Experience in medical treatment of ectopic pregnancy, cesarean scar with three comparative methods: Methotrexate intra-gestational-sac injection, ultrasound-guided KCL injection, and hysteroscopy-assisted resection.

Delayed hysteroscopic resection for retained placenta accreta following vaginal delivery

Background. Cesarean scar pregnancy (CSP) represents a significant problem in contemporary obstetrics and gynecology. This condition may result in life-threatening complications requiring urgent medical care. Hysteroscopic resection in the “cold loop” mode combined with vacuum aspiration of the gestational sac has been shown to be an effective and safe surgical method for managing CSP. Objective. To analyze various treatment approaches for cesarean scar pregnancy and to determine optimal surgical strategies, as well as to assess morphological findings in operative specimens from patients with CSP. Materials and Methods. The study was conducted at the Moscow Regional Research Institute of Obstetrics and Gynecology named after Academician V.I. Krasnopolsky. Between 2016 and 2025, 41 patients with CSP underwent surgical management. The study compared treatment strategies employed between 2016–2019 with those applied in the last five years. Clinical features, preoperative ultrasound findings, and surgical methods were analyzed, including laparotomic metroplasty, vacuum aspiration of the gestational sac, hysteroscopic resection using the “cold loop” technique, and hysterectomy. Results. More than half of the women had a history of more than two cesarean sections with cervical dilatation exceeding 5 cm. Ultrasonography confirmed localization of the gestational sac within the scar zone in all cases (COS-1 sign). Chorionic invasion was identified in 22.7% of patients. Both organ-preserving and radical treatment strategies were applied. Over the past five years, there has been a clear trend toward minimally invasive surgical techniques, which reduce hospitalization time and accelerate postoperative recovery. The morphological complex identified in scar niches with ectopic pregnancy resembled that of abnormal placentation (placenta accreta), but given the early gestational stage and the absence of a fully formed placenta, it may be more accurately described as chorionic invasion. Conclusion. Cesarean scar pregnancy is a rare but extremely dangerous complication that may result in uterine rupture, massive hemorrhage, and maternal mortality. Minimally invasive, organ-preserving interventions — vacuum aspiration and hysteroscopic resection in the “cold loop” mode — represent the optimal treatment strategies. In cases of severe structural damage to the uterine wall, metroplasty is justified.

A 34-year-old nulligravid lady was referred to the outpatient gynecology department with the symptoms of abnormal menstrual bleeding and mild anemia. A transvaginal ultrasound (TVS) revealed the presence of a hyperechoic lesion measuring 9.5x4.5 mm in the uterine cavity at the level isthmus (lower uterine segment), suggestive of an endometrial polyp. Consequently, a diagnostic hysteroscopy was performed. Transcervical hysteroscopic resection (TCR) and diagnostic curettage (D&C) were accomplished. A macroscopic analysis of the specimen exhibited a white, pale polypoid formation measuring 1x1 cm with a hard consistency. Histology analysis confirmed the diagnosis of an atypical polypoid adenomyoma (APA). All these findings were explained to the patient and the risk of potential progression to endometrial carcinoma was discussed in detail. A multidisciplinary meeting (MDT) was held and conservative management with levonorgestrel coil insertion or Methoxy progesterone administration per os, along with frequent hysteroscopies every three months, was offered. The patient decided to undergo a hysterectomy with preservation of the ovaries, despite the lack of childbearing. A laparoscopic-assisted vaginal hysterectomy with preservation of adnexa was performed. The pathology analysis confirmed the diagnosis of APA with coexistence of well-differentiated (low-grade) endometrioid carcinoma of the endometrium, stage Ia. We performed a systematic review of systematic reviews with APA and quality assessment of the included studies. Furthermore, a flow-chart guideline for the management of APA in premenopausal and postmenopausal women is offered. Atypical polypoid adenomyoma is a rare clinical entity. It occurs mainly during the reproductive period of a woman. It is associated with abnormal vaginal bleeding, infertility, nulliparity, obesity, metabolic syndrome, hyperprolactinemia and hyperestrogenism. It is a risk factor for the development of endometrial hyperplasia and subsequent endometrial cancer. Preoperative diagnosis is extremely difficult; there are no specific imaging landmarks in ultrasound and magnetic resonance imaging (MRI) assessment. In patients with a desire for fertility, the management is complicated and should be based on a four-step hysteroscopic transcervical resection of the lesion. Hysterectomy is the right option for post-menopausal women and for women not wishing to conceive.

Background/Objective: Cesarean scar pregnancy (CSP) represents a challenging and potentially life-threatening form of ectopic pregnancy. This study aims to assess the feasibility, safety, and clinical efficacy of employing the hysteroscopic mechanical tissue removal system as a primary treatment modality for CSP. Methods: This retrospective cohort study included 53 patients diagnosed with CSP who underwent primary hysteroscopic resection at a tertiary care center. The surgical procedure was performed by prioritizing the “no-touch” vaginoscopic approach, which avoids instrumentation. Success rates, operation time, time to negative serum β-hCG, complications, and differences between the anatomical types of CSP (Type 1 vs. Type 2) were analyzed. Results: Primary hysteroscopic treatment was successful in 51 of 53 patients (96.2%). For the entire cohort, the median operative time was 7 min (range: 2–30), and the median interval to β-hCG negativization was 11 days (range: 6–45). The overall major complication rate was 3.8% (n = 2). One case was deemed unsuccessful due to conversion to laparotomy following uterine perforation during cervical dilation. Another patient, diagnosed with persistent trophoblastic disease requiring methotrexate (MTX) therapy, was also considered a treatment failure. Operative time was significantly longer in patients with Type II CSP compared with Type I (median 9 min vs. 5 min; p = 0.0004). Conclusions: Hysteroscopic mechanical tissue removal as a primary treatment for cesarean scar pregnancy represents an effective and safe “one-step” approach, characterized by a high success rate, rapid β-hCG resolution, and a low incidence of complications. This fertility-preserving, minimally invasive technique may be considered a primary treatment option for hemodynamically stable patients with CSP, provided that appropriate patient selection is undertaken and sufficient surgical expertise is available.

The study aimed to evaluate the efficacy of hormone treatment, barrier gel and their combined application following hysteroscopic metroplasty in women with septate (U2) and T-shaped uteri (U1a). Hysteroscopic uterine septum resection was performed in 236 patients with U2, while lateral metroplasty was conducted in 191 patients with U1a. After surgery, 56 women with U2 and 58 women with U1a received hormone therapy (HT). Cross-linked hyaluronic acid (cHA) gel was applied to 54 women with U2 and 37 with U1a. Combined therapy (CT) using both HT and cHA gel was implemented for 48 women with U2 and 33 with U1a. Postoperative treatment was not performed in corresponding control groups. Reproductive outcomes were evaluated within 18 ± 6 months postoperatively. Compared to the control group, the clinical pregnancy rate was significantly higher in the U2-HT, U2-cHA and U2-CT groups, as well as in the U1a-HT and U1a-CT groups (p < 0.05). The miscarriage rate was significantly lower in the U2-cHA and U2-CT groups (p < 0.05). The live birth rate was significantly higher in the U2-cHA and U2-CT groups (p < 0.05). A second-look hysteroscopy revealed intrauterine adhesions in U2-HT (9%) and its respective control group (33%), as well as in the U1a control group (18%). Hysteroscopic metroplasty enhances reproductive outcomes in women with septate and T-shaped uteri. Postoperative treatment is necessary to prevent the development of intrauterine adhesions.

Background/Objectives: Pain assessment during hysteroscopy facilitates rapid operator intervention (e.g., repeated anesthesia, administration of additional analgesics, or termination of the procedure), thereby improving patient comfort. Traditionally, pain intensity has been evaluated based on the patient’s subjective reporting; however, the introduction of an objective indicator in combination with subjective measures can considerably improve pain assessment. In this context, the present study aimed to evaluate pain intensity in patients undergoing hysteroscopy under local anesthesia (GUBBINI Mini Hystero-Resectoscope; Tontarra Medizintechnik, Tuttlingen, Germany), with simultaneous assessment using the Visual Analog Scale (VAS) and the Analgesia Nociception Index (ANI). Determining the relationship between ANI and VAS could contribute to improving patient comfort during hysteroscopic procedures performed under local anesthesia. Methods: The study included a total of 221 patients between the ages of 22 and 82 years, divided into two groups: 125 patients underwent diagnostic hysteroscopy (HD) and 96 patients underwent operative hysteroscopy (HO). After the procedure, patients were asked to assess pain intensity by using the VAS. The ANI was also monitored during the procedure. Measurements were conducted immediately before the procedure (T0), at the 1st minute (T1), mid-procedure (T1/2), and at the end of the procedure (T2). Results: The mean pain score in the study group was 3 points (3.04 ± 2.29), with a mean post-procedure score of 2.79 ± 2.19 and 3.36 ± 2.38 in the DH and OH groups, respectively. At Tmean, the ANI values ranged from 42 to 97 points, with a mean value of 70 points (70.37 ± 10.99). All correlations between the ANI values and VAS pain scores were statistically nonsignificant (p > 0.05), with correlation coefficients close to zero. This finding indicates that subjective pain assessment (VAS) does not correspond to the ANI values, which reflects the physiological autonomic response. Conclusions: Further research on pain assessment during hysteroscopy is warranted. Future studies should include larger patient populations, conduct continuous ANI monitoring, and correlate ANI with real-time subjective pain assessments (e.g., VAS during the procedure). The determination of psychological factors, such as pre-procedural anxiety, and the use of additional autonomic nervous system measures (e.g., skin conductance and pupillometry) could facilitate the development of a comprehensive model for objective pain assessment in patients undergoing gynecological procedures through hysteroscopy.

This study aimed to evaluate the safety and feasibility of manual vacuum aspiration (MVA) for the removal of endometrial polyp-like lesions, an approach potentially simpler and less resource-intensive than conventional hysteroscopic techniques. We conducted a prospective case series including 29 patients with suspected endometrial polypoid lesions based on ultrasound findings. After informed consent, transcervical resection (TCR) using a 26Fr rigid resectoscope was performed to visualize the uterine cavity. MVA was then applied to aspirate the endometrial tissue, including polyp-like lesions, immediately followed by TCR to check for residual tissue. Clinical data were collected for each patient, and the study was approved by the institutional review board. Complete removal by MVA alone was achieved in 25 of 29 patients (86.2%). In 4 cases (13.8%) with lesions > 20mm and thick stalks, additional TCR was required for complete resection. The number of aspirations in complete cases ranged from 1 to 3. No perioperative complications occurred. MVA is a safe, simple, and cost-effective technique for removing small-to-moderate endometrial polyp-like lesions. Except for particularly large polyps, MVA may represent a viable alternative to hysteroscopic resection, reducing the need for specialized equipment.

To analyze the incidence and characteristics of postoperative intrauterine adhesions (IUAs) and septal remnants (SRs) following hysteroscopic septum resection performed without anti-adhesion adjuvant therapies. This retrospective cohort study included patients with a septate uterus (U2a/U2b, ESHRE/ESGE classification) who underwent hysteroscopic septum resection without anti-adhesion adjuvant therapies between 2014 and 2023. Only patients with second-look hysteroscopy performed within 1-6 months postoperatively were included. Patients with pre-existing intrauterine adhesions, submucosal fibroids, prior septum resection, or adjuvant therapy use were excluded. Primary outcomes were the incidence, location, and type of postoperative IUAs and SRs. A total of 285 patients were included in the analysis. Postoperative IUAs were identified in two (0.7%) cases. SRs were observed in 98 (34.4%) patients, with 21 (7.4%) cases measuring <5 mm, 76 (26.7%) cases between 5-10 mm, and one (0.4%) case exceeding 10 mm. Among the 196 patients who attempted conception postoperatively, 161 (82.1%) achieved pregnancy. A total of 39 (24.2%) patients experienced miscarriage, three (1.9%) had an ectopic pregnancy, and live birth was achieved in 114 (58.2%) cases. Hysteroscopic septum resection without anti-adhesion therapies resulted in a low incidence of IUA and frequent SRs. Routine second-look hysteroscopy may aid early detection and treatment. Further studies are needed to clarify its role in optimizing reproductive outcomes.

Purpose: Retained products of conception (RPOC) are a common complication after pregnancy. While hysteroscopic resection is the standard treatment when RPOC does not resolve spontaneously, highly vascular tissue can lead to severe bleeding during the procedure. This study assessed clinical outcomes, procedural safety, and reproductive performance in patients with highly vascular RPOC treated with uterine artery embolization (UAE) prior to hysteroscopy, compared to those treated with hysteroscopy alone. Methods: This retrospective study included 42 women diagnosed with RPOC at University Medical Centre Ljubljana, Slovenia (2010–2020). Patients were divided into two groups: UAE followed by hysteroscopic resection (UAE + HSC, n = 21) and hysteroscopic resection alone (HSC-only, n = 21). Data on clinical outcomes, complications, and reproductive history were analyzed using Fisher’s exact and t-tests (p < 0.05). Results: Groups were similar in baseline characteristics, except for greater vascularity in the UAE + HSC group (100% vs. 4.8%, p < 0.05). Bleeding >300 mL occurred more often in the UAE + HSC group, but all cases were managed conservatively and only one patient required transfusion. No uterine perforations occurred. Residual RPOC was found in one patient per group. Rates of endometritis, menstrual changes, and pelvic pain were comparable. Among those who attempted conception, live birth and miscarriage rates did not differ significantly. Conclusions: UAE prior to hysteroscopic surgery appears to be a safe and effective option for highly vascular RPOC, especially in patients at risk of hemorrhage, with no adverse impact on fertility. Further prospective studies are recommended.

"Combined use of Radiofrequency ablation and hysteroscopy in the treatment of uterine Myomas: An innovative approach".

Impact of hysteroscopic septum resection on pregnancy Outcomes: A 20-Year retrospective monocentric study.

13194 Treatment of 13-Week Placenta Accreta: Hysteroscopic Resection, Uterine Artery Embolization and Robotic Isthmocele Repair

Endometrial polyps (EPs) are prevalent benign intrauterine growths linked to abnormal uterine bleeding and a potential risk of malignancy. While transvaginal sonography (TVS) is commonly used as a non-invasive screening method, its diagnostic performance varies depending on patient characteristics. Hysteroscopy (HSC), although more invasive, remains the gold standard for EP diagnosis. In this prospective cohort study involving 80 patients with suspected EPs, both TVS and HSC were performed to evaluate their diagnostic accuracy. Overall, HSC demonstrated superior accuracy (95.0% vs. 82.5%), specificity (94.4% vs. 72.2%), and area under the curve (0.94 vs. 0.79) compared to TVS. The sensitivity of TVS was significantly lower in postmenopausal women (66.7%) than in perimenopausal women (86.8%). For polyps smaller than 1.5 cm, TVS also showed markedly reduced sensitivity compared to HSC. However, TVS performance improved in cases with endometrial thickness no less than 8 mm. These findings suggest that while TVS is a useful first-line tool, especially for perimenopausal women or those with thickened endometrium, HSC provides higher diagnostic accuracy and should be prioritized in cases involving postmenopausal status or smaller polyps.

Hysteroscopic management of early miscarriage is a safe and effective technique with positive later reproductive outcomes. A systematic literature review was carried out to evaluate the use of hysteroscopy in the management of early miscarriage. Twenty-four articles were selected and their characteristics and results were analyzed. The different studies demonstrate the advantages of hysteroscopic resection over standard dilatation and curettage. This method can be an innovative treatment for early miscarriage in selected cases such as patients with recent uterine surgery, recurrent pregnancy losses, history of retained products of conception, congenital uterine alformations or intracavitary structural lesions.

Background/Objectives: This study compared the cost-effectiveness of 4D transvaginal ultrasonography (TVUSG), hysterosalpingography (HSG), and hysteroscopy (HS) in evaluating postoperative uterine correction among patients who underwent hysteroscopic metroplasty for a dysmorphic uterus. Additionally, pregnancy outcomes following surgery were assessed. Materials and Methods: Thirty-one patients who underwent hysteroscopic metroplasty due to a dysmorphic uterus between July 2023 and June 2024 were retrospectively analysed. Postoperative uterine cavity evaluations were performed exclusively using 4D transvaginal ultrasonography (4D-TVUSG). The characteristics of alternative imaging modalities (HSG and HS) were evaluated conceptually in terms of invasiveness, feasibility, and cost based on official Ministry of Health data and previously published literature, rather than through direct patient-based comparison. One-year postoperative pregnancy outcomes were also recorded. Results: Notably, 4D-TVUSG was considered preferable to HSG and HS due to its non-invasive nature, ease of use, lack of anaesthesia requirement, and lower cost. Postoperatively, 14 patients (45.2%) achieved pregnancy, of whom 3 (21.4%) experienced miscarriages and 11 (78.6%) had ongoing pregnancies or live births. All patients demonstrated a normalised uterine cavity on follow-up and a 100% surgical success rate. Conclusions: It was found that 4D-TVUSG is a reliable, cost-effective, and non-invasive method for postoperative assessment in patients with a dysmorphic uterus undergoing hysteroscopic metroplasty. This is the first study to compare the cost-effectiveness of these three imaging methods, highlighting 4D-TVUSG as a potential first-line follow-up tool in clinical practice.

This study aims to investigate the clinicopathological features, imaging findings, and reasons for misdiagnosis of uterine atypical polypoid adenomyoma (APA) to improve its preoperative diagnostic accuracy. We report a case of a 46-year-old woman presenting with irregular vaginal bleeding who was admitted in April 2025. Preoperative imaging, including transvaginal ultrasound, MRI, and PET-CT, was misinterpreted as endometrial or cervical cancer. However, postoperative pathological examination confirmed APA, characterized by architecturally complex endometrial glands with extensive squamous metaplasia and a stroma composed of proliferating smooth muscle and fibrous tissue. Following hysteroscopic resection, the patient recovered well. This case underscores that APA is a rare uterine lesion with malignant potential, often misdiagnosed due to nonspecific imaging features. Improved recognition of its imaging characteristics combined with pathological evaluation is essential to avoid misdiagnosis and guide individualized treatment.

BackgroundEndometrial polyps are a common gynecological condition that often cause significant clinical symptoms. Hysteroscopic resection is considered the gold standard treatment; however, recurrence remains a notable risk even after surgery. The recurrence of endometrial polyps after surgery raises concerns for women, due to persistent symptoms and potential malignancy risk. Therefore, this study aims to identify factors influencing recurrence in reproductive-aged women undergoing hysteroscopic polyp resection.Material/MethodsWe conducted a retrospective analysis of 1021 reproductive-aged women who underwent hysteroscopic polypectomy for abnormal uterine bleeding between 2010 and 2024. Diagnoses were confirmed by histopathological examination. Multivariable logistic regression modeling was used to determine predictors of recurrence.ResultsEndometrial polyp recurrence occurred in 8% of patients, with a median recurrence time of 42.5 months. Levonorgestrel-releasing intrauterine system (LNG-IUS) treatment significantly reduced recurrence (odds ratio [OR]=0.043, 95% CI=0.019–0.097, P<0.001). Risk factors for recurrence included adenomyosis (OR=10.297, 95% CI=5.251–20.188, P<0.001), polycystic ovarian syndrome (OR=8.990, 95% CI=2.855–28.312, P<0.001), body mass index ≥30 kg/m2 (OR=8.698, 95% CI=4.521–16.736, P<0.001), tamoxifen use (OR=6.088, 95% CI: 1.936–19.140, P=0.002), and leiomyoma uteri (OR=4.012, 95% CI: 2.143–7.509, P<0.001).ConclusionsClinicians should inform patients at high risk, including those with adenomyosis, myoma uteri, polycystic ovarian syndrome, or tamoxifen use, about the increased risk of recurrence and should conduct regular follow-ups. LNG-IUS treatment can be considered for the prevention of recurrence and enhancement of management strategies.

Predictive factors for two-step hysteroscopic resection of submucosal fibroids. A single-center retrospective study

A description of a manual mechanical hysteroscopy tissue removal device for operative hysteroscopy in the office setting.