The oncological and reproductive outcomes of fertility-preserving treatments for stage 1 grade 1 endometrial carcinoma: a systematic review and meta-analysis

INTRODUCTION

The number of patients desiring fertility-preserving treatment for endometrial cancer rather than standard surgical management continues to increase.

OBJECTIVE

We aimed to evaluate the efficacies of fertility-preserving treatments on the live birth rate, remission and relapse rates for women with stage 1a grade 1 endometrial carcinoma to support patient counselling.

METHODS

We performed a meta-analysis for our primary outcomes of overall remission and relapse rate, and for secondary analysis, we divided papers into treatment type: systemic progestins, intrauterine progestins or hysteroscopic resection and adjuvant hormonal treatment.

RESULTS

Thirty-five observational studies met inclusion criteria, with a total of 624 patients. Overall, conservative treatment of endometrial cancer showed a remission rate of 77% (95% CI: 70-84%), a relapse rate of 20% (95% CI: 13-27%) and a live birth rate of 20% (95% CI: 15-25%) with more favourable outcomes for the hysteroscopic resection group.

CONCLUSIONS

Hysteroscopic resection and adjuvant hormonal treatment had the most favourable fertility and oncological outcomes. Further high-quality prospective multi-centre trials are warranted to determine the optimal treatment regimen and dosage and risk stratification for these patients.

Oncological and reproductive outcomes of endometrial atypical hyperplasia and endometrial cancer patients undergoing conservative therapy with hysteroscopic resection: A systematic review and meta-analysis

INTRODUCTION

Our objective was to conduct a systematic review and meta-analysis of studies evaluating the oncological and reproductive outcomes of patients with endometrial atypical hyperplasia (AH) and endometrioid endometrial cancer (EEC) undergoing conservative therapy with hysteroscopic resection (HR).

MATERIAL AND METHODS

This study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement for systematic reviews and meta-analyses. The study strictly followed the methodological framework proposed by the Cochrane Handbook and was retrospectively registered in PROSPERO (CRD42023469986). Searches were conducted in PubMed, Embase, and the Cochrane Library, from inception to October 10, 2023. A checklist based on items of the Newcastle-Ottawa Scale and the Methodological Index for Non-randomized Studies was used for quality assessment. The primary end points for this meta-analysis were complete response (CR), pregnancy, and live birth rates following HR-based therapy in patients with EEC or AH. The secondary end point was the recurrence rate (RR).

RESULTS

Twenty-one articles involving 407 patients with clinical stage IA, low or intermediate grade, EEC, and 444 patients with AH managed with HR-based conservative treatment were included for this systematic review. CR to HR-based conservative therapy was achieved in 88.6% of patients with EEC and 97.0% of patients with AH. Of these, 30.6% and 24.2%, respectively, had live births. The overall pooled disease RR was 18.3% and 10.8% in patients with EEC and AH, respectively. Further subset analyses revealed that EEC patients with body mass index (BMI) ≤28 kg/m2 had higher CR rates as well as higher chances of pregnancy and live birth (91.6% CR, 32.9% pregnancy, 31.1% live birth) compared with patients with BMI >28 kg/m2 (86.4% CR, 28.4% pregnancy, 23.0% live birth). The HR followed by oral progestogen subgroup had higher CR rates and higher chances of pregnancy and live birth (91.8% CR, 36.3% pregnancy, 28.2% live birth) than the HR followed by the levonorgestrel intrauterine system subgroup (82.5% CR, 25.3% pregnancy, 16.3% live birth).

CONCLUSIONS

Hysteroscopic resection followed by progestins appears to be a promising choice for fertility-sparing treatment in young patients with AH and EEC, with effective and safe responses. The live birth rate remains to be improved by providing medical guidance and encouragement.

Retained products of conception - a retrospective analysis of 200 cases of surgical procedures for the diagnosis of residua postpartum

OBJECTIVES

Postpartum retained products of conception are a relatively rare diagnosis occurring in approximately 1% of cases after spontaneous deliveries and abortions. The most common clinical signs are bleeding and abdominal pain. The diagnosis is based on clinical signs and ultrasound examination.

MATERIAL AND METHODS

Retrospective analysis of 200 surgical procedures for the diagnosis of residua postpartum obtained in 64 months. We correlated the method and accuracy of diagnosis with definitive histological findings.

RESULTS

During 64 months, we performed 23 412 deliveries. The frequency of procedures for diagnosis of retained products of conception (RPOC) was 0.85%. Most (73.5%) of the D&C were performed within six weeks of delivery. Histologically, the correct diagnosis was confirmed in 62% (chorion + amniotic envelope). There was interestingly lower concordance of histologically confirmed RPOC in post-CS patients (only 42%). In women after spontaneous delivery of the placenta, the diagnosis of RPOC was confirmed by histological correlate in 63%, and the highest concordance occurred in women after manual removal of the placenta in 75%.

CONCLUSIONS

Concordance with histological findings of chorion or amnion was seen in 62% of cases; this means that the incidence rate in our study was around 0.53%. The lowest concordance is after CS deliveries, 42%. D&C for RPOC should be performed after adequate clinical evaluation and in the knowledge of 38% false positivity. There is certainly more space for a conservative approach under appropriate clinical conditions, especially in patients after CS.

hysteroscopic resection in patients with symptomatic uterine niche

Objective

To compare the efficacy of transvaginal repair and hysteroscopic resection in improving niche associated postmenstrual spotting.

Methods

The improvement rate of postmenstrual spotting in women who underwent transvaginal repair or hysteroscopic resection treatment was assessed retrospectively in patients accepted at the Niche Sub-Specialty Clinic in International Peace Maternity and Child Health Hospital between June 2017 and June 2019. Postoperative spotting symptom within one year after surgery, pre- and postoperative anatomical indicators, women' satisfaction with menstruation and other perioperative parameters were compared between the two groups.

Results

68 patients in the transvaginal group and 70 patients in the hysteroscopic group were included for analysis. The improvement rate of postmenstrual spotting in the transvaginal group at the 3rd, 6th, 9th, and 12th months after surgery was 87%, 88%, 84%, and 85%, significantly higher than 61%, 68%, 66%, and 68% in the hysteroscopic group, respectively (P < 0.05). The total days of spotting improved significantly at the 3rd month after surgery but did not change over time within one year in each group (P > 0.05). After surgery, the disappearance rates of the niche are 68% in transvaginal group and 38% in hysteroscopic group, however, hysteroscopic resection had shorter operative time and hospitalization duration, less complications, and lower hospitalization costs.

Conclusion

Both treatments can improve the spotting symptom and anatomical structures of uterine lower segments with niches. Transvaginal repair is better in thickening the residual myometrium than hysteroscopic resection, however, hysteroscopic resection has shorter operative time and hospitalization duration, less complications, and lower hospitalization costs.

High-intensity focused ultrasound as a pretreatment combined with hysteroscopic resection for gestational trophoblastic neoplasia with chemotherapy intolerance: a case report

BACKGROUND

Due to resistance and intolerance to chemotherapy, localized lesion resection may be required in some patients with Gestational trophoblastic neoplasia (GTN), which may lead to massive bleeding. In this case report, we describe the successful use of high-intensity focused ultrasound (HIFU) as an effective pretreatment method for surgical procedure in a patient with GTN to reduce the perioperative risk and the impact on fertility.

CASE PRESENTATION

A 26-year-old woman was diagnosed with high-risk GTN (FIGO Stage III: 12 prognostic scores) after a hydatidiform mole. The fifth chemotherapy cycle was interrupted due to severe chemotherapy toxicity. However, the uterine lesion was still present and the beta-human chorionic gonadotropin (β-hCG) level was not restored to normal. Therefore, ultrasound-guided HIFU was performed as a pretreatment method to shrink the lesion and prevent massive bleeding during localized lesion resection. The effectiveness of ablation was evaluated immediately using contrast-enhanced ultrasound and Color Flow Doppler ultrasonography. One month after HIFU treatment, the uterine lesion was completely resected under hysteroscopic surgery. During the surgery, HIFU was found to have shrunk the lesion and there was minimal bleeding (5 mL). The uterine cavity morphology and menstruation returned to normal after surgery. The patient has showed no signs of recurrence as of one-year follow-up.

CONCLUSION

Ultrasound-guided HIFU ablation may be a new choice for high-risk GTN patients with chemoresistance or chemo-intolerance. As a noninvasive pretreatment method, HIFU can shrink the uterine lesion, and reduce the risk of bleeding with no obvious effect on fertility.

Fertility-preserving treatment in patients with early-stage endometrial cancer: A protocol for systematic review and meta-analysis

BACKGROUND

Endometrial cancer (EC) is the second most common malignancy of the female reproductive system worldwide, and the standard treatment for early-stage EC potentially leads to permanent infertility. The objective of this study was to investigate the efficacies of different methods on fertility preservation in patients with early-stage EC.

METHODS

We searched the major online databases (PubMed, Embase, The Cochrane Library, and Web of Science) to collect the research literature on fertility preservation therapy in patients with early-stage well-differentiated EC aged ≤ 40 years from January 1999 to October 2019. The inclusion was performed using the R software (version R3.5.3) meta-analysis of a single rate. The efficacy of the following three fertility preservation treatments was evaluated from four aspects, the complete remission rate (CRR), recurrence rate (ReR), pregnancy rate (PregR), and live birth rate (LBR): a) taking oral progestin only therapy, b) hysteroscopic resection combined with progestin/levonorgestrel-releasing intrauterine system (LNG-IUS)/GnRH-a, c) LNG-IUS or combined with progestin/GnRH-a.

RESULTS

A total of 23 articles were included in this study, including 446 patients with early-stage EC. In the group that took oral progestin only (n = 279), CRR, ReR, PregR, and LBR were 82% (95% confidence interval [CI], 74%-92%, P = .01), 38% (95% CI, 31%-45%, P = .35), 70% (95% CI, 62%-79%, P = .68), and 63% (95% CI, 55%-73%, P = .55), respectively. Hysteroscopic resection combined with progestin/LNG-IUS/GnRH-a therapy group (n = 96) achieved a CRR, ReR, PregR, and LBR of 95% (95% CI, 90%-100%, P = .42), 16% (95% CI, 6%-39%, P = .03), 84% (95% CI, 73%-96%, P = .39), and 72% (95% CI, 59%-87%, P = .28), respectively. LNG-IUS or combined with progestin/GnRH-a therapy group (n = 91) achieved a CRR, ReR, PregR, and LBR of 69% (95% CI, 54%-89%, P < .01), 30% (95% CI, 19%-49%, P = .36), 48% (95% CI, 18%-100%, P < .01), and 36% (95% CI, 10%-100%, P < .01), respectively.

CONCLUSION

It is safe and effective for young patients with early-stage EC to receive oral progestin, hysteroscopic resection combined with progestin/LNG-IUS/GnRH-a, LNG-IUS, or progestin/GnRH-a.

INPLASY REGISTRATION NUMBER

DOI 10.37766/inplasy2020.12.0137.

Early versus late hysteroscopic resection after high-intensity focused ultrasound for retained placenta accreta

Objective: To compare early and late hysteroscopic resection after high-intensity focused ultrasound (HIFU) for retained placenta accreta. Methods: This retrospective study included 63 women with retained placenta accreta who were treated with HIFU combined with hysteroscopic resection. They were divided into an early group (n = 40) and a late group (n = 23), depending on the time between the HIFU and the hysteroscopic resection. The number of sessions of hysteroscopy needed, adverse events, menstrual recovery, and reproductive outcomes were compared. Results: The mean largest diameter of the retained placenta accreta was 67.6 ± 14.0 mm and 71.6 ± 23.6 mm in each group (p = .47), respectively. In the early group, the first hysteroscopic procedure was done at a mean interval of 2.7 ± 1.4 days after HIFU ablation, while in the late group, the interval was 34.7 ± 15.0 days (p < .001). The rate of complete resection of placenta residue after one hysteroscopic procedure in the late group was 73.9% (17/23). This was significantly higher than in the early group, where the rate was 45% (p = .03). During the follow-up, there was no difference in menstrual recovery and pregnancy outcomes between the groups. Conclusion: This study was the first to compare the effects and safety of early and late hysteroscopic resection after HIFU for retained placenta accreta. Late hysteroscopic resection seems to increase the rate of complete resection of retained placenta accreta after one hysteroscopic procedure.

A comparison of results following the treatment of placenta accreta and placenta increta using high-intensity focused ultrasound followed by hysteroscopic resection

OBJECTIVE

To compare the safety and efficacy of high-intensity focused ultrasound (HIFU) followed by hysteroscopic resection for different placenta accreta spectrum disorders.

MATERIALS AND METHODS

Thirty-four patients with placenta accreta, placenta increta, or placenta percreta were treated with USgHIFU from January 2016 to December 2019 and were retrospectively reviewed. The patients were classified into three categories according to the relationship between the trophoblastic villi and the myometrium, based on magnetic resonance imaging (MRI). Fifteen patients were classified as placenta accreta, 17 patients were classified as placenta increta, and 2 were classified as placenta percreta. All patients completed follow-up. Treatment efficacy and safety were evaluated.

RESULTS

No significant differences in baseline characteristics and results of HIFU ablation were observed between the patients with placenta accreta and those with placenta increta. The return of HCG levels to normal was longer in patients with placenta accreta compared with patients with placenta increta, while no significant difference was observed in the amount of intraoperative blood loss, the return of normal menstruation and the length of hospital stay.

CONCLUSIONS

HIFU treatment followed by hysteroscopic resection is safe and effective in the treatment of patients with placenta accreta and placenta increta.

Cesarean scar defects: management of an iatrogenic pathology whose prevalence has dramatically increased

Around 20% of pregnant women undergo cesarean section (CS), and in most regions of the world CS rates continue to grow. There is still no clear definition of what is considered a normal physiologic aspect of a CS scar and what is abnormal. Cesarean scar defects (CSDs) should be suspected in women presenting with spotting, dysmenorrhea, pelvic pain, or infertility and a history of CS. CSDs can be visualized with the use of hysterosalpingography, transvaginal sonography, saline infusion sonohysterography, hysteroscopy, and magnetic resonance imaging. It is reasonable to consider hormone therapy for CSDs as a symptomatic treatment in women who no longer wish to conceive and have no contraindications. In case of failure of or contraindications to medical treatment, surgery should be contemplated according to the severity of symptoms, including infertility, the desire or otherwise to preserve the uterus, the size of the CSD, and residual myometrium thickness (RMT) measurement. Hysteroscopy is considered to be more of a resection than a repair, so women who desire pregnancy should be excluded from this technique if the RMT is <3 mm, in which case repair is essential and can be achieved by only laparoscopic or vaginal approach. Women with CSDs need to be given complete information, including available literature, before any treatment decision is made. Because prevention is better than cure, risk factors should be identified early to ensure appropriate management.

Hysteroscopic Resection for Missed Abortion: Feasibility, Operative Technique and Potential Benefit Compared to Curettage

Objective: To evaluate the feasibility of hysteroscopic resection (HsR) for primary surgical management of missed abortion. Reproductive outcomes and potential benefit of this technique will be compared to traditional dilatation and curettage (D&C).

Design: Retrospective cohort study in two Departments (Gynecology and Obstetrics) of a tertiary medical care center (Canadian Task Force classification II-2).

Patients: Women with first trimester missed abortion.

Intervention: Two techniques were used for the management of missed abortion: ultrasound-guided dilatation and curettage (D&C) and hysteroscopic resection (HsR).

Results: We evaluated 358 patients who underwent primary surgical removal of missed abortion. Hundred seventy three patients have been treated by D&C and 185 underwent HsR. In the HsR group, 110 patients (59.5%) have obtained their pregnancy with in vitro fertilization (IVF) vs. 7 patients (4.0%) in the D&C group which make the HsR population hypofertile in comparison to the D&C population. The intra- and post-operative complication rates are low and comparable. Intrauterine anomalies were diagnosed during the HsR in 10 patients (5.4%) and could be investigated after the intervention as a possible cause of miscarriage. Because of the difference in term of fertility, the reproductive outcomes have been analyzed by multivariate analysis. The hazard ratio of pregnancy at 6 months, adjusted to the factor IVF for D&C compared to HsR is 0.69 [0.49–0.96] (p = 0.026). That could represent a significant benefit in the particular population followed in IVF, but regarding the retrospective analysis, and the very different population in the two groups, it doesn't allow us to draw any evidence based conclusion.

Conclusion: Hysteroscopic resection is a feasible and safe procedure for the management of missed abortion that could increase the diagnosis of uterine abnormalities. With all the limitation of the design of our study, our data seems to show a trend to a potential benefit in term of reproductive outcomes for hypofertile patient undergoing IVF treatment.

Management of postpartum pulmonary embolism combined with retained placenta accreta: A case report

RATIONALE

Retained placenta accreta is an increasing obstetric problem in recent years, and pulmonary embolism (PE) during pregnancy and the postpartum period is a vital condition, but lack of standard therapy guidelines. This report describes a case of postpartum PE combined with retained placenta accreta.

PATIENT CONCERNS

A 27-year-old woman presenting with fever and dyspnea after delivery was admitted to our hospital with retained placenta accreta.

DIAGNOSES

The patient was diagnosed with the infection, postpartum PE, and residual placenta.

INTERVENTIONS

The antibiotics and low molecular weight heparin were initially started to cure the infection and control PE. Mifepristone was then used to promote the necrosis of residual placenta while long-term use of warfarin was served as continuous anticoagulant therapy. Hysteroscopic resection of retained placenta was not performed until thrombi had been almost disappeared after more than 2 months of anticoagulation therapy.

OUTCOMES

The patient's menstruation returned to normal within several weeks after hysteroscopic resection and she completely recovered from PE after 3 months of anticoagulant therapy.

LESSONS

Treatment of retained placenta accreta can be postponed when encountering complicated cases, such as postpartum PE. PE in perinatal stage can be managed referring to nonmaternal PE.

Early Second-Look Hysteroscopy: Prevention and Treatment of Intrauterine Post-surgical Adhesions

Introduction: Intra-uterine adhesion (IUA) is one of the main causes of secondary infertility. The aim of this study was to evaluate the prevalence of IUA developing in women undergoing hysteroscopic resection for submucous myomas, polyps, and intrauterine synechiae and test the efficacy of second look hysteroscopy for diagnosing and treating post-surgical adhesions.

Materials and Methods: We retrospectively collected data from reproductive age women who had a second look office hysteroscopy following hysteroscopic resection for myoma, polyp, or IUA at Foch hospital (Suresnes, France) between 2009 and 2017.

Results: Six hundred and twenty two reproductive-age women underwent hysteroscopic resection for myoma, polyp, and/or IUA. Among them, 155 women had a second look hysteroscopy. In this group, 29/155 (18.7%) had IUA formation: 17/83 (20.5%) women who underwent hysteroscopic myomectomy, 5/46 (10.9%) women who underwent hysteroscopic polypectomy, and 7/26 (26.9%) women who underwent hysteroscopic lysis of adhesions. These IUA have been lysed by the office hysteroscopy procedure in 16/29 (55.2%) patients: 11/17 (64.7%), 2/5 (40%), and 3/7 (42.9%) in women who underwent hysteroscopic myomectomy, polypectomy and lysis of adhesion, respectively.

Conclusion: IUA is a common complication of hysteroscopic surgery. Second look office hysteroscopy is an easy and effective procedure for diagnosing and removing newly formed IUA. It should be recommended for all women undergoing hysteroscopic resection for myomas, polyps, or IUA.

Pregnancy outcomes in viable pregnancies with a septate uterus compared with viable pregnancies after hysteroscopic uterine septum resection

BACKGROUND

Septate uterus is one of the more common Müllerian anomalies and is the anomaly most amenable to surgical correction. It is currently uncertain if hysteroscopic septum resection reduces the incidence of adverse pregnancy outcomes.

OBJECTIVE

The purpose of this study was to compare pregnancy outcomes in women who had reached at least 20 weeks gestation with those women with a uterine septum and those women who had undergone septum resection before pregnancy.

STUDY DESIGN

Retrospective cohort study of women with a history of uterine septum who were cared for by a large maternal-fetal medicine practice from 2005-2018. We included women with singleton pregnancies at >20 weeks gestation. Baseline characteristics and pregnancy outcomes were compared between women with a history of a hysteroscopic uterine septum resection and women with an unresected septum. Regression analysis was performed to control for differences in baseline characteristics. The analysis was repeated in nulliparous women only.

RESULTS

A total of 109 women (163 pregnancies) were included. In the entire population, pregnancy outcomes did not differ between the groups, aside from a higher rate of cesarean delivery in the resected septum group. In the 63 nulliparous women, septum resection was associated with later gestational ages at delivery (39.1 vs 37 weeks; P=.030), decreased preterm birth <37 weeks gestation (4.5% vs 31.6%; adjusted odds ratio, 0.154; 95% confidence interval, 0.027-0.877), and an increased incidence of cesarean delivery in women who attempted vaginal delivery (30.6% vs 0%; P=.012). There was no difference in the rates of small for gestational age, preeclampsia, blood transfusion, retained placenta, or morbidly adherent placenta.

CONCLUSION

In nulliparous women with viable pregnancies, hysteroscopic resection of a uterine septum is associated with a decreased incidence of preterm birth and an increased incidence of cesarean delivery. These findings need to be confirmed in a well-designed randomized trial before uterine septum resection is recommended routinely.

Conservative endovascular and hysteroscopic management of a cesarean scar pregnancy in a woman with previous history of uterine artery embolization for intractable hemorrhage after cesarean section for placenta previa

Transcatheter arterial chemoembolization (TACE), followed by hysteroscopic resection of the gestational products, could be a feasible option for the conservative management of cesarean scar pregnancy (CSP) in a woman with a previous history of uterine artery embolization (UAE) with coils for intractable hemorrhage after cesarean section.

Conservative treatment for well-differentiated endometrial cancer: when and why it should be considered in young women

The aim of this review was to update current knowledge on the conservative treatment of endometrial cancer (EC) based on a literature review. A web-based search in the MEDLINE database was carried out on EC management and treatment. All relevant information has been collected and analysed. Case series were mainly found in the literature search. Conservative treatments were offered to young patients with stage I low-grade endometrioid carcinomas of the endometrium. Different options included high/low dose progestin treatments, hysteroscopic resection of the disease, a levonorgestrel intrauterine device or a combination of various strategies. The overall complete response rate was near 76.5% with a recurrence rate of up to 33.8%. Pregnancy outcomes reached rates of 64.8% for live births. The current clinical outcomes show that conservative treatment aimed at preserving fertility is feasible for stage I endometrial well-differentiated adenocarcinomas in motivated patients under close monitoring.

Comparison among fertility-sparing therapies for well differentiated early-stage endometrial carcinoma and complex atypical hyperplasia

OBJECTIVE

To compare fertility-sparing therapies including oral progestogens, hysteroscopic resection (HR), and the levonorgestrel- releasing intrauterine system (LNG-IUS) in achieving disease regression, recurrence and live birth rate in well differentiate early-stage endometrial carcinoma (eEC) and complex atypical hyperplasia(CAH).

STUDY DESIGN

This was a meta-analysis of previous studies focus on the fertility-sparing therapy for well differentiate early-stage endometrial carcinoma (eEC) and complex atypical hyperplasia (CAH).

DATE SOURCES

Medline, the Cochrane Library and Embase was searched with the terms and Synonyms: words similar to eEC and CAH with therapies associated with fertility-sparing.

MAIN OUTCOME MEASURES

The number of all patients accepted fertility sparing therapies, patients got regressed, relapsed and delivered were extracted from each study, and the regression, recurrence, and live birth rate of each study were calculated. The regression, recurrence and live birth rates between each two interventions were compared with the aid of meta-regression in packages of "meta" and "meta for" written in R.

RESULTS

Fifty-four studies reported fertility sparing therapies in young women with eEC and CAH were included. Meta-analysis showed that HR followed by progestogens achieved a higher pooled regression (98.06% vs 77.20% P < 0.0001) and live birth rate (52.57% vs 33.38%, P = 0.0944) and a lower recurrence rate compared with oral progestogens alone (4.79% vs 32.17% P = 0.0004). At the same time, the pooled live birth rate (52.57% vs 18.09% P =0.0399) of HR followed by progestogens are significantly higher than the LNG-IUS alone. Which no statistical difference in regression (98.06% vs 94.24%; P = 0.4098) and recurrence rates (4.79% vs 3.90% P = 0.8561) was seen.

CONCLUSIONS

Of the available fertility-sparing therapeutic options, HR followed by progestogens may be a more effective one.

Hysteroscopic resection of a uterine caesarean scar defect (niche) in women with postmenstrual spotting: a randomised controlled trial

Objective

To compare the effectiveness of a hysteroscopic niche resection versus no treatment in women with postmenstrual spotting and a uterine caesarean scar defect.

Design

Multicentre randomised controlled trial.

Setting

Eleven hospitals collaborating in a consortium for women's health research in the Netherlands.

Population

Women reporting postmenstrual spotting after a caesarean section who had a niche with a residual myometrium of ≥3 mm, measured during sonohysterography.

Methods

Women were randomly allocated to hysteroscopic niche resection or expectant management for 6 months.

Main outcome measures

The primary outcome was the number of days of postmenstrual spotting 6 months after randomisation. Secondary outcomes were spotting at the end of menstruation, intermenstrual spotting, dysuria, sonographic niche measurements, surgical parameters, quality of life, women's satisfaction, sexual function, and additional therapy. Outcomes were measured at 3 months and, except for niche measurements, also at 6 months after randomisation.

Results

We randomised 52 women to hysteroscopic niche resection and 51 women to expectant management. The median number of days of postmenstrual spotting at baseline was 8 days in both groups. At 6 months after randomisation, the median number of days of postmenstrual spotting was 4 days (interquartile range, IQR 2–7 days) in the intervention group and 7 days (IQR 3–10 days) in the control group (P = 0.04); on a scale of 0–10, discomfort as a result of spotting had a median score of 2 (IQR 0–7) in the intervention group, compared with 7 (IQR 0–8) in the control group (P = 0.02).

Conclusions

In women with a niche with a residual myometrium of ≥3 mm, hysteroscopic niche resection reduced postmenstrual spotting and spotting‐related discomfort.

Tweetable abstract

A hysteroscopic niche resection is an effective treatment to reduce niche‐related spotting.

A hysteroscopic niche resection is an effective treatment to reduce niche‐related spotting.

Choosing the optimal therapeutic strategy for placental polyps using power Doppler color scoring: Transarterial embolization followed by hysteroscopic resection or expectant management?

OBJECTIVE

To evaluate a protocol for selection of placental polyp management, including expectant management and hysteroscopic resection with or without transarterial embolization (TAE), using power Doppler color score (PDCS) as the vascularity parameter.

MATERIALS AND METHODS

This retrospective case-control study included 25 patients who were diagnosed with placental polyps. We evaluated the vascularity of placental polyps with PDCS measured by transvaginal ultrasonography as follows: PDCS 1, no blood flow; PDCS 2, minimal flow; PDCS 3, moderate flow; and PDCS 4, marked blood flow. We then selected expectant management or hysteroscopic resection with or without TAE.

RESULTS

Three of 17 patients with PDCS 1 or 2 underwent surgical intervention, and expectant management was successful in 14. Seven of eight patients with PDCS 3 or 4 underwent surgical intervention, while expectant management was successful in only one patient.

CONCLUSION

PDCS is a simple examination for evaluating the vascularity of placental polyps. PDCS might be useful for selecting the optimal treatment for placental polyps, such as expectant management or surgical intervention, according to their vascularity.

Fertility-conservation combined therapy with hysteroscopic resection and oral progesterone for local early stage endometrial carcinoma in young women

OBJECTS

This paper explored the suitable population for the combined therapy of hysteroscopic resection and oral megestrol acetate (MA) to treat local stage I endometrial cancer. Therapeutic effectiveness, safety, as well as pregnancy rate and relapse rate after treatment were also examined. The aim was to provide guidance for the treating similar cases in the future.

METHODS

This perspective study analyzed the clinical data of early stage endometrial cancer patients who have received combined therapy of hysteroscopic resection of local endometrial lesion and oral administration of MA at the Obstetrics and Gynecology Hospital of Fudan University, Shanghai.

RESULTS

A total of six patients met the entry criteria and were enrolled into the trial. All of them achieved a pathologic complete response to hysteroscopic resection of local lesion combined with oral administration of MA for 3 months to 6 months. Among the patients, three became pregnant after natural conception and had healthy infants delivered vaginally at full term without assistance. No relapse occurred in the follow-up study over 48.5 months on average.

CONCLUSIONS

In early-stage endometrial cancer, young patients who had already given birth demand may receive hysteroscopic resection combined with oral administration of MA as conservative treatment. The patients can consider natural conception after complete remission, but a close follow-up was crucial to ensuring that the patients were free from other factors affecting childbearing ability.

Uterine preservation surgery for placental polyp

AIM

To examine clinical and surgical performances of cases with placental polyps in which uterine preservation surgery was conducted.

METHODS

During the period September 2002 to April 2009, we examined eight cases (hysteroscopic resection, six cases; laparotomy, one case; dilatation and curettage, one case) diagnosed with placental polyp that had been treated with polyp extraction surgery. Imaging evaluation was done using magnetic resonance imaging and 2-D ultrasound.

RESULTS

Three of the eight cases (37.5%) had been first-time pregnancies. Most of our cases experienced minimal surgical manipulation after medical abortion. Among them, six cases (75%) were mid-term medical abortions, one case (12.5%) received no treatment after spontaneous abortion, and one case (12.5%) had postsurgical abortion (dilatation and curettage). All cases showed variable amount of blood flow in the internal mass and myometrium by color Doppler ultrasound. Magnetic resonance imaging angiography showed contrast effects in the intrauterine cavity and myometrium in selected cases. The average duration from diagnosis to surgery was 32 days (range, 11-105). Color Doppler revealed a reduction in blood flow in five cases during the waiting period until surgery with an average blood loss of 10 g (range, 0-20) during surgery.

CONCLUSION

Use of color Doppler ultrasound may be useful in diagnosing placental polyp. Although hysteroscopic resection of placental polyp is effective in patients hoping for uterine preservation, delaying timing of surgery may reduce blood loss during operative procedure.