- Email: [email protected]
Argon laser versus microscissors for hysteroscopic incision of uterine septa
JlP spectroscopy of human placenta
Volume 164 Number I, Part 1
3lp nuclear magnetic resonance. Magn Reson Med 1986; 3:262-9. 17. Malloy CR, Cunningham CC, Radda GK. The metabolic state of the rat liver in vivo measured by 3lp-NMR spectroscopy. Biochim Biophys Acta 1986;885: 1-11. 18. lies RA, Stevens AN, Griffiths JR, Morris PG. Phosphorylation status of liver by 3lP-n.m.r. spectroscopy, and its implications for metabolic control. Biochem J 1985; 229: 141-51.
19. Sostman HD, Armitage 1M, Fischer J). NMR in cancer. I. High resolutio'n spectroscopy of tumors. Magn Reson Imaging 1984;2:265-78. 20. Bloxam DL, 'Bobinski PM. Energy metabolism and glycolysis in the human placenta during ischaemia and in normal labour. Placenta 1984;5:381-94.
Argon laser versus microscissors for hysteroscopic incision of uterine septa Giovanni Battista Candiani, MD, Paolo Vercellini, MD, Luigi Fedele, MD, Salvatore Garsia, MD, Diana Brioschi, MD, and Laura Villa, MD Milan, Italy We performed hysteroscopic metroplasty in 21 women with repeated abortion and subseptate uterus. The patients were randomly allocated to septal incision with the argon laser (group I, 10 subjects) or microscissors (group II, 11 subjects) to compare these instruments in terms of surgical feasibility and anatomic results. The mean operating time was 57% longer in group I than in group II (p = 0.001), the intra- and postoperative morbidity of the whole series was negligible, and the anatomic results at abdominal ultrasonography and hysteroscopy performed 2 months postoperatively were similar in the two groups. This study confirms that microscissors are the simplest, fastest, most effective, and least expensive instrument to correct a septate uterus. The complete agreement of the findings at follow-up hysteroscopy and Ultrasonography suggest the use of the latter as the method of choice to check the surgical results. (AM J OasTET GVNECOl1991;164:87-90.)
Key words: Uterine malformations, recurrent abortion, hysteroscopy, laser Hysteroscopic incision seems to be the method of c:hoice to correct a septate uterus. )·3 The endoscopic use of microscissors and the resectoscope has proved successful, t·, and hysteroscopic metroplasty with fiberoptic laser has been proposed: We designed a randomized study to compare the surgical and anatomic results of section of the uterine septum performed with the argon laser versus microscissors.
Material and methods During 1989 we studied 21 women with a mean age of 28 years (range, 23 to 34) with two or more spontaneous abortions, a double uterine cavity at hysterosalpingography (Fig. I) and evidence of a normal uterine fundus at ultrasonographic examination with a half-
From the First Department of Obstetrics and Gynecology, University of Milano School of Medicine. Received for publication April 23, 1990; revised July 30, 1990; accepted August 3, 1990. Reprint requests: Paolo Vercellini, MD, First Department of Obstetrics and Gynecology "L. Mangiagalli," University of Milano School of Medicine, Via Commenda 12, Milano, Italy 20122. 611124440
full bladder. 6 • 7 All the uteri were classified as American Fertility Society class Vb (partial septate uterus).8 After giving informed consent, the patients were allocated according to a randomization list to hysteroscopic metroplasty with argon laser (group I, 10 women) or microscissors (group II, 11 women) between day 7 and day 10 of the cycle. Preoperative hysterosalpingography and ultrasonography showed the septum was broad (>3 em wide at the base) in two subjects in group I and in four subjects in group II. Under general endotracheal anesthesia and laparoscopic control, the cervix was dilated to 7 mm and a rigid hysteroscope (model 26157 B, Storz Endoscopy, Tuttlingen, Federal Republic of Germany) with a 7 mm diameter operating sheath (Storz model 26163 C and 26163 H) was introduced. The uterine cavity was distended with a 10% solution of dextran of molecular weight 40,000 in normal saline solution (Rheomacrodex, Baxter-Travenol, Trieste, Italy). In the group I women the septal incision was performed with the argon laser (model 20, HGM Medical Laser Systems Inc., Salt Lake City, Utah), passing the 0.6 mm flexible quartz fiber through the operating channel of the hystero-
87
88 Candiani at al.
January 1991 Am J Obstet Gynecol
Fig. 1. Hysterosalpingogram of septate uterus before hysteroscopic metroplasty with argon laser.
scopic sheath and using a touch technique. The power was set at 12 watts in continuous mode. Rigid scissors (Storz model 26158 EK) were used in the group II patients. After visualization of the tubal ostia, the section was started from the inferior margin of the septum and carried cephalad with progressive horizontal incisions in the midline. The six broad septa were sectioned with the technique suggested by March and Israel! The incision was considered complete when a normal uterine cavity was obtained and the hysteroscope could be moved freely from one tubal ostium to the other. The operating time was calculated from the insertion of the flexible fiber or microscissors into the uterine cavity to the removal of the hysteroscope. No intrauterine contraceptive device was inserted and no pre- or postoperative hormone treatment was administered. The patients were scheduled to undergo transabdominal ultrasonography in the late secretory phase of the second postoperative cycle and follow-up hysteroscopy in the next proliferative phase. The ultrasonographist did not know the surgical results and the hysteroscopist was unaware of the ultrasonographic findings. For statistical analysis the Student t test and Fischer's test were used.
Results All the procedures were completed without complications. Incision of the septum with argon laser was relatively slow and difficult. The mean operating time was 57% longer than with microscissors, the difference being 11 minutes (95% confidence limits, 5 to 17; Table I). This was attributable partly to the lower cutting capability of the laser fiber and partly to the difficult op-
erating conditions and to the reduction of the visual field by the eye protection filter. The mean amount of distension medium used was 75% greater with the argon laser, with a difference of 333 ml (95% confidence limits, 105 to 561). The postoperative course was uneventful in all patients, and they were discharged within 24 hours. At follow-up ultrasonographic examination a residual fundal notch ~ I cm deep with respect to the orthogonal plane passing through the two tubal ostia was observed in two women in each group. Minor fundal irregularities «1 cm deep) were present in four group I and five group II patients. The hysteroscopic findings always confirmed the ultrasonographic data. All the uterine cavities had a uniform lining of grossly normal endometrium. During the repeat hysteroscopy the four central fundal adhesions of ~ I cm deep were sectioned. Three group I and two group II subjects had a follow-up hysterosalpingography that confirmed the ultrasonographic and hysteroscopic findings (Fig. 2). Six patients who underwent surgery with the argon laser attempted to conceive: one aborted at 10 weeks' gestation, one took a pregnancy to term and was delivered vaginally, three are currently pregnant (14, 19, and 28 weeks, respectively), and one has not conceived after 6 months. Of the eight women who underwent surgery with microscissors who sought a pregnancy, one underwent right salpingectomy for ectopic pregnancy, one had a vaginal delivery at term, one had a cesarean section at 39 weeks' gestation for obstetric reasons, four have an ongoing pregnancy (7, 9, 18, and 26 weeks), and one has not conceived after 4 months.
Volume 164 Number I, Part 1
Laser vs scissors for hysteroscopic metroplasty 89
Fig. 2. Same case as in Fig. I. Postoperative hysterosalpingogram shows minimal septal remnant
Comment
The argon laser is a simple instrument to use, and is practical and effective in the laparoscopic treatment of endometriosis. 9 Energy is delivered through a flexible quartz optical fiber of 0.3 or 0.6 mm diameter. Unlike the carbon dioxide laser, the argon laser can be used through clear fluids, and is thus suitable for operative hysteroscopy. Also the Nd-YAG laser can be used with fibers through fluids, but because of the power of its beam, which can penetrate to depths of 4 to 5 mm and thus effectively ablate endometrium, to it does not seem to be indicated in conservative intrauterine surgery where endometrial sparing is most important. The argon laser can coagulate small vessels and, when used at relatively high power settings with a near-contact or touch technique, the predominant effect is vaporization and incision with an extremely narrow band of thermal damage to surrounding tissues. 9 Because of these characteristics we considered the argon laser (the KTP/ 532 laser is not yet available in Italy) the best choice for a comparative study on microscissors, the current "gold standard" for hysteroscopic metroplasty.I-3 Our study had a major limitation, the small sample size, but it was designed as a pilot study to identify clinically important differences in the feasibility and duration of operation and in the postoperative anatomic results. This initial experience of hysteroscopic correction of septate uteri with the argon laser was unsatisfactory. The operating times were appreciably longer than when microscissors were used. The slowness
Table I. Data on hysteroscopic incision of uterine septa with argon laser or microscissors
(n = 10)
Group II, microscissors (n = 11)
30 ± 7*
19 ± 6t
16-41 776 ± 228*
12-37 442 ± 266 ml:j:
340-1280 2 (20%)
240-1150 2 (18%)
Group I, argon laser
Operating time (min) Range Distension medium used (ml) Range No. of patients (%) with residual fundal notch ~ I em deep at follow-up ultrasonography and hysteroscopy
*Mean ± SD. tp = 0.001 versus group I (Student's t test). :j:p = 0.006 versus group I (Student's t test).
of the incision could possibly be related to the range of light wavelength of the argon laser (488 to 514 mm), which is preferentially absorbed by tissues rich in red pigment such as hemoglobin, whereas the cut septum is white and avascular. When the section reaches the cranial part of the septum, arteriolar bleeding is frequently observed. The argon laser's power of coagulation seems of no advantage in these circumstances. In fact, as noted by others, bleeding from the incised septum is minimal: fundal bleeding is the physiologic sign that parietal myometrium has been reached. I-3
Candiani et al.
After the section we did not insert an intrauterine contraceptive device nor did we administer estrogens inasmuch as in a previous study we had found these measures of no benefit. 11 Postoperative morbidity was negligible in both groups. We observed no differences in the intracavitary morphologic results after metroplasty with the argon laser compared with microscissors. The follow-up of the patients is too short to draw conclusions on the reproductive outcome. As a secondary observation we found that the data obtained at the follow-up ultrasonographic examination corresponded to those of the "second look" hysteroscopy. If this finding is confirmed, it would mean that an ultrasonographic scan with half-full bladder6 ,7 would be sufficient to check the results of surgery before allowing patients to try to conceive. Hysteroscopy could be reserved for patients who require correction of deep septal remnants. This study confirmed that microscissors are the most simple, rapid, effective, and economic instrument for hysteroscopic correction of a septate uterus. Other disadvantages of the argon laser include the necessity for running water to cool the laser generator and for a special three-phase electricity supply. The eye safety filter necessary to protect the operator's retina from backscatter alters color perception, reduces the field of view, adds an extra encumbrance to the eyepiece of the hysteroscope, and makes photographic or television documentation of the operation difficult. It takes longer to learn to use the argon laser than microscissors in hysteroscopy. Lastly, an argon laser has a very high initial cost and should be acquired only by hospitals that can
January 1991 Am J Obstet Gynecol
amortize the expense on a large number of endoscopic operations. Otherwise the economic advantage of hysteroscopic metroplastt is lost.
REFERENCES 1. Valle RF, Sciarra JJ. Hysteroscopic treatment of the septate uterus. Obstet Gynecol 1986;67:253-7. 2. March CM, Israel R. Hysteroscopic management of recurrent abortion caused by septate uterus. AM J OBSTET GYNECOL 1987;156:834-42. 3. Daly DC, Maier D, Soto-Albors C. Hysteroscopic metroplasty: six years' experience. Obstet Gynecol 1989;73: 201-5. 4. De Cherney AH, Russell JB, Graebe RA, Polan MC. Resectoscopic management of mullerian fusion defects. Fertil Steril 1986;45:726-8. 5. DaniellJF, Osher S, Miller W. Hysteroscopic resection of uterine septi with visible light laser energy. Colposc Gynecol Laser Surg 1987;3:217-20. 6. Candiani GB, Ferrazzi E, Fedele L, Vercellini P, Dorta M. Sonographic evaluation of uterine morphology: a new scanning technique. Acta Eur Fertil 1986;17:345-7. 7. Fecide L, Ferrazzi E, Dorta M, Vercellini P, Candiani GB. Ultrasonography in the differential diagnosis of "double" uteri. Fertil SterilI988;50:361-4. 8. The American Fertility Society. The American Fertility Society classifications of adnexal adhesions, distal tubal occlusion, tubal occlusion secondary to tubal ligation, tubal pregnancies, miillerian anomalies and intrauterine adhesions. Fertil Steril 1988;49:944-55. 9. Keye WR. Laparoscopic treatment of endometriosis. Obstet Gynecol Clin North Am 1989;16:157-66. 10. Baggish MS, Baltoyannis P. New techniques for laser ablation of the endometrium in high-risk patients. AM J OBSTET GYNECOL 1988;159:287-92. 11. Vercellini P, Fedele L, Arcaini L, Rognoni MT, Candiani GB. Value of intrauterine device insertion and estrogen administration after hysteroscopic metroplasty. J Reprod Med 1989;447-50.
Angiosarcoma of the uterus: A case report Guillermo E. Quinonez, MD, MSc, Maria P. Paraskevas, MD, MSc, Malkit S. Diocee, EMT, and Susan M. Lorimer, MD Winnipeg, Manitoba, Canada We are reporting a case of angiosarcoma of the uterus in which the diagnosis was confirmed ultrastructurally by demonstration of Weibel-Palade bodies in the tumor cells. Only 10 cases of this entity have been previously documented in the literature. (AM J OBSTET GVNECOL 1991;164:90-2.)
Key words: Uterine angiosarcoma, Weibel-Palade bodies
From the Department of Pathology, Health Sciences Centre, Faculty of Medicine, University of Manitoba. Received for publication July 30, 1990; accepted August 8, 1990. Reprint requests: G. Quinonez, MD, 820 Sherbrook St., Winnipeg, Manitoba, Canada R3A 1R9.
6/1124446
90
Angiosarcomas of the uterus are rare. Ten cases have been previously documented in the literature. I, 2 We are reporting a case of angiosarcoma of the uterus in which the diagnosis was confirmed ultrastructurally by demonstrating Weibel-Palade bodies.
Volume 164 Number I, Part 1
3lp nuclear magnetic resonance. Magn Reson Med 1986; 3:262-9. 17. Malloy CR, Cunningham CC, Radda GK. The metabolic state of the rat liver in vivo measured by 3lp-NMR spectroscopy. Biochim Biophys Acta 1986;885: 1-11. 18. lies RA, Stevens AN, Griffiths JR, Morris PG. Phosphorylation status of liver by 3lP-n.m.r. spectroscopy, and its implications for metabolic control. Biochem J 1985; 229: 141-51.
19. Sostman HD, Armitage 1M, Fischer J). NMR in cancer. I. High resolutio'n spectroscopy of tumors. Magn Reson Imaging 1984;2:265-78. 20. Bloxam DL, 'Bobinski PM. Energy metabolism and glycolysis in the human placenta during ischaemia and in normal labour. Placenta 1984;5:381-94.
Argon laser versus microscissors for hysteroscopic incision of uterine septa Giovanni Battista Candiani, MD, Paolo Vercellini, MD, Luigi Fedele, MD, Salvatore Garsia, MD, Diana Brioschi, MD, and Laura Villa, MD Milan, Italy We performed hysteroscopic metroplasty in 21 women with repeated abortion and subseptate uterus. The patients were randomly allocated to septal incision with the argon laser (group I, 10 subjects) or microscissors (group II, 11 subjects) to compare these instruments in terms of surgical feasibility and anatomic results. The mean operating time was 57% longer in group I than in group II (p = 0.001), the intra- and postoperative morbidity of the whole series was negligible, and the anatomic results at abdominal ultrasonography and hysteroscopy performed 2 months postoperatively were similar in the two groups. This study confirms that microscissors are the simplest, fastest, most effective, and least expensive instrument to correct a septate uterus. The complete agreement of the findings at follow-up hysteroscopy and Ultrasonography suggest the use of the latter as the method of choice to check the surgical results. (AM J OasTET GVNECOl1991;164:87-90.)
Key words: Uterine malformations, recurrent abortion, hysteroscopy, laser Hysteroscopic incision seems to be the method of c:hoice to correct a septate uterus. )·3 The endoscopic use of microscissors and the resectoscope has proved successful, t·, and hysteroscopic metroplasty with fiberoptic laser has been proposed: We designed a randomized study to compare the surgical and anatomic results of section of the uterine septum performed with the argon laser versus microscissors.
Material and methods During 1989 we studied 21 women with a mean age of 28 years (range, 23 to 34) with two or more spontaneous abortions, a double uterine cavity at hysterosalpingography (Fig. I) and evidence of a normal uterine fundus at ultrasonographic examination with a half-
From the First Department of Obstetrics and Gynecology, University of Milano School of Medicine. Received for publication April 23, 1990; revised July 30, 1990; accepted August 3, 1990. Reprint requests: Paolo Vercellini, MD, First Department of Obstetrics and Gynecology "L. Mangiagalli," University of Milano School of Medicine, Via Commenda 12, Milano, Italy 20122. 611124440
full bladder. 6 • 7 All the uteri were classified as American Fertility Society class Vb (partial septate uterus).8 After giving informed consent, the patients were allocated according to a randomization list to hysteroscopic metroplasty with argon laser (group I, 10 women) or microscissors (group II, 11 women) between day 7 and day 10 of the cycle. Preoperative hysterosalpingography and ultrasonography showed the septum was broad (>3 em wide at the base) in two subjects in group I and in four subjects in group II. Under general endotracheal anesthesia and laparoscopic control, the cervix was dilated to 7 mm and a rigid hysteroscope (model 26157 B, Storz Endoscopy, Tuttlingen, Federal Republic of Germany) with a 7 mm diameter operating sheath (Storz model 26163 C and 26163 H) was introduced. The uterine cavity was distended with a 10% solution of dextran of molecular weight 40,000 in normal saline solution (Rheomacrodex, Baxter-Travenol, Trieste, Italy). In the group I women the septal incision was performed with the argon laser (model 20, HGM Medical Laser Systems Inc., Salt Lake City, Utah), passing the 0.6 mm flexible quartz fiber through the operating channel of the hystero-
87
88 Candiani at al.
January 1991 Am J Obstet Gynecol
Fig. 1. Hysterosalpingogram of septate uterus before hysteroscopic metroplasty with argon laser.
scopic sheath and using a touch technique. The power was set at 12 watts in continuous mode. Rigid scissors (Storz model 26158 EK) were used in the group II patients. After visualization of the tubal ostia, the section was started from the inferior margin of the septum and carried cephalad with progressive horizontal incisions in the midline. The six broad septa were sectioned with the technique suggested by March and Israel! The incision was considered complete when a normal uterine cavity was obtained and the hysteroscope could be moved freely from one tubal ostium to the other. The operating time was calculated from the insertion of the flexible fiber or microscissors into the uterine cavity to the removal of the hysteroscope. No intrauterine contraceptive device was inserted and no pre- or postoperative hormone treatment was administered. The patients were scheduled to undergo transabdominal ultrasonography in the late secretory phase of the second postoperative cycle and follow-up hysteroscopy in the next proliferative phase. The ultrasonographist did not know the surgical results and the hysteroscopist was unaware of the ultrasonographic findings. For statistical analysis the Student t test and Fischer's test were used.
Results All the procedures were completed without complications. Incision of the septum with argon laser was relatively slow and difficult. The mean operating time was 57% longer than with microscissors, the difference being 11 minutes (95% confidence limits, 5 to 17; Table I). This was attributable partly to the lower cutting capability of the laser fiber and partly to the difficult op-
erating conditions and to the reduction of the visual field by the eye protection filter. The mean amount of distension medium used was 75% greater with the argon laser, with a difference of 333 ml (95% confidence limits, 105 to 561). The postoperative course was uneventful in all patients, and they were discharged within 24 hours. At follow-up ultrasonographic examination a residual fundal notch ~ I cm deep with respect to the orthogonal plane passing through the two tubal ostia was observed in two women in each group. Minor fundal irregularities «1 cm deep) were present in four group I and five group II patients. The hysteroscopic findings always confirmed the ultrasonographic data. All the uterine cavities had a uniform lining of grossly normal endometrium. During the repeat hysteroscopy the four central fundal adhesions of ~ I cm deep were sectioned. Three group I and two group II subjects had a follow-up hysterosalpingography that confirmed the ultrasonographic and hysteroscopic findings (Fig. 2). Six patients who underwent surgery with the argon laser attempted to conceive: one aborted at 10 weeks' gestation, one took a pregnancy to term and was delivered vaginally, three are currently pregnant (14, 19, and 28 weeks, respectively), and one has not conceived after 6 months. Of the eight women who underwent surgery with microscissors who sought a pregnancy, one underwent right salpingectomy for ectopic pregnancy, one had a vaginal delivery at term, one had a cesarean section at 39 weeks' gestation for obstetric reasons, four have an ongoing pregnancy (7, 9, 18, and 26 weeks), and one has not conceived after 4 months.
Volume 164 Number I, Part 1
Laser vs scissors for hysteroscopic metroplasty 89
Fig. 2. Same case as in Fig. I. Postoperative hysterosalpingogram shows minimal septal remnant
Comment
The argon laser is a simple instrument to use, and is practical and effective in the laparoscopic treatment of endometriosis. 9 Energy is delivered through a flexible quartz optical fiber of 0.3 or 0.6 mm diameter. Unlike the carbon dioxide laser, the argon laser can be used through clear fluids, and is thus suitable for operative hysteroscopy. Also the Nd-YAG laser can be used with fibers through fluids, but because of the power of its beam, which can penetrate to depths of 4 to 5 mm and thus effectively ablate endometrium, to it does not seem to be indicated in conservative intrauterine surgery where endometrial sparing is most important. The argon laser can coagulate small vessels and, when used at relatively high power settings with a near-contact or touch technique, the predominant effect is vaporization and incision with an extremely narrow band of thermal damage to surrounding tissues. 9 Because of these characteristics we considered the argon laser (the KTP/ 532 laser is not yet available in Italy) the best choice for a comparative study on microscissors, the current "gold standard" for hysteroscopic metroplasty.I-3 Our study had a major limitation, the small sample size, but it was designed as a pilot study to identify clinically important differences in the feasibility and duration of operation and in the postoperative anatomic results. This initial experience of hysteroscopic correction of septate uteri with the argon laser was unsatisfactory. The operating times were appreciably longer than when microscissors were used. The slowness
Table I. Data on hysteroscopic incision of uterine septa with argon laser or microscissors
(n = 10)
Group II, microscissors (n = 11)
30 ± 7*
19 ± 6t
16-41 776 ± 228*
12-37 442 ± 266 ml:j:
340-1280 2 (20%)
240-1150 2 (18%)
Group I, argon laser
Operating time (min) Range Distension medium used (ml) Range No. of patients (%) with residual fundal notch ~ I em deep at follow-up ultrasonography and hysteroscopy
*Mean ± SD. tp = 0.001 versus group I (Student's t test). :j:p = 0.006 versus group I (Student's t test).
of the incision could possibly be related to the range of light wavelength of the argon laser (488 to 514 mm), which is preferentially absorbed by tissues rich in red pigment such as hemoglobin, whereas the cut septum is white and avascular. When the section reaches the cranial part of the septum, arteriolar bleeding is frequently observed. The argon laser's power of coagulation seems of no advantage in these circumstances. In fact, as noted by others, bleeding from the incised septum is minimal: fundal bleeding is the physiologic sign that parietal myometrium has been reached. I-3
Candiani et al.
After the section we did not insert an intrauterine contraceptive device nor did we administer estrogens inasmuch as in a previous study we had found these measures of no benefit. 11 Postoperative morbidity was negligible in both groups. We observed no differences in the intracavitary morphologic results after metroplasty with the argon laser compared with microscissors. The follow-up of the patients is too short to draw conclusions on the reproductive outcome. As a secondary observation we found that the data obtained at the follow-up ultrasonographic examination corresponded to those of the "second look" hysteroscopy. If this finding is confirmed, it would mean that an ultrasonographic scan with half-full bladder6 ,7 would be sufficient to check the results of surgery before allowing patients to try to conceive. Hysteroscopy could be reserved for patients who require correction of deep septal remnants. This study confirmed that microscissors are the most simple, rapid, effective, and economic instrument for hysteroscopic correction of a septate uterus. Other disadvantages of the argon laser include the necessity for running water to cool the laser generator and for a special three-phase electricity supply. The eye safety filter necessary to protect the operator's retina from backscatter alters color perception, reduces the field of view, adds an extra encumbrance to the eyepiece of the hysteroscope, and makes photographic or television documentation of the operation difficult. It takes longer to learn to use the argon laser than microscissors in hysteroscopy. Lastly, an argon laser has a very high initial cost and should be acquired only by hospitals that can
January 1991 Am J Obstet Gynecol
amortize the expense on a large number of endoscopic operations. Otherwise the economic advantage of hysteroscopic metroplastt is lost.
REFERENCES 1. Valle RF, Sciarra JJ. Hysteroscopic treatment of the septate uterus. Obstet Gynecol 1986;67:253-7. 2. March CM, Israel R. Hysteroscopic management of recurrent abortion caused by septate uterus. AM J OBSTET GYNECOL 1987;156:834-42. 3. Daly DC, Maier D, Soto-Albors C. Hysteroscopic metroplasty: six years' experience. Obstet Gynecol 1989;73: 201-5. 4. De Cherney AH, Russell JB, Graebe RA, Polan MC. Resectoscopic management of mullerian fusion defects. Fertil Steril 1986;45:726-8. 5. DaniellJF, Osher S, Miller W. Hysteroscopic resection of uterine septi with visible light laser energy. Colposc Gynecol Laser Surg 1987;3:217-20. 6. Candiani GB, Ferrazzi E, Fedele L, Vercellini P, Dorta M. Sonographic evaluation of uterine morphology: a new scanning technique. Acta Eur Fertil 1986;17:345-7. 7. Fecide L, Ferrazzi E, Dorta M, Vercellini P, Candiani GB. Ultrasonography in the differential diagnosis of "double" uteri. Fertil SterilI988;50:361-4. 8. The American Fertility Society. The American Fertility Society classifications of adnexal adhesions, distal tubal occlusion, tubal occlusion secondary to tubal ligation, tubal pregnancies, miillerian anomalies and intrauterine adhesions. Fertil Steril 1988;49:944-55. 9. Keye WR. Laparoscopic treatment of endometriosis. Obstet Gynecol Clin North Am 1989;16:157-66. 10. Baggish MS, Baltoyannis P. New techniques for laser ablation of the endometrium in high-risk patients. AM J OBSTET GYNECOL 1988;159:287-92. 11. Vercellini P, Fedele L, Arcaini L, Rognoni MT, Candiani GB. Value of intrauterine device insertion and estrogen administration after hysteroscopic metroplasty. J Reprod Med 1989;447-50.
Angiosarcoma of the uterus: A case report Guillermo E. Quinonez, MD, MSc, Maria P. Paraskevas, MD, MSc, Malkit S. Diocee, EMT, and Susan M. Lorimer, MD Winnipeg, Manitoba, Canada We are reporting a case of angiosarcoma of the uterus in which the diagnosis was confirmed ultrastructurally by demonstration of Weibel-Palade bodies in the tumor cells. Only 10 cases of this entity have been previously documented in the literature. (AM J OBSTET GVNECOL 1991;164:90-2.)
Key words: Uterine angiosarcoma, Weibel-Palade bodies
From the Department of Pathology, Health Sciences Centre, Faculty of Medicine, University of Manitoba. Received for publication July 30, 1990; accepted August 8, 1990. Reprint requests: G. Quinonez, MD, 820 Sherbrook St., Winnipeg, Manitoba, Canada R3A 1R9.
6/1124446
90
Angiosarcomas of the uterus are rare. Ten cases have been previously documented in the literature. I, 2 We are reporting a case of angiosarcoma of the uterus in which the diagnosis was confirmed ultrastructurally by demonstrating Weibel-Palade bodies.