- Email: [email protected]
Hysteroscopic morcellator to overcome cervical stenosis
VIDEO
The hysteroscopic morcellator to overcome cervical stenosis Bijan W. Salari, M.D.,a Bala Bhagavath, M.D.,b Michael L. Galloway, D.O.,a Austin D. Findley, M.D.,a,c Jerome L. Yaklic, M.D.,a and Steven R. Lindheim, M.D.a a Department of Obstetrics and Gynecology, Boonshoft School of Medicine, Wright State University; c Department of Obstetrics and Gynecology, Wright-Patterson Air Force Base, Dayton, Ohio; and b Department of Obstetrics and Gynecology, School of Medicine and Dentistry, University of Rochester Medical Center, Rochester, New York
Objective: To report a step-by-step technique to using a hysteroscopic morcellator to safely gain access into the intrauterine cavity in two patients with severe cervical stenosis and concomitant intrauterine pathology. Design: Video article introducing the hysteroscopic morcellator for overcoming severe cervical stenosis. Setting: Academic-based practice. Patient(s): A 36-year-old G0 female with primary infertility and uterine polyps and a 34-year-old G0 female with uterine polyps and a difficult trial transfer before undergoing an IVF cycle. In both patients, preoperative saline-infused sonography revealed submucosal filling defects and severe cervical stenosis. Intervention(s): A hysteroscopic technique using the Hologic Myosure to overcome severe cervical stenosis with or without the use of intraoperative ultrasound. Main Outcome Measure(s): Despite using preoperative Cytotec, cervical stenosis was identified. Under direct visualization, a 4-mm Myosure XL blade was placed through a 7.25-mm Myosure XL hysteroscopy. The cutter blade, powered by an electromechanical drive system, enables simultaneous rotation and reciprocation. The blade allows one to shave and remove tissue and is applied to cervical stenosis, allowing safe access into the intrauterine cavity. Result(s): The intrauterine hysteroscopic Myosure morcellator allowed for safe and direct entry into the uterine cavity. We have since applied this technique to all patients where cervical stenosis is identified and have minimized potential uterine perforation and false tracks in our patients. Conclusion(s): Our technique is an alternative method for overcoming severe cervical stenosis and minimizing potential intraoperative complications. (Fertil SterilÒ 2016;-:-–-. Ó2016 by American Society for Reproductive Medicine.) Key Words: Cervical stenosis, morcellation, hysteroscopy, intraoperative ultrasound, challenging cervix Discuss: You can discuss this article with its authors and with other ASRM members at https://www.fertstertdialog.com/posts/11353the-hysteroscopic-morcellator-to-overcome-cervical-stenosis
AVAILABLE ON YOUTUBE https://youtu.be/ZKe2U18_8TM
3.
SUGGESTED READING 1.
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Baldauf JJ, Dreyfus M, Ritter J, Meyer P, Philippe E. Risk of cervical stenosis after large loop excision or laser conization. Obstet Gynecol 1996;88:933–8. Barbieri RL. Stenosis of the external cervical os: an association with endometriosis in women
4.
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with chronic pelvic pain. Fertil Steril 1998;70: 571–3. Bettocchi S, Bramante S, Bifulco G, Spinelli M, Ceci O, Fascilla FD. Challenging the cervix: strategies to overcome the anatomic impediments to hysteroscopy: analysis of 31,052 office hysteroscopies. Fertil Steril 2016;105: e16–7. Borgatta L, Lopatinsky I, Shaw FM. Overcoming unsatisfactory colposcopy. Use of osmotic dilators. J Reprod Med 1997;42:271–5. Christianson MS, Barker MA, Lindheim SR. Overcoming the challenging cervix: techniques
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9. Received April 5, 2016; accepted July 15, 2016. B.W.S. has nothing to disclose. B.B. has nothing to disclose. M.L.G. has nothing to disclose. A.D.F. has nothing to disclose. J.L.Y. has nothing to disclose. S.R.L. has nothing to disclose. IRB: Approval was not required for this video. Patient consent to use pictures and video for publications and education was obtained for each surgical case. Reprint requests: Steven R. Lindheim, M.D., 128 Apple Street, Suite 3800, Weber CHE, Dayton, Ohio 45409 (E-mail: [email protected]). Fertility and Sterility® Vol. -, No. -, - 2016 0015-0282/$36.00 Copyright ©2016 American Society for Reproductive Medicine, Published by Elsevier Inc. http://dx.doi.org/10.1016/j.fertnstert.2016.07.1091 VOL. - NO. - / - 2016
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to access the uterine cavity. J Low Genit Tract Dis 2008;12:24–31. Darwish A, Ahmad AM, Mohammad AM. Cervical priming prior to operative hysteroscopy: a randomized comparison of laminaria versus misoprostol. Hum Reprod 2004;19: 2391–4. Gupta JK, Johnson N. Effect of mifepristone on dilatation of the pregnant and non-pregnant cervix. Lancet 1990;335:1238–40. Houlard S, Perrotin F, Fourquet F, Marret H, Lansac J, Body G. Risk factors for cervical stenosis after laser cone biopsy. Eur J Obstet Gynecol Reprod Biol 2002;104:144–7. Jansen FW, Vredevoogd CB, van Ulzen K, Hermans J, Trimbos JB, Trimbos-Kemper TC. Complications of hysteroscopy: a prospective, multicenter study. Obstet Gynecol 2000;96: 266–70. Kristenson GB, Jensen LK, Holund B. A randomized trial comparing two methods of cold knife conization with laser conization. Obstet Gynecol 1990;76:1009–13. Lin YH, Hwang JL, Huang LW, Seow KM, Chen HJ, Tzeng CR. Efficacy of hysteroscopic e1
VIDEO
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13.
14.
e2
cervical resection for cervical stenosis. J Minim Invasive Gynecol 2013;20: 836–41. Luesley DM, Redman CW, Buxton EJ, Lawton FG, Williams DR. Prevention of post-cone biopsy cervical stenosis using a temporary cervical stent. Br J Obstet Gynaecol 1990;97:334–7. Mahajan N, Gupta I. Use of Versapoint to refashion the cervical canal to overcome unusually difficult embryo transfers and improve in-vitro fertilizationembryo transfer outcome: a case series. J Hum Reprod Sci 2011;4:12–6. Noyes N, Licciardi F, Grifo J, Krey L, Berkeley A. In vitro fertilization outcome relative to embryo transfer difficulty: a novel approach to the forbidding cervix. Fertil Steril 1999;72:261–5.
15. 16.
17. 18.
Ostrzenski A. Resectoscopic cervical trauma minimized by inserting Laminaria digitata preoperatively. Int J Fertil Menopausal Stud 1994;39:111–3. Phillips DR, Nathanson HG, Milim SJ, Haselkorn JS. The effect of dilute vasopressin solution on the force needed for cervical dilatation: a randomized controlled trial. Obstet Gynecol 1997;89:507–11. Wortman M, Daggett A. Hysteroscopic endocervical resection. J Am Assoc Gynecol Laparosc 1996;4:63–8. Zhuo Z, Yu H, Jiang X. A systematic review and meta-analysis of randomized controlled trials on the effectiveness of cervical ripening with misoprostol administration before hysteroscopy. Int J Gynaecol Obstet 2016;123: 272–7.
VOL. - NO. - / - 2016
The hysteroscopic morcellator to overcome cervical stenosis Bijan W. Salari, M.D.,a Bala Bhagavath, M.D.,b Michael L. Galloway, D.O.,a Austin D. Findley, M.D.,a,c Jerome L. Yaklic, M.D.,a and Steven R. Lindheim, M.D.a a Department of Obstetrics and Gynecology, Boonshoft School of Medicine, Wright State University; c Department of Obstetrics and Gynecology, Wright-Patterson Air Force Base, Dayton, Ohio; and b Department of Obstetrics and Gynecology, School of Medicine and Dentistry, University of Rochester Medical Center, Rochester, New York
Objective: To report a step-by-step technique to using a hysteroscopic morcellator to safely gain access into the intrauterine cavity in two patients with severe cervical stenosis and concomitant intrauterine pathology. Design: Video article introducing the hysteroscopic morcellator for overcoming severe cervical stenosis. Setting: Academic-based practice. Patient(s): A 36-year-old G0 female with primary infertility and uterine polyps and a 34-year-old G0 female with uterine polyps and a difficult trial transfer before undergoing an IVF cycle. In both patients, preoperative saline-infused sonography revealed submucosal filling defects and severe cervical stenosis. Intervention(s): A hysteroscopic technique using the Hologic Myosure to overcome severe cervical stenosis with or without the use of intraoperative ultrasound. Main Outcome Measure(s): Despite using preoperative Cytotec, cervical stenosis was identified. Under direct visualization, a 4-mm Myosure XL blade was placed through a 7.25-mm Myosure XL hysteroscopy. The cutter blade, powered by an electromechanical drive system, enables simultaneous rotation and reciprocation. The blade allows one to shave and remove tissue and is applied to cervical stenosis, allowing safe access into the intrauterine cavity. Result(s): The intrauterine hysteroscopic Myosure morcellator allowed for safe and direct entry into the uterine cavity. We have since applied this technique to all patients where cervical stenosis is identified and have minimized potential uterine perforation and false tracks in our patients. Conclusion(s): Our technique is an alternative method for overcoming severe cervical stenosis and minimizing potential intraoperative complications. (Fertil SterilÒ 2016;-:-–-. Ó2016 by American Society for Reproductive Medicine.) Key Words: Cervical stenosis, morcellation, hysteroscopy, intraoperative ultrasound, challenging cervix Discuss: You can discuss this article with its authors and with other ASRM members at https://www.fertstertdialog.com/posts/11353the-hysteroscopic-morcellator-to-overcome-cervical-stenosis
AVAILABLE ON YOUTUBE https://youtu.be/ZKe2U18_8TM
3.
SUGGESTED READING 1.
2.
Baldauf JJ, Dreyfus M, Ritter J, Meyer P, Philippe E. Risk of cervical stenosis after large loop excision or laser conization. Obstet Gynecol 1996;88:933–8. Barbieri RL. Stenosis of the external cervical os: an association with endometriosis in women
4.
5.
with chronic pelvic pain. Fertil Steril 1998;70: 571–3. Bettocchi S, Bramante S, Bifulco G, Spinelli M, Ceci O, Fascilla FD. Challenging the cervix: strategies to overcome the anatomic impediments to hysteroscopy: analysis of 31,052 office hysteroscopies. Fertil Steril 2016;105: e16–7. Borgatta L, Lopatinsky I, Shaw FM. Overcoming unsatisfactory colposcopy. Use of osmotic dilators. J Reprod Med 1997;42:271–5. Christianson MS, Barker MA, Lindheim SR. Overcoming the challenging cervix: techniques
6.
7.
8.
9. Received April 5, 2016; accepted July 15, 2016. B.W.S. has nothing to disclose. B.B. has nothing to disclose. M.L.G. has nothing to disclose. A.D.F. has nothing to disclose. J.L.Y. has nothing to disclose. S.R.L. has nothing to disclose. IRB: Approval was not required for this video. Patient consent to use pictures and video for publications and education was obtained for each surgical case. Reprint requests: Steven R. Lindheim, M.D., 128 Apple Street, Suite 3800, Weber CHE, Dayton, Ohio 45409 (E-mail: [email protected]). Fertility and Sterility® Vol. -, No. -, - 2016 0015-0282/$36.00 Copyright ©2016 American Society for Reproductive Medicine, Published by Elsevier Inc. http://dx.doi.org/10.1016/j.fertnstert.2016.07.1091 VOL. - NO. - / - 2016
10.
11.
to access the uterine cavity. J Low Genit Tract Dis 2008;12:24–31. Darwish A, Ahmad AM, Mohammad AM. Cervical priming prior to operative hysteroscopy: a randomized comparison of laminaria versus misoprostol. Hum Reprod 2004;19: 2391–4. Gupta JK, Johnson N. Effect of mifepristone on dilatation of the pregnant and non-pregnant cervix. Lancet 1990;335:1238–40. Houlard S, Perrotin F, Fourquet F, Marret H, Lansac J, Body G. Risk factors for cervical stenosis after laser cone biopsy. Eur J Obstet Gynecol Reprod Biol 2002;104:144–7. Jansen FW, Vredevoogd CB, van Ulzen K, Hermans J, Trimbos JB, Trimbos-Kemper TC. Complications of hysteroscopy: a prospective, multicenter study. Obstet Gynecol 2000;96: 266–70. Kristenson GB, Jensen LK, Holund B. A randomized trial comparing two methods of cold knife conization with laser conization. Obstet Gynecol 1990;76:1009–13. Lin YH, Hwang JL, Huang LW, Seow KM, Chen HJ, Tzeng CR. Efficacy of hysteroscopic e1
VIDEO
12.
13.
14.
e2
cervical resection for cervical stenosis. J Minim Invasive Gynecol 2013;20: 836–41. Luesley DM, Redman CW, Buxton EJ, Lawton FG, Williams DR. Prevention of post-cone biopsy cervical stenosis using a temporary cervical stent. Br J Obstet Gynaecol 1990;97:334–7. Mahajan N, Gupta I. Use of Versapoint to refashion the cervical canal to overcome unusually difficult embryo transfers and improve in-vitro fertilizationembryo transfer outcome: a case series. J Hum Reprod Sci 2011;4:12–6. Noyes N, Licciardi F, Grifo J, Krey L, Berkeley A. In vitro fertilization outcome relative to embryo transfer difficulty: a novel approach to the forbidding cervix. Fertil Steril 1999;72:261–5.
15. 16.
17. 18.
Ostrzenski A. Resectoscopic cervical trauma minimized by inserting Laminaria digitata preoperatively. Int J Fertil Menopausal Stud 1994;39:111–3. Phillips DR, Nathanson HG, Milim SJ, Haselkorn JS. The effect of dilute vasopressin solution on the force needed for cervical dilatation: a randomized controlled trial. Obstet Gynecol 1997;89:507–11. Wortman M, Daggett A. Hysteroscopic endocervical resection. J Am Assoc Gynecol Laparosc 1996;4:63–8. Zhuo Z, Yu H, Jiang X. A systematic review and meta-analysis of randomized controlled trials on the effectiveness of cervical ripening with misoprostol administration before hysteroscopy. Int J Gynaecol Obstet 2016;123: 272–7.
VOL. - NO. - / - 2016