Effectiveness of Manual Hysteroscopic Tissue Removal Device for Intrauterine Polyps in Infertile Women in Both Operating and Office Settings

Background: Mechanical hysteroscopic tissue removal (mHTR) systems are widely used for removing intrauterine pathology. Given the startup and procedural costs for electrically powered mechanical units, disposable manual mHTR systems have been developed. Methods: With little published, we describe its effectiveness for hysteroscopic intrauterine polypectomy. Results: One-hundred fifty-seven infertile women underwent hysteroscopic polypectomy with the manual mHTR device. Complete removal was accomplished in all but three cases, with blood loss being <10 mL and all specimens deemed sufficient for histopathologic diagnosis. Conclusions: These results suggest that the disposable manual mHTR system is effective in removing endometrial polyps. Head-to-head comparisons with other alternative technologies are needed.

Angular Pregnancy: A Case Report

Angular pregnancy, a rare condition, marked by implantation positioned medially to the uterotubal junction within the lateral angle of the endometrial cavity poses a risk of severe complications, such as uterine rupture, placental retention, postpartum hemorrhage, and even necessitating hysterectomy, all of which can be fatal. Distinguishing angular pregnancy from other emergent conditions, particularly interstitial and cornual pregnancies, is crucial due to similar presentations and difference in embryo viability, risk, and management. While angular pregnancies can progress to term, they are associated with an elevated complication rate. Here, we present a case of primigravida with angular pregnancy who opted for evacuation under hysteroscopic guidance subsequent to unsuccessful pregnancy.

Hysteroscopic resection as a safe minimally invasive technique for the management of cornual pregnancy: A case report and literature review

Hysteroscopic resection of ectopic cornual pregnancy following MRI imaging is a safe and effective treatment option without significantly impacting fertility potential or increasing the risk of future obstetrical complications.

Comparison of Efficacy of Vaginal Misoprostol versus a Synthetic Osmotic Dilator (Dilapan-S) for Cervical Preparation before Operative Hysteroscopy: A Randomized Controlled Study

Objectives

To compare the need for mechanical cervical dilatation following vaginal misoprostol or synthetic osmotic dilator (Dilapan-S) usage for cervical preparation before operative hysteroscopy.

Materials and Methods

Fifty-five premenopausal women scheduled for operative hysteroscopic procedures with a 26 Fr resectoscope were included in this randomized, controlled clinical trial. After randomization, either 400 μg of vaginal misoprostol or intracervical synthetic osmotic dilator (Dilapan-S) was inserted 12 h before operative hysteroscopy. The need for additional mechanical cervical dilatation before insertion of the resectoscope was compared between the two groups. Initial cervical diameter before mechanical dilatation, intraoperative complications (cervical tears, creation of a false passage), and ease of dilatation were also compared between the two groups.

Results

In the misoprostol group, 92% of women required additional mechanical cervical dilatation, whereas only 36% of women in the Dilapan-S group required additional dilatation (P < 0.05). The median initial cervical diameter achieved with Dilapan was 9 mm (Q1: 7 mm; Q3: 10 mm), and with misoprostol, it was 6 mm (Q1: 4.5 mm; Q3: 8 mm) (P < 0.05). There was no significant difference in other outcome parameters between the two groups.

Conclusion

Synthetic osmotic dilator (Dilapan-S) is more efficacious than vaginal misoprostol at ripening the cervix before operative hysteroscopy.

Analgesic Effects of Magnesium Sulphate as an Adjuvant to Fentanyl for Monitored Anaesthesia Care During Hysteroscopy

BACKGROUND

Magnesium sulphate (MgSO4) is conventionally used in the treatment of eclampsia, refractive arrhythmias, asthma, etc. In our study, we aimed to study the analgesic effects of MgSO4 as an adjuvant to fentanyl and reduce the intraoperative opioid requirement to decrease their adverse effects.

METHODS

A total of 122 patients scheduled for hysteroscopy were randomly divided into two groups. Patients in the magnesium group (group A) received intravenous MgSO4 50 mg/kg in 100 ml of isotonic saline over 15 minutes before anaesthesia induction and then 15 mg/kg per hour by continuous intravenous infusion. Patients in the control group (group B) received an equal volume of isotonic saline as a placebo. All the patients were induced with fentanyl and propofol. Perioperative haemodynamic monitoring and postoperative assessment of pain were done.

RESULTS

Only 18% of the patients in group A required rescue analgesics as compared to 39.3% of patients in group B. The patients receiving MgSO4 displayed lower verbal numeric rating scale scores in the postoperative period. In addition, the intraoperative requirement of fentanyl (101 (21.33) vs. 144 (28.4) µg, mean (SD)) and propofol (121 (13.3) vs. 140 (16.5) mg, mean (SD)) was significantly lower in group A as compared to that in group B.

CONCLUSION

MgSO4, when administered as an adjuvant to opioids, provided effective postoperative analgesia thereby reducing the need for rescue analgesics. It also decreases intraoperative fentanyl consumption and its dose-related side effects.

Spontaneous Pregnancy After Surgical Repair of Subseptate Uterus: A Case Report and Review of the Available Literature

Septate uterus is the most common congenital uterine malformation. It has been associated with poor reproductive outcomes, such as infertility and recurrent miscarriage, in the context of both assisted and non-assisted reproduction, though the exact underlying pathophysiological reasons remain unclear. Diagnosis is based on two-dimensional and three-dimensional ultrasound, magnetic resonance imaging, or laparoscopic/hysteroscopic findings. Hysteroscopic repair of the uterine septum has been shown to confer several benefits to reproductive outcomes, though this fact remains in question, due to inconsistent and or low-quality evidence in the medical literature. An individualized approach to the treatment of infertility patients with septate uteri is imperative, given the plethora of possible underlying factors that may complicate management. In this report, we present the case of a patient with a subseptate uterus and a history of infertility, who, following hysteroscopic metroplasty, managed to conceive and ultimately successfully deliver a healthy child.

Outpatient Hysteroscopic Polypectomy-A Retrospective Study Comparing Rigid and Semirigid Office Hysteroscopes

Endometrial polyps are one of the most common pathological conditions in gynecology. Hysteroscopy is the gold standard for the diagnosis and treatment of endometrial polyps. The purpose of this multicenter, retrospective study was to compare patients' pain perception during an operative hysteroscopic endometrial polypectomy in an outpatient setting with two different hysteroscopes (rigid and semirigid) and to identify some clinical and intraoperative characteristics that are related to worsening pain during the procedure. We included women that underwent, at the same time as an diagnostic hysteroscopy, the complete removal of an endometrial polyp (using the see-and-treat strategy) without any kind of analgesia. A total of 166 patients were enrolled, of which 102 patients underwent a polypectomy with a semirigid hysteroscope and 64 patients underwent the procedure with a rigid hysteroscope. No differences were found during the diagnostic step; on the contrary, after the operative procedure, a statistically significant greater degree of pain was reported when the semirigid hysteroscope was used. Cervical stenosis and menopausal status were risk factors for pain both in the diagnostic step and in the operative one. Our results confirm that operative hysteroscopic endometrial polypectomy in an outpatient setting is an effective, safe, and well-tolerated procedure and indicate that it might be better tolerated if a rigid rather than semirigid instrument is used.

Manual morcellation (Resectr™ 9Fr) vs electromechanical morcellation (TruClear™) for hysteroscopic polypectomy: A randomized controlled non-inferiority trial

INTRODUCTION

Meta-analyses comparing hysteroscopic electromechanical morcellation with electrosurgical resection showed a shorter operating time for electromechanical morcellation, mainly for polypectomy. The Resectr™ 9Fr is a new hysteroscopic manual morcellator, designed to simplify this procedure. We aimed to compare manual with electromechanical morcellation for hysteroscopic polypectomy.

MATERIAL AND METHODS

This two-center randomized controlled non-inferiority trial was performed from 2018 to 2021 in the Catharina Hospital and the Ghent University Hospital. The study was registered at the Dutch Trial Register (NL6922; ICTRP ID: NTR7118). One hundred and forty women with polyps (between 8 and 20 mm) scheduled for hysteroscopic removal were randomized between manual (Resectr™ 9Fr) or electromechanical (TruClear™) morcellation. The primary outcome was time (instrumentation set-up, resection, and total procedure time).

RESULTS

The non-inferiority margin for the primary outcome time was 1.3. Mean instrumentation set-up time was 10% shorter with the manual compared with the electromechanical morcellator (estimated mean ratio manual/electromechanical = 0.9; 97.5% confidence interval [CI] 0.8-1.1). Mean resection time was 30% longer with the manual compared with the motor-driven system (estimated mean ratio manual/electromechanical = 1.3; 97.5% CI 0.9-1.9). Mean total procedure time was 10% longer with the manual compared with the electromechanical morcellator (estimated mean ratio manual/electromechanical = 1.1; 95% CI 0.91-1.298). The estimated odds (electromechanical/manual) of better surgeon's safety, effective and comfort scores were, respectively, 4.5 (95% CI 0.9-22.1), 7.0 (95% CI 1.5-31.9), and 5.9 (95% CI 1.1-30.3) times higher with the motor-driven compared with the manual morcellator. Conversion rates and incomplete resection rates were comparable in both groups (manual vs electromechanical) (7.6% [4/66] vs 2.9% [2/68] and 6.1% [4/66] vs 3.0% [2/66], respectively). No intraoperative and postoperative complications were registered.

CONCLUSIONS

The manual morcellator was non-inferior to the electromechanical morcellator for hysteroscopic polypectomy in terms of mean instrumentation set-up time and total procedure time. Results on resection time were inconclusive. Conversion and incomplete resection rates were within the range reported in the literature. Surgeon's reported rating for both devices was high, however, in favor of the motor-driven tissue removal system.

Expectant versus medical management for retained products of conception after medical termination of pregnancy: A randomized controlled study

BACKGROUND

Despite the rise of medical treatments for the termination of pregnancy, to-date no prospective trial has evaluated the efficacy of misoprostol in treating retained products of conception after induced termination of pregnancy.

OBJECTIVE

To compare medical management with misoprostol with expectant management for retained products of conception after first trimester medical termination of pregnancy.

STUDY DESIGN

An open-label randomized controlled trial conducted at a university-affiliated tertiary medical center. Consenting consecutive women who underwent a routine 3-week follow-up evaluation after medical termination of pregnancy and had a sonographic suspicion of retained products of conception, defined as sonographic evidence of intra-uterine remnant (>12 mm) with a positive Doppler flow, were recruited. The participants were randomized into a medical treatment group (800 mcg of sublingually administered misoprostol) or expectant management. They all underwent repeat ultrasound scans every 2 weeks until a maximum of 6 weeks, and those suspected for persistent retained products of conception were referred to operative hysteroscopy. The primary endpoint was successful treatment defined as no need for surgical intervention due to persistent retained products of conception within 8 weeks from pregnancy termination.

RESULTS

There were no significant differences in demographic characteristics between the study groups. The median sonographically demonstrated retained product length was 20 mm (interquartile range, [IQR] 17-25) in the medically managed group compared with 20 mm (IQR 17-26) in the expectantly managed group (P=.733). Treatment succeeded in 42/68 (61.8%) women in the medically managed group compared with 36/63 (57.1%) women in the expectantly managed group (relative risk [RR] = 1.12, 95% confidence interval [CI] 0.74-1.70; P=.590). There was no difference in adverse outcomes between the 2 groups.

CONCLUSION

There is no clinically meaningful advantage for medical treatment with misoprostol compared with expectant management after first trimester medical termination of pregnancy in women with suspected retained products of conception. Surgical intervention can be avoided in up to 60% of women who are managed expectantly over 8 weeks of follow-up.

Management of acquired uterine arteriovenous malformation associated with retained products of conception

PURPOSE

To evaluate the efficacy and safety of different treatments for acquired uterine arteriovenous malformation associated with retained products of conception (UAVM-RPOC) and investigate the role of uterine artery embolization (UAE) in acquired UAVM-RPOC.

MATERIALS AND METHODS

This was a retrospective study of consecutive patients who presented with UAVM by ultrasound after recent termination pregnancy. 48 patients were included in this study, divided into two groups (massive and minor bleeding groups) according to vaginal bleeding. The treatments were analyzed between groups. Technical and clinical success of UAE was analyzed.

RESULTS

Of the 48 patients, 11 patients were in the massive bleeding group, and 37 were in the minor bleeding group. 5 patients were referred for UAE in each group, and UAE was a priority for patients with unstable hemodynamics (chi-square value=5.524, p=0.022). Conservative management, dilation and curettage (D&C), operative hysteroscopy, and UAE were performed in 16 (33%), 18 (38%), 7 (15%) and 13 (27%) patients, respectively. Two patients following ectopic pregnancy suffered uncontrollable bleeding during D&C and required UAE. Three patients underwent UAE before surgery to prevent hemorrhage. The technical and clinical success rate of UAE was 100%. No complications or recurrence occurred.

CONCLUSION

UAE is a safe and effective treatment for UAVM-RPOC and a priority for patients with unstable hemodynamics. Conservative management, D&C and hysteroscopy are safe and effective for UAVM-RPOC patients with stable hemodynamics. However, UAVM-RPOC following ectopic pregnancy may have high risks of massive hemorrhage during procedures.

Outcomes of surgical hysteroscopy: 25 years of observational study

The aim of this prospective study was to analyse the complications of operative hysteroscopy over the last 25 years and determine whether such complications were related to patient characteristics, surgery type, surgical time or distension-medium balance. Three thousand and sixty-three operative hysteroscopies were performed; 52.7% were polypectomies and 31.5% were myomectomies. Myectomies had the highest incidence of complications, at 14%, followed by septolysis, at 6.9%. The most common complications were mechanical (52%). Myomectomies had seven times higher risk than polypectomies of distension-medium complications (RR 7.5, p<.001) but three times lower risk of mechanical complications (RR 0.32, p<.001). The highest incidence of complications occurred in type I myomas and those larger than 3 cm. If we define fluid-balance complications as only those patients who absorbed more than 1.5 L and developed related symptoms, our overall complication rate, including all mechanical complications, was 5.6%.Impact StatementWhat is already known on this subject? In recent years, the importance of properly preventing and managing hysteroscopic complications has risen in line with the number of diagnostic and operative hysteroscopies performed. Complications in operative hysteroscopy differ between surgery types, patient characteristics and the distending media used.What do the results of this study add? This study provides data from a high number of patients compared to previously published studies on the complications of operative hysteroscopies, and includes a study of the relationship between type of surgery and type of complication.What are the implications of these findings for clinical practice and/or further research? Our study shows the importance of a good preoperative assessment, since the complications of hysteroscopy differ greatly depending on the indication. Thus, within myomectomies, knowing the exact type, size and location of the myoma will allow the surgeon to carefully plan the procedure to avoid complications.

Comparison between 200 μg and 800 μg of vaginal misoprostol for cervical ripening before operative hysteroscopy: A randomized controlled trial

OBJECTIVE

To compare between 200 and 800 μg of vaginal misoprostol for cervical ripening before operative hysteroscopy.

METHODS

Quadruple-blind randomized clinical trial conducted between November 2019 and September 2020 involving 76 patients undergoing cervical dilatation before surgical hysteroscopy at teaching hospitals in Pernambuco, Brazil. Women received the vaginal misoprostol dosage of 200 or 800 μg,10-12 h before operative hysteroscopy. The cervical width was the primary outcome, and secondary outcomes were patient satisfaction, adverse effects, surgical complications, and duration of cervical dilatation. Chi-square tests of association, Fisher's exact and Mann-Whitney U tests were used with an α error of <5%.

RESULTS

There was no statistical difference between the groups in the mean of the cervical width (800 μg: 6.5 ± 1.6 mm vs 200 μg: 5.8 ± 1.8 mm, P = 0.055), patient satisfaction, and surgical findings, but the duration of cervical dilatation was lower in the 800-μg group (28.16 ± 28.5 s vs 41.97 ± 31.0 s, P = 0.035). Among the adverse effects, diarrhea was more frequent in the 800-μg group with statistical difference (100% vs 0%; P = 0.01).

CONCLUSION

For cervical ripening, 200 μg misoprostol is equally effective with fewer adverse effects than 800 μg before operative hysteroscopy. ClinicalTrials.gov: NCT04152317. https://clinicaltrials.gov/ct2/show/NCT04152317.

Chronic endometritis in women with suspected retained products of conception and their reproductive outcomes

OBJECTIVE

To determine whether women who underwent operative hysteroscopy for suspected retained products of conception (rPOC) have histopathologic evidence of chronic endometritis (CE).

DESIGN

Retrospective cohort.

SETTING

Academic center.

PATIENT(S)

One hundred and eleven women who underwent operative hysteroscopy for suspected rPOC between 2016 and 2018.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Evidence of CE on histopathology and subsequent reproductive outcomes.

RESULT(S)

One hundred and eleven women with retained products of conception were included in our study of which 26 (23.4%) were diagnosed with CE. Women without CE had a higher median gravidity (1 vs. 2, p = .021) and a higher median number of prior pregnancy losses (1 vs. 2 prior losses, p = .005) compared to those with CE. Subsequent pregnancy data were available for 63 women. There was no difference in the subsequent pregnancy rate (61.5 vs. 54%, p = .626) between those with and without CE. Once pregnant, miscarriage (37.5 vs. 25.9%, p = .524) and live birth rates (50 vs. 44.4%, p = .782) were similar between the groups. Women with CE received antibiotics 57.7% of the time, the most common of which was doxycycline (46.6%). Of the women with CE who received antibiotics (n = 10), 8 became pregnant, and 4 of whom went on to have a live birth.

CONCLUSION(S)

Nearly 1 in 4 women undergoing hysteroscopy for rPOC was incidentally diagnosed with CE. It is not clear whether CE is a causative agent for retained products or a response to the pregnancy loss. In this cohort, a diagnosis of CE did not negatively impact subsequent reproductive outcomes.

Anti-adhesion Gel versus No gel following Operative Hysteroscopy prior to Subsequent fertility Treatment or timed InterCourse (AGNOHSTIC), a randomised controlled trial: protocol

STUDY QUESTIONS

Does the application of anti-adhesion gel, compared to no gel, following operative hysteroscopy to treat intrauterine pathology in women wishing to conceive increase the chance of conception leading to live birth?

WHAT IS KNOWN ALREADY

Intrauterine adhesions (IUAs) following operative hysteroscopy may impair reproductive success in women of reproductive age. Anti-adhesion barrier gels may decrease the occurrence of IUAs, but the evidence on their effectiveness to improve reproductive outcomes is sparse and of low quality.

STUDY DESIGN SIZE DURATION

This multicentre, parallel group, superiority, blinded and pragmatic randomised controlled trial is being carried out in seven participating centres in Belgium. Recruitment started in April 2019. Women will be randomly allocated to treatment with anti-adhesion gel (intervention group) or no gel (control group). Sterile ultrasound gel will be applied into the vagina as a mock-procedure in both treatment arms. The patient, fertility physician and gynaecologist performing the second-look hysteroscopy are unaware of the allocated treatment. Power analysis, based on a target improvement of 15% in conception leading to live birth using anti-adhesion gel, a power of 85%, a significance level of 5%, and a drop-out rate of 10%, yielded a number of 444 patients to be randomised. The baseline rate of conception leading to live birth in the control group is expected to be 45%.

PARTICIPANTS/MATERIALS SETTING METHODS

Women of reproductive age (18-47 years), wishing to conceive (spontaneously or by fertility treatment) and scheduled for operative hysteroscopy to treat intrauterine pathology (endometrial polyps, myomas with uterine cavity deformation, uterine septa, IUAs or retained products of conception) are eligible for recruitment. Women may try to conceive from 3 to 6 weeks after receiving allocated treatment with follow-up ending at 30 weeks after treatment. If the woman fails to conceive within this timeframe, a second-look hysteroscopy will be scheduled within 2-6 weeks to check for IUAs. The primary endpoint is conception leading to live birth, measured at 30 weeks after randomisation. The secondary endpoints are time to conception, clinical pregnancy, miscarriage and ectopic pregnancy rates, measured at 30 weeks after receiving allocated treatment. The long-term follow-up starts when the patient is pregnant and she will be contacted every trimester.

STUDY FUNDING/COMPETING INTERESTS

This work is funded by the Belgian Healthcare Knowledge Centre (KCE). The anti-adhesion gel is supplied at no cost by Nordic Pharma and without conditions. Dr. Tomassetti reports grants and non-financial support from Merck SA, non-financial support from Ferring SA, personal fees and non-financial support from Gedeon-Richter, outside the submitted work. None of the other authors have a conflict of interest.

Atypical polypoid adenomyoma follow-up and management: Systematic review of case reports and series and meta-analysis

BACKGROUND

Atypical polypoid adenomyoma (APA) is a rare uterine tumor typically found in fertile age and associated with infertility. Among young nullipara women, conservative treatment is proposed despite the high recurrence rate and the association with endometrial cancer.Our aim was to assess the risk of recurrence with different conservative treatments in fertile ages and the prevalence of malignant or pre-malignant associated lesions to better address an adequate patient counselling when treatment modalities are discussed.

METHODS

This study is a systematic review and meta-analysis of case reports and case series about APA management and follow-up. A literature search was carried from Medline and Scopus for studies published from January 1, 1980 to December 31, 2018.

RESULTS

We included 46 observational studies and 296 cases in fertile women. The prevalence of APA relapse was 44% (CI.95 33-57%) and was lower in cases treated with operative hysteroscopy (22%; CI.95 11-39%) than in cases treated with blind curettage and polypectomy (38%; CI.95 15-67%). The prevalence of the concomitant or during the follow-up diagnosis of endometrial carcinoma was 16% (CI.95 9-29%). The risk of cancer development during follow-up was significantly less in cases treated with histeroscopy (10.56% new cumulative diagnosis at 5 years follow up; CI.95 0-23.7%) than blind curettage and polypectomy (35.5% new cumulative diagnosis at 5 years; CI.95 11.65-52.92%; P < .05). Medical treatment with medroxyprogesterone acetate after surgery does not reduce APA recurrence. Pregnancy was observed in 79% cases in which the desire was expressed.

CONCLUSION

This review suggests that conservative treatment performed by operative hysteroscopy is the optimal choice because it lowers the risk of recurrence, improves the accuracy of concomitant carcinoma or hyperplasia diagnosis, and leaves the possibility of future pregnancies.

Balloon Catheter for Cervical Priming before Operative Hysteroscopy in Young Women: A Pilot Study

Aim: To investigate regarding the safety and effectiveness of a balloon catheter (Aqueduct-100 device) to dilate the uterine cervix before operative hysteroscopies. Secondary objectives were to evaluate the duration of the dilatation procedure and to investigate on physicians' satisfaction with the device. Methods: Fifty women younger than 40 years, wishing pregnancies and diagnosed with apparently benign intrauterine lesions and/or uterine anomalies, were enrolled into this study and submitted to cervical priming with Aqueduct-100 device before operative hysteroscopy. Results: Initial cervical dilatation was ≤4 mm in all but one patient. Adequate (10 mm) cervical dilatation was achieved in only one patient, the remaining forty-nine needed additional cervical dilatation. All women, however, presented with a ≥6 mm cervical width after balloon catheter removal. The mean time to final cervical dilatation was 8.5 minutes. No perioperative complications occurred. Physicians reported, in the majority of cases, satisfaction for the dilatation achieved (66%), the ease of balloon catheter insertion/use (82%), and for the ease of additional dilatation (96%). Conclusions: Aqueduct-100 device before operative hysteroscopy is safe and useful to increase the baseline cervical width and facilitate additional dilatation, with good effects on physician satisfaction and acceptable dilatation times.

The 19 Fr. Intrauterine Bigatti Shaver (IBS®): a clinical and technical update

In this case report we describe the first two surgeries conducted with the 19 Fr. IBS®. The indication for operative hysteroscopy in both patients was the removal of polyps. The size of the polyps was between 15 mm and 20 mm with a mean resection time of 40 seconds. Normal saline solution (500 ml) was used with a negative fluid loss (100 ml). Both operations were successfully performed under general anaesthesia and no speculum, no tenaculum and no dilatation of the cervical canal were necessary.

The effect of endometrial thickness on pregnancy outcome in patients with Asherman's syndrome post-hysteroscopic adhesiolysis

Background

Hysteroscopic adhesiolysis anatomically restores the uterine cavity in cases of Asherman’s syndrome (AS); however, the extent of endometrial fibrosis could determine the pregnancy outcome.

Objectives

To determine whether endometrial thickness could influence pregnancy outcome of hysteroscopic adhesiolysis in women with a history of AS.

Subjects and methods

This was a retrospective cohort study that included 41 women who attended Women’s Specialized Hospital, King Fahad Medical City from December 2008 to December 2015, presented with a history of infertility or recurrent pregnancy loss, and were diagnosed with intrauterine adhesions and treated by hysteroscopic adhesiolysis. To analyze the causative factors of AS, history of curettage, miscarriage, postpartum hemorrhage, hysteroscopy, endometritis, and any uterine surgery were recorded. Patients were followed up for 2 years to account for pregnancy. Patients were divided into two groups based on measurement of endometrial thickness in the midsagittal plane at mid-cycle of a menstrual period. Group A consisted of 26 patients with endometrial thickness ≤5 mm, and group B included 15 patients with endometrial thickness >5 mm. The main outcome measures included endometrial thickness and pregnancy outcome.

Results

Group A had significantly (P<0.001) lower pregnancy rates compared with group B (38.4% versus 80%, respectively). Five of 10 pregnancies (50%) from group A miscarried, compared with 1 of 12 (8.3%) pregnancies in group B. This was statistically significant (P<0.001).

Conclusion

Pregnancy rates were observed to be higher when the endometrium was >5 mm in thickness among patients with AS and miscarriage rates may be reduced in this group.

Intrauterine adhesion prevention after hysteroscopy: a systematic review and meta-analysis

BACKGROUND

Despite years of studies evaluating prevention strategies for intrauterine adhesion formation after operative hysteroscopy, it is still unclear which strategies are most effective.

OBJECTIVE

The objective of the study was to perform a systematic review and meta-analysis to evaluate the effectiveness of postoperative prevention strategies on intrauterine adhesion formation following operative hysteroscopy.

STUDY DESIGN

Literature searches were conducted in MEDLINE, Embase, ClinicalTrials.gov, and Cochrane Library databases. Inclusion criteria were published randomized controlled clinical trials from 1989 to 2014 comparing any postoperative preventative measures of intrauterine adhesion after hysteroscopy. The main outcome measure was a reduction in postoperative intrauterine adhesion. Heterogeneity of the studies was evaluated using a Q test and an I(2) index. Analyses were performed using a random-effects model with outcome data reported as relative risk with 95% confidence interval.

RESULTS

Twelve studies were included in the systematic review. Eight studies compared similar treatment methods and were included in the meta-analysis. Three studies evaluated hyaluronic acid gel, of which 2 reported a significant decrease in intrauterine adhesion with treatment. The meta-analysis demonstrated a significant reduction of intrauterine adhesion when using hyaluronic acid gel. Two studies evaluated polyethylene oxide-sodium carboxymethylcellulose gel, 1 of which demonstrated a decrease in intrauterine adhesion with treatment. A meta-analysis showed a significant reduction of intrauterine adhesion with polyethylene oxide-sodium carboxymethyl cellulose gel. However, these 3 studies demonstrating a benefit of the gels in preventing adhesion formation were all conducted by the same research group. Other research groups have not confirmed these results. A sensitivity analysis excluding these trials from this single group demonstrated no benefit to adhesion prevention with either gel formation. Three studies investigated oral estrogen therapy after hysteroscopy and found no difference in intrauterine adhesion. A meta-analysis showed no decrease in intrauterine adhesion with estrogen therapy after hysteroscopy. Data were lacking to perform metaanalyses on the use of intrauterine balloon, intrauterine device, and other adhesion prevention barriers in preventing intrauterine adhesion.

CONCLUSION

There was a lack of definitive evidence to conclude that any treatment is effective in preventing posthysteroscopy uterine adhesion formation. The available literature has significant heterogeneity and a high risk of bias, making any definitive conclusions difficult.

Local Anesthesia Combined With Sedation Compared With General Anesthesia for Ambulatory Operative Hysteroscopy: A Randomized Study

PURPOSE

The purpose of this study was to compare two anesthetic techniques for postoperative pain after ambulatory operative hysteroscopy.

DESIGN

A randomized trial.

METHODS

Women (N = 153) scheduled for ambulatory operative hysteroscopy were assigned to receive either paracervical local anesthesia combined with sedation (group LA + S; n = 76) or general anesthesia (group GA; n = 77). Primary outcome was the worst pain intensity score in the postanesthesia care unit (PACU) rated by the patients on a numerical rating scale.

FINDING

Data from 144 patients were available for analysis (LA + S: n = 69; GA: n = 75). There were no significant differences in worst pain intensity between groups in the PACU (P = .13) or after discharge from PACU (P = .40). In group LA + S, fewer patients received treatment with intravenous fentanyl intraoperatively (P < .01) and time until discharge from PACU was shorter (P < .01). More patients in group LA + S experienced vomiting after discharge (P < .05).

CONCLUSIONS

Local anesthesia with sedation can be recommended as a first choice anesthetic technique for operative ambulatory hysteroscopy.

Uterine myomata: Organ-preserving surgery

Most women with uterine myoma are asymptomatic and do not require any treatment. However, myoma can also lead to menorrhagia, pressure symptoms, abdominal pain, and infertility. Management of symptomatic women with myoma depends on several factors, including age, desire for fertility, and myoma characteristics. Uterine myoma that distorts the uterine cavity, either submucous myoma or intramural myoma, with a submucous component reduces fertility, and is associated with increased uterine bleeding. The treatment of choice is hysteroscopic myomectomy or abdominal myomectomy, preferably by laparoscopy. Robotic assistance in laparoscopic myomectomy leads to outcomes similar to conventional laparoscopic myomectomy. However, it is expensive. Newer techniques include either laparoscopic or transcervical radiofrequency thermal ablation.

Is the cold loop hysteroscopic technique a myometrial sparing treatment for placenta accreta residuals in a puerperal uterus?

Placenta accreta is a life-threatening obstetric pathology characterized by an abnormal invasion of chorionic villi into the uterine wall. The management represents a challenge for the gynecologist, especially in patients desiring to preserve their fertility. Several methods have been proposed to avoid hysterectomy. A case of a hysteroscopic conservative management with the cold loop technique in a puerpera with a large mass of placenta accreta residuals is described. The chorionic tissue was safely detached and it was subsequently removed by an electric cutting loop. Even in the absence of a clear cleavage plane, the thermal damage of surrounding healthy myometrium and dreadful complications as uterine perforation due to the electric cutting loop were avoided. The cold-loop hysteroscopic resection seems to be a safe and effective choice for the treatment of retained placenta accreta in patients desiring to preserve fertility. Moreover, it can also be proposed to patients who need to be treated immediately after delivery.

Intracervical versus vaginal misoprostol for cervical dilatation prior to operative hysteroscopy-a comparative study

BACKGROUND

Hysteroscopic surgery requires pre-operative cervical ripening to facilitate adequate dilatation of the cervix for insertion of operative hysteroscope. This study was conducted to compare the efficacy of intracervical misoprostol with vaginal misoprostol in achieving cervical ripening before operative hysteroscopy.

METHODS

In this randomised comparative study conducted at a tertiary care teaching hospital, 56 patients needing operative hysteroscopy were divided into two groups of 28 patients, one for intracervical misoprostol and the other for vaginal misoprostol. Four hundred microgram of misoprostol was inserted on the night before and in the morning of operative hysteroscopy intracervically in group I and vaginally in group II.

RESULTS

Primary outcome measure was number of patients achieving 7 mm preoperative dilatation of cervix. Largest Hegar dilator that could be passed into the uterine cavity past the internal optic sheath without resistance was noted in each case. Mean cervical dilatation prior to operative hysteroscopy was calculated. In addition, incidence of slipping of vulsellum and cervical laceration was also noted. Time to achieve full cervical dilatation was recorded. In 23/28 cases of group I and 5/28 in group II, size 7 Hegar dilator could be passed without effort. Mean cervical dilatation was 7.5 mm in group I and 5.7 mm in group II. Slipping of the vulsellum and cervical lacerations were seen in significantly less patients in group I. Mean time to achieve cervical dilatation to 10 mm was 43.39 seconds in group I and 103.96 seconds in group II (P<0.0001).

CONCLUSION

Intracervical administration of misoprostol is an effective method of achieving cervical ripening for easy cervical dilatation up to 10 mm prior to operative hysteroscopy.

Hysteroscopic resection of cervical nerve sheath tumor

Isolated nerve sheath tumors of the uterine cervix are very rare entities. This is especially true for benign nerve sheath tumors. We present, to the best of our knowledge, the first case of a benign nerve sheath tumor resected hysteroscopically. Our patient is a 69 year-old white female with a history of post menopausal bleeding. Initial workup included an endometrial biopsy and an ultrasound. A 4 cm cervical mass was identified on that study. Further characterization of the mass was obtained with magnetic resonance imaging (MRI). Gynecologic-Oncology consultation was obtained, and the opinion was that this was a cervical myoma. The patient continued to have bleeding and was taken to the operating room for a hysteroscopy and dilatation and curettage. At surgery, a large cervical mass was resected hysteroscopically. Final pathology report showed this to be a benign nerve sheath tumor.