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Hysteroscopy Newsletter is an opened forum to all professionals who want to contribute with their knowledge and even share their doubts with a word-wide gynecological community

Fluid intra-vasation syndrome

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The fluid intra-vasation syndrome, also known as Fluid Overload Syndrome, Intravascular Absorption Syndrome of Surgical Hysteroscopy (IAsSH) or Tur(p) Syndrome, is a terrible complication of resectoscopic surgery, which manifests itself acutely after the massive and rapid absorption of the distention medium.

It is a possible complication of any “liquid medium” surgery, and is therefore present not only in urology or gynecology field but also in arthroscopies (Chai C, 1996), rectal tumor interventions, treatment of nephrolithiasis and percutaneous renal ultrasound (Dimberg 1993) and even during cardiac ablation (Di Biase l., 2013)

It is difficult to define the amount of fluid from which the syndrome begins to appear, and its onset depends not only on the intravascular volume but also on the type of fluid, the procedure performed, the general conditions of the patient, age and finally of subjective factors that sometimes are not identified.

Since resectoscopy is performed in two different ways – monopolar and bipolar – and therefore with two different types of distension media – non-conductors and conductors. It is accepted that the limit that can cause the development of the syndrome will be 1000 ml for the first case and 2000 ml for the second. (2013 AAGL, J Minim Invasive Gynecol.)

The incidence of the syndrome is around 5% of the resectoscopic procedures, including patients who have developed less obvious or subclinical forms. (Shveiky D, 2007)

 

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Osseous Metaplasia

Osseous metaplasia

This type of metaplasia is a rare condition in which there is a transformation of the
normal endometrial tissue into bone. It is an uncommon clinical finding with an
incidence of 0,3/1000 and most cases occur after miscarriage or abortion. The
presence of bone in the endometrium was first described by Virchow who related this
condition to a spontaneous differentiation of fibroblasts into osteoblasts. Typically, this
type of metaplasia occurs during reproductive years and more than 80% of reported
cases ocurr after pregnancy.
There are two main theories to explain the existence of bone fragments in the
endometrial tissue. The one by Thaler, who relate this entity to retention of osseous
fetal parts after abortion or miscarriage after 12 weeks of pregnancy. This first theory
cannot explain cases that occurr in patients without previous pregnancies. The second
theory is that of a true endometrial osseous metaplasia, in which there is a osseus
transformation of the endometrial stromal cells, this metaplasia is consequence of
irritative, toxic or hormonal stimuli. Probably both theories are right, with cases of true
metaplasia and cases in which retained bones, causes an endometrial inflammation
which leads to a secondary osseous metaplasia.

 

Hysteroscopy Newsletter

Hysteroscopy and Fertility (full article at Hysteroscopy Newsletter)

Early polyp 3

Endometrial polyps are benign, localized overgrowths of endometrial glands and stroma covered by endometrial epithelium.

Several authors agree that polyps may interfere with fertility, both by natural conception and intrauterine insemination.There are only few reports assessing the effect of endometrial polyps on IVF/ICSI cycles. In a study by Isikoglu et al, endometrial polyps <1,5cm discovered both before or during IVF/ICSI cycles did not seen to affect implantation and pregnancy rates. Lass et al, claimed that polyps <2cm did notdecrease pregnancy rates but increased miscarried rates. In this chapter we are going to analyses the factors that can influence the presence of endometrial polyps and the fertility of the women. Also studies have shown a higher frequency of endometrial polyps in patients with endometriosis compared those without the disease. Shen et al found endometrial polyps in 68,35% of the patients with endometriosis, compared with 20,51% in the control group.
The polyps are often asymptomatic but they can sometimes cause menstrual irregularities such as intermenstrual bleeding. They are commonly identified during the investigation for abnormal uterine bleeding and infertility. Little is know about the association between endometrial polyps and fertility. The mechanism by which polyps may adversely affect fertility is also poorly understood but may be related to mechanical
interference with sperm transport, embryo implantation, or through increased production of inhibitory factors such as glycodelin. Among other possible mechanism, the most empathized is an inflammatory process caused by the polyp acting in a similar way as an intrauterine device. Anatomical distortion of the endometrial cavity is another postulation and focuses mainly in the diminished volume of the endometrial cavity.

There area lot of postulations about a single or multiple mechanisms by why the polyps affect the endometrial receptivity.

Hysteroscopy in Acute Uterine Bleeding

Clots

The use of operative hysteroscopy in acute uterine bleeding that does not respond to medical treatment is a change in diagnostic and therapeutic paradigm to improve the results, to avoid unnecessary repetition of procedures and increase significantly the diagnostic sensitivity, in addition to adapt to the international recommendations to classify HUA PALM-COEIN within the system.

The quality and quantity of material removed for biopsy, with the intact endometrium without lesions or disrupted areas without hemorrhagic material with measures that allow multiple cuts, and the presence of myometrium to evaluate the eventual depth of invasion, significantly increase the effectiveness of study.

The procedure will always be operative in an operating room with a resectoscopy of 10mm, with a liquid medium which may be glycine or irrigation water, to make a good washing of the cavity, to evacuate clots and achieve a correct view.

Methodology
1. Evacuation of blood clots.
2. Bleeding control and to form the image.
3. Evaluation and endometrial biopsy.
4. Treatment of concomitant disease.
5. Endometrial surgery.

 

Full article at Hysteroscopy Newsletter

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Intrauterine adhesions classifications

adhesion

The first reference to the presence of intrauterine adhesions was made by Heinrich Fritsch in 1894 in a patient who developed secondary amenorrhea after a postpartum curettage (Fritsch H. Ein fall von volligem schwund der gebormutterhohle nach auskratzung Zentralbl Gynaekol 1894; 18: 1337- 42)

Although it was not until 1948 that Professor Joseph Asherman of the Hadassah Hospital of TelAviv published the first article on the pathology that bears his name and which he defined as traumatic amenorrhea (Asherman JG. Traumatic amenorrhea. Obstetrics and Gynecology of the British Empire, 1948; 55 (1): 23-30). Since then, interest in this syndrome has been increasing mainly due to the development hysteroscopy and its relation to secondary infertility.

The correct definition of the pathology should be that of intrauterine adhesions, reserving the concept of Asherman Syndrome for those cases in which these adhesions are accompanied by amenorrhea as a result of a total obliteration of the uterine cavity. Indeed, this differentiation between intrauterine adhesions and Asherman syndrome is not very popular and most gynecologists use the term Asherman syndrome to denote
any type of adhesions of the uterine cavity regardless of the existence or absence of accompanying amenorrhea.

The involvement of the cavity can vary from minimal adhesions to a total obliteration. These adhesions can present great variety in both their density and size. Some are so fragile that they break with the tip of the hysteroscope while others require surgical incision.

 

Full article at Hysteroscopy Newsletter

Tubal Ostial Polyp

Tubal Ostial Polyp

The fallopian tubes measure between 7 and 14 cm in length. They are composed of
three layers: mucous, muscular and serous layer. The mucosal layer is located directly
under the muscular layer that is formed by bundles of smooth muscle fibers with a
circular arrangement in its interior and longitudinal fibers in the exterior. The proximal
tubal opening is called ostium tubaricum and plays an important role in the prevention
of retrograde menstruation, in the transport of spermatozoa and in the transport of the
embryo to the uterine cavity.
Polyps at the level of the tubal ostium present as small, well-defined lesions.
According to Reasbeck, benign polypoid lesions in the intramural tubal portion are
found in up to 10% of hysterosalpingograms performed on infertile patients. Many of
these polypoid lesions are visible through hysteroscopy if the hysteroscope is placed
close enough to the ostium. Interestingly, in a series of 52 polyps of this location
resected by Gordts, all of them were made of endometrial tissue, despite the tubal
location. Rarely they produce total obstruction of the lumen, and although the role they
play in infertile patients is unclear, more and more authors believe that there is a clear
relationship between tubal polyps and infertility.

Resectr

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High-performance disponsable tissue resector

Basic manual devices are cost-efective ans easy-to-use, but often lack speed, power, control, and effectiveness. Electromechanical system may improve speed and power for certain cases, but require costly capital equipement, complex set-up and expensive disponsables. Some electromechanical systems introduce new procedural risks that may
outweigh their benefit.

The RESECTR ia a single –use, non-powered, hand-held, and hand-manipulated system designed to combine the benefits of basic manual devices and electromechanical powered systems. Clinicians squeeze and release the handle with their fingers to actuate cutting speed and control. Improved control means physicians can perform tissue resection based on what they see and feel during the procedure.

RESECTRs are 100% disponsable , ship “ready-to-use”, and do not require new capital equipement, complex set-up, or service contacts to cut.The cost-effective RESECTR can also be used in a variety of clinical settings allowing physicians to “see-ans-treat” lesions in the hospital, clinic, surgery centre or office.

Hysteroscopy Newsletter

Bleeding after subtotal hysterectomy

Cervical stump

The debate about whether supracervical hysterectomy, when performed for benign
conditions, has benefits over a total hysterectomy, remains open. There are many
arguments both for and against performing a supracervical hysterectomy.
Among the different arguments presented, it is clearly demonstrated by different
studies that a supracervical hysterectomy involves shorter surgical time, associated
lower blood loss and faster postoperative recovery. It has also been argued that
preservation of the cervical stump has positive implications in the sexual response as
well as favors the support of the pelvic floor and urinary function, although the latter is
yet to be confirmed.
It is clear that the main difference between one technique and the other lies in the
preservation of the cervical stump and in possible problems associated with it. These
include the development of cervical cancer in the remaining cervix that is estimated to
occur in less than 1% of patients. The other associated problem is persistent cyclic
menstrual bleeding after surgery, this happens between 0% and 25% of cases
according to the different series.

Hysteroscopy Newsletter

Hysteroscopy and Fertility: Fibroids

mioma resector

Fibroids or myomas are benign, monoclonal tumors of the uterus, mostly composed of smooth muscle cells and extracellular matrix. They are the most common solid tumor of the female pelvis. The prevalence varies widely, according to age, ethnicity, family and might be as high as 80% at age 50. They can be asymptomatic, but around 25% of women
might have pain or menorrhagia.Fibroids can be found in up to 10% of infertile women and can be the only abnormal finding in around 2,5%.

A review by Pritts et al. (2009) concluded that fibroids causing intracavitary distortion result in decreased rates of clinical pregnancy, implantation and livebirth, as well as an increased rate of spontaneous miscarriage.

Although no evidence was found against sub-serosal myomas, concerning intramural fibroids the same author concluded that fibroids with no intracavitary involvement,
had also decreased rates of implantation and live birth, and increased rate of spontaneous miscarriage.

Another review by Sunkara (2010) concluded that there was a significant decrease in the live birth in the presence of intramural fibroids that distort the endometrial cavity. Several explanations have been proposed, mostly related to impairment of the uterine peristalsis, vascular flow as well as disruption of sperm and ovum transportation and
embryo implantation.

However other studies are against the conclusion ofPritts, when concerning intra mural fibroids. A cohortstudy by Somigliana with 238 patients comparing the rate of success of IVF in women with small (less than 50mm) fibroids not encroaching the endometrial cavity in asymptomatic patients selected for IVF, concluded that such fibroids did have an impact on the rate of success of the procedure. Bodzag at all. reached the same
conclusion after comparing 61 cases against 444 controls.

In 2015 a Cochrane review addressing this question concluded that probably there might be a trend towards the benefit of removal of submucous fibroids in women with otherwise unexplained subfertility. The odds ratio in a group having regular fertility-oriented intercourse during 12 months for the outcome of clinical pregnancy was 2,44 (95% confidence interval 0.97- 6.17, p=0.06). Concerning miscarriage, there was no evidence of a difference between the groups.

Full article at Hysteroscopy Newsletter

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