A modified technique for correction of the complete septate uterus

Evidence-based diagnosis and treatment for uterine septum: a guideline

OBJECTIVE

To provide evidence-based recommendations regarding the diagnosis and effectiveness of surgical treatment of a uterine septum.

METHODS

This guideline provides evidence-based recommendations regarding the diagnosis and effectiveness of surgical treatment of a uterine septum. This replaces the last version of the same name (Fertil Steril. 2016 Sep 1;106(3):530-40).

MAIN OUTCOME MEASURE(S)

Outcomes of interest included the impact of a septum on underlying fertility, live birth, clinical pregnancy, and obstetrical outcomes.

RESULT(S)

The literature search identified relevant studies to inform the evidence for this guideline.

CONCLUSION(S)

The treatment of uterine septa and subsequent outcomes associated with infertility, recurrent pregnancy loss, and adverse obstetrical outcomes are summarized. Resection of a septum has been shown to improve outcomes in patients with recurrent pregnancy loss and to decrease the likelihood of malpresentation. In the setting of infertility, it is recommended to use a shared decision-making model after appropriate counseling to determine whether or not to proceed with septum resection.

Hysteroscopic Fenestration with Precise Incision of the Cavity Septum: A Novel Minimally Invasive Surgery of Complete Septate Uterus with Double Cervix

STUDY OBJECTIVE

This study aimed to develop and describe a novel surgical procedure that involves hysteroscopic fenestration with precise incision of the complete uterine septum and double cervix preservation after magnetic resonance imaging (MRI) evaluation in patients and to evaluate its efficacy.

DESIGN

A prospective consecutive clinical study.

SETTING

A university teaching hospital.

PATIENTS

Twenty-four patients with complete septate uterus and double cervix.

INTERVENTIONS

Three-dimensional reconstruction of uterus was performed with pelvic MRI and three-dimensional SPACE sequence scanning. Hysteroscopic fenestration with precise incision of the cavity septum and double cervix preservation was performed in patients. Three months after operation, follow-up pelvic MRI and second-look hysteroscopy were performed conventionally.

MEASUREMENTS AND MAIN RESULTS

Operating time, blood loss, operative complications, MRI and hysteroscopic changes of uterus, symptoms improvement, and reproductive outcomes were assessed. The surgery was successfully completed without any intraoperative complications in all patients. Operating time was 21.71 ± 8.28 minutes (range, 10-40 minutes) and blood loss was 9.92 ± 7.14 mL (range, 5-30 mL). Postoperative MRI showed the uterine anteroposterior diameter (3.66 cm vs 3.92 cm; p <.05) was increased. Postoperative MRI and the second-look hysteroscopy showed the cavity shape and uterine volume were expanded to the normal. Symptoms of dysmenorrhea, abnormal uterine bleeding, and dyspareunia were ameliorated after the surgery in 70% of patients (7 of 10), 60% of patients (3 of 5), and 1 patient, respectively. The preoperative spontaneous abortion rate was 80% (4 of 5) and the postoperative spontaneous abortion rate was 11.11% (1 of 9). After the surgery, there were 2 ongoing pregnancies and 6 pregnancies ended in term births. Two live births were delivered by cesarean section and 4 by vaginal delivery without cervical incompetence during pregnancy.

CONCLUSIONS

Hysteroscopic fenestration with precise incision of the uterine septum and double cervix preservation is an effective surgical procedure.

Aggressive Cervical Dilation Exploits Potential Weakness in the Septum of Duplicated Cervix during Hysteroscopic Cervix-preserving Metroplasty of Complete Septate Uterus: A Cohort Study

STUDY OBJECTIVE

To evaluate whether aggressive cervical dilation is effective for creating the initial perforation between noncommunicating cavities of the complete septate uterus (CSU), which serves as the first step of hysteroscopic cervix-preserving metroplasty (CPM).

DESIGN

A retrospective cohort.

SETTING

A tertiary referral center.

PATIENTS

Fifty-three patients with CSU were diagnosed using vaginal examinations, combined two- and three-dimensional vaginal ultrasounds, and office-based hysteroscopies.

INTERVENTIONS

Patients who had received hysteroscopic CPM with the initial perforation created by aggressive cervical dilation or by the traditional method of bougie-guided incisions were compared.

MEASUREMENTS AND MAIN RESULTS

Of the 53 patients with CSU, 44 patients received hysteroscopic CPM that required the creation of a perforation. Patients who received aggressive cervical dilation for creation of the perforation had nonsignificantly shorter surgical times (33.5 minutes, 95% confidence interval [CI], 28.4-38.6 vs 48.7 minutes, 95% CI, 28.2-71.3, p = .099), used significantly lower volumes of distending media (3.6 liters, 95% CI, 3.1-4.1 vs 6.8 liters, 95% CI, 4.2-9.3, p <.001), and had higher success rates (84.4%, 95% CI, 67.2-94.7 vs 50.0%, 95% CI, 21.1-78.9, p = .019). The sites of perforation all occurred on the endocervical septum and were generally fibrous and avascular.

CONCLUSION

We present a novel, effective method for creating the initial perforation in hysteroscopic CPM. The success may be because of the existence of a potential weakness in the septum of the duplicated cervix, which spontaneously tears upon aggressive mechanical dilation. The method forgoes the risks associated with sharp incisions based on potentially unreliable cues and may greatly simplify the procedure.

Hysteroscopic metroplasty for the septate uterus: review and meta-analysis

The introduction of hysteroscopy to diagnose and treat intrauterine conditions, specifically to divide the uterine septum, or metroplasty, has replaced the traditional laparotomy approach, and objective results demonstrate its salutary effects in women treated. Hysteroscopic metroplasty averts the implications of major invasive abdominal surgery, with good and satisfactory results in pregnancy and live-birth rates, despite the lack of prospective, randomized, controlled studies. A careful review of the published results supports this type of treatment when the uterine septum adversely affects normal reproductive function.

Leiomyoma on the septum of a septate uterus with double cervix and vaginal septum: a challenge to manage

OBJECTIVE

To describe the first case of a leiomyoma localized in the septum of a septate uterus that had cervical duplication and a longitudinal vaginal septum.

DESIGN

Case report.

SETTING

A university hospital.

PATIENT(S)

A 43-year-old patient with primary infertility and complaint of menorrhagia.

INTERVENTION(S)

Laparotomy, adhesiolysis, myomectomy, and resection of the vaginal septum in the first operation. Hysteroscopic resection of the complete uterine septum in the second operation.

MAIN OUTCOME MEASURE(S)

Magnetic resonance imaging findings and two-step repair of the anomaly. Cervical length at second trimester.

RESULT(S)

Restoration of normal anatomy was achieved after correct diagnosis and a two-step operation procedure. A normal cervical length was measured at 26 weeks of gestation.

CONCLUSION(S)

Large leiomyoma at rare localizations in the presence of uterine anomalies is a diagnostic challenge, but with available diagnostic technology and appropriate operations, successful results can be obtained.

Hysteroscopic metroplasty of the complete uterine septum, duplicate cervix, and vaginal septum

OBJECTIVE

To determine if sectioning of the cervical septum in hysteroscopic metroplasty of the complete uterine septum is associated with intraoperative bleeding, cervical incompetence, and secondary infertility.

DESIGN

Multicenter, randomized, controlled clinical trial.

SETTING

University hospitals.

PATIENT(S)

Twenty-eight women with a diagnosis of complete uterine septum who had a history of pregnancy wastage or infertility. They were randomized into two groups: group A underwent metroplasty including section of the cervical septum; group B underwent the same procedure with preservation of the cervical septum.

INTERVENTION(S)

Hysteroscopic metroplasty was performed for all patients in the two groups.

MAIN OUTCOME MEASURE(S)

Operating time, distending media deficit, total distending media used, intraoperative bleeding, complications, and reproductive outcome.

RESULT(S)

Operating times were 36.40 +/- 10.67 minutes and 73 +/- 14.40 minutes in group A and group B, respectively. Distending media deficit was 456.66 +/- 165.68 mL in group A, while in group B it was 673.84 +/- 220.36. Two cases of pulmonary edema and three cases of significant bleeding (> 150 mL) were seen in group B. The cesarean section rate was significantly higher in group B. There were no significant differences in the reproductive outcome in the two groups.

CONCLUSION(S)

Resection of the cervical septum during hysteroscopic metroplasty of complete uterine septum makes the procedure safer, easier, and less complicated than the procedure with preservation of the cervical septum. This procedure is recommended for all cases of complete uterine septum.

Successful twin pregnancy in a patient with complete uterine septum corrected during cesarean section

OBJECTIVE

To describe a successful in vitro fertilization (IVF) twin pregnancy in a patient with complete uterine septum who underwent partial correction during cesarean section.

DESIGN

Case report.

SETTING

An IVF unit at a university hospital.

PATIENT(S)

A 29-year-old female patient with complete uterine septum undergoing IVF-intracytoplasmic sperm injection.

INTERVENTION(S)

In vitro fertilization-intracytoplasmic sperm injection with single embryo transfer to each uterine cavity.

MAIN OUTCOME MEASURE(S)

Pregnancy course and outcome.

RESULT(S)

Both transferred embryos underwent implantation, resulting in twin pregnancy with a single embryo in each hemi-uterus. Cesarean section was performed at 34 weeks' gestation. Two healthy neonates were born. Resection of the uterine septum by electrocauterization was attempted during cesarean section. Diagnostic hysteroscopy performed 6 months later demonstrated the presence of the uterine septum reaching approximately 40% of the cavity.

CONCLUSION(S)

Whether prophylactic metroplasty should be performed in patients with uterine septae without prior history of miscarriage or pregnancy complications is still under debate. Successful implantation and fetal development might occur without prior metroplasty, as described in our case report. Metroplasty during cesarean section might be only partly successful because part of the septum might be confined in the stretched gravid uterus.

Successful outcome of twin gestation after endoscopic metroplasty of complete septate uterus

The successful outcome of twin gestation after the endoscopic metroplasty of uterus septus class Va was described. Authors described and discussed the technical details of diagnosis and treatment of this rare malformation. Five months after treatment the patient spontaneously became pregnant. The pregnancy was determined as dizygotic twins. The cesarean section was performed in the 36th week of gestation because of growth arrest of one fetus and two healthy newborns were delivered.

The diagnosis and reproductive outcome after surgical treatment of the complete septate uterus, duplicated cervix and vaginal septum

OBJECTIVE

This study was undertaken to evaluate the diagnostic management and the reproductive outcome after surgical repair of a rare reproductive malformation.

STUDY DESIGN

Sixteen women with a complete septate uterus, double cervix, and a longitudinal vaginal septum were referred for evaluation. Presenting complaints were chiefly pregnancy loss in parous women (n=9) and dyspareunia in nulligravid women (n=7). The combination of hysterosalpingography, ultrasonography, and/or magnetic resonance imaging was used to correctly identify the anomaly in 15 of the 16 cases. Both hysteroscopic (n=11) and transabdominal (n=5) surgical techniques were used to repair the uterine septum.

RESULTS

In no case was the correct diagnosis made before referral; the uterus didelphys was the most common misdiagnosis. The preoperative pregnancy loss was 81%. Postoperatively, 12 women conceived for a total of 17 pregnancies; there were 14 term live births or ongoing pregnancies in the third trimester (82%), with a first trimester spontaneous abortion rate of 18%. In 9 women who conceived after hysteroscopic surgery, term live births occurred in 9 of 12 (75%) conceptions. A modified Tompkins metroplasty was performed in 5 women with subsequent term live births or ongoing third trimester pregnancies in 5 of 5 (100%) patients.

CONCLUSION

The identification of a duplicated cervix and a vaginal septum is consistent with several uterine malformations, which leads to frequent misdiagnosis and errors in management. Significant pregnancy wastage, obstetric complications, and dyspareunia are common, and surgical treatment is therefore advisable. Making the best choice between hysteroscopic or transabdominal metroplasty depends on the anatomic features of the cervix and the uterine cavity, but optimal patient management requires familiarity with both techniques.

Hysteroscopic metroplasty of the Class Va uterus with preservation of the cervical septum

OBJECTIVE

To assess the safety and efficacy of hysteroscopic resection of the uterine septum in patients with a Class Va septate uterus.

DESIGN

Retrospective clinical study.

SETTING

University outpatient surgical center.

PATIENT(S)

Twenty-one patients with Class Va uterus treated between 1985-1998 in the senior author's academic practice.

INTERVENTION(S)

Hysteroscopic metroplasty with preservation of cervical septum.

MAIN OUTCOME MEASURE(S)

Intraoperative and postoperative complications; postoperative cumulative pregnancy and delivery rates.

RESULT(S)

No long-term complications were encountered. Fourteen of 15 women who attempted pregnancy postoperatively delivered viable neonates; the 15th is in an ongoing pregnancy.

CONCLUSION(S)

Surgical correction of the complete uterine septum with preservation of the cervical septum is associated with low morbidity and satisfactory postoperative obstetric outcome.

Metroplasty for the complete septate uterus: does cervical sparing matter?

STUDY OBJECTIVES

To verify if section of the cervical septum facilitates hysteroscopic metroplasty of a complete septate uterus, and to determine if this technique is associated with intraoperative bleeding or postoperative obstetric complications.

DESIGN

Prospective, observational study.

SETTING

Academic department and tertiary care referral center for malformations of the female genital tract.

PATIENTS

Ten women with complete septate uterus.

INTERVENTIONS

The cervical portion of the septum was incised with Metzenbaum scissors and the corporeal portion with microscissors under hysteroscopic guidance.

MEASUREMENTS AND MAIN RESULTS

Mean +/- SD operating time for the entire procedure was 24 +/- 7 minutes, with a mean distention fluid deficit of 480 +/- 190 ml. No significant bleeding was encountered during cervical septum incision. At follow-up hysteroscopy, the cervices were competent, and no women experienced second-trimester abortion or premature delivery.

CONCLUSIONS

Section of the cervical septum with scissors is simple, rapid, and safe, facilitates corporeal hysteroscopic metroplasty, and may be considered a valid procedure to correct a completely septate uterus.