Postoperative morphologic changes of the isthmocele and clinical impact in patients treated by channel-like (360°) hysteroscopic technique

OBJECTIVE

To evaluate the changes in (1) residual myometrial thickness (RMT), (2) cesarean scar defect (CSD) size, and (3) clinical symptoms, before and after channel-like (360°) hysteroscopic resection for the treatment of CSD.

METHODS

A single-center, observational, prospective, cohort study was carried out enrolling all symptomatic patients of childbearing age, diagnosed with CSD and routinely scheduled for channel-like (360°) hysteroscopic resection from July 2020 to July 2021 at the Division of Gynecology and Human Reproduction Physiopathology, Department of Medical and Surgical Sciences, IRCCS Azienda Ospedaliero-Univeristaria di Bologna. University of Bologna, Italy. The primary outcome was the difference in mean RMT before and after the procedure. Secondary outcomes were the differences before and 4 months after the surgery in: (1) CSD size measured by transvaginal ultrasound, (2) visual analog scale (VAS) scores for the symptoms, and (3) abnormal uterine bleeding (AUB) rate. Lastly, patients' satisfaction was assessed by the global impression of improvement (PGI-I) score.

RESULTS

We found a significant difference before and after the procedure in: (1) mean RMT (+2.0 mm; P < 0.001); mean size of the CSD (base: +1.6 mm; height: -2.5 mm; transverse diameter: -3.2 mm; volume: -263.7 mm³ ; P < 0.001); (2) mean VAS score for dyspareunia (-5.84; P < 0.001), dysmenorrhea (-8.94; P < 0.001), pelvic pain (-2.94; P < 0.001); (3) AUB rate (91% vs. 3%; P < 0.001). Lastly, the mean PGI-I score ± SD was 1.7 ± 0.9.

CONCLUSION

Channel-like (360°) hysteroscopic resection for the treatment of patients with symptomatic CSD may lead to an increase in RMT, decrease in CSD, and improvement of symptoms after the procedure, with high patient satisfaction.

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

Background

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

Objective

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

Material and Methods

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

Main outcome measures

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

Results

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

Conclusion

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

Comparison of Hysteroscopic Cesarean Scar Defect Repair with 26 Fr Resectoscope and 16 Fr Mini-resectoscope: A Prospective Pilot Study

STUDY OBJECTIVE

Several studies have been published on hysteroscopic treatment of cesarean scar defect using the 26 Fr resectoscope. This study compared the effects of the 26 Fr resectoscope with those of the 16 Fr mini-resectoscope in terms of efficacy, safety profile, and peri- and postoperative complications.

DESIGN

A prospective cohort study.

SETTING

Tertiary care university hospital (S. Orsola-Malpighi, Bologna, Italy).

PATIENTS

Three hundred and nine women having symptoms and with a cesarean scar defect diagnosis were divided into 2 groups according to a temporal criterion: from March 2012 to March 2015, 155 consecutive women (control group) underwent isthmoplasty with the 26 Fr resectoscope (Karl Storz, Tuttlingen, Germany), whereas from April 2015 to March 2018, 154 consecutive women (study group) underwent isthmoplasty with the 16 Fr mini-resectoscope (Gubbini system, Tontarra Medizintechnik, Tuttlingen, Germany).

INTERVENTIONS

One hundred and fifty-five women (control group) underwent isthmoplasty with the 26 Fr resectoscope, and 154 women (study group) underwent isthmoplasty with the 16 Fr mini-resectoscope. The so-called "channel-like" 360° endocervical resection technique was applied.

MEASUREMENTS AND MAIN RESULTS

The isthmoplasty time with the 2 resectoscopes, excluding cervical dilatation, was similar (p = .25), whereas the overall surgical time was shorter in the case of the mini-resectoscope. The use of the 16 Fr mini-resectoscope was significantly associated with a reduced volume of distension medium used (p <.001) and a lower fluid absorption (p <.001). A significant increase (p = .01) in postoperative complications in the control group (9/155; 5.8%) compared with the study group (1/154; 0.7%) was also found. No significant reduction in discharge time was observed between the 2 groups (p = .13). Patient satisfaction immediately after surgery was significantly higher (p <.001) in the study group than in the control group.

CONCLUSION

Isthmoplasty with a 16 Fr mini-resectoscope seems to be as effective as isthmoplasty with a 26 Fr resectoscope in reducing postmenstrual abnormal uterine bleeding and suprapubic pelvic pain. It is associated with a significant reduction in overall surgical time owing to the non-necessity of performing cervical dilatation. The 16 Fr mini-resectoscope facilitates surgery in small anatomical spaces such as the cervical canal and reduces the complication rate linked to blind maneuvers not respecting the uterine anatomy.

Channel-like 360° Isthmocele Treatment with a 16F Mini-Resectoscope: A Step-by-step Technique

STUDY OBJECTIVE

To show the technique of hysteroscopic channel-like 360° repair of a cesarean scar defect performed with a Gubbini 16F miniresectoscope (GUBBINI system; Tontarra Medizintechnik, Tuttlingen, Germany).

DESIGN

A step-by-step demonstration of the surgical technique using slides, pictures, and a video (an instructive video [Video 1]).

SETTING

A university hospital (Bologna University Hospital, Sant'Orsola-Malpighi Polyclinic, Bologna, Italy).

PATIENTS

A 35-year-old woman with a history of a previous cesarean section complaining of pelvic pain and postmenstrual spotting.

INTERVENTIONS

With the vaginoscopic approach, the isthmocele was localized; a high-frequency 90° angled circular loop electrode and pure cutting current of 100 W were used to resect the fibrotic tissue of the proximal (step 1) and distal (step 2) part of the niche. We performed resection not only of the fibrotic tissue underneath the niche but also of the inflamed tissue placed around the niche and on the opposite site (the so-called channel-like 360° endocervical ablation). A high-frequency angled ball electrode was used to obtain focused coagulation of all residual inflamed tissue still present on the niche surface and on the cervical canal walls (step 3); the aim of this step is to facilitate the re-epithelialization of the cervical canal walls by the paraphysiological endocervical epithelium. The procedure was ended by controlling any bleeding of the endocervical vessels by reducing the inflow and pressure of the distending medium and by focused electrocauterization with a ball electrode (step 4).

MEASUREMENTS AND MAIN RESULTS

The operative time was 14 minutes. The small diameter of a 16F resectoscope and the use of a miniaturized loop without cervical dilation allow the operative procedures to be performed without cervical dilation and without anatomic distortion of the defect, reducing the risk of complications. The small diameter of the sheaths also makes the surgical gesture faster with an easier and faster approach to the niche compared with isthmocele hysteroscopic standard surgery.

CONCLUSION

The presence of a uterine scar defect is usually asymptomatic or refers to postmenstrual spotting with dark red or brown discharge, dysmenorrhea, dyspareunia, chronic pelvic pain, infertility, or a dull sensation after menstruation. Several factors may play a role in isthmocele development such as a low uterine incision, a deficient suturing technique of the uterine incision, and patient-related factors that impair wound healing or increase inflammation or adhesion formation. Different techniques were used as reconstructive therapies of the cesarean scar defect including laparoscopic or robot-assisted laparoscopic excision, vaginal repair, or hysteroscopic treatment. All of these procedures remove or ablate the niche fibrotic tissue with the aim of relieving symptoms. Asymptomatic cases should not be treated. According to the most recent literature, hysteroscopic repair of a cesarean scar represents an effective and safe surgical option in cases of a symptomatic isthmocele. The persistence of symptoms has been reported in up to 18% of cases, so adequate counseling should be performed before the procedure.

New outpatient subclassification system for American Fertility Society Classes V and VI uterine anomalies

STUDY OBJECTIVE

To produce and validate a simple, systematic and reproducible subclassification system for uterine anomalies previously classified by the American Ferility Society as Class V and VI to achieve a precise definition of each uterine anomaly, confirm the feasibility and safety of surgical correction of the anomalies, determine the type of hysteroscopic treatment, and provide a standard by which patient selection, treatment, and reproductive outcomes can be compared between centers.

DESIGN

Descriptive study (Canadian Task Force Classification III).

SETTING

Department of obstetrics and gynecology of a private clinic (hospital).

PATIENTS

Eighty-nine patients undergoing office hysteroscopy to assess partial or complete "double" uterine cavity.

INTERVENTIONS

All patients underwent 3-dimensional ultrasound. Data from hysteroscopy and untrasonography were combined to produce a geometric model comprising uterine septum length (Z variable) and fundus depth (Y variable) through which a new subclassification of the uterine anomalies was elaborated.

MEASUREMENT AND MAIN RESULTS

One patient with a bicornuate uterus detected at ultrasonography was excluded from the study. The remaining 88 patients were classified according to our subclassification system. Seventy-three patients categorized as having Z 2 cm or greater (septum intersecting one-third of the uterine cavity or more) and Y more than 0 cm (normal or straight uterine fundus) underwent resectoscopic metroplasty without laparoscopic control. Twelve patients categorized as A1 (normal uterine fundus and septum < or =0.5 cm) underwent office metroplasty. Two patients categorized as B1 (straight fundus and septum < or =0.5 cm) and 1 categorized as C1 (concave fundus and septum < or =0.5 cm) were not considered candidates for surgery. Second-look hysteroscopy confirmed complete removal of the septum in the 12 patients who underwent office metroplasty (100%) and in 70 of 73 patients (96%) who underwent resectoscopic metroplasty. Comparison of these data with data retrospectively obtained in 596 women who had undergone traditional resectoscopic metroplasty under laparoscopic control did not demonstrate any significant difference in success and complication rates.

CONCLUSION

Our outpatient subclassification system may address a precise diagnosis and a thorough categorization of patients with a partial or complete double uterine cavity, enabling safe and effective metroplasty without use of laparoscopy.

Accuracy of three-dimensional ultrasound in diagnosis and classification of congenital uterine anomalies

OBJECTIVE

To assess the accuracy of three-dimensional (3D) ultrasound in the diagnosis of congenital uterine anomalies.

DESIGN

Prospective study.

SETTING

University hospital.

PATIENT(S)

Nulliparae with three or more consecutive miscarriages.

INTERVENTION(S)

All women underwent 3D transvaginal ultrasound study of the uterine cavity.

MAIN OUTCOME MEASURE(S)

Women with negative ultrasound findings subsequently underwent office hysteroscopy, whereas a combined laparoscopic-hysteroscopic assessment was performed in cases of suspected Müllerian anomaly.

RESULT(S)

A specific Müllerian malformation was sonographically diagnosed in 54 women of the 284 included in the study group. All negative ultrasound findings were confirmed at office hysteroscopy. Among the women with abnormal ultrasound findings, the presence of a Müllerian anomaly was endoscopically confirmed in all. Concordance between ultrasound and endoscopy around the type of anomaly was verified in 52 cases, including all those with septate uterus and two out of three with bicornuate uterus.

CONCLUSION(S)

Volume transvaginal ultrasound appears to be extremely accurate for the diagnosis and classification of congenital uterine anomalies and may conveniently become the only mandatory step in the assessment of the uterine cavity in patients with a history of recurrent miscarriage.

Hysteroscopic metroplasty

STUDY OBJECTIVE

To evaluate 10 years' experience with hysteroscopic treatment of septate uterus in Italy.

DESIGN

Multicenter retrospective study conducted from January 1988 to March 1997 (Canadian Task Force classification II-2).

SETTING

Twelve Italian centers for minimally invasive therapy.

PATIENTS

Women (total 973) with hysteroscopically diagnosed septate uterus.

INTERVENTIONS

Hysteroscopic metroplasty performed with scissors, resectoscope, or neodymium:yttrium-aluminum-garnet laser.

MEASUREMENTS AND MAIN RESULTS

Data on indications for hysteroscopic metroplasty, details of patient management from pretreatment to follow-up, and pregnancy course and delivery were collected by questionnaire. Main indications were two or more abortions and primary infertility. Most procedures were performed with the resectoscope, followed by scissors and laser. Few minor complications occurred. Pregnancy rates were good.

CONCLUSION

Hysteroscopy is safe and effective treatment of septate uterus in terms of both pregnancy rate and outcome.

[The role of hysteroscopy in the diagnosis and follow-up of endometrial hyperplasia]

BACKGROUND

Preneoplastic lesions of endometrium such as endometrial hyperplasia (simple and complex with or without cytological atypias) represent an important cause of abnormal uterine bleeding. Among diagnostic techniques, hysteroscopy presents several advantages: it is an out-patient procedure, minimally invasive, repeatable, of rapid execution and with low cost. The hysteroscopic pattern of endometrial hyperplasia appears with an over-development of the endometrial mucosa with increased glandular openings, increased vascularization, cystic dilatations, polypoid aspects.

METHODS

Since October 1984 to January 1995 at the Gynecologic Endoscopic Service of Obstetrics and Gynecology Department of the University of Bologna, 13,438 hysteroscopies were performed: 291 (2.16%) in patients submitted to hysteroscopy for previous diagnosis of endometrial hyperplasia. The first diagnosis of endometrial hyperplasia was made in 125 (42.3%) patients through hysteroscopic biopsy, while for 166 patients (57.04%) the first diagnosis was made by endometrial curettage of VABRA.

RESULTS

The results showed that the endometrial hyperplasia is typical in perimenopausal age and this finding is more frequently symptomatic. The histological diagnosis after hysteroscopy was: simple hyperplasia in 106 patients (84.8%), complex in 12 patients (9.6%) and atypical in 6 patients (4.8%). One case of simplex hyperplasia was associated with endometrial cancer (0.8%). The comparison between histological diagnosis and hysteroscopic diagnosis showed that agreement is reached in 113 cases (90.4%). However, it is to note that diagnostic agreement of complex hyperplasia cases was about 100%, but in 22 cases the hysteroscopic diagnosis was simplex hyperplasia rather than complex or atypical. The errors of hysteroscopy were observed in 10 cases (8%).

CONCLUSIONS

The hysteroscopic diagnosis should not replace histological diagnosis, mostly in hysteroscopies performed after progestagen therapy, because the changes induced by drugs make more difficult the interpretation of hysteroscopy. However, hysteroscopy is complementary to histological analysis since permits a global evaluation of endometrial mucosa, directs biopsy on dishomogeneous areas and represents the only means to make diagnosis when biopsy is not practicable.

[Outpatient diagnostic hysteroscopy: 14,000 cases]

Hysteroscopy is a technique which plays a fundamental diagnostic role in gynecological practice. The possibility of obtaining a direct intracavitary view and performing specific biopsies give it a greater level of diagnostic accuracy than intrauterine curettage. The authors' personal experience of 13,923 case enables the correct method of performing this procedure to be codified in order to avoid the inherent risks and complications. The main indication is abnormal uterine bleeding which is the most frequently observed pathology in gynecological practice. In cases of metrorrhagia in women of child-bearing age benign organic pathology accounts for 45% of patients and malignant pathology 0.3%. Post-menopausal patients reveal an increase in the incidence of organic pathology in general and neoplastic pathologies in particular (8.1%). Complications linked to this type of technique are extremely rare and in overall terms affect 1% of cases. The analysis of results shows that hysteroscopy today represents an extremely reliable and repeatable outpatient procedure. However, in spite of these advantages, including savings in health costs, it is not widely used at a capillary level given that if performed by persons who are not expert it may become traumatic and unreliable. The correct execution of hysteroscopy in fact calls for dexterity acquired over time which is not conditioned by the learning of previous techniques and requires an adequate period of training.

Transvaginal sonography vs. hysteroscopy in the preoperative staging of endometrial carcinoma

The aim of this study was to evaluate the diagnostic accuracy of transvaginal sonography vs. hysteroscopy in the preoperative staging of endometrial carcinoma, in order to establish the most appropriate surgical therapy. Transvaginal sonography and hysteroscopy were used preoperatively in 67 women with histologically proven endometrial carcinoma. Deep myometrial invasion (> 50%) was present at postoperative pathology in 26/67 (39%) women and spread to the cervix occurred in 11/67 (16%) women. Transvaginal sonographic examination was initially directed at assessing myometrial invasion, which was correctly predicted in 52/67 (78%) women. Transvaginal sonography demonstrated a sensitivity of 88% (23/26) and a specificity of 71% (29/41) for deep invasion, with a positive predictive value (PPV) of 66% (23/35) and a negative predictive value (NPV) of 91% (29/32). The accuracy of transvaginal sonography in detecting cervical involvement was 82% (55/67), and that of hysteroscopy was 72% (48/67): transvaginal sonography was slightly less sensitive (54% vs. 64%), but more specific (87% vs. 73%) than hysteroscopy. When cervical invasion was present, the PPVs of transvaginal sonography and hysteroscopy were 46% (6/13) and 32% (7/22), respectively, while the NPV was 91% for both techniques (49/54; 41/45). Our data show that the accuracy of transvaginal sonography was comparable with that of hysteroscopy in detecting cervical involvement. Therefore, in the majority of cases, when both techniques showed that disease was limited, the appropriately limited type of surgery would be performed. Conversely, detection of a myometrial invasion of > 50% or an extension to the cervix would lead to an unnecessarily extensive operation if this was the sole criterion used for making the decision.

A case of unsuspected endometrial stromal sarcoma removed by operative hysteroscopy

A 26-year-old woman underwent operative hysteroscopy to remove a polypoid lesion, responsible for recurrent abnormal uterine bleeding. The polypoid mass was 4 cm long, smooth, with dilated vessels. It had a large base and originated from the fundum and posterior wall of the uterus. Pathological examination of the resected specimen showed low-grade stromal sarcoma. The patient subsequently underwent a total abdominal hysterectomy and bilateral salpingo-oophorectomy. No tumor residual was found in the surgical specimen. As diagnosis of stromal sarcoma is too difficult to be made preoperatively, the complete resection of all intracavitary lesions and the pathology of all tissue specimens are suggested.

Hysteroscopic metroplasty

Between February 1990 and June 1993 40 patients underwent hysteroscopic metroplasty for septate uterus. Twenty-six patients had previous miscarriages (65%) and fourteen were infertile (35%). Hysteroscopic section of uterine septa was performed by means of Hamou resectoscope with sorbitol-mannitol solution as distending medium. Surgical outcome was excellent without intraoperative and postoperative morbidity. After 40-60 days the uterine cavity was completely epithelialized without intrauterine adhesions in all the cases. One patient had incomplete septum section that required a second procedure. Postoperative reproductive outcome was evaluated in 26 patients: the cumulative pregnancy and birth rate was 73% and 86%, respectively. Five patients delivered by cesarean section (39%). In the infertile group the pregnancy and birth rate was much lower (44% and 75%, respectively) than in previous miscarriage group (88% and 91%, respectively). Infertile patients do not seem to be cured by hysteroscopic metroplasty; however, in these cases the endoscopic operation should be performed, because it may prevent subsequent miscarriage. Hysteroscopic metroplasty by means of Hamou resectoscope is a very successful, quick, simple and safe procedure that may replace abdominal metroplasty.

A method for evaluating human tubal motility in vivo: a new approach for infertility investigation

The motility of the Fallopian tube plays an important role in the gametes and embryo transport. Disorders of the tubal motor function may be involved in a great number of patients with unexplained infertility. The aim of this study was to develop a method to measure the tubal motility by means of an hysteroscopic approach in humans. The following motor parameters were evaluated: 1) the basal pressure of each 1 cm tract of the tube; 2) amplitude and frequency of the tubal contractions; 3) the uterine intraluminal pressure eight patients in the follicular phase (FP group) and 8 in the luteal phase (LP group) of the menstrual cycle, were studied. The duration of the motility recording session was 12 +/- 3 minutes (range 7-19 minutes). No significant differences were shown between the two groups of patients, and no differences were found between the recordings obtained from the right and the left tubes.