Development and Application of a Falloposcope for Transvaginal Endoscopy of the Fallopian Tube

Abstract

A small flexible microendoscope with an outside diameter (OD) of 0.5 mm has been developed for effective visualization of the entire length of the human fallopian tube. Using a transvaginal approach, a small flexible operating hysteroscope with an OD ranging from 3.3 to 4.5 mm, was used to visualize the uterotubal ostium (UTO) for cannulation of the tube. A coaxial technique, incorporating guidewire cannulation, placement of an "over the wire" Teflon catheter, and replacement of the guidewire with a falloposcope, for video documentation of endotubal surface anatomy has been carried out without complication in 55 women who had a total of 84 tubes available for tubal endoscopy. Characterization of normal and abnormal epithelial changes has been documented for the intramural, isthmic, ampullary, and fimbrial tube. Technical difficulties related to failure to negotiate the entire tubal lumen in the absence of obstructive disease occurred in 9 (11%) of the 84 endoscopy cases. These technical difficulties have been partly overcome by the incorporation of smaller directional guidewires, softer distortion-free Teflon catheters, improved microendoscopes, and the acquisition of new surgical skills necessary for safe and successful endoscopy of the fallopian tube. Minor difficulties were experienced in 7 (8%) of 84 endoscopies due to ostial spasm secondary to attempted guidewire cannulation. Cannulation was successful once spasm ceased. Of the 75 (89%) remaining successful tubal endoscopies, documentation of endotubal lesions ranging from accumulated debris, nonobstructive intraluminal adhesions, stenosis, polyps, to total fibrotic obstruction were observed in 43 (57%) examinations. The majority (70%) of these lesions were confined to the medial third of the tube, between the UTO and ampullary isthmic junction (AIJ). The tubal lumen was considered to be endoscopically normal in 32 (42%) examinations. Techniques of tubal aquadissection (TA), guidewire cannulation (GC), wire guide dilitation, and direct balloon tubuloplasty (DBT) under hysteroscopic-falloposcopic-laparoscopic control were devised for attempting to break down intraluminal adhesions, dilate a stenosis, or open up an obstruction in 35 of the 43 tubes containing a lesion. Combinations of these tubuloplasty techniques were effective for dislodging debris, breaking down adhesions, or dilating stenoses in 16 (58%) of 29 cases and consistently ineffective for bypassing true fibrotic obstructions in 6 (100%) of 6 cases. A detailed description of the falloposcope, its accessory instrumentation, and technique of falloposcopy is outlined. Additionally, preliminary evaluation of falloposcopically directed tuboplasty techniques and their effects on tubal lesions are described. This transvaginal endoscopic technique has been termed falloposcopy and the microendoscopic instrument, a falloposcope.