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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

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

Hysteroscopic patterns of Endometrial Tuberculosis by Alka Kumar

 

Alka picture

According to our data from 1992 to 2016 , we have encountered some specific hysteroscopic markers which are common to cases of endometrial TB:

I) Bizzare endometrial character: where the endometrium loses its color, glands and starts to look dirty, pale, white powdery nibbled, and has flimsy adhesions.

II) Granulomas or tubercles: They appear as small pale white irregular objects either on the endometrium directly or attached to flimsy adhesion bands. The tubercles vary in size.

III) Adhesions: From flimsy adhesions to moderate to severe adhesion bands, and often when looked closely these adhesions have tubercles /granulomas that look like whitish colored irregular deposits that are attached on the adhesions. It is very important therefore to start doing hysteroscopy at very low flow rates so that the deposits do not get washed away with continuous fluid irrigation.

IV) Tubal ostia: Tubal ostia are commonly involved in endometrial TB. The minor endosalpigean folds are scarred, white, pale and usually devoid of the longitudionally arranged vascularity. The ostia usually do not show the normal opening and closing physiological motion at lower intrauterine pressures. Flimsy large adhesion bands may be seen surrounding the ostia. Sometimes the ostia are completely hidden behind adhesions. Flimsy adhesions can also be seen in the intramural part of the ostia.

 

Read the full interview at Hysteroscopy Newsletter

http://www.hysteroscopy.info

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

http://www.hysteroscopy.info

Endometrial Cancer. Hysteroscopy Newsletter

1154-_5.jpgEndometrial cancer is the most common gynecological cancer in developed countries and is the 5th most frequent cancer affecting woman. The estimated frequency is 19.1 / 100,000 cases in the USA and Canada and 15.6 / 100,000 in Europe.

It is usually associated with menopause, although up to 14% of cases are diagnosed in premenopausal women and up to 5% of cases in patients under the age of 40 years. It is usually diagnosed in early stages and with the tumor usually confined to the uterine cavity, which generally gives it a good prognosis

The main risk factor is continued unopposed exposure to elevated estrogen levels. Among the different causes related to endometrial cancer are:

1- Obesity: is present in 40-50% of endometrial carcinomas in developed countries. Obese women are 2-4 times more likely to develop endometrial cancer than non-obese women.

2- Unopposed estrogen therapy (UET). The use of UET greatly increases the formation of endometrial hyperplasia and endometrial carcinoma. This risk increases in relation to the dose and duration of the exposure. The administration of progesterone during HRT eliminates the risk of both endometrial hyperplasia and carcinoma.

3- Tamoxifen: It is a selective estrogen receptor modulator (SERM) that is commonly used as an adjuvant hormone treatment in women with breast cancer. The use of tamoxifen is associated with a 2-5-fold increased risk of developing endometrial pathology, including polyps and endometrial cancer.

4- Hereditary: Endometrial carcinoma may appear in the context of a Lynch II syndrome or hereditary colorectal cancer not associated with polyposis (HNPCC). It is an autonomic dominant disorder with incomplete penetrance. Women with HNPCC have a risk of about 50% developing endometrial cancer.

Read full article at Hysteroscopy Newsletter

http://www.hysteroscopy.info

Hysteroscopy Pictures: Uterine septum

uterine-septum

The septate uterus is the result of a failure in the process of resorption of the medial septum that can range from a minimal septum in the uterine fundus to a complete one dividing the uterine cavity completely or even asociating double cervix and vaginal septum. The proposed mechanism by which the uterine septum regresses is apoptosis, the presence of Blc-2 protein protects from apoptosis. The absence of Blc-2 in the embryonal uterine septum may indicate a lack of protection from apoptosis in this area. On the other hand different studies have allowed the identification of several genes that can be implicated in the development of uterine malformations

In an interesting study comparing the use of resectoscope to VersaPoint in 63 women for the treatment of septum (Resectoscope or Versapoint for hysteroscopic metroplasty. Int J Obstet Gynaecol 2008 Apr; 101 (1):39-42) Dr. Litta concludes that the VersaPoint system does not require cervical dilation, avoiding potential cervical incompetence, cervical lacerations and uterine perforation related to the dilation process. The use of VersaPoint is a safe alternative to the use of resectoscope, especially in nulligravid or patients with cervical stenosis.

 

what is an Endometrial Hyperplasia?

Endometrial Complex HyperplasiaEndometrial hyperplasia is an overgrowth of endometrial glands, with different shapes and sizes, which causes increased endometrial thickness which results in a greather gland / stroma ratio than observed in normal endometrium.

The term endometrial hyperplasia includes different pathologies that have the common feature to increased endometrial thickness. Some of these pathologies have virtually no potential for malignancy while others are clearly premalignant lesions. The pathological diagnosis is the key to the diagnosis of this entity.

Little is known on the actual incidence of endometrial hyperplasia although it is estimated to affect about 8/1000 in asymptomatic menopausal patients and 15% of patients with postmenopausal bleeding. There are different classifications, perhaps the most accepted is that of the International Society of Gynecological Pathologists that defines the following types:

1-Simple hyperplasia without atypia: Glandular dilatation and increased evidence glands and stroma.

2-Complex hyperplasia without atypia: Great growth of the endometrial glands with little stroma. The distribution pattern is irregularly glandular.

3-Simple hyperplasia with atypia: There are atypical cells present in the lining of the glands.

4-Complex hyperplasia with atypia: pattern of complex hyperplasia with atypical cells in the lining of the glands.

 

Read the full article

http://www.hysteroscopy.info

 

Chronic endometritis: Hysteroscopy Picture

Chronic endometritis is usually presents in a silent way, becoming an incidental finding when performing endometrial biopsy for other reasons.

The use of hysteroscopy with liquid distention media of the uterine cavity has been shown to be an effective method for the diagnosis of chronic endometritis. A common hysteroscopic finding in chronic endometritis is the presence of a thickened endometrial edematous mucosa. Also, a thin hyperemic micropolyps layer (less than 1 mm) that appears to float in the endometrial cavity can be seen.

Using these criteria, the hysteroscopic diagnosis of chronic endometritis has a sensitivity up to 93%.

 

Dysmorphic uterus: metroplasty with scissors.

Patient with two previous miscarriages. Diagnosis of dysmorphic uterus. Lateral and fundal metroplasty with scissors.

“When faced with a tubular uterine cavity or an increased smooth muscle component on the walls of a ‘T’ shaped uterus, the literature reports success with a resectoscopic technique designed to improve the volume and the morphology of the uterine cavity. The technique involves the use of a hooked loop which is meticulously guided by the surgeon placing parallel longitudinal incisions along the main axis of the uterine cavity. The aim is to decrease the centripetal force of muscle fibers and of any fibro-muscular rings that have contributed to the stenosis, and to promote a consecutive increase in the volume of the uterine cavity.”

Dr. A. Di Spiezo Sardo

Hysteroscopy Newsletter Vol. 1, Issue 3. P. 3-4

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