Hysteroscopic Treatment Research Articles

Primary Hysteroscopic Treatment of Early Pregnancy Loss

<h3>Study Objective</h3> To demonstrate safety and feasibility of primary hysteroscopic treatment of first trimester miscarriage <h3>Design</h3> A surgical video reviewing the evidence supporting a hysteroscopic approach to surgical treatment of miscarriage followed by a step-by-step demonstration of two cases of miscarriage successfully treated with hysteroscopic resection. <h3>Setting</h3> Operating room and office. <h3>Patients or Participants</h3> We present two patients presenting with pregnancy loss at 7 weeks and 9 weeks gestation. <h3>Interventions</h3> Both patients are managed surgically with hysteroscopic resection of miscarriage. <h3>Measurements and Main Results</h3> Our hysteroscopic approach to the treatment of first trimester miscarriage has been highly successful, and so far, we have treated 45 patients with this approach. We are able to achieve complete resection in one procedure and follow up shows no intrauterine adhesions or remnant products of conception. Additionally, as prior evidence has demonstrated, with a directed biopsy approach we see a much higher rate of successful genetic analysis. This technique is both highly efficacious and feasible. <h3>Conclusion</h3> Primary hysteroscopic treatment of first trimester miscarriage is superior to blind suction D&C as it allows directed retrieval of products of conception, leading to comparatively minimal rates of intrauterine adhesions, remnant products of conception, and higher rates of successful genetic analysis. Adopting this alternative surgical approach is a natural and necessary step in the evolution of the treatment paradigm.

Incidence and Clinical Implications of Placenta Accreta Spectrum (PAS) after Hysteroscopic Treatment for Asherman's Syndrome

<h3>Study Objective</h3> To investigate the incidence of placenta accreta spectrum (PAS), predictors for malplacentation and clinical implications in pregnancies after hysteroscopic treatment for Asherman syndrome. <h3>Design</h3> Retrospective cohort study. <h3>Setting</h3> Minimally invasive gynecologic surgery practice in a community teaching hospital. <h3>Patients or Participants</h3> 355 patients hysteroscopically treated for Asherman's Syndrome 01/01/2015 - 03/01/2019 <h3>Interventions</h3> Observational study, retrospectively followed patients after hysteroscopic treatment for Asherman's Syndrome <h3>Measurements and Main Results</h3> Through telephone survey and confirmatory chart review, we identified 97 patients who achieved pregnancy passed the first trimester, following hysteroscopic treatment for Asherman's Syndrome. Among these patients, 23 (23.71%) patients had PAS. History of cesarean section was the only variable statistically significantly associated with having PAS (adjusted OR 4.03, 95% CI 1.31-12.39). PAS was diagnosed antenatally in three patients (13.04%), with patients having placenta previa more likely to be diagnosed (P<0.01). Nine patients (39.13%) with PAS required cesarean hysterectomy, which is 9.28% of those whose pregnancy progressed past first trimester. Factors associated with higher risk for cesarean hysterectomy were etiology of Asherman's syndrome (dilation and evacuation after the second trimester pregnancy or postpartum instrumentation, p<0.01), invasive placenta (increta or percreta, p<0.05) and history of morbidly adherent placenta in previous pregnancies (p<0.05). Two patients (8.70%) had uterine rupture, and another two (8.70%) experienced uterine inversion. For 76.19% patients with PAS, there was antenatal documentation on counseling on Asherman's Syndrome as a risk factor for PAS, however only 11 (47.82%) had documented counseling about the possible risk for having a cesarean hysterectomy. <h3>Conclusion</h3> High incidence of PAS and associated morbidity in pregnancies following hysteroscopic treatment for Asherman's Syndrome, together with the low rate of antenatal diagnosis, stresses the importance of clinical awareness, counseling and delivery planning. Clinicians who treat Asherman's Syndrome, including gynecologic surgeons and reproductive endocrinologists, should properly counsel and empower women to be their own advocates.

Does Procedure Time and Size Matter for Office Hysteroscopy Treatment of Retained Products of Conception?

<h3>Study Objective</h3> To establish the procedure time (PT) and mean size of retained products of conception (RPOC) treated in office hysteroscopy (OH). <h3>Design</h3> Retrospective Study (Canadian Task Force II- b). <h3>Setting</h3> Private Office Setting. <h3>Patients or Participants</h3> Patients with RPOC with or without prior treatment. <h3>Interventions</h3> Patients treated with a 5 mm continuous flow office hysteroscope, or Truclear^TM 5C System, or with 16 Fr resectoscope. <h3>Measurements and Main Results</h3> A total of 486 cases were reviewed, and 137 cases were included. 74(54%) patients had a PUS, and adherent RPOC was found in 6 (4.4%) (Chi - square analysis, p=-021) patients, all of which had a PUS. Descriptive analysis found the overall intra-operative visual analogue score (VAS) of pain < 5 to be 96.9 % and the Likert's scale of satisfaction with the procedure to be high (93.4%). The overall mean PT is 14.2±8 (mean±SD) min & the overall mean size is 2.1±.8 cm, and in PUS group it is 15±9 min & 2.2±.8 cm. Independent samples test was applied to variables, and no significant difference was found in VAS or satisfaction rates with or without PUS, but as the overall PT increases, the VAS increases (.307; sig(2-tailed)=.00) and satisfaction rate decreases (-.219; sig(2-tailed)=.01). Truclear had the shortest duration at 10±4 min(p=.00). 127(87.6%) patients who were very satisfied with the procedure, had a PT of 13.6±8 min(p=.064) & size of 2.1±.9 cm. The ROC curve was plotted for the PT and the size of RPOC. The PT was > 6.5 min in patients who had a PUS (86.5% sensitivity), but the specificity is low (14.3%), therefore, even in patients who had no PUS, the PT may be > 6.5 min. A risk of RPOC size > 1.55 cm is higher in PUS with 77% sensitivity and 42.9% specificity. <h3>Conclusion</h3> Women reported highest satisfaction with RPOC of size < 2.1 cm and the procedure time of < 14 min.

Osseous metaplasia of the endometrium: A multicenter retrospective study

ObjectiveTo describe clinical and demographic characteristics, ultrasound appearance, and hysteroscopic outcomes of patients with endometrial osseous metaplasia. Study designWe conducted a multicenter retrospective study. We retrospectively reviewed the medical records of all consecutive patients who were referred for hysteroscopy at fourteen institutions in Venezuela, Spain, Morocco, India, Ukraine, Argentina, the United States, and Italy between 1994 and 2018. We identified and included all patients who had a diagnosis of osseous metaplasia at the pathologic report, and data were retrieved from the medical records. ResultsBetween January 1st, 1994, and December 31st, 2018, 63 patients out of a total of 419,673 women who underwent hysteroscopy had a diagnosis of osseous metaplasia (0.015%). Most patients were 31–40 years old (53.7%), were Caucasian or Hispanic (95.5%), and had at least one previous pregnancy (86.9%). Forty-one out of 63 patients (65.1%) had at least one miscarriage before the index hysteroscopy. Dysmenorrhea, abnormal uterine bleeding, and infertility were reported by 34.9%, 27.0%, and 23.8% of patients. 14.3% of women were asymptomatic. Preoperative transvaginal ultrasound was available and identified a hyperechoic area of variable size with posterior acoustic shadowing in all cases. Hysteroscopy was successful without complications in all 63 cases. Follow-up data were available in 30.2% of patients: 69.2% of patients were infertile, and 44.4% of them conceived and achieved a live birth; all other symptoms improved after hysteroscopic treatment in all patients. ConclusionsOsseous metaplasia appears associated with multiple unspecific gynecologic symptoms without the predominant role of infertility, as previously suggested. Although endometrial osseous metaplasia is rare, gynecologists should consider this pathologic condition when the characteristic ultrasound appearance is detected, being hysteroscopic treatment effective.

Hysteroscopic treatment and reproductive outcomes in cesarean scar pregnancy: experience at a single institution

To study the risk factors leading to type II/III cesarean scar pregnancy and evaluate the efficacy of hysteroscopic treatment and subsequent reproductive outcomes. Retrospective study from 2013 to2018. Inpatient samples. A total of 439 patients with cesarean scar pregnancy received hysteroscopic treatment. They were grouped according to the type of surgery as hysteroscopy combined with dilation and curettage, systemic methotrexate followed by hysteroscopy combined with dilation and curettage, and uterine artery embolization or laparoscopic ligation of bilateral uterine arteries followed by hysteroscopy combined with dilation and curettage. Cesarean scar pregnancy was classified as types I, II, and III on the basis of the relationship between the gestational sac and myometrial thickness by ultrasound. Not applicable. Risk factors leading to type II/III cesarean scar pregnancy. The success of hysteroscopic treatment as well as favorable reproductive outcomes. The significant variables were multiple parity, prior cesarean section (CS), hysteroscopic therapy, and dilation and curettage after the last CS between type I and type II/III. There were significant differences among the three groups in symptoms, largest diameter of the gestational sac, presence of fetal heartbeat, myometrial thickness, type of cesarean scar pregnancy, blood loss, length of hospital stay, and expense. The rates of complications and success were 8.2% and 93.6%, respectively. Thirty-seven women conceived again, and 22 women completed a term pregnancy with no uterine rupture. The recurrence rate of cesarean scar pregnancy was 10.8%. The type of cesarean scar pregnancy is related to the rates of multiple parity, cesarean deliveries, and dilation and curettage procedures after the last CS. Hysteroscopic therapy is a safe and effective surgical approach with a low risk of subsequent ectopic pregnancy.

Symptoms and Quality of Life Changes after Hysteroscopic Treatment in Patients with Symptomatic Isthmocele-Preliminary Results.

Due to an increasing number of cesarean section deliveries, the common consequences of that surgery are observed more often in the population. One of them is the uterine cesarean scar defect known as niche or isthmocele. Most patients with that aliment are asymptomatic, but some of them can report abnormal uterine bleeding, pelvic pain, subfertility which can be the reason for reduced quality of life (QoL) of the patients. In our study, we analyzed the subjective feelings of changes in the severity of symptoms and quality of life of women with niche after diagnostic and operative hysteroscopy. The patients n = 85 included in the study group completed a follow up questionnaire six months after the procedure. Patients after operative hysteroscopy in comparison to patients after diagnostic procedure reported statistically significant reduction in post-menstruation bleeding/spotting and improvement in the quality of sexual activity. We have also noticed a higher pregnancy rate in the operative group, however, the difference was not statistically significant. According to our study, most women reported a positive effect of hysteroscopy on their QoL in social, psychological, environmental, and health domains.

Isthmocèle : définition, diagnostic, facteurs de risque, prévention, symptômes, complications, et traitements

ObjectivesTo review the definitions, diagnostic methods, risk factors, symptoms, and treatments for caesarean scar niche. MethodsReview of the literature, critical reflection, and pragmatic advice. ResultsThere is no consensus on the definition of caesarean scar niche. Some suggest an indentation≥2mm of the myometrium of the caesarean scar, but this is present in more than half of women with caesarean history and takes no account of woman's symptoms. The most popular diagnostic method is ultrasound±hysterosonography. Risks factors for niche are multiple Caesareans, Cesarean during labor with too low incision, and retroverted uterus. Symptoms include abnormal gynaecologic bleeding and pelvic pain, and their presence establish the “Caesarean scar syndrome”. The risks of pregnancy with niche is poorly studied, but pregnancy is not contraindicated, even if the niche is untreated. The treatment of caesarean scar niche is mainly surgery and conservative. The former should be reserved for symptomatic patients, and those with secondary infertility and fertility treatment failure. Patients with residual myometrium thickness≥2.5mm may benefit from first-line hysteroscopic treatment, whereas a laparoscopic or vaginal approach could be offered in other cases. ConclusionsA pragmatic definition of caesarean scar niche as a disease including symptoms is the necessary prerequisite for the management of women. The treatment is mainly surgical, or conservative depending on the desire for subsequent pregnancy.

The step-by-step hysteroscopic treatment of patients with vaginal and complete uterine septum with double cervix (U2bC2V1)

To demonstrate a systematic approach for the hysteroscopic management of a patient with uterine septum with double cervix and a nonobstructive longitudinal vaginal septum (Class U2bC2V1 of the ESHRE/ESGE classification). A step-by-step demonstration of the technique with narrated video footage of three different cases. University Hospital. We present three patients diagnosed with uterine septum with double cervix and a nonobstructive longitudinal vaginal septum (Class U2bC2V1 of the ESHRE/ESGE classification). Case 1 is a 31-year-old woman with class U2bC2V1 müllerian anomaly and primary infertility. Case 2 is a 29-year-old patient with class U2bC2V1 müllerian anomaly, infertility, and dyspareunia. Case 3 is a 32-year-old patient with class U2bC2V1 müllerian anomaly, infertility, and abnormal uterine bleeding. She also was diagnosed with a submucous leiomyoma. Hysteroscopic management of this complex müllerian anomaly using miniaturized hysteroscopic instruments, including the mini-resectoscope, was performed. All three procedures were performed in the operating room with the patient under general anesthesia. No complications were encountered. Patients were discharged home the same day of the procedure after a short period of observation. The critical aspects of the procedure are highlighted. Description of the systematic approach with a detailed demonstration of the critical steps of the procedure. Complete resolution of the vaginal septum with creation of a single uterine cavity was obtained in all three cases. Absence of intrauterine adhesion formation was confirmed. Due to the recent innovations in hysteroscopic equipment and improved surgical techniques, the hysteroscopic management of patients with complex müllerian anomalies using miniaturized instruments is a feasible and effective treatment option.

Transcervical fibroid ablation with the Sonata™ system for treatment of submucous and large uterine fibroids.

ObjectiveTo examine the role and benefits of transcervical fibroid ablation (TFA) in the treatment of submucous and large uterine fibroids.MethodsA subgroup of patients with submucous or large fibroids were analyzed from two prospective clinical trials (FAST‐EU and SONATA) of sonography‐guided TFA with the Sonata® system. Key outcomes were changes in menstrual blood loss, symptom severity and health‐related quality of life on the Uterine Fibroid Symptom and Quality‐of‐Life Questionnaire, health‐related quality of life on the EQ‐5D questionnaire, and surgical reinterventions for heavy menstrual bleeding.ResultsAmong 197 women (534 treated fibroids), 86% of women with only submucous fibroids and 81% of women with large fibroids (>5 cm) experienced bleeding reduction within 3 months post‐ablation. Overall symptom severity and health‐related quality of life showed sustained, significant improvements over 12 months. Additional fibroid mapping of large fibroids with magnetic resonance imaging in the FAST‐EU trial showed an average volume reduction of 68%. Among women with only submucous fibroids, the rate of surgical reintervention through 1 year of follow up was 3.7% in FAST‐EU and 0.0% in SONATA.ConclusionWith the Sonata system, TFA is an effective single‐stage treatment option for non‐pedunculated submucous myomata, and larger or deeper uterine fibroids (including fibroid clusters) for which hysteroscopic treatment is not suitable. ClinicalTrials.gov: FAST‐EU, NCT01226290; SONATA, NCT02228174.

Hysteroscopic Intact Removal of Angular and Caesarean Scar Pregnancy: A Novel and Markedly Less Invasive Surgical Treatment

Introduction: Ectopic pregnancy is the most common cause of mortality during the first trimester of pregnancy, and intrauterine ectopic pregnancies show significantly higher morbidity and mortality than extrauterine ones. Despite being less invasive, safety and effectiveness of the hysteroscopic treatment are still unclear. Moreover, such approach is not standardized. We aimed to evaluate safety and effectiveness of hysteroscopic intact removal of angular or cesarean section scar pregnancies, defining a novel and markedly less invasive hysteroscopic technique with a 5-mm Bettocchi hysteroscope or a 3.5-mm Versascope hysteroscope. Materials and Methods: Medical records and video archives were reviewed for all the patients with angular or caesarean scar pregnancies treated with hysteroscopic intact removal technique from January 2000 to December 2018 at our Department. Success and complication rates were assessed. Results: Four patients with angular (n = 1) or cesarean scar pregnancy (n = 3) met inclusion criteria. Case #1 was treated with bipolar resectoscope, cases #2 and #3 with 5-mm Bettocchi hysteroscope, and case #4 with 3.5-mm Versascope hysteroscope. Cases #2–4 did not require cervical dilatation. Before hysteroscopic treatment, cases #2–4 underwent unsuccessful medical therapy with multiple-dose methotrexate. Hysteroscopic treatment success rate was 100%, while complication rate was 0%. All patients were treated with a novel technique: hysteroscopic intact removal of angular or cesarean scar pregnancies. Such technique was described step-by-step. Conclusions: Hysteroscopic treatment of angular and cesarean scar pregnancies may be a safe and effective minimally invasive option. The novel technique of hysteroscopic intact removal technique may allow a markedly less invasive approach.

Comparative retrospective study on transvaginal sonography versus office hysteroscopy in the diagnosis of endometrial pathology among different subgroups.

Transvaginal sonography (TVS) and office hysteroscopy are considered essential diagnostic tool for the gynecologic everyday practice. Through the years equipment developments in both techniques along with cumulative experience gained by the gynecologists result in a disunity among clinicians in choosing optimal diagnostic approach with regards to endometrial pathology. To evaluate the diagnostic accuracy of TVS versus office hysteroscopy (OHSC) in detecting endometrial pathology. Results were compared to available scientific evidence available among similar published studies. Comparative Retrospective study performed at the Endoscopic Unit, Department of Gynecology, University Hospital of Ioannina, Greece. A total of 2675 cases were collected for this study from January 1997 until August 2019. All cases recruited underwent a TVS followed by office hysteroscopy (OHSC) for various indications according to the local protocol. Endometrial samples from all cases were obtained and histology confirmed the diagnosis. Sonographic and hysteroscopic results were correlated with histologic reports to assess the diagnostic accuracy of both techniques. In a total of 2675 cases recruited for this study, 23.2% were postmenopausal while the majority (76.7%) was of reproductive age. The commonest indication for hysteroscopy was abnormal uterine bleeding (AUB) accounting for 29.7% of the cases. Overall, TVS demonstrated diagnostic accuracy of 84.7%% in detecting endometrial pathology, compared to 97.3% of OHSC. Sensitivity, specificity, positive prognostic value (PPV) and negative prognostic value (NPV) of TVS detecting endometrial pathology were 84.0, 86.8, 95.3 and 63.0%, respectively. The corresponding values for hysteroscopy were 98.9, 95.1, 98.4 and 93.9%, respectively. Diagnostic value of both techniques was estimated in 6 (six) additional subgroups: total sample with AUB, women of reproductive age, women of reproductive age with AUB, women of reproductive age with infertility issues, postmenopausal women and postmenopausal women suffering from postmenopausal bleeding (PMB). All values were calculated with regards to histologic findings as gold standard technique. All results were correlated with scientific evidence collected from the international literature. Office hysteroscopy is a more reliable tool in detecting endometrial pathologies compared to TVS regardless of reproductive status or clinical presentation. TVS is likely to orientate and guide specialists on what to expect prior to an hysteroscopic intervention.

A Single Center Experience on Reproductive Outcome Following Hysteroscopic Treatment of Patients with Septate Uterus

A Single Center Experience on Reproductive Outcome Following Hysteroscopic Treatment of Patients with Septate Uterus

ULTRASONOGRAPHIC PARAMETERS PREDICT THE IMPROVEMENT OF POSTMENSTRUAL SPOTTING IN PATIENTS UNDERGOING HYSTEROSCOPIC TREATMENT OF ISTHMOCELE

Current literature supports a role for hysteroscopic isthmoplasty in treating isthmocele-related abnormal uterine bleeding. However, limited data is available on preoperative factors predicting successful hysteroscopic treatment. The objective of this study is to investigate the performance of bidimensional ultrasonography (TVS) and three-dimensional saline contrast sonohysterography (3D-SCSH) in predicting the improvement of symptoms in patients undergoing hysteroscopic treatment of cesarean scar isthmocele.

Hysteroscopic Treatment of Angular Pregnancy

Hysteroscopic Treatment of Angular Pregnancy

Hysteroscopic treatment of cesarean scar defect.

To investigate the effect of hysteroscopic surgery on the outcomes of obstetrics and gynecology among patients with cesarean section diverticulum. Ninety-nine infertile patients with cesarean section diverticulum received hysteroscopic treatment and were retrospectively analyzed. Patients were followed for 1year. The study included ninety-nine symptomatic patients with cesarean section diverticulum. After surgery, the menstrual periods of patients were improved from 11.15 ± 4.44 to 7.69 ± 2.85 days. Forty-seven (47/99) women became pregnant after surgery. The number of patients who became pregnant with an anteflexion uterus after hysteroscopic surgery is 32 (32/57), and the number of women who became pregnant with a retroflexion uterus is 15 (15/42). Hysteroscopic surgery could improve the PCSD-associated prolonged menstrual bleeding, and satisfactory obstetrical outcomes could be achieved by the surgery treatment in women with cesarean defect.

Randomized Study Comparing a Reusable Morcellator with a Resectoscope in the Hysteroscopic Treatment of Uterine Polyps: The RESMO Study

To compare a reusable hysteroscopic morcellator and standard resectoscopes in the hysteroscopic management of uterine polyps. Single-center randomized prospective single-blind trial (resectoscope-morcellator study). Centre Médico-chirurgical Obstétrique teaching hospital, Strasbourg University Hospitals, France. All patients presenting with a single endometrial polyp of size 1 cm or larger. 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. 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. 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. 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.

Hysteroscopic treatment of symptomatic adenomyoma

Hysterectomy has been the definitive treatment option for symptomatic adenomyosis and/or adenomyoma when medical or other conservative treatments fail to control the symptoms. Conservative surgery has already developed as an alternative treatment because of patients’ increasing desire to preserve their uterus. This video demonstrates a novel hysteroscopic treatment of symptomatic adenomyoma for patients with no desire for fertility.

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

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. A prospective cohort study. Tertiary care university hospital (S. Orsola-Malpighi, Bologna, Italy). 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). 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. 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. 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.

From hysteroscopy to laparoendoscopic surgery: what is the best surgical approach for symptomatic isthmocele? A systematic review and meta-analysis.

To investigate the effectiveness and risks of different surgical therapies for isthmocele in symptomatic women with abnormal uterine bleeding, infertility, or for the prevention of obstetric complications, considering safety and surgical complications. PubMed/MEDLINE, Scopus, Embase, Science Direct, and Cochrane Library were systematically searched (n° CRD4201912035) for original articles on the surgical treatment of isthmocele published between 1950 and 2018. Data synthesis was completed using MedCalc 16.4.3. The body of evidence was assessed using the GRADE methodology. We retrieved 33 publications: 28 focused on a single surgical technique, and five comparing different techniques. Meta-analysis showed an improvement of symptoms in 85.00% (75.05-92.76%) of women after hysteroscopic correction, 92.77% (85.53-97.64%) after laparoscopic/robotic correction, and 82.52% (67.53-93.57%) after vaginal correction. Hysteroscopic surgery was associated with the lowest risk of complications (0.76%, 0.20-1.66%). We found adequate evidence supporting the use of surgery for the treatment of symptomatic isthmocele, as it was found to improve the bleeding symptoms in more than 80% of patients. Differently, we found a lack of evidence regarding the role of surgery with the purpose of improving fertility or reducing the risk of obstetric complications in women with asymptomatic isthmocele. The hysteroscopic correction of isthmocele may be the safest and most effective strategy in those patients with adequate residual myometrial thickness overlying the isthmocele. Laparoscopic and vaginal surgeries may be the preferred options for patients with a thinner residual myometrium over the defect (< 2.5mm) and when hysteroscopic treatment is inconclusive.

Temporary Uterine Artery Embolization Followed by Hysteroscopy to Treat a Case of Acquired Uterine Arteriovenous Malformation (UAVM): Case Report with Systematic Literature Review

Objective: This paper provides information about conservative surgery to correct uterine arteriovenous malformations (UAVMs). The main objectives are to review the current literature on this subject and to share our very interesting and challenging case of UAVM. Our innovative surgical approach consisted in a combined method with temporary uterine artery embolization (UAE) plus hysteroscopic treatment. Materials and Methods: A search of MEDLINE, EMBASE, Web of Sciences, Scopus, ClinicalTrial.gov, OVID and Cochrane Library was performed. Any type of study has been considered including case reports. We identify articles published from the inception to July 2019. Three hundred sixty-three articles were identified: 286 articles were excluded for any reason. Overall, 77 articles were incorporated for further assessment. Results: Four surgical techniques have been employed to treat 125 cases of UAVMs: uterine artery embolization (UAE) (69.9%),dilatation and curettage (D&C) (10.4%), operative hysteroscopy (14.4%), uterine artery ligation (4%). Two patients (1.6%) underwent combined approach. Failed procedures which required a new treatment were twenty-one (16.8%). Forty-five pregnancies after surgical conservative management of UAVMs were reported. Conclusion: UAVM is a rare condition. In literature, there is no gold standard of treatment. For young women who wish to preserve fertility, a conservative surgical management should be recommended. As in our case, using a resorbable agent to perform UAE permitted a normal restoration of the flow in the uterine artery after the hysteroscopic resection.