Three-contrasts method hysteroscopy: the use of real-time ultrasonography for monitoring intrauterine operations

Ultrasound is the optimal choice for guidance in difficult hysteroscopy

OBJECTIVES

To compare costs and complications associated with ultrasound-guided hysteroscopy vs laparoscopy-guided hysteroscopy vs hysteroscopy alone for the surgical repair of intrauterine septa and synechiae.

METHODS

This was a retrospective cohort study. Charts of all patients undergoing reparative surgery for intrauterine synechiae or uterine septa at our academic institution between 2000 and 2008 were reviewed. A total of 159 procedures were included in the study, categorized into concurrent laparoscopic guidance (n = 69), ultrasound guidance (n = 52) or no guidance (n = 38). Data regarding billing, surgical case logs and complications were collected for these procedures. Using these data, complication rates and inflation-adjusted charges were compared between the groups. Statistical analysis was performed using Fisher's exact test and Student's t-test, as appropriate.

RESULTS

A uterine perforation rate of 8.7% was observed with laparoscopic guidance vs 1.9% with ultrasound guidance (P = 0.12) and 5.3% with no guidance (P = 0.41). Analysis of billing data showed that average total costs were significantly less for ultrasound guidance than for laparoscopic guidance ($9124 vs $11 895, P < 0.001). Ultrasound guidance did not increase costs over hysteroscopy alone ($9124 vs $8242, P = 0.54).

CONCLUSION

Real-time transabdominal ultrasound guidance during the resection of intrauterine synechiae or septa resulted in a trend towards reduced uterine perforation. Moreover, ultrasound guidance is less costly than laparoscopic guidance and adds no additional cost over hysteroscopy alone. Taken together, transabdominal ultrasound guidance is the optimal means of intraoperative guidance for the resection of uterine synechiae and septa.

Management of Asherman's syndrome

Intrauterine adhesions (IUA) or Asherman's syndrome is a multifaceted condition which is being diagnosed with increasing frequency. Although it usually occurs following curettage of the pregnant or recently pregnant uterus, any uterine surgery can lead to IUA. Most women with IUA have amenorrhoea or hypomenorrhoea, but some have normal menses. Those who have amenorrhoea may also have cyclic pelvic pain secondary to 'trapped' menses and the accompanying retrograde menstruation may lead to endometriosis. In addition to menstrual disorders, most women with IUA will present with infertility or recurrent spontaneous abortion. Over the last four decades hysteroscopy has become the standard method to diagnose and treat this condition. Various techniques for adhesiolysis and for prevention of scar reformation have been advocated. The most efficacious appears to be the use of miniature scissors for adhesiolysis and the placement of a balloon stent inside the uterus immediately after surgery. Post-operative oestrogen therapy is prescribed in order to stimulate endometrial regrowth. Follow-up studies to assure resolution of the IUA are mandatory before the patient attempts to conceive as is careful monitoring of pregnancies for cervical incompetence, placenta accreta and intrauterine growth restriction.

Hysteroscopic complications

Diagnostic and operative hysteroscopic procedures are performed to evaluate women with abnormal uterine bleeding structural uterine anomalies. Diagnostic and minimally invasive hysteroscopic surgical procedures in the hands of well-trained, experienced hysteroscopists offer little chance of serious complications. More extensive procedures offer greater risks, with fluid overload being the most common. The well-prepared and experienced hysteroscopic surgeon should have the ability, equipment, ancillary personnel, and facilities to prevent and to treat this problem, as well as the knowledge necessary to handle mechanical accidents, anesthetic complications, and post-procedure infections. The greatest risk in this procedure is, as always, an inadequately trained or ill-prepared operator.

Laparoscopic intracorporeal ultrasound guidance during hysteroscopic adhesiolysis

We introduce a case of hysteroscopic adhesiolysis by the guidance of laparoscopic intracorporeal ultrasound (LIU) in a patient complaining of amenorrhea and infertility found to have total intrauterine synechia. Adequate intrauterine adhesiolysis was performed by resectoscope with a wire loop, coordinating images of the endometrial cavity, uterine wall and the tip of the hysteroscope. She had regular menses after the operation and follow-up hysterosalpingogram at 3 months demonstrated satisfactory surgical results, with no evidence of intrauterine adhesions. To avoid the possibility of inadvertent uterine perforation, complex intrauterine procedures can be easily performed by the guidance of endoscopic ultrasonography.

Uterine rupture after hysteroscopic resection of uterine septum

OBJECTIVE

To describe a patient who underwent hysteroscopic resection of a uterine septum for recurrent miscarriage. The subsequent labor caused uterine rupture.

DESIGN

Case report.

SETTING

Academic medical center.

PATIENT(S)

A 37-year-old nullipara with three previous miscarriages.

INTERVENTION(S)

Resection of the septum by cutting diathermy using the operating hysteroscope.

MAIN OUTCOME MEASURE(S)

Pregnancy and delivery.

RESULT(S)

The patient had an uneventful pregnancy and spontaneous labor at 41 weeks. Cesarean section was performed because of suspected fetal distress. During cesarean section, the uterus was ruptured transversely along the fundus at the line of the attachment of the septum.

CONCLUSION(S)

When fetal distress occurs after previous uterine surgery, uterine rupture must be considered as a possible cause and appropriate treatment is necessary.

Reoperative hysteroscopic surgery in the management of patients who fail endometrial ablation and resection

STUDY OBJECTIVE

To determine the safety and efficacy of reoperative hysteroscopic surgery for women who fail endometrial ablation and resection.

DESIGN

Retrospective chart review and follow-up (Canadian Task Force classification II-2).

SETTING

Private office practice.

PATIENTS

Twenty-six women who had undergone endometrial ablation or resection and experienced failure characterized by intolerable pain, bleeding, or asymptomatic hematometra.

INTERVENTION

Sonographically guided hysteroscopic endomyometrial resection.

MEASUREMENTS AND MAIN RESULTS

Mean length of time from initial treatment for abnormal uterine bleeding and reoperative hysteroscopic surgery was 41.2 +/- 47.9 months. Five (19.2%) women required simple dilatation and 21 (80.8%) required endocervical resection to achieve access to the uterine cavity. There were no operative complications. Mean operating time was 20.3 +/- 9.5 minutes. Mean specimen weight was 6.7 +/- 4.9 g. Adenomyosis was present in 15 (57.7%) specimens. Women were followed for a mean of 23.2 +/- 22.7 months. Twenty-three (88.5%) achieved satisfactory results and avoided hysterectomy. Three women (11.5%) eventually required hysterectomy because of recurrent pain or bleeding.

CONCLUSION

Reoperative hysteroscopy is useful in managing women after failed endometrial ablation and resection. It produces excellent results in achieving amenorrhea and relief of cyclic pelvic pain, thereby avoiding hysterectomy in most patients.

Ultrasound guidance during endoscopic procedures

The use of laparoscopic ultrasound probes has been shown to improve outcomes and facilitate surgery for hepatobiliary and pancreatic cancers. It is a useful, inexpensive, and safe imaging technique that should also supplement operative laparoscopy for gynecologic indications. These techniques are new, and their use in gynecologic surgery has not been adequately evaluated to recommend widespread use. The principal benefit of ultrasound monitoring during operative laparoscopy is its potential impact on operative management and decision making. Theoretically, the intentions would be to reduce the amount of tissue dissection, for example, by more precisely locating an ovarian endometrioma; to reduce operating time; and to monitor more closely intrauterine procedures. Further prospective randomized studies are needed to define the exact role of ultrasound monitoring in gynecologic surgery. An exciting possibility is its use to define intraovarian anatomy more definitively in the hope of minimizing the amount of ovarian dissection and, in select circumstances, guiding further intrauterine surgery. With the use of steerable probes, an assessment could be made of the pelvic side wall in oncologic surgery to select specifically nodes that are highly suspicious for malignancies, thereby minimizing the amount of dissection necessary in staging procedures. Intraoperative ultrasound guidance in intrauterine endoscopic procedures offers a noninvasive means of assessing the precision of such procedures and provides information regarding the exact location of instruments within the uterine cavity and uterine wall. It has been used for almost 15 years, and adequate clinical experience has been accrued. It offers an alternative to more invasive laparoscopy and may be considered as an adjunct to any complicated intrauterine procedure.

Complications of hysteroscopy-their cause, prevention, and correction

Complications of hysteroscopy occur more frequently in operative than in diagnostic cases. Problems related to uterine distention are common, usually preventable, and potentially extremely serious. Perforation of the uterus may occur during hysteroscopy but do not always cause significant problems. In procedures of high risk for perforation the use of mechanical energy is safer than either laser or electrical energy. Laparoscopy and ultrasonography have some limited use in facilitating operative hysteroscopic procedures. Most complications occur during the hysteroscopic surgical procedure. However, some problems may not be apparent until the post operative period.