without PCOS, and the OR (95% CI) was 2.505 (1.113–5.639); patients with multiple polyps (≥2) were at an increased risk of recurrence than those with a single polyp, with an OR (95% CI) of 66.552 (14.711–301.084); patients with polyp diameter ≥ 2 cm had a higher risk of recurrence than those with polyp diameter < 2 cm, and the OR (95% CI) was 1084.76 (148.743–7910.999). Conclusions PCOS patients are at an elevated risk of EP recurrence than non-PCOS patients. In patients with multiple polyps, those with a diameter ≥ 2 cm have an increased risk of polyp recurrence compared with those with polyp diameter < 2 cm; electrotomy is associated with a lower recurrence risk of EPs than curettage. The risk of EP recurrence in patients treated with postoperative progesterone for 3 months is lower than that of patients without postoperative medication.
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Ren H, Duan H, Wang S, Chang Y. Hysteroscopy Combined with Laser Vaporesection for Endometrial Polyps. J INVEST SURG 2022; 35:1772-1778. [PMID: 36062372 DOI: 10.1080/08941939.2022.2116134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
OBJECTIVE To compare the safety and efficiency of hysteroscopic laser vaporesection and hysteroscopic resection in the treatment of endometrial polyps.Methods: The literatures in databases were searched comprehensively, the literatures that met the inclusion criteria were screened out and the data were extracted. The data were combined with Stata12.0 statistical software. RESULTS 4 literatures were included with a total sample size of 334. Meta-analysis showed that intraoperative blood loss in laser group was less than that in electrosurgical group [-3.043, 95% CI (-4.09, -2.00), P < 0.001]. Length of stay in the laser group was shorter than that in the electrotomy group [-1.013, 95% CI (-1.37, -0.65), P < 0.001]. The recurrence rate [0.275, 95%CI (0.135,0.563), P < 0.001] and complication rate [0.148, 95%CI (0.07,0.32), P < 0.001] in the laser group were lower than those in the electrotomy group. There was no significant difference in operative time between hysteroscopy combined with 2 μm laser and hysteroscopic electrotomy for endometrial polyps [-0.38, 95% CI (-1.34, 0.58), P = 0.441 > 0.05]. CONCLUSION Hysteroscopic 2 μm laser vaporesection for the treatment of endometrial polyps has better safety and clinical efficacy. Compared with hysteroscopic electroresection, hysteroscopic laser vaporesection in the treatment of endometrial polyps may be safer and more effective. Given the potential limitations, we need larger, well-designed randomized controlled trials to verify our findings.
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Affiliation(s)
- Hongyan Ren
- Department of Minimally Invasive Gynecologic Center, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, China
| | - Hua Duan
- Department of Minimally Invasive Gynecologic Center, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, China
| | - Sha Wang
- Department of Minimally Invasive Gynecologic Center, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, China
| | - Yanan Chang
- Department of Minimally Invasive Gynecologic Center, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, China
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van Gemert J, Herman M, Beelen P, Geomini P, Bongers M. Endometrial polypectomy using tissue removal device or electrosurgical snare: a randomised controlled trial. Facts Views Vis Obgyn 2022; 14:235-243. [DOI: 10.52054/fvvo.14.3.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background: Hysteroscopic transcervical resection of endometrial polyps is a widely used method and is increasingly performed in office or outpatient care. To ensure patient comfort is key, smaller instruments are preferred while also achieving a complete resection of the pathology.
Objectives: To evaluate the effectiveness of the electrosurgical polyp snare (DPS) in comparison with a tissue removal device (TRD).
Materials and Methods: This was a randomised controlled non-inferiority trial which included 66 women with symptomatic endometrial polyps who had been referred to the gynaecological outpatient clinic at the Máxima Medical Centre, Veldhoven, the Netherlands. The patients were randomly allocated by using sealed envelopes to treatment with either the DPS (Duckbill®, Cook) or the TRD (Truclear™, Medtronic). Clinicians and patients were not blinded to the treatment performed. An independent observer blindly assessed the results.
Main outcome measures: The primary outcome was the complete removal of the endometrial polyp. Secondary outcomes were woman acceptability and pain during the procedure, operating time, peri-operative and immediate postoperative complications.
Results: 57% of the polyps in the DPS group and 95% in the TRD group were completely removed (risk difference -0.39; 95% CI: -0.60 to -0.15). Average operating time was longer with DPS compared to the TRD (11.7 min. vs. 6.8 min., p = 0.018). The number of insertions of the hysteroscope was higher with the DPS compared to the TRD (3.9 vs. 1.7, p <0.001). One serious adverse event, a uterine perforation, occurred in the DPS group.
Conclusion: The TRD was superior to the DPS in completeness of polyp removal.
What is new? TRD has a higher rate of complete polyp resection, overall safety and higher patient satisfaction, this instrument should be considered as the preferred option in outpatient and office gynaecology.
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Franchini M, Ceci O, Casadio P, Carugno J, Giarrè G, Gubbini G, Catena U, Chiara de Angelis M, Di Spiezio Sardo A. Mechanical hysteroscopic tissue removal or hysteroscopic morcellator: understanding the past to predict the future. A narrative review. Facts Views Vis Obgyn 2021; 13:193-201. [PMID: 34555873 PMCID: PMC8823270 DOI: 10.52054/fvvo.13.3.026] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
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.
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Raz N, Feinmesser L, Moore O, Haimovich S. Endometrial polyps: diagnosis and treatment options - a review of literature. MINIM INVASIV THER 2021; 30:278-287. [PMID: 34355659 DOI: 10.1080/13645706.2021.1948867] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION AND AIM Endometrial polyps (EPs) are a common gynecologic condition, associated with abnormal uterine bleeding (AUB), infertility, and premalignant and malignant conditions. Technologies for diagnosis and treatment of EPs are constantly evolving. We aim to provide an updated review on diagnosis and management options for patients with EPs. MATERIAL AND METHODS We conducted an electronic search in databases including MEDLINE, PubMed, Cochrane Central Register and others. We included 68 publications regarding EPs, their clinical burden, diagnostic modalities, treatment options and new technologies. RESULTS Transvaginal ultrasound (TVS) is the common modality for EP detection and color doppler increases its diagnostic accuracy. Dilation and curettage (D&C) should be avoided for diagnosis and treatment of EPs. Hysteroscopy shows high diagnostic value in EPs and allows for both histological diagnosis and effective treatment. Office hysteroscopy and see and treat hysteroscopy without anesthesia is feasible and safe for EP diagnosis and treatment, gaining more trained surgeons globally. Effective and safe technological tools for EP resection include Laser, resectoscopes, morcellators, MyoSure, Truclear and scissors\graspers. CONCLUSIONS EPs are safely and effectively diagnosed and treated with the hysteroscopic tools reviewed in this article. More research is needed to define the best treatment modality.
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Affiliation(s)
- Nili Raz
- Gynecology Ambulatory Surgery Unit, Department of Obstetrics and Gynecology, Hillel Yaffe Medical Center, Hadera, Israel.,Technion Israel Institute of Technology, Haifa, Israel
| | - Larissa Feinmesser
- Gynecology Ambulatory Surgery Unit, Department of Obstetrics and Gynecology, Hillel Yaffe Medical Center, Hadera, Israel.,Technion Israel Institute of Technology, Haifa, Israel
| | - Omer Moore
- Gynecology Ambulatory Surgery Unit, Department of Obstetrics and Gynecology, Hillel Yaffe Medical Center, Hadera, Israel.,Technion Israel Institute of Technology, Haifa, Israel
| | - Sergio Haimovich
- Gynecology Ambulatory Surgery Unit, Department of Obstetrics and Gynecology, Hillel Yaffe Medical Center, Hadera, Israel.,Technion Israel Institute of Technology, Haifa, Israel
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Vitale SG, Haimovich S, Laganà AS, Alonso L, Di Spiezio Sardo A, Carugno J. Endometrial polyps. An evidence-based diagnosis and management guide. Eur J Obstet Gynecol Reprod Biol 2021; 260:70-77. [PMID: 33756339 DOI: 10.1016/j.ejogrb.2021.03.017] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Revised: 03/02/2021] [Accepted: 03/08/2021] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To provide an updated practice guideline for the management of patients with endometrial polyps. MATERIALS AND METHODS A committee of six expert researchers draw the recommendations according to AGREE II Reporting Guideline. An electronic search was performed querying the following databases MEDLINE (accessed through PubMed), Scopus, PROSPERO, EMBASE, CINAHL, Cochrane Library (including the Cochrane Database of Systematic Reviews), Scielo.br, Google Scholar, from inception to May 2020. A combination of text-words and Medical Subject Headings (MeSH) regarding endometrial polyps, diagnosis, management and treatment was used. Trials were assessed for methodologic rigor and graded using the United States Preventive Services Task Force classification system. RECOMMENDATIONS Transvaginal ultrasonography (TVUS) should be the imaging modality of choice for the detection of endometrial polyps in woman of fertile age (level B). Its accuracy increases when color-doppler, 3D investigation and contrast are used (level B). Dilation and Curettage (D&C) should be avoided for the diagnosis and management of polyps (level A). In office hysteroscopy showed the highest diagnostic accuracy in infertile patients with suspected endometrial polyps (level B). Polyps might alter endometrial receptivity, and embryo implantation reducing pregnancy rates (level C). Hysteroscopic polypectomy is feasible and safe with negligeble risk of intrauterine adhesion formation (level B). Polypectomy does not compromise reproductive outcomes from subsequent IVF procedures but the removal of polyps as a routine practice in sub-fertile women is not currently supported by the evidence (level B). Cost-effectiveness analysis suggest performing office polypectomy in women desiring to conceive (level B). Saline infused sonohysterography is highly accurate in detecting polyps in asymptomatic postmenopausal women (level B). Postmenopausal women with vaginal bleeding and suspected endometrial polyp should be offered diagnostic hysteroscopy with hysteroscopic polypectomy if endometrial polyps are present (level B). In-office hysteroscopy has the highest diagnostic accuracy with high cost-benefits ratio for premalignant and malignant pathologies of the uterine cavity (level B). Due to risk of malignancy, histopathological analysis of the polyp is mandatory (level B). Blind D&C should be avoided due to inaccuracy for the diagnosis of focal endometrial pathology (level A). Expectant management is not recommended in symptomatic patients especially in postmenopausal women (level B). In case of atypical hyperplasia or carcinoma on a polyp, hysterectomy is recommended in all post-menopausal patients and in premenopausal patients without desire of future fertility (level B). Asymptomatic endometrial polyps in postmenopausal women should be removed in case of large diameter (> 2 cm) or in patients with risk factors for endometrial carcinoma (level B). Excision of polyps smaller than 2 cm in asymptomatic postmenopausal patients has no impact on cost-effectiveness or survival (level B). Removal of asymptomatic polyps in premenopausal women should be considered in patients with risk factors for endometrial cancer (level B).
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Affiliation(s)
- Salvatore Giovanni Vitale
- Department of General Surgery and Medical Surgical Specialties, University of Catania, Catania, Italy
| | - Sergio Haimovich
- Hillel Yaffe Medical Center, Technion-Israel Technology Institute, Hadera, Israel
| | - Antonio Simone Laganà
- Department of Obstetrics and Gynecology, "Filippo Del Ponte" Hospital, University of Insubria, Varese, Italy
| | - Luis Alonso
- Centro Gutenberg, Endoscopy Unit, Malaga, Spain
| | | | - Jose Carugno
- Department of Obstetrics, Gynecology and Reproductive Sciences, Minimally Invasive Gynecology Division, University of Miami, Miller School of Medicine, 1321 NW 14(th) Street Suite 201, Miami, FL 33136, USA.
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Cea García J, Jiménez Caraballo A, Ríos Vallejo MDM, Zapardiel I. Retrospective Cohort Study on the Symptomatic Recurrence Pattern after Hysteroscopic Polypectomy. Gynecol Minim Invasive Ther 2020; 9:209-214. [PMID: 33312864 PMCID: PMC7713653 DOI: 10.4103/gmit.gmit_102_19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 05/06/2020] [Accepted: 07/01/2020] [Indexed: 11/04/2022] Open
Abstract
Objectives The recurrence rate of benign endometrial polyps after a hysteroscopic polypectomy is low, between 0% and 15%. There are limited follow-up duration data on recurrence factors for benign polyps after hysteroscopic polypectomy, including recurrences with Versapoint® versus resectoscope. This study aims to estimate the rate of symptomatic recurrence following hysteroscopic polypectomy and to analyze the possible risk factors involved with Versapoint® versus resectoscope. Materials and Methods We designed a retrospective cohort study in a tertiary university hospital in Seville (Spain) which looked at the results of polypectomy with a 9-mm resectoscope on 42 women between 2008 and 2015 compared to 151 women using Versapoint® during 2014. Results The rate of first recurrence was 24.35%. There was a strong positive correlation between the recurrence and the follow-up duration (odds ratio [OR] = 2.58; 95% confidence interval [CI] = 1.68-5.04; P = 0.000), the polyps causing abnormal uterine bleeding (OR = 2.5; 95% CI: 1.1-3; P = 0.04), and a polyp size >15 mm (OR = 1.63; 95% CI = 1.3-3.1; P = 0.02). There were no statistical differences in polyps' recurrence among the types of hysteroscopic polypectomy (P > 0.05). Conclusion The main risk factors for recurrence were polyps causing abnormal uterine bleeding, size, and follow-up duration.
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Affiliation(s)
- Jorge Cea García
- Department of Gynecology, Clinical Management Unit of Obstetrics and Gynecology, Virgen Macarena University Hospital, Seville, Spain
| | - Antonio Jiménez Caraballo
- Department of Gynecology, Clinical Management Unit of Obstetrics and Gynecology, Virgen Macarena University Hospital, Seville, Spain
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Wang Z, Wen Y, Xiong Y, Li Y, Huang J, Xu Y. Retrospective analysis of the endometrial preparation protocols for frozen-thawed embryo transfers in women with endometrial polyps. HUM FERTIL 2020; 25:534-539. [PMID: 33251884 DOI: 10.1080/14647273.2020.1855368] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
We aimed to explore the clinical effects of the endometrial preparation protocol for frozen-thawed embryo transfer (FET) in women with endometrial polyps. This retrospective study was performed at the Reproductive Medicine Centre of the First Affiliated Hospital of Sun Yat-sen University between January 2015 and May 2018 involving women diagnosed with endometrial polyps by hysteroscopy. The freeze-all strategy was performed in controlled ovarian stimulation cycles followed by FET cycles. Endometrial preparation protocols included: (i) gonadotropin-releasing hormone agonist-hormone replacement therapy (GnRHa-HRT); (ii) hormone replacement therapy (HRT); (iii) natural cycle (NC); and (iv) ovulation induction (OI). Recurrence rate of polyps and clinical results were compared among the four groups. If polyp recurrence was found in ultrasound scans during the FET cycles, the embryo transfers were cancelled. The recurrence rate of polyps was lower in the GnRHa-HRT protocol [2.13% (2/94)] than in the other three protocols [6.15% (26/423), 6.7% (28/418), and 4% (1/25) in the HRT, NC, and OI, respectively; p = 0.038], showing statistically significant difference. Pregnancy, early pregnancy loss, and live birth rates among the four protocols were similar (p = 0.922, p = 0.171, and p = 0.072, respectively). The GnRHa-HRT protocol used for FET in women with endometrial polyps could reduce the recurrence rate of the polyps. In addition, we found that it did not decrease pregnancy or live birth rates.
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Affiliation(s)
- Zengyan Wang
- Reproductive Medicine Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,The Key Laboratory for Reproductive Medicine of Guangdong Province, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yangxing Wen
- Reproductive Medicine Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,The Key Laboratory for Reproductive Medicine of Guangdong Province, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yujing Xiong
- Reproductive Medicine Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,The Key Laboratory for Reproductive Medicine of Guangdong Province, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yubin Li
- Reproductive Medicine Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,The Key Laboratory for Reproductive Medicine of Guangdong Province, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Jia Huang
- Reproductive Medicine Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,The Key Laboratory for Reproductive Medicine of Guangdong Province, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yanwen Xu
- Reproductive Medicine Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,The Key Laboratory for Reproductive Medicine of Guangdong Province, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
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12
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Ceci O, Franchini M, Cardinale S, Cannone R, Giarrè G, Fascilla FD, Bettocchi S, Cicinelli E. Comparison of endometrial polyp recurrence in fertile women after office hysteroscopic endometrial polypectomy using two widely spread techniques. J Obstet Gynaecol Res 2020; 46:2084-2091. [PMID: 32715585 DOI: 10.1111/jog.14400] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Revised: 05/28/2020] [Accepted: 06/28/2020] [Indexed: 11/29/2022]
Abstract
AIM To compare the recurrence of benign endometrial polyps after office hysteroscopic polypectomy performed with a bipolar electrode (BE) or a small diameter hysteroscopic tissue removal system (HTRs). METHODS From July 2018 to December 2019 we evaluated the charts of 114 asymptomatic fertile women who underwent office hysteroscopic polypectomy, 1 year before, for a single large benign endometrial polyp (size between 10 and 20 mm) using a 4 mm continuous flow hysteroscope with a BE or a 5 mm HTRs. Patients, divided into two groups according to surgical procedure, each performed exclusively by one expert gynecologist, were scheduled for a 12-month postoperative transvaginal sonography to evaluate the recurrence of endometrial polyps. RESULTS Forty-eight women of the BE group and 42 of the HTRs group were considered for the 1-year transvaginal sonography follow-up. Five polyps were identified in the BE group and three in the HTRs group (5/48 vs 3/42, P = n.s.). All polyps were removed hysteroscopically (in three out of five and in two out of three cases, respectively, in the same places of the previous polypectomy) and evaluated as 'benign' by the pathologist. CONCLUSION Office hysteroscopic endometrial polypectomy with small HTRs compared to BE revealed at a 1-year follow-up no difference in terms of complete removal and recurrence of polyps. HTRs polypectomy resulted in less pain and significantly quicker time of procedure compared to BE. This data should be kept in mind for patient comfort any time hysteroscopic polypectomy is planned in an office setting.
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Affiliation(s)
- Oronzo Ceci
- Second Unit of Obstetrics and Gynecology, Department of Biomedical Sciences and Human Oncology, University of Bari 'Aldo Moro', Bari, Italy
| | - Mario Franchini
- Department of Gynecology, Tuscany Regional Health Agency, Florence, Italy
| | - Silvia Cardinale
- Second Unit of Obstetrics and Gynecology, Department of Biomedical Sciences and Human Oncology, University of Bari 'Aldo Moro', Bari, Italy
| | - Rossella Cannone
- Second Unit of Obstetrics and Gynecology, Department of Biomedical Sciences and Human Oncology, University of Bari 'Aldo Moro', Bari, Italy
| | - Giovanna Giarrè
- Department of Gynecology Palagi, Freestanding Unit, Health Authority, Florence, Italy
| | - Fabiana D Fascilla
- Second Unit of Obstetrics and Gynecology, Department of Biomedical Sciences and Human Oncology, University of Bari 'Aldo Moro', Bari, Italy
| | - Stefano Bettocchi
- Second Unit of Obstetrics and Gynecology, Department of Biomedical Sciences and Human Oncology, University of Bari 'Aldo Moro', Bari, Italy
| | - Ettore Cicinelli
- Second Unit of Obstetrics and Gynecology, Department of Biomedical Sciences and Human Oncology, University of Bari 'Aldo Moro', Bari, Italy
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13
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Gordon HG, Mooney S, Readman E. Introduction of the MyoSureLITE in an established outpatient hysteroscopy clinic. Aust N Z J Obstet Gynaecol 2020; 60:784-789. [PMID: 32696466 DOI: 10.1111/ajo.13207] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Accepted: 06/06/2020] [Indexed: 12/01/2022]
Abstract
BACKGROUND Endometrial polyps are a common cause of abnormal uterine bleeding. The MyoSureLITE intrauterine morcellation device is effective at resecting endometrial polyps; however, its use in the outpatient setting requires appraisal. AIM To assess the feasibility, utility, acceptability and costs associated with introduction of the MyoSureLITE into an established outpatient hysteroscopy (OPH) clinic. MATERIAL AND METHODS A prospective clinical database from a tertiary Melbourne hospital was analysed from 1 July 2015 to 30 June 2018. Three 12-month time periods were compared: pre-introduction and trial phase, early use, and established use of the MyoSureLITE. Wait times, patient acceptability, second OPH bookings and procedure costs were measured. RESULTS Eight hundred and seventy-one women underwent OPH during the study period, with 238 (27.3%) women presenting with endometrial polyp(s). At each timepoint, 78.5, 25 and 6.3% of women required rebooking for a subsequent hysteroscopy for pathology otherwise suitable for MyoSureLITE resection. Introduction of the MyoSureLITE avoided a subsequent procedure for 4, 60 and 69 women respectively for each year of use, with potentially reduced treatment costs for the institution. Median (IQR) wait time for definitive treatment of intrauterine pathology was 56 (24-84) days at time-period 1, decreasing to 0 (0-0) days during time-period 3, (P < 0.001); 87.6% would undergo OPH again. CONCLUSIONS Routine use of the MyoSureLITE is effective, feasible, and acceptable to women. Provision of this device in outpatient service allows a 'see-and-treat' model, saving theatre time and treatment costs, facilitating a more direct throughput from presentation to treatment.
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Affiliation(s)
- Hannah G Gordon
- Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Victoria, Australia.,Mercy Hospital for Women, Melbourne, Victoria, Australia
| | | | - Emma Readman
- Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Victoria, Australia.,Mercy Hospital for Women, Melbourne, Victoria, Australia
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14
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Stoll F, Lecointre L, Meyer N, Faller E, Host A, Hummel M, Boisrame T, Akladios C, Garbin O. Randomized Study Comparing a Reusable Morcellator with a Resectoscope in the Hysteroscopic Treatment of Uterine Polyps: The RESMO Study. J Minim Invasive Gynecol 2020; 28:801-810. [PMID: 32681995 DOI: 10.1016/j.jmig.2020.07.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 07/09/2020] [Accepted: 07/11/2020] [Indexed: 11/17/2022]
Abstract
STUDY OBJECTIVE To compare a reusable hysteroscopic morcellator and standard resectoscopes in the hysteroscopic management of uterine polyps. DESIGN Single-center randomized prospective single-blind trial (resectoscope-morcellator study). SETTING Centre Médico-chirurgical Obstétrique teaching hospital, Strasbourg University Hospitals, France. PATIENTS All patients presenting with a single endometrial polyp of size 1 cm or larger. INTERVENTIONS After consent, the patients were randomized into 2 groups: hysteroscopic morcellation (HM) group or standard resection (SR) group. Office-based review hysteroscopy was performed 6 weeks to 8 weeks after surgery. Primary end point: time of morcellation or resection. SECONDARY OUTCOMES total operating time (minutes), volume of fluid used (mL), fluid deficit (mL), number of morcellator or resectoscope insertions, operator comfort (visual analog scale: 0 to 10) and quality of vision (0 to 5), perioperative complications, completeness of resection, need to convert to another technique, pain assessment (visual analog scale), and length of hospitalization. At review hysteroscopy, we noted whether the resection or morcellation had been effective and if synechiae were present or absent. Statistical analyses followed Bayesian methods. MEASUREMENTS AND MAIN RESULTS Ninety patients were randomized: 45 in the HM group and 45 in the SR group. The average size of polyps at hysteroscopy was 13.3 mm. Morcellation time was lower than resection time (6.1 minutes vs 9 minutes; p [HM < SR] = .996). This also applied to total operating time (12.7 minutes vs 15.6 minutes; p [HM < SR] = .985), number of device insertions (1.50 vs 6; p [HM < SR] > .999), volume of fluid used (766.9 mL vs 1118.9 mL; p [HM < SR] = .994), and fluid deficit (60.2 mL vs 169.8 mL; p [HM < SR] = .989). Operator comfort was better in the HM group (8.4 vs 7.4; p [HM > SR] = .999) as was visualization (4 vs 3.7; p [HM > SR] = .911, highly probable). Operative complications were higher in the SR group (5 vs 0; p [HM < SR] = .989]. One patient in the SR group died after surgery owing to an anesthetic complication (anaphylactic shock complicated by pulmonary embolism). No differences were noted between the groups for pain assessment, length of hospitalization, and outcome on review hysteroscopy. CONCLUSION The reusable morcellator is quicker, uses less fluid with less deficit and fewer introductory maneuvers, and offers better comfort and visualization than the resectoscope while being as effective for the hysteroscopic treatment of uterine polyps.
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Affiliation(s)
- François Stoll
- Department of Obstetrics and Gynecology (Drs. Stoll, Lecointre, Faller, Host, Hummel, Boisrame, Akladios, and Garbin); Medical Information Department (Dr. Meyer), Hôpitaux Universitaires de Strasbourg, Strasbourg, France.
| | - Lise Lecointre
- Department of Obstetrics and Gynecology (Drs. Stoll, Lecointre, Faller, Host, Hummel, Boisrame, Akladios, and Garbin); Medical Information Department (Dr. Meyer), Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Nicolas Meyer
- Department of Obstetrics and Gynecology (Drs. Stoll, Lecointre, Faller, Host, Hummel, Boisrame, Akladios, and Garbin); Medical Information Department (Dr. Meyer), Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Emilie Faller
- Department of Obstetrics and Gynecology (Drs. Stoll, Lecointre, Faller, Host, Hummel, Boisrame, Akladios, and Garbin); Medical Information Department (Dr. Meyer), Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Aline Host
- Department of Obstetrics and Gynecology (Drs. Stoll, Lecointre, Faller, Host, Hummel, Boisrame, Akladios, and Garbin); Medical Information Department (Dr. Meyer), Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Michel Hummel
- Department of Obstetrics and Gynecology (Drs. Stoll, Lecointre, Faller, Host, Hummel, Boisrame, Akladios, and Garbin); Medical Information Department (Dr. Meyer), Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Thomas Boisrame
- Department of Obstetrics and Gynecology (Drs. Stoll, Lecointre, Faller, Host, Hummel, Boisrame, Akladios, and Garbin); Medical Information Department (Dr. Meyer), Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Cherif Akladios
- Department of Obstetrics and Gynecology (Drs. Stoll, Lecointre, Faller, Host, Hummel, Boisrame, Akladios, and Garbin); Medical Information Department (Dr. Meyer), Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Olivier Garbin
- Department of Obstetrics and Gynecology (Drs. Stoll, Lecointre, Faller, Host, Hummel, Boisrame, Akladios, and Garbin); Medical Information Department (Dr. Meyer), Hôpitaux Universitaires de Strasbourg, Strasbourg, France
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15
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Wang Y, Yang M, Huang X, Li X, Lin E, Feng Y. Prevention of Benign Endometrial Polyp Recurrence Using a Levonorgestrel-releasing Intrauterine System in Premenopausal Patients: A Retrospective Cohort Study. J Minim Invasive Gynecol 2020; 27:1281-1286. [PMID: 32446971 DOI: 10.1016/j.jmig.2019.11.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 11/14/2019] [Accepted: 11/21/2019] [Indexed: 10/24/2022]
Abstract
STUDY OBJECTIVE To evaluate the levonorgestrel-releasing intrauterine system (LNG-IUS) to prevent the recurrence of endometrial polyps (EPs) after hysteroscopic polypectomies in premenopausal female patients. DESIGN A retrospective cohort study. SETTING A tertiary-care women's hospital. PATIENTS A total of 451 premenopausal female patients underwent hysteroscopic polypectomies between January 1, 2016, and December 31, 2017. INTERVENTIONS Treatment with LNG-IUS after hysteroscopic polypectomies. MEASUREMENTS AND MAIN RESULTS After the hysteroscopic polypectomies and placement of LNG-IUS, transvaginal ultrasounds were performed every 6 months to measure the recurrence of EPs. Overall, 5 (3.47%) of 144 patients in the LNG-IUS cohort and 49 (15.96%) of 307 patients in the control cohort experienced EP recurrence within the follow-up period of up to 3 years. The recurrence exhibited a strongly negative correlation when LNG-IUS was inserted (relative risk, 0.218; 95% confidence interval, 0.089-0.535; p <.05), but this did not significantly correlate with age, polyp size, number of polyps, previous history of polypectomy, and abnormal uterine bleeding. For the LNG-IUS and control cohorts, the recurrence in the first postoperative year was 1.39% and 6.19%, respectively, and 5.41% and 19.23% in the second postoperative year, respectively. CONCLUSION LNG-IUS reduces the recurrence of postoperative EPs in premenopausal patients.
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Affiliation(s)
- Yue Wang
- Department of Ambulatory Surgery, Women's Hospital, Zhejiang University School of Medicine (Dr. Wang)
| | - Min Yang
- Department of Reproductive Endocrinology, Zhejiang University School of Medicine (Dr. Yang)
| | - Xiufeng Huang
- Department of Gynecology, Zhejiang University School of Medicine (Dr. Huang)
| | - Xingmiao Li
- Department of Obstetrics, Zhejiang University School of Medicine (Dr. Li)
| | - Enze Lin
- Institute of Translational Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine (Dr. Feng and Mr. Lin); Key Laboratory of Microbial Technology and Bioinformatics of Zhejiang Province (Dr. Feng and Mr. Lin), Hangzhou, Zhejiang, China
| | - Ye Feng
- Institute of Translational Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine (Dr. Feng and Mr. Lin); Key Laboratory of Microbial Technology and Bioinformatics of Zhejiang Province (Dr. Feng and Mr. Lin), Hangzhou, Zhejiang, China..
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16
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Lindheim SR, Lincenberg K, Wood MA, Kemner E, Burns MK, Hood DL, Maxwell R, Lee M. The Impact of Hysteroscopic Tissue Removal Systems on Histopathologic Analysis for Benign and Cancerous Endometrial Pathology: An Ex Vivo Study. J Obstet Gynaecol India 2019; 69:182-187. [PMID: 31686754 DOI: 10.1007/s13224-018-1177-6] [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: 06/18/2018] [Accepted: 08/22/2018] [Indexed: 10/28/2022] Open
Abstract
Objective To assess the impact of hysteroscopic tissue removal systems (TRS) on histopathology tissue diagnosis. Measurements and Methods This is a paired-comparison ex vivo study in which 23 endometrial sections from hysterectomized uteri (13 benign and 10 hyperplasia/cancer) were analyzed in a simulation laboratory center at a university teaching hospital. After routine tissue processing, a section of endometrium was provided for ex vivo TRS with suture mounting to a uterine model (Polly, Remedy). Morcellated specimens using the Hologic® MyoSure hysteroscopic device were processed for histopathologic analysis by two blinded pathologists (Pa and Pb) and compared to the original specimens' tissue diagnoses. Results Sufficient tissue for evaluation was found in 100% (23/23) of TRS specimens by Pa and 91.3% by Pb. TRS specimen diagnoses were concordant with routine histologic diagnosis 86.9% (20/23, k = 0.76) for Pa and 80.9% (17/21, k = 0.68) for Pb. Sensitivity and specificity were 70%/100% for Pa and 80%/91% for Pb, respectively. The false-positive (overdiagnosed) and false-negative rates (underdiagnosed) were 0%/30% and 9%/20% for Pa and Pb. Both Pa and Pb underdiagnosed most specimens confirmed by routine tissue diagnosis. TRS specimen diagnoses between Pa and Pb were concordant in 76.2% (16/21, k = 0.60). Conclusion TRS may adversely impact the ability to provide a histologic tissue analysis. Up to 30% of samples were overdiagnosed and 20% underdiagnosed. If confirmed, pathologists may need to reassess workflows to better offset potential underdiagnosis of malignant specimens as findings may be obscured through TRS. Additionally, surgeons may need to reconsider specimen handling, so highest yield specimens are provided to pathology.
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Affiliation(s)
- Steven R Lindheim
- 1Division of Reproductive Endocrine Infertility, Department of Obstetrics and Gynecology, Boonshoft School of Medicine, Wright State University, 128 Apple St; Suite 3800 Weber CHE, Dayton, OH 45409 USA
| | - Kimberly Lincenberg
- 1Division of Reproductive Endocrine Infertility, Department of Obstetrics and Gynecology, Boonshoft School of Medicine, Wright State University, 128 Apple St; Suite 3800 Weber CHE, Dayton, OH 45409 USA
| | - Michelle A Wood
- Camran Nezhat Institute, 900 Welch Road, Palo Alto, CA 94304 USA
| | - Emily Kemner
- 1Division of Reproductive Endocrine Infertility, Department of Obstetrics and Gynecology, Boonshoft School of Medicine, Wright State University, 128 Apple St; Suite 3800 Weber CHE, Dayton, OH 45409 USA.,2Department of Obstetrics and Gynecology, Wright-Patterson Medical Center, Wright-Patterson Air Force Base, 4881 Sugar Maple Dr, Dayton, OH 45433 USA
| | - Megan K Burns
- Camran Nezhat Institute, 900 Welch Road, Palo Alto, CA 94304 USA
| | - Daniel L Hood
- 4Department of Pathology, Miami Valley Hospital, Dayton, OH USA
| | - Rose Maxwell
- 1Division of Reproductive Endocrine Infertility, Department of Obstetrics and Gynecology, Boonshoft School of Medicine, Wright State University, 128 Apple St; Suite 3800 Weber CHE, Dayton, OH 45409 USA
| | - Miryoung Lee
- 5Department of Epidemiology, Human Genetics and Environmental Sciences, School of Public Health, The University of Texas Health Science Center at Houston, Brownsville, TX USA
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Maheux-Lacroix S, Mennen J, Arnold A, Budden A, Nesbitt-Hawes E, Won H, Abbott J. Resolution of Abnormal Uterine Bleeding After Hysteroscopic Morcellation of Endometrial Polyps. J Gynecol Surg 2019. [DOI: 10.1089/gyn.2018.0058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Sarah Maheux-Lacroix
- Department of Obstetrics and Gynecology, CHU de Quebec, Laval University, Quebec, Canada
| | - Jennifer Mennen
- School of Women's and Children's Health, Royal Hospital for Women, University of New South Wales, Sydney, Australia
| | - Amy Arnold
- School of Women's and Children's Health, Royal Hospital for Women, University of New South Wales, Sydney, Australia
| | - Aaron Budden
- School of Women's and Children's Health, Royal Hospital for Women, University of New South Wales, Sydney, Australia
| | - Erin Nesbitt-Hawes
- School of Women's and Children's Health, Royal Hospital for Women, University of New South Wales, Sydney, Australia
| | - HaRyun Won
- School of Women's and Children's Health, Royal Hospital for Women, University of New South Wales, Sydney, Australia
| | - Jason Abbott
- School of Women's and Children's Health, Royal Hospital for Women, University of New South Wales, Sydney, Australia
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18
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Recurrent endometrial polyps – influencing factors and treatment. GINECOLOGIA.RO 2019. [DOI: 10.26416/gine.23.1.2019.2219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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19
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Ceci O, Franchini M, Cannone R, Giarrè G, Bettocchi S, Fascilla FD, Cicinelli E. Office treatment of large endometrial polyps using truclear 5C: Feasibility and acceptability. J Obstet Gynaecol Res 2018; 45:626-633. [PMID: 30506805 DOI: 10.1111/jog.13874] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Accepted: 11/02/2018] [Indexed: 11/27/2022]
Abstract
AIM This retrospective multicenter study was carried out to evaluate feasibility, effectiveness and patient acceptability of a small diameter hysteroscopic tissue removal system in the treatment of large endometrial polyps (≥20 mm), usually not removed in an office setting. METHODS Hundred and forty-six women with a single greater than 10-mm diameter polyp considered for polypectomy between April 2016 and August 2017. Sixty-five of these patients had a polyp size greater than 20 mm. All hysteroscopic polypectomy, using Hysteroscopic Tissue Removal system (TruClear 5C System Medtronic), were performed in an office setting with vaginoscopic approach. RESULTS Procedural success, time to complete the polypectomy and patient pain scores were evaluated. Polyps less than 20 mm were completely removed in 79/81 cases (97.53%). The completeness of greater than or equal to 20-mm polyp removal was achieved in 63/65 cases (96.92%). The median time for polypectomy was 4.19 ± 1.03 min for polyps less than 20 mm and 4.97 ± 1.30 min for polyps greater than or equal to 20 mm, respectively. Pain was minimal and brief, and the mean pain score measured on a 10-point visual analog scale at the end of polypectomy showed no significant difference between the two groups. In 4/79 (5.06%) cases with polyps less than 20 mm and in 4/63 (6.35%) cases with polyps greater than or equal to 20 mm women reported moderate pain. All specimens were adequate for pathologic measurements. CONCLUSION Hysteroscopic treatment of polyps greater than or equal to 20 mm in size with TruClear 5C is feasible and well tolerated in an office setting with no significant difference regarding completeness compared to polyps less than 20 mm, but with a minimal increase in procedure times.
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Affiliation(s)
- Oronzo Ceci
- 2nd Unit of Obstetrics and Gynecology, Department of Biomedical Science and Human Oncology, University of Bari, Bari, Italy
| | - Mario Franchini
- Department of Gynecology, Tuscany Regional Health Agency, Florence, Italy
| | - Rossella Cannone
- 2nd Unit of Obstetrics and Gynecology, Department of Biomedical Science and Human Oncology, University of Bari, Bari, Italy
| | - Giovanna Giarrè
- Department of Gynecology Palagi, Freestanding Unit, Health Authority, Florence, Italy
| | - Stefano Bettocchi
- 2nd Unit of Obstetrics and Gynecology, Department of Biomedical Science and Human Oncology, University of Bari, Bari, Italy
| | - Fabiana D Fascilla
- 2nd Unit of Obstetrics and Gynecology, Department of Biomedical Science and Human Oncology, University of Bari, Bari, Italy
| | - Ettore Cicinelli
- 2nd Unit of Obstetrics and Gynecology, Department of Biomedical Science and Human Oncology, University of Bari, Bari, Italy
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20
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Georgiou D, Tranoulis A, Jackson TL. Hysteroscopic tissue removal system (MyoSure) for the resection of polyps, sub-mucosal leiomyomas and retained products of conception in an out-patient setting: A single UK institution experience. Eur J Obstet Gynecol Reprod Biol 2018; 231:147-151. [DOI: 10.1016/j.ejogrb.2018.10.030] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Revised: 10/08/2018] [Accepted: 10/11/2018] [Indexed: 11/30/2022]
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21
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Zhu Y, Liu Z, Du M, Yi L, Gong G, Tang X. Macrophages in patients with recurrent endometrial polyps could exacerbate Th17 responses. Clin Exp Pharmacol Physiol 2018; 45:1128-1134. [PMID: 29908068 DOI: 10.1111/1440-1681.12994] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Revised: 06/09/2018] [Accepted: 06/13/2018] [Indexed: 11/30/2022]
Abstract
Endometrial polyps (EPs) are outgrowths in the endometrium with unknown etiology. The fact that EPs can often recur after surgical removal suggests that EPs are not induced by random events but by continuous or recurrent processes in patients. We previously demonstrated that the risk of EP development was positively associated with overactive Th17 responses. However, the requirements of Th17 upregulation are yet unclear. Here, we recruited 26 women with symptomatic EP and 24 without EP, and peripheral mononuclear cells were harvested for the examination of circulating immunity. Compared to controls without EP, the patients with symptomatic EP presented significantly elevated levels of monocyte activation. The circulating monocytes from patients secreted higher levels of tumor necrosis factor (TNF), interleukin (IL)-1β, IL-6 and IL-23 directly ex vivo and with LPS stimulation. In memory CD4+ T cells, monocytes were not required for IL-17 expression, but the presence of activated monocytes significantly increased the secretion of IL-17. In naive CD4+ T cells, activated monocytes were required for significant IL-17 secretion and RORC transcription. Interestingly, the monocytes from EP individuals were significantly more potent in promoting Th17 differentiation from naive CD4+ T cells than the monocytes from controls. Furthermore, we showed that monocyte-mediated Th17 differentiation required the secretion of TNF, IL-1β and IL-6. Together, this study demonstrated activated monocytes supported Th17 inflammation in patients with EP.
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Affiliation(s)
- Yali Zhu
- Department of Gynaecology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Zhihong Liu
- Department of Gynaecology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Miaomiao Du
- Department of Gynaecology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Lisha Yi
- Department of Gynaecology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Guifang Gong
- Department of Gynaecology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Xiang Tang
- Department of Gynaecology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong, China
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Gu F, Zhang H, Ruan S, Li J, Liu X, Xu Y, Zhou C. High number of endometrial polyps is a strong predictor of recurrence: findings of a prospective cohort study in reproductive-age women. Fertil Steril 2018. [DOI: 10.1016/j.fertnstert.2017.11.029] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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23
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Hysteroscopic Endometrial Polypectomy: Clinical and Economic Data in Decision Making. J Minim Invasive Gynecol 2018; 25:418-425. [DOI: 10.1016/j.jmig.2017.08.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2017] [Revised: 07/17/2017] [Accepted: 08/03/2017] [Indexed: 11/20/2022]
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Zhu Y, Du M, Yi L, Liu Z, Gong G, Tang X. CD4 + T cell imbalance is associated with recurrent endometrial polyps. Clin Exp Pharmacol Physiol 2018; 45:507-513. [PMID: 29292524 DOI: 10.1111/1440-1681.12913] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 12/22/2017] [Accepted: 12/22/2017] [Indexed: 12/21/2022]
Abstract
Endometrial polyps (EPs) are localized benign overgrowths at the endometrium, with currently unknown aetiology and pathogenesis. Although symptoms of EP can be alleviated or resolved by hysteroscopic polypectomy, a significant fraction of individuals develop recurrent EPs after initial EP removal. In rare cases, EPs may also undergo malignant transformation. In-depth understanding of the mechanisms that are involved in EP development is urgently needed. Recent works indicate that dysregulations in the immune system participate in the development of a variety of symptoms, such as aging, obesity and hypertension, many of which are EP risk factors. Based on these discoveries, we investigated the cellular immune system in premenopausal women with and without EP. Compared to EP-free controls, the women with EP presented significantly higher RORC expression but unchanged TBX21 and FOXP3 expression in the circulating CD4+ T cells. When stimulated with PMA/ionomycin, CD4+ T cells from women with EP presented significantly higher interferon (IFN)-γ and interleukin (IL)-17 secretion, and lower transforming growth factor (TGF)-β secretion. Hysteroscopic polypectomy did not significantly alter the composition of CD4+ T cells, as the women with EP presented a similar upregulation of Th17 inflammation and a downregulation of regulatory T cell (Treg) response postoperatively. Notably, in women that developed recurrent EP, the CD4+ T cells presented higher preoperative and postoperative RORC, IFN-γ, and IL-17 expression, as well as lower postoperative FOXP3 and TGF-β expression, than hysteroscopic polypectomy-treated women without EP recurrence. These data demonstrated an association between CD4+ T cell imbalance and recurrent EP development.
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Affiliation(s)
- Yali Zhu
- Department of Gynaecology, Guangzhou Women and Children's Medical Centre, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Miaomiao Du
- Department of Gynaecology, Guangzhou Women and Children's Medical Centre, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Lisha Yi
- Department of Gynaecology, Guangzhou Women and Children's Medical Centre, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Zhihong Liu
- Department of Gynaecology, Guangzhou Women and Children's Medical Centre, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Guifang Gong
- Department of Gynaecology, Guangzhou Women and Children's Medical Centre, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Xiang Tang
- Department of Gynaecology, Guangzhou Women and Children's Medical Centre, Guangzhou Medical University, Guangzhou, Guangdong, China
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Maheux-Lacroix S, Mennen J, Arnold A, Budden A, Nesbitt-Hawes E, Won H, Abbott J. The need for further surgical intervention following primary hysteroscopic morcellation of submucosal leiomyomas in women with abnormal uterine bleeding. Aust N Z J Obstet Gynaecol 2018; 58:570-575. [DOI: 10.1111/ajo.12781] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Accepted: 12/21/2017] [Indexed: 02/04/2023]
Affiliation(s)
- Sarah Maheux-Lacroix
- School of Women's and Children's Health; University of New South Wales; Sydney New South Wales Australia
| | - Jennifer Mennen
- School of Women's and Children's Health; University of New South Wales; Sydney New South Wales Australia
| | - Amy Arnold
- School of Women's and Children's Health; University of New South Wales; Sydney New South Wales Australia
| | - Aaron Budden
- School of Women's and Children's Health; University of New South Wales; Sydney New South Wales Australia
| | - Erin Nesbitt-Hawes
- School of Women's and Children's Health; University of New South Wales; Sydney New South Wales Australia
| | - HaRyun Won
- School of Women's and Children's Health; University of New South Wales; Sydney New South Wales Australia
| | - Jason Abbott
- School of Women's and Children's Health; University of New South Wales; Sydney New South Wales Australia
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Liang Y, Ren Y, Wan Z, Guo L, Dong J, Chen Y, Lv L. Clinical evaluation of improved MyoSure hysteroscopic tissue removal system for the resection of type II submucosal myomas. Medicine (Baltimore) 2017; 96:e9363. [PMID: 29390412 PMCID: PMC5815824 DOI: 10.1097/md.0000000000009363] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
This study aims to determine whether clinical evaluation of improved MyoSure hysteroscopic tissue removal system can remove type II submucosal myomas with safety and high success rate of the first operation.Fifty-three patients with type II submucosal myomas hospitalized in the Huzhou Maternity and Child Care Hospital were enrolled in this study. The submucosal myomas were with the diameter of >2 cm and ≤5 cm. All patients have surgical indications.Fifty-one of 53 hysteromyomas were successfully resected through 1-time operation. The average time was 37.92 ± 18.57 minutes, average amount of bleeding: 24.80 ± 12.12 mL, average length of stay: 2.02 ± 0.14 days. One patient had a transient postoperative fever and one patient had slight fluid overload with hyponatremia.The success rate of the first operation for resecting type II submucosal myomas showed an increase using improved MyoSure hysteroscopic tissue removal system, which can be a new, safer, and more efficient operation for treating type II submucosal myomas.
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Resectoscopic Surgery for Polyps and Myomas: A Review of the Literature. J Minim Invasive Gynecol 2017; 24:1104-1110. [PMID: 28843536 DOI: 10.1016/j.jmig.2017.08.645] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Revised: 08/08/2017] [Accepted: 08/10/2017] [Indexed: 11/21/2022]
Abstract
Resectoscopic surgery is routinely performed to remove endometrial polyps and uterine myomas. A search of Medline, PubMed, and the Cochrane Library was conducted through November 2016 for studies written in English, regardless of sample size or study type. The studies were then filtered by selecting those evaluating resectoscopic surgery. An analysis of peer-reviewed, published literature was performed to examine the clinical application of this treatment modality on patients requiring polypectomy and myomectomy. Different surgical techniques were also compared: hysteroscopy with scissors, forceps, or a cold loop; resectoscopy with radiofrequency energy; and mechanical resection. The literature finds that operative time during resectoscopic surgery is significantly longer than with mechanical resection. Resectoscopic myomectomy, however, may be necessary for removal of larger or more deeply embedded myomas. Ultimately, both techniques result in symptom resolution and a low recurrence rate.
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Tanos V, Berry KE, Seikkula J, Abi Raad E, Stavroulis A, Sleiman Z, Campo R, Gordts S. The management of polyps in female reproductive organs. Int J Surg 2017; 43:7-16. [DOI: 10.1016/j.ijsu.2017.05.012] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Accepted: 05/02/2017] [Indexed: 02/07/2023]
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Li C, Dai Z, Gong Y, Xie B, Wang B. A systematic review and meta-analysis of randomized controlled trials comparing hysteroscopic morcellation with resectoscopy for patients with endometrial lesions. Int J Gynaecol Obstet 2016; 136:6-12. [PMID: 28099700 DOI: 10.1002/ijgo.12012] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Revised: 07/03/2016] [Accepted: 10/10/2016] [Indexed: 11/11/2022]
Affiliation(s)
- Chunbo Li
- Department of Obstetrics and Gynaecology; Shanghai First Maternity and Infant Hospital; Tongji University School of Medicine; Shanghai China
| | - Zhiyuan Dai
- Department of Obstetrics and Gynaecology; Shanghai First Maternity and Infant Hospital; Tongji University School of Medicine; Shanghai China
| | - Yuping Gong
- Department of General Surgery; Zhongshan Hospital of Fudan University; Shanghai China
| | - Bingying Xie
- Department of Gynaecology and Obstetrics; Gynaecology and Obstetrics Hospital of Fudan University; Shanghai China
| | - Bei Wang
- Department of Anesthesia; Zhongshan Hospital of Fudan University; Shanghai China
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Shazly SA, Laughlin-Tommaso SK, Breitkopf DM, Hopkins MR, Burnett TL, Green IC, Farrell AM, Murad MH, Famuyide AO. Hysteroscopic Morcellation Versus Resection for the Treatment of Uterine Cavitary Lesions: A Systematic Review and Meta-analysis. J Minim Invasive Gynecol 2016; 23:867-77. [DOI: 10.1016/j.jmig.2016.04.013] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2016] [Revised: 04/22/2016] [Accepted: 04/26/2016] [Indexed: 10/21/2022]
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Demographic and Clinical Features of Endometrial Polyps in Patients with Endometriosis. BIOMED RESEARCH INTERNATIONAL 2016; 2016:1460793. [PMID: 27243030 PMCID: PMC4868887 DOI: 10.1155/2016/1460793] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Accepted: 04/06/2016] [Indexed: 11/20/2022]
Abstract
Aims. To compare the clinical features of endometrial polyps (EPs) between patients with endometriosis (EM) (EM group) and without EM (non-EM group). Methods and Results. Seventy-six cases in the EM group and 133 cases in the non-EM group underwent laparotomy or hysteroscopy and laparoscopy; later, it was confirmed that the results by pathology from July 2002 to April 2008 in the Department of Gynecology and Obstetrics at the First Affiliated Hospital of Sun Yat-sen University. The recurrence of EPs was followed up after the surgery until 2013. The following parameters were assessed: age, gravidity, parity, infertility, and menstrual cycle changes, as well as polyps diameters, locations, number, association with the revised American Fertility Society (r-AFS) classification, and their recurrence. On review, 76 EPs cases of EM group histologically resembled EPs but the majority of EPs with EM occurred in primary infertility cases and in fewer pregnancy rate women who had stable and smaller EPs without association with the AFS stage. The recurrence rate of EPs in EM group was higher than that in non-EM group. Conclusion. It is important to identify whether infertile patients with EM are also having EPs. Removing any coexisting EPs via hysteroscopy would be clinically helpful in treating endometriosis-related infertility in these patients.
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Clark TJ, Middleton LJ, Cooper NA, Diwakar L, Denny E, Smith P, Gennard L, Stobert L, Roberts TE, Cheed V, Bingham T, Jowett S, Brettell E, Connor M, Jones SE, Daniels JP. A randomised controlled trial of Outpatient versus inpatient Polyp Treatment (OPT) for abnormal uterine bleeding. Health Technol Assess 2016; 19:1-194. [PMID: 26240949 DOI: 10.3310/hta19610] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Uterine polyps cause abnormal bleeding in women and conventional practice is to remove them in hospital under general anaesthetic. Advances in technology make it possible to perform polypectomy in an outpatient setting, yet evidence of effectiveness is limited. OBJECTIVES To test the hypothesis that in women with abnormal uterine bleeding (AUB) associated with benign uterine polyp(s), outpatient polyp treatment achieved as good, or no more than 25% worse, alleviation of bleeding symptoms at 6 months compared with standard inpatient treatment. The hypothesis that response to uterine polyp treatment differed according to the pattern of AUB, menopausal status and longer-term follow-up was tested. The cost-effectiveness and acceptability of outpatient polypectomy was examined. DESIGN A multicentre, non-inferiority, randomised controlled trial, incorporating a cost-effectiveness analysis and supplemented by a parallel patient preference study. Patient acceptability was evaluated by interview in a qualitative study. SETTING Outpatient hysteroscopy clinics and inpatient gynaecology departments within UK NHS hospitals. PARTICIPANTS Women with AUB - defined as heavy menstrual bleeding (formerly known as menorrhagia) (HMB), intermenstrual bleeding or postmenopausal bleeding - and hysteroscopically diagnosed uterine polyps. INTERVENTIONS We randomly assigned 507 women, using a minimisation algorithm, to outpatient polypectomy compared with conventional inpatient polypectomy as a day case in hospital under general anaesthesia. MAIN OUTCOME MEASURES The primary outcome was successful treatment at 6 months, determined by the woman's assessment of her bleeding. Secondary outcomes included quality of life, procedure feasibility, acceptability and cost per quality-adjusted life-year (QALY) gained. RESULTS At 6 months, 73% (166/228) of women who underwent outpatient polypectomy were successfully treated compared with 80% (168/211) following inpatient polypectomy [relative risk (RR) 0.91, 95% confidence interval (CI) 0.82 to 1.02]. The lower end of the CIs showed that outpatient polypectomy was at most 18% worse, in relative terms, than inpatient treatment, within the 25% margin of non-inferiority set at the outset of the study. By 1 and 2 years the corresponding proportions were similar producing RRs close to unity. There was no evidence that the treatment effect differed according to any of the predefined subgroups when treatments by variable interaction parameters were examined. Failure to completely remove polyps was higher (19% vs. 7%; RR 2.5, 95% CI 1.5 to 4.1) with outpatient polypectomy. Procedure acceptability was reduced with outpatient compared with inpatient polyp treatment (83% vs. 92%; RR 0.90, 95% CI 0.84 to 0.97). There were no significant differences in quality of life. The incremental cost-effectiveness ratios at 6 and 12 months for inpatient treatment were £1,099,167 and £668,800 per additional QALY, respectively. CONCLUSIONS When treating women with AUB associated with uterine polyps, outpatient polypectomy was non-inferior to inpatient polypectomy at 6 and 12 months, and relatively cost-effective. However, patients need to be aware that failure to remove a polyp is more likely with outpatient polypectomy and procedure acceptability lower. TRIAL REGISTRATION Current Controlled Trials ISRCTN 65868569. FUNDING This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 19, No. 61. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- T Justin Clark
- Birmingham Women's Hospital NHS Foundation Trust, Edgbaston, Birmingham, UK.,School of Clinical and Experimental Medicine, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Lee J Middleton
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Natalie Am Cooper
- Women's Health Research Unit, The Blizard Institute, Queen Mary University of London, London, UK
| | - Lavanya Diwakar
- Health Economics Unit, School of Health and Population Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Elaine Denny
- Centre for Health and Social Care Research, Faculty of Health, Birmingham City University, Edgbaston, Birmingham, UK
| | - Paul Smith
- Birmingham Women's Hospital NHS Foundation Trust, Edgbaston, Birmingham, UK.,School of Clinical and Experimental Medicine, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Laura Gennard
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Lynda Stobert
- Centre for Health and Social Care Research, Faculty of Health, Birmingham City University, Edgbaston, Birmingham, UK
| | - Tracy E Roberts
- Health Economics Unit, School of Health and Population Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Versha Cheed
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Tracey Bingham
- Birmingham Women's Hospital NHS Foundation Trust, Edgbaston, Birmingham, UK
| | - Sue Jowett
- Health Economics Unit, School of Health and Population Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Elizabeth Brettell
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Mary Connor
- Jessop Wing, Sheffield Teaching Hospitals NHS Trust, Sheffield, UK
| | - Sian E Jones
- Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Jane P Daniels
- School of Clinical and Experimental Medicine, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.,Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
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Arnold A, Ketheeswaran A, Bhatti M, Nesbitt-Hawes E, Abbott J. A Prospective Analysis of Hysteroscopic Morcellation in the Management of Intrauterine Pathologies. J Minim Invasive Gynecol 2016; 23:435-41. [DOI: 10.1016/j.jmig.2016.01.013] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2015] [Revised: 01/06/2016] [Accepted: 01/11/2016] [Indexed: 10/22/2022]
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Lara-Domínguez MD, Arjona-Berral JE, Dios-Palomares R, Castelo-Branco C. Outpatient hysteroscopic polypectomy: bipolar energy system (Versapoint®) versus diode laser - randomized clinical trial. Gynecol Endocrinol 2016; 32:196-200. [PMID: 26527251 DOI: 10.3109/09513590.2015.1105209] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To compare the resection of endometrial polyps with two different devices: the Versapoint biopolar electrode and the Diode Laser. METHODS One hundred and two patients diagnosed with endometrial polyps were randomly assigned to undergo hysteroscopic polypectomy: one group (n = 52) performed with Versapoint bipolar electrode through a 5Fr working channel and the other group with Biolitec Diode Laser (n = 50) using a specific fiber for polyps in a 7Fr working channel. All cases were managed on an outpatient basis, without anesthesia and using a rigid 30(o) hysteroscope and saline solution as a distention medium. MAIN OUTCOME MEASURES Complete resection rate, operative time, complications, intraoperative pain and relapse rate after three months. RESULTS Intraoperative pain and polyp resection time was similar in both groups. Upon second look hysteroscopy at 3-month, a higher percentage of women of the Versapoint group presented polyp relapse (32.6 versus 2.2%, p = 0.001). Elimination of the polyp after incomplete resection was higher in the Laser group. A significantly higher number of patients in the Laser group considered the procedure to be highly recommendable (p = 0.02). CONCLUSION Polypectomy with Diode Laser resulted in fewer relapses and a higher procedure satisfaction rate as compared to Versapoint.
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Affiliation(s)
| | | | - Rafaela Dios-Palomares
- b Department of Statistics and Operational Research , University of Córdoba , Córdoba , Spain , and
| | - Camil Castelo-Branco
- c Faculty of Medicine-University of Barcelona , Institut Clínic of Gynecology, Obstetrics and Neonatology, Hospital Clínic-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) , Barcelona , Spain
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Yang JH, Chen CD, Chen SU, Yang YS, Chen MJ. Factors Influencing the Recurrence Potential of Benign Endometrial Polyps after Hysteroscopic Polypectomy. PLoS One 2015; 10:e0144857. [PMID: 26660149 PMCID: PMC4676604 DOI: 10.1371/journal.pone.0144857] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Accepted: 11/24/2015] [Indexed: 11/18/2022] Open
Abstract
Background An endometrial polyp is a frequently encountered gynecologic disease with abnormal uterine bleeding and infertility being the two common presenting problems, and hysteroscopic polypectomy is an effective method to remove them. The postoperative polyp recurrence might result in reappearance of abnormal uterine bleeding or infertility, whereas factors influencing the postoperative recurrence potential have limited data. Methods This case-series report included 168 premenopausal women who suffered from endometrial polyps and underwent hysteroscopic polypectomy. All of them were awaiting a future pregnancy. Office hysteroscopy was done before and after hysteroscopic polypectomy, in which preoperative hysteroscopy examined the number, type, and location of endometrial polyps, and postoperative hysteroscopy checked the polyp recurrence. Surgical indications, either infertility or the presentation of abnormal uterine bleeding, and follow-up duration were recorded. Results Seventy-three out of 168 (43%) women had polyp recurrence after hysteroscopic polypectomy. Multivariate logistic regression analysis revealed that more endometrial polyps (P = 0.015) and longer duration of follow-up (P = 0.004) were significantly associated with an increased risk of postoperative polyp recurrence. The type of endometrial polyps was not correlated with polyp recurrence potential, whereas pedunculated type endometrial polyps were closely related to the presentation of abnormal uterine bleeding (P = 0.001). Conclusions A higher number of endometrial polyps and longer follow-up duration are associated with a greater potential of polyp recurrence after hysteroscopic polypectomy.
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Affiliation(s)
- Jehn-Hsiahn Yang
- Department of Obstetrics and Gynecology, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Chin-Der Chen
- Department of Obstetrics and Gynecology, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Shee-Uan Chen
- Department of Obstetrics and Gynecology, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Yu-Shih Yang
- Department of Obstetrics and Gynecology, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Mei-Jou Chen
- Department of Obstetrics and Gynecology, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
- * E-mail:
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McIlwaine P, McElhinney B, Karthigasu KA, Hart R. A prospective study of the use of the Myosure resectoscope to manage endometrial polyps in an outpatient setting. Aust N Z J Obstet Gynaecol 2015; 55:482-6. [DOI: 10.1111/ajo.12382] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2014] [Accepted: 05/16/2015] [Indexed: 11/28/2022]
Affiliation(s)
- Patrick McIlwaine
- Gynaecological Endoscopy Unit; King Edward Memorial Hospital; Subiaco WA Australia
| | | | - Krishnan Andrew Karthigasu
- Gynaecological Endoscopy Unit; King Edward Memorial Hospital; Subiaco WA Australia
- Hollywood Medical Centre; Nedlands, Perth WA Australia
- School of Women's and Infants' Health; The University of Western Australia; Crawley WA Australia
| | - Roger Hart
- School of Women's and Infants' Health; The University of Western Australia; Crawley WA Australia
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Franchini M, Zolfanelli F, Gallorini M, Giarrè G, Fimiani R, Florio P. Hysteroscopic polypectomy in an office setting: specimen quality assessment for histopathological evaluation. Eur J Obstet Gynecol Reprod Biol 2015; 189:64-7. [DOI: 10.1016/j.ejogrb.2015.03.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2014] [Revised: 02/24/2015] [Accepted: 03/04/2015] [Indexed: 11/30/2022]
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Elfayomy AK, Soliman BS. Risk Factors Associated with the Malignant Changes of Symptomatic and Asymptomatic Endometrial Polyps in Premenopausal Women. J Obstet Gynaecol India 2015; 65:186-92. [PMID: 26085741 PMCID: PMC4464569 DOI: 10.1007/s13224-014-0576-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2014] [Accepted: 05/20/2014] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE This study aimed to evaluate the prevalence of premalignant and malignant lesions of symptomatic and asymptomatic endometrial polyps among premenopausal women and to verify whether different clinical parameters, and polyp volume and number are associated with a more precise estimate of malignancy. METHODS One hundred and fifty women aged 29-52 years and with certain diagnosis of endometrial polyp were enrolled in a prospective observational study. The recruited patients underwent hysteroscopic polypectomy based on saline infusion sonohysterography and diagnostic hysteroscopy. Pathologic report was the main outcome. RESULTS Among women with endometrial polyps, 62 % had asymptomatic polyps. The prevalence of premalignant and malignant polyps comprised 4.6 % of cases (3.3 % hyperplasia with atypia and 1.3 % carcinomatous polyps). The presence of abnormal uterine bleeding was not a predictor of premalignant and malignant changes in the polyp. On logistic regression analysis, the premalignant and malignant lesions were influenced by polycystic ovary syndrome (p < 0.001; OR 4.61; CI 1.9-27), polyp volume >10 ml (p < 0.001; OR 5.83; CI 4.31-9.17), and multiple polyps (p = 0. 01; OR 2.05; CI 1.09-3.76). Notably, the odds ratio of polyp volume >10 ml was 5.83. This additional risk confirms the importance of polyp volume in the detection of malignant transformation rather than associating bleeding in premenopausal women. CONCLUSION Polycystic ovary syndrome, polyp volume greater than 10 ml, and increased polyp number represent the markers of risk for premalignant and malignant transformation of endometrial polyps in premenopausal women. Nonetheless, the majority of polyps are asymptomatic, and the risk of malignancy is very low. Therefore, for women with polyp volume ≤10 ml and no risk factors, a more expectant approach may be warranted in order to reduce surgical risks and costs.
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Affiliation(s)
- Amr K. Elfayomy
- />Department of Obstetrics & Gynecology, Faculty of Medicine, Zagazig University, Zagazig, Egypt
- />Department of Obstetrics & Gynecology, Faculty of Medicine, Taibah University, Al-Madinah Al-Munawarah, Saudi Arabia
| | - Badeea S Soliman
- />Department of Obstetrics & Gynecology, Faculty of Medicine, Zagazig University, Zagazig, Egypt
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Noventa M, Ancona E, Quaranta M, Vitagliano A, Cosmi E, D’Antona D, Gizzo S. Intrauterine Morcellator Devices. Reprod Sci 2015; 22:1289-96. [DOI: 10.1177/1933719115578929] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Marco Noventa
- Department of Woman and Child Health, University of Padua, Padua, Italy
| | - Emanuele Ancona
- Department of Woman and Child Health, University of Padua, Padua, Italy
| | - Michela Quaranta
- Department of Obstetrics and Gynaecology, University of Verona, Verona, Italy
| | - Amerigo Vitagliano
- Department of Obstetrics and Gynaecology, University of Verona, Verona, Italy
| | - Erich Cosmi
- Department of Woman and Child Health, University of Padua, Padua, Italy
| | - Donato D’Antona
- Department of Woman and Child Health, University of Padua, Padua, Italy
| | - Salvatore Gizzo
- Department of Woman and Child Health, University of Padua, Padua, Italy
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Cooper NAM, Clark TJ, Middleton L, Diwakar L, Smith P, Denny E, Roberts T, Stobert L, Jowett S, Daniels J. Outpatient versus inpatient uterine polyp treatment for abnormal uterine bleeding: randomised controlled non-inferiority study. BMJ 2015; 350:h1398. [PMID: 25801579 PMCID: PMC4370502 DOI: 10.1136/bmj.h1398] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To compare the effectiveness and acceptability of outpatient polypectomy with inpatient polypectomy. DESIGN Pragmatic multicentre randomised controlled non-inferiority study. SETTING Outpatient hysteroscopy clinics in 31 UK National Health Service hospitals. PARTICIPANTS 507 women who attended as outpatients for diagnostic hysteroscopy because of abnormal uterine bleeding and were found to have uterine polyps. INTERVENTIONS Participants were randomly assigned to either outpatient uterine polypectomy under local anaesthetic or inpatient uterine polypectomy under general anaesthesia. Data were collected on women's self reported bleeding symptoms at baseline and at 6, 12, and 24 months. Data were also collected on pain and acceptability of the procedure at the time of polypectomy. MAIN OUTCOME MEASURES The primary outcome was successful treatment, determined by the women's assessment of bleeding at six months, with a prespecified non-inferiority margin of 25%. Secondary outcomes included generic (EQ-5D) and disease specific (menorrhagia multi-attribute scale) quality of life, and feasibility and acceptability of the procedure. RESULTS 73% (166/228) of women in the outpatient group and 80% (168/211) in the inpatient group reported successful treatment at six months (intention to treat relative risk 0.91, 95% confidence interval 0.82 to 1.02; per protocol relative risk 0.92, 0.82 to 1.02). Failure to remove polyps was higher (19% v 7%; relative risk 2.5, 1.5 to 4.1) and acceptability of the procedure was lower (83% v 92%; 0.90, 0.84 to 0.97) in the outpatient group Quality of life did not differ significantly between the groups. Four uterine perforations, one of which necessitated bowel resection, all occurred in the inpatient group. CONCLUSIONS Outpatient polypectomy was non-inferior to inpatient polypectomy. Failure to remove a uterine polyp was, however, more likely with outpatient polypectomy and acceptability of the procedure was slightly lower. TRIAL REGISTRATION International Clinical Trials Registry 65868569.
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Affiliation(s)
- Natalie A M Cooper
- Women's Health Research Unit, Queen Mary University of London, UK OPT Trial Office, Birmingham Clinical Trials Unit, College of Medical and Dental Sciences, Robert Aitken Institute for Clinical Research, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK
| | | | - Lee Middleton
- OPT Trial Office, Birmingham Clinical Trials Unit, College of Medical and Dental Sciences, Robert Aitken Institute for Clinical Research, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK
| | - Lavanya Diwakar
- Health Economics Unit, School of Health and Population Science, University of Birmingham, UK
| | - Paul Smith
- Birmingham Women's NHS Foundation Trust, Birmingham, UK School of Clinical and Experimental Medicine, University of Birmingham, UK
| | - Elaine Denny
- Centre for Health and Social Care Research, Birmingham City University, UK
| | - Tracy Roberts
- Health Economics Unit, School of Health and Population Science, University of Birmingham, UK
| | - Lynda Stobert
- School of Allied and Public Health Professions, Birmingham City University, UK
| | - Susan Jowett
- Health Economics Unit, School of Health and Population Science, University of Birmingham, UK
| | - Jane Daniels
- OPT Trial Office, Birmingham Clinical Trials Unit, College of Medical and Dental Sciences, Robert Aitken Institute for Clinical Research, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK
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Pampalona JR, Bastos MD, Moreno GM, Pust AB, Montesdeoca GE, Guerra Garcia A, Pruñonosa JCM, Collado RC, Torras PB. A Comparison of Hysteroscopic Mechanical Tissue Removal With Bipolar Electrical Resection for the Management of Endometrial Polyps in an Ambulatory Care Setting: Preliminary Results. J Minim Invasive Gynecol 2015; 22:439-45. [DOI: 10.1016/j.jmig.2014.12.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2014] [Revised: 11/27/2014] [Accepted: 12/02/2014] [Indexed: 10/24/2022]
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Rubino RJ, Lukes AS. Twelve-Month Outcomes for Patients Undergoing Hysteroscopic Morcellation of Uterine Polyps and Myomas in an Office or Ambulatory Surgical Center. J Minim Invasive Gynecol 2015; 22:285-90. [DOI: 10.1016/j.jmig.2014.10.015] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2014] [Revised: 10/17/2014] [Accepted: 10/18/2014] [Indexed: 10/24/2022]
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Hysteroscopic Morcellation: Review of the Manufacturer and User Facility Device Experience (MAUDE) Database. J Minim Invasive Gynecol 2015; 22:110-4. [DOI: 10.1016/j.jmig.2014.08.008] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2014] [Revised: 08/06/2014] [Accepted: 08/08/2014] [Indexed: 10/24/2022]
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Hysteroscopic Morcellation Compared With Electrical Resection of Endometrial Polyps. Obstet Gynecol 2014; 123:745-51. [DOI: 10.1097/aog.0000000000000187] [Citation(s) in RCA: 82] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Affiliation(s)
- Natalie AM Cooper
- Birmingham Women’s Hospital; Mindelsohn Way; Edgbaston; Birmingham; B15 2TG; UK
| | - T Justin Clark
- Birmingham Women’s Hospital; Mindelsohn Way; Edgbaston; Birmingham; B15 2TG; UK
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