1
|
Wang Y, Hao X, Chen Y, Wang L, Zhou Y, Xue M, Dong Y, Sun L. Treatment of uterine scar cystoid diverticulum by hysteroscopy combined with laparoscopy. Fertil Steril 2023; 120:922-924. [PMID: 37499779 DOI: 10.1016/j.fertnstert.2023.07.013] [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: 11/05/2022] [Revised: 07/19/2023] [Accepted: 07/19/2023] [Indexed: 07/29/2023]
Abstract
OBJECTIVE To report a patient with prolonged intermenstrual bleeding and a cystic mass at a cesarean scar treated with laparoscopic folding sutures and hysteroscopic canalization. DESIGN A 4.0 cm-cystic mass formed at the uterine scar caused continuous menstrual blood outflow in the diverticulum and was treated with hysteroscopy combined with laparoscopy. SETTING University hospital. PATIENTS A 38-year-old woman of childbearing age who had undergone two cesarean sections and two abortions reported vaginal bleeding for 10 years, which began shortly after the second cesarean section. Curettage was performed, but no abnormality was found. The patient unsuccessfully tried to manage her symptoms with traditional Chinese medicine and hormone drugs. The muscular layer of the lower end of the anterior wall of the uterus was weak, and there were cystic masses on the right side. INTERVENTION The bladder was stripped from the lower uterine segment under laparoscopy, and the surrounding tissue of the mass at the uterine scar was separated. The position of the cesarean scar defect was identified by hysteroscopy combined with laparoscopy, and the relationship between the uterine mass and surrounding tissues was analyzed. An electric cutting ring resection on both sides of the obstruction was performed to eliminate the valve effect. The active intima of the scar diverticulum was destroyed by electrocoagulation, followed by laparoscopic treatment of the uterine scar diverticulum mass. An intraoperative tumor incision revealed visible bloody fluid mixed with intimal material. The uterine scar diverticulum defect was repaired using 1-0 absorbable barbed continuous full-thickness mattress fold sutures. Finally, the bilateral round ligament length was adjusted so that the uterus tilted forward. MAIN OUTCOME MEASURES Recovery of menstruation and anatomy of the uterine isthmus. RESULTS The operation was successful, and the postoperative recovery was fast. There was no interphase bleeding at the 1-month follow-up, and the uterine scar diverticulum was repaired, with the thickness of the uterine scar muscle layer increasing to 0.91 cm. CONCLUSION The simple, straightforward procedure to resolve the abnormal cystic, solid mass formed because of the continuous deposition of blood in the uterine scar diverticulum involved laparoscopic folding and docking sutures combined with hysteroscopic canal opening.
Collapse
Affiliation(s)
- Yanan Wang
- Departments of Gynecology and Obstetrics, Clinical Medical College of Jining Medical University, Jining, Shandong, People's Republic of China
| | - Xianhua Hao
- Department of Gynecology, Affiliated Hospital of Jining Medical University, Jining, Shandong, People's Republic of China
| | - Yahui Chen
- Departments of Gynecology and Obstetrics, Clinical Medical College of Jining Medical University, Jining, Shandong, People's Republic of China
| | - Lin Wang
- Departments of Gynecology and Obstetrics, Clinical Medical College of Jining Medical University, Jining, Shandong, People's Republic of China
| | - Yan Zhou
- Departments of Gynecology and Obstetrics, Clinical Medical College of Jining Medical University, Jining, Shandong, People's Republic of China
| | - Mei Xue
- Departments of Gynecology and Obstetrics, Clinical Medical College of Jining Medical University, Jining, Shandong, People's Republic of China
| | - Yan Dong
- Departments of Gynecology and Obstetrics, Clinical Medical College of Jining Medical University, Jining, Shandong, People's Republic of China; Department of Obstetrics, Affiliated Hospital of Jining Medical University, Jining, Shandong, People's Republic of China
| | - Lin Sun
- Department of Gynecology, Affiliated Hospital of Jining Medical University, Jining, Shandong, People's Republic of China.
| |
Collapse
|
2
|
Wang X, Feng K, He S, Xie X, Ma Z. The continuous treatment of anterior segment open globe injury: an eye injury vitrectomy study. Quant Imaging Med Surg 2023; 13:6257-6267. [PMID: 37711825 PMCID: PMC10498217 DOI: 10.21037/qims-23-645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 08/04/2023] [Indexed: 09/16/2023]
Abstract
Background The prognostic significance of debridement has long been demonstrated for trauma in tissues other than ocular. Unfortunately, the impact of wound healing in the anterior segment (AS) was not paid as much attention as in the posterior segment (PS). This study aims to evaluate whether a better prognosis can be obtained from continuous surgical treatment (CST) before fibrosis or scar formation in an open AS injury. Methods In this prospective comparative cohort study, 19 eyes of 19 patients with an experience of AS open globe injury (OGI) were selected from the database of the eye injury vitrectomy study (EIVS) from January 1, 2020 to July 31, 2021. Of 19 patients, 9 who received CST were assigned to group 1, and 10 patients without CST after the initial wound repair were included in group 2. Comparison between the two groups was conducted in the final best corrected visual acuity (BCVA). Significant AS complications after injury were evaluated with χ2 test. The corneal leucoma area ratio, astigmatism, and the score of AS abnormalities were analyzed using the Student's t-test. Results The differences of baseline clinical factors between the two groups were not statistically significant. The final BCVA was better in group 1 than in group 2 (P=0.011). The complications directly caused by AS injury, namely adhesive corneal leucoma, uneven anterior chamber, block of light passing through the pupil, and fibrosis or scarring, were more frequent in group 2 than in group 1 (P=0.011, 0.022, 0.037, and 0.040, respectively). Secondary glaucoma (3 cases) and severe AS structure destruction (2 cases) occurred only in group 2 (P=0.037 and 0.474, respectively). The area ratio of leucoma (0.79±0.44, 0.82±0.50, respectively) and corneal astigmatism (3.69±1.90, 4.50±4.80, respectively) revealed no statistical significance between the two groups. On the other hand, the score of AS abnormalities, mean values being 93.33±11.18 for group 1 and 67.00±29.46 for group 2, was statistically different (P=0.022). Conclusions Initiating CST before fibrosis or scar formation might improve the prognosis of open AS injury, which was preferable to natural wound healing after wound repair.
Collapse
Affiliation(s)
- Xijuan Wang
- Department of Ophthalmology, Peking University International Hospital, Beijing, China
| | - Kang Feng
- Department of Ophthalmology, Peking University Third Hospital, Beijing, China
| | - Shikun He
- Departments of Pathology and Ophthalmology, USC Roski Eye Institute, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Xin Xie
- Department of Ophthalmology, Peking University Third Hospital, Beijing, China
| | - Zhizhong Ma
- Department of Ophthalmology, Peking University International Hospital, Beijing, China
- Department of Ophthalmology, Peking University Third Hospital, Beijing, China
| |
Collapse
|
3
|
Klein Meuleman SJM, Min N, Hehenkamp WJK, Post Uiterweer ED, Huirne JAF, de Leeuw RA. The definition, diagnosis, and symptoms of the uterine niche - A systematic review. Best Pract Res Clin Obstet Gynaecol 2023; 90:102390. [PMID: 37506497 DOI: 10.1016/j.bpobgyn.2023.102390] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 07/03/2023] [Accepted: 07/06/2023] [Indexed: 07/30/2023]
Abstract
Of all neonates, 21% are delivered by cesarean section (CS). A long-term maternal complication of an SC is a uterine niche. The aim of this review is to provide an overview of the current literature on imaging techniques and niche-related symptomatology. We performed systematic searches on imaging and niche symptoms. For both searches, 87 new studies were included. Niche evaluation by transvaginal sonography (TVS) or contrast sonohysterography (SHG) proved superior over hysteroscopy or magnetic resonance imaging. Studies that used SHG in a random population identified a niche prevalence of 42%-84%. Niche prevalence differed based on niche definition, symptomatology, and imaging technique. Most studies reported an association with gynecological symptoms, poor reproductive outcomes, obstetrical complications, and reduced quality of life. In conclusion, non-invasive TVS and SHG are the superior imaging modalities to diagnose a niche. Niches are prevalent and strongly associated with gynecological symptoms and poor reproductive outcomes.
Collapse
Affiliation(s)
- S J M Klein Meuleman
- Amsterdam University Medical Center, Location Vrije Universiteit Amsterdam, Department of Obstetrics & Gynaecology, De Boelelaan 1117, Amsterdam, the Netherlands; Amsterdam Reproduction and Development, Amsterdam, the Netherlands.
| | - N Min
- Amsterdam University Medical Center, Location Vrije Universiteit Amsterdam, Department of Obstetrics & Gynaecology, De Boelelaan 1117, Amsterdam, the Netherlands; Amsterdam Reproduction and Development, Amsterdam, the Netherlands.
| | - W J K Hehenkamp
- Amsterdam University Medical Center, Location Vrije Universiteit Amsterdam, Department of Obstetrics & Gynaecology, De Boelelaan 1117, Amsterdam, the Netherlands.
| | - E D Post Uiterweer
- Amsterdam University Medical Center, Location Amsterdam Medical Center, Uterine Repair Center, Department of Obstetrics & Gynaecology, Meibergdreef 9, Amsterdam, the Netherlands.
| | - J A F Huirne
- Amsterdam University Medical Center, Location Vrije Universiteit Amsterdam, Department of Obstetrics & Gynaecology, De Boelelaan 1117, Amsterdam, the Netherlands; Amsterdam Reproduction and Development, Amsterdam, the Netherlands.
| | - R A de Leeuw
- Amsterdam University Medical Center, Location Vrije Universiteit Amsterdam, Department of Obstetrics & Gynaecology, De Boelelaan 1117, Amsterdam, the Netherlands; Amsterdam Reproduction and Development, Amsterdam, the Netherlands.
| |
Collapse
|
4
|
Ma Y, Hu Y, Ma J. Animal models of the placenta accreta spectrum: current status and further perspectives. Front Endocrinol (Lausanne) 2023; 14:1118168. [PMID: 37223034 PMCID: PMC10200980 DOI: 10.3389/fendo.2023.1118168] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 03/20/2023] [Indexed: 05/25/2023] Open
Abstract
Placenta accreta spectrum disorder (PAS) is a kind of disease of placentation defined as abnormal trophoblast invasion of part or all of the placenta into the myometrium, even penetrating the uterus. Decidual deficiency, abnormal vascular remodeling in the maternal-fetal interface, and excessive invasion by extravillous trophoblast (EVT) cells contribute to its onset. However, the mechanisms and signaling pathways underlying such phenotypes are not fully understood, partly due to the lack of suitable experimental animal models. Appropriate animal models will facilitate the comprehensive and systematic elucidation of the pathogenesis of PAS. Due to the remarkably similar functional placental villous units and hemochorial placentation to humans, the current animal models of PAS are based on mice. There are various mouse models induced by uterine surgery to simulate different phenotypes of PAS, such as excessive invasion of EVT or immune disturbance at the maternal-fetal interface, which could define the pathological mechanism of PAS from the perspective of the "soil." Additionally, genetically modified mouse models could be used to study PAS, which is helpful to exploring the pathogenesis of PAS from the perspectives of both "soil" and "seed," respectively. This review details early placental development in mice, with a focus on the approaches of PAS modeling. Additionally, the strengths, limitations and the applicability of each strategy and further perspectives are summarized to provide the theoretical foundation for researchers to select appropriate animal models for various research purposes. This will help better determine the pathogenesis of PAS and even promote possible therapy.
Collapse
Affiliation(s)
- Yongdan Ma
- Department of Obstetrics and Gynecology, Peking University First Hospital, Beijing, China
| | - Yongyan Hu
- Laboratory Animal Center, Peking University First Hospital, Beijing, China
| | - Jingmei Ma
- Department of Obstetrics and Gynecology, Peking University First Hospital, Beijing, China
- Beijing Key Laboratory of Maternal Fetal Medicine of Gestational Diabetes Mellitus, Beijing, China
| |
Collapse
|
5
|
Zhu M, Xia W, Liang Y, Zhang J. Hysteroscopy-assisted Transvaginal Repair without Scar Defect Resection: A Novel Technique for the Treatment of Uterine Niche. J Minim Invasive Gynecol 2023; 30:178-179. [PMID: 36646313 DOI: 10.1016/j.jmig.2023.01.004] [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: 10/31/2022] [Revised: 12/08/2022] [Accepted: 01/10/2023] [Indexed: 01/15/2023]
Abstract
STUDY OBJECTIVE To describe hysteroscopy-assisted transvaginal repair technique without scar defect resection for uterine niche. DESIGN Surgical video article (Supplemental Videos 1-3). Stepwise narrated video demonstration of the novel technique. A total of 15 women diagnosed as having niche in the uterus were enrolled in our study. Patients provided a signed consent and there are no conflicts of interest. SETTING Niche in the uterus is defined as an indentation in the myometrium at the uterine incision owing to healing defects [1]. Surgical treatment options for niche include hysteroscopic, laparoscopic, and vaginal surgery [2]. Compared with hysteroscopic surgery, regular vaginal surgery may effectively increase the residual myometrium thickness, reducing the risk of subsequent pregnancy [3-5]. However, regular vaginal surgery removes the original scar defect followed by suture, which can lead to a new niche after the surgery and may postpone conception because of the new uterine incision [6]. Here we describe a new technique of hysteroscopy-assisted transvaginal repair for the niche, which does not remove the original scar defect [7]. This surgery may be beneficial for those who plan conceive as soon as possible after the operation. INTERVENTIONS Hysteroscopy-assisted vaginal surgery without scar defect resection was selected as ideal surgical approach. Hysteroscopy was used for abnormal structures in the niche [8,9]. Opening the peritoneum through the vaginal wall confirmed the position of the niche, and a 2-0 absorbable suture was used to interruptedly suture the upper and lower margins of the scar defect and close the niche (or reduce its size), rather than resection. Hysteroscopy was used again to assess the status of the niche after suture and confirm repair. If unsatisfactory, suture procedure was repeated to close the remaining part of the niche. CONCLUSION Our novel technique, described and demonstrated in this video article, is an efficacious and viable approach to treat uterine niche. Chinese experts recommend at least a 1-year gap between conventional scar defect resection with suturing and conception, because of the new uterine incision [6]. In contrast, this novel procedure avoids removal of the original scar defect and the surrounding scar tissue by directly repairing the lower uterine segment. Meanwhile, hysteroscopy can treat abnormal structures in the niche and improve effectiveness. Given that the integrity of the uterine myometrium is retained, this technique may help shorten contraception time after operation. Further studies with larger sample size, longer follow-up time, and more postoperative follow-up indicators, such as fertility outcomes, are needed to comprehensively evaluate the restorative effect of this novel technique.
Collapse
Affiliation(s)
- Minjiao Zhu
- International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China; Shanghai Key Laboratory of Embryo Original Diseases, Shanghai, China; Shanghai Municipal Key Clinical Specialty, Shanghai, China (all authors)
| | - Wei Xia
- International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China; Shanghai Key Laboratory of Embryo Original Diseases, Shanghai, China; Shanghai Municipal Key Clinical Specialty, Shanghai, China (all authors)
| | - Yan Liang
- International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China; Shanghai Key Laboratory of Embryo Original Diseases, Shanghai, China; Shanghai Municipal Key Clinical Specialty, Shanghai, China (all authors)
| | - Jian Zhang
- International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China; Shanghai Key Laboratory of Embryo Original Diseases, Shanghai, China; Shanghai Municipal Key Clinical Specialty, Shanghai, China (all authors).
| |
Collapse
|
6
|
Cetin F, Kayar İ, Serin AN, Birge Ö. Efficacy of suction curettage as the first-line treatment of cesarean scar pregnancy: A retrospective study. J Gynecol Obstet Hum Reprod 2023; 52:102531. [PMID: 36592889 DOI: 10.1016/j.jogoh.2022.102531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 12/03/2022] [Accepted: 12/28/2022] [Indexed: 12/31/2022]
Abstract
OBJECTIVE There is still no consensus on a safe and efficient treatment modality for cesarean scar pregnancy (CSP), which is known to cause severe complications, such as life-threatening hemorrhage. Suction curettage (SC) has been used as the first-line treatment for CSP with controversial outcomes. In this context, the objective of this study is to analyze the efficacy of SC in the treatment of CSP. METHODS The sample of this retrospective study consisted of 64 CSP patients treated using SC between 2012 and 2022. Patients' demographic and clinical variables, including the thickness of the myometrium at the lower uterine segment between the urinary bladder and cesarean scar, were obtained from their medical records. The study's primary outcome was determined as the success rate of SC. Accordingly, the patients were categorized into two groups: successful SC (Group 1) and unsuccessful SC (Group 2). RESULTS The success rate of SC was determined as 78.1%. The number of previous cesarean deliveries, gestational age, baseline beta-human chorionic gonadotropin (β-hCG) values, and endometrial thickness was significantly higher in Group 2 (p<0.05 for all), whereas the fetal cardiac activity and absence of an embryonic pole were significantly higher in Group 2 (p = 0.001 and p = 0.004, respectively). There was no significant difference between the groups in the thickness of the myometrium at the lower uterine segment (p = 0.890). The hemoglobin levels decreased significantly after SC in both Groups 1 and 2 (p<0.001 and p = 0.009, respectively). There was no significant difference between the groups in preoperative and postoperative hemoglobin values and the decrease in hemoglobin levels (p>0.05). CONCLUSION The study findings did not indicate any significant correlation between myometrial thickness at the lower uterine segment and the efficacy of SC in CSP patients. On the other hand, the number of cesarean deliveries, gestational age, baseline β-hCG values, endometrium thickness, fetal cardiac activity, and embryonic pole may be used to predict the outcome of SC in the treatment of CSP.
Collapse
Affiliation(s)
- Ferhat Cetin
- Department of Gynecology and Obstetrics, Osmaniye Private Park Hospital, Osmaniye, Turkey
| | - İlkan Kayar
- Department of Gynecology and Obstetrics, Osmaniye State Hospital, Osmaniye, Turkey.
| | - Aliye Nigar Serin
- Department of Gynecology and Obstetrics, Faculty of Medicine, Karamanoglu Mehmetbey University, Karaman, Turkey
| | - Özer Birge
- Department of Gynecology and Obstetrics, Ordu Training and Research Hospital, Ordu, Turkey
| |
Collapse
|
7
|
Tsuji S, Nobuta Y, Hanada T, Takebayashi A, Inatomi A, Takahashi A, Amano T, Murakami T. Prevalence, definition, and etiology of cesarean scar defect and treatment of cesarean scar disorder: A narrative review. Reprod Med Biol 2023; 22:e12532. [PMID: 37577060 PMCID: PMC10412910 DOI: 10.1002/rmb2.12532] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 07/05/2023] [Accepted: 07/25/2023] [Indexed: 08/15/2023] Open
Abstract
Background Cesarean scar defects (CSD) are caused by cesarean sections and cause various symptoms. Although there has been no previous consensus on the name of this condition for a long time, it has been named cesarean scar disorder (CSDi). Methods This review summarizes the definition, prevalence, and etiology of CSD, as well as the pathophysiology and treatment of CSDi. We focused on surgical therapy and examined the effects and procedures of laparoscopy, hysteroscopy, and transvaginal surgery. Main findings The definition of CSD was proposed as an anechoic lesion with a depth of at least 2 mm because of the varied prevalence, owing to the lack of consensus. CSD incidence depends on the number of times, procedure, and situation of cesarean sections. Histopathological findings in CSD are fibrosis and adenomyosis, and chronic inflammation in the uterine and pelvic cavities decreases fertility in women with CSDi. Although the surgical procedures are not standardized, laparoscopic, hysteroscopic, and transvaginal surgeries are effective. Conclusion The cause and pathology of CSDi are becoming clear. However, there is variability in the prevalence and treatment strategies. Therefore, it is necessary to conduct further studies using the same definitions.
Collapse
Affiliation(s)
- Shunichiro Tsuji
- Department of Obstetrics and Gynecology Shiga University of Medical Science Otsu Shiga Japan
| | - Yuri Nobuta
- Department of Obstetrics and Gynecology Shiga University of Medical Science Otsu Shiga Japan
| | - Tetsuro Hanada
- Department of Obstetrics and Gynecology Shiga University of Medical Science Otsu Shiga Japan
| | - Aike Takebayashi
- Department of Obstetrics and Gynecology Shiga University of Medical Science Otsu Shiga Japan
| | - Ayako Inatomi
- Department of Obstetrics and Gynecology Shiga University of Medical Science Otsu Shiga Japan
| | - Akimasa Takahashi
- Department of Obstetrics and Gynecology Shiga University of Medical Science Otsu Shiga Japan
| | - Tsukuru Amano
- Department of Obstetrics and Gynecology Shiga University of Medical Science Otsu Shiga Japan
| | - Takashi Murakami
- Department of Obstetrics and Gynecology Shiga University of Medical Science Otsu Shiga Japan
| |
Collapse
|