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Hysteroscopy for diagnosis and treatment of intrauterine pathology
Abstracts
they did not have histologic confirmation of endometriosis, six withdrew before surgery, and two became pregnant before surgery. This left 39 women available for analysis. In group 1, 22% reported improvement after the first surgery compared with 73% in group 2 (p <0.01). The degree of improvement was statistically different (group 1, median improvement 0%, interquartile range 0-13; group 2, 30%, 0-50, p <0.017). After second surgery, 83% of women in group 1 and 60% in group 2 reported improvement in symptoms. As part of the protocol, 16/20 women in group 2 had further disease excised at second-look laparoscopy. At the end of follow-up 79% of patients in group 1 and 100% in group 2 reported improved symptoms. Of 12 women trying to conceive during follow-up, 6 were successful. Three of them were in group 1 and they conceived only after the second (true) surgery. Three women in group 2 became pregnant after the first (true) surgery. No women became pregnant after placebo surgery. Conclusion. We found a clear relationship between excision of endometriosis and improvement in overall pain symptoms. Second-look laparoscopy appears to be beneficial. Excision of endometriosis appears to benefit women wishing to conceive.
Conclusion. RF bladder neck suspension has acceptable success rates that may be improved with concurrent repair of paravaginal defects.
4. Endoscopic Correction of Malformation of Uterus and Vagina LV Adamyan. Scientific Center for Obstetrics, Gynecology, and Perinatology, Moscow, Russia.
Objective. To evaluate the effectiveness of laparoscopic diagnosis and treatment in women with symmetric and asymmetric malformations of uterus and vagina. Measurements and Main Results. Of 239 women with malformations of uterus and vagina undergoing final diagnosis and plastic surgery by endoscopic approach, 75 had unicornuate uterus with rudimentary horn, 123 uterine septum, 34 double uterus and vagina with partial vaginal aplasia, and 7 bicornuate uterus. A subgroup of patients had vaginal and uterine aplasia (129) and vaginal aplasia with functional uterus (23). Laparoscopy and hysteroscopy were final diagnostic procedures. All cases of uterine septum were managed by resectoscopy controlled by laparoscopy. In 75 patients rudimentary uterine horn was removed laparoscopically. In all cases of double uterus and vagina with partial vaginal aplasia, laparoscopy was useful for evacuating hematocolpos and preventing complications. Laparoscopic metroplasty was performed in three cases of bicornuate uterus associated with reproductive failure. In 129 patients with aplastic uterus and vagina, laparoscopy was applied to all steps of colpopoiesis from pelvic peritoneum. An LAVH of functional uterus was performed through a formed canal together with colpopoiesis. Conclusion. Endoscopic techniques are beneficial for diagnosis and management of mullerian anomalies. Hysteroresectoscopy is the method of choice in cases of uterine septum, providing complete restoration of endometrium and good reproductive outcomes. In other malformations laparoscopy facilitates the procedure, reduces risk of intraoperative complications, and permits management of concomitant diseases.
3. Paravaginal Defects and Radio-Frequency Bladder Neck Suspension KR Abbott. Athena Women's Medical Group, San Mateo, California.
Objective. To evaluate the success of the radiofrequency (RF) bladder neck suspension relative to paravaginal defects in 96 women with GSUI for an average of 7.1 + 5.6 years. Measurements and Main Results. All patients had positive leak point pressures and 80% of them used more than 1 pad/day. A standard extraperitoneal laparoscopic approach was used to expose and visualize endopelvic fascia (EPF). With a bipolar RF probe (SURx, Inc. Pleasanton, CA) low-power RF energy was directly applied to heat EPE Shrinkage was noted as EPF and bladder neck lifted. All procedures were recorded on videotapes, which were reviewed to document the absence or existence of paravaginal defects and whether or not they affected final outcomes. Paravaginal defects were not repaired at the time of surgery. Overall success was 81.2% at 12 months. It was highest in women with small or absent paravaginal defects.
5. Hysteroscopy for Diagnosis and Treatment of Intrauterine Pathology LV Adarnyan. Scientific Center for Obstetrics, Gynecology, and Perinatology, Moscow, Russia.
Objective. To evaluate retrospectively the effectiveness of hysteroscopic management of intrauterine $2
August 2002, Vol. 9, No. 3 Supplement TheJournal of the American Association of Gynecologic Laparoscopists
pathology in 1214 women with intrauterine conditions (endometrial hyperplasia, endometrial polyps, submucous myomas, intrauterine synechiae, foreign bodies in the uterine cavity, uterine septa, bicomuate uterus, uterine obstruction due to cervical aplasia) diagnosed and/or managed by hysteroscopy. Measurements and Main Results. All patients underwent diagnostic and/or operative hysteroscopy: removal of foreign bodies, surgery with semirigid scissors, resectoscopy (resection or ablation of endometrium, submucous myomas or fibrotic polyps, intrauterine septa), or retrograde hysteroscopy in occluded uterus with cervical aplasia. Hysteroresectoscopic surgery in most cases was assisted by laparoscopy for final diagnosis, correction of associated pathology, and safety. Operating time, blood loss, complication rate, and length of postoperative hospital stay were compared with those of similar laparotomic procedures, and showed advantages of endoscopic methods. Histologic, histochemical, and electron microscopic studies of endometrial biopsy specimens from sites of resection of submucous myomas and intrauterine septa obtained 3 months after procedures revealed complete restoration and functional adequacy of endometrium. Long-term results available in 575 patients showed endometrial ablation or resection to be effective in achieving amenorrhea or hypomenorrhea in 73.1%, with no recurrences; 76.3% of women wishing to conceive succeeded, of whom 69.9% had fullterm pregnancies. Conclusion. Hysteroscopic management of intrauterine conditions is an advantageous altemative to laparotomic or radical surgery, and beneficial for patients' health and quality of life.
rectovaginal endometriosis was present. Intrafascial TLH was performed with bipolar coagulation and transection of both round ligaments and simultaneous opening of the uterovesical peritoneal fold. Windows were created in both broad ligaments. The posterior layer of broad ligament was peeled to uterosacral ligaments, with partial transection if possible. Uterine vessels were dissected and sutured close to the cervix at the level of the internal os. Upper pedicles were ligated and cut. Cutting of vessels and circular transection of pelvic fascia and vaginal walls simultaaaeously with uterosacral-cardinal complex were performed with a monopolar cutter, pushing the vaginal fornix upward with the uterine manipulator. Two or more figure-of-eight sutures were placed on the vaginal cuff, including peritoneum of posterior cul-de-sac and uterosacral ligaments. In multiparous women or those with a tendency to pelvic floor relaxation, prophylactic McCall or Moscovitz procedure was performed. No conversions to laparotomy or vaginal approach were necessary. The only vaginal manipulation was morcellation of myomas. Average operating time was 82.4 + 10.8 minutes. Blood loss did not exceed 155 ml. No intraoperative or postoperative complications occurred. Conclusion. Laparoscopic intrafascial technique appeared safe for important structures such as ureters and bowel, controlled blood loss by initial securing of vessels even in women with significantly distorted pelvic anatomy due to enlarged and deformed uterus and associated endometriosis, and was effective in preserving supporting pelvic structures.
7. Laparoscopic Supracervical Hysterectomy for the Large Uterus AJ Adolph, WK Winer, TL Lyons. Center for Women's Care and Reproductive Surgery, Atlanta, Georgia.
6. Technical Aspects and Results of TLH LV Adamyan, VI Kulakov, SI Kiselev. Scientific Center for Obstetrics, Gynecology, and Perinatology, Moscow, Russia.
Objective. To review outcomes of laparoscopic supracervical hysterectomy (LSH) performed in women with large uteri. Measurements and Main Results. A retrospective chart review was carried out for all patients undergoing LSH for uteri weighing greater than 300 g between 1997 and 2001. Videotapes of surgeries were reviewed. Of 329 hysterectomies, 54 uteri (16.4%) weighed more than 300 g and 67% more than 500 g. Symptoms of menorrhagia and pressure were present in 79.6% of women. Leiomyomata were present in all women.
Objective. To evaluate retrospectively technical aspects and results of TLH in 1000 patients with uterine myomas and/or adenomyosis, and peritoneal or rectovaginal endometriosis. Measurements and Main Results. Uterine size ranged from 8 to 20 gestational weeks (average 12.8 wks, weight 458 g). In 132 women myomas up to 8 cm in diameter were localized between ligaments or in the lower uterine segment. In 141 patients peritoneal or
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they did not have histologic confirmation of endometriosis, six withdrew before surgery, and two became pregnant before surgery. This left 39 women available for analysis. In group 1, 22% reported improvement after the first surgery compared with 73% in group 2 (p <0.01). The degree of improvement was statistically different (group 1, median improvement 0%, interquartile range 0-13; group 2, 30%, 0-50, p <0.017). After second surgery, 83% of women in group 1 and 60% in group 2 reported improvement in symptoms. As part of the protocol, 16/20 women in group 2 had further disease excised at second-look laparoscopy. At the end of follow-up 79% of patients in group 1 and 100% in group 2 reported improved symptoms. Of 12 women trying to conceive during follow-up, 6 were successful. Three of them were in group 1 and they conceived only after the second (true) surgery. Three women in group 2 became pregnant after the first (true) surgery. No women became pregnant after placebo surgery. Conclusion. We found a clear relationship between excision of endometriosis and improvement in overall pain symptoms. Second-look laparoscopy appears to be beneficial. Excision of endometriosis appears to benefit women wishing to conceive.
Conclusion. RF bladder neck suspension has acceptable success rates that may be improved with concurrent repair of paravaginal defects.
4. Endoscopic Correction of Malformation of Uterus and Vagina LV Adamyan. Scientific Center for Obstetrics, Gynecology, and Perinatology, Moscow, Russia.
Objective. To evaluate the effectiveness of laparoscopic diagnosis and treatment in women with symmetric and asymmetric malformations of uterus and vagina. Measurements and Main Results. Of 239 women with malformations of uterus and vagina undergoing final diagnosis and plastic surgery by endoscopic approach, 75 had unicornuate uterus with rudimentary horn, 123 uterine septum, 34 double uterus and vagina with partial vaginal aplasia, and 7 bicornuate uterus. A subgroup of patients had vaginal and uterine aplasia (129) and vaginal aplasia with functional uterus (23). Laparoscopy and hysteroscopy were final diagnostic procedures. All cases of uterine septum were managed by resectoscopy controlled by laparoscopy. In 75 patients rudimentary uterine horn was removed laparoscopically. In all cases of double uterus and vagina with partial vaginal aplasia, laparoscopy was useful for evacuating hematocolpos and preventing complications. Laparoscopic metroplasty was performed in three cases of bicornuate uterus associated with reproductive failure. In 129 patients with aplastic uterus and vagina, laparoscopy was applied to all steps of colpopoiesis from pelvic peritoneum. An LAVH of functional uterus was performed through a formed canal together with colpopoiesis. Conclusion. Endoscopic techniques are beneficial for diagnosis and management of mullerian anomalies. Hysteroresectoscopy is the method of choice in cases of uterine septum, providing complete restoration of endometrium and good reproductive outcomes. In other malformations laparoscopy facilitates the procedure, reduces risk of intraoperative complications, and permits management of concomitant diseases.
3. Paravaginal Defects and Radio-Frequency Bladder Neck Suspension KR Abbott. Athena Women's Medical Group, San Mateo, California.
Objective. To evaluate the success of the radiofrequency (RF) bladder neck suspension relative to paravaginal defects in 96 women with GSUI for an average of 7.1 + 5.6 years. Measurements and Main Results. All patients had positive leak point pressures and 80% of them used more than 1 pad/day. A standard extraperitoneal laparoscopic approach was used to expose and visualize endopelvic fascia (EPF). With a bipolar RF probe (SURx, Inc. Pleasanton, CA) low-power RF energy was directly applied to heat EPE Shrinkage was noted as EPF and bladder neck lifted. All procedures were recorded on videotapes, which were reviewed to document the absence or existence of paravaginal defects and whether or not they affected final outcomes. Paravaginal defects were not repaired at the time of surgery. Overall success was 81.2% at 12 months. It was highest in women with small or absent paravaginal defects.
5. Hysteroscopy for Diagnosis and Treatment of Intrauterine Pathology LV Adarnyan. Scientific Center for Obstetrics, Gynecology, and Perinatology, Moscow, Russia.
Objective. To evaluate retrospectively the effectiveness of hysteroscopic management of intrauterine $2
August 2002, Vol. 9, No. 3 Supplement TheJournal of the American Association of Gynecologic Laparoscopists
pathology in 1214 women with intrauterine conditions (endometrial hyperplasia, endometrial polyps, submucous myomas, intrauterine synechiae, foreign bodies in the uterine cavity, uterine septa, bicomuate uterus, uterine obstruction due to cervical aplasia) diagnosed and/or managed by hysteroscopy. Measurements and Main Results. All patients underwent diagnostic and/or operative hysteroscopy: removal of foreign bodies, surgery with semirigid scissors, resectoscopy (resection or ablation of endometrium, submucous myomas or fibrotic polyps, intrauterine septa), or retrograde hysteroscopy in occluded uterus with cervical aplasia. Hysteroresectoscopic surgery in most cases was assisted by laparoscopy for final diagnosis, correction of associated pathology, and safety. Operating time, blood loss, complication rate, and length of postoperative hospital stay were compared with those of similar laparotomic procedures, and showed advantages of endoscopic methods. Histologic, histochemical, and electron microscopic studies of endometrial biopsy specimens from sites of resection of submucous myomas and intrauterine septa obtained 3 months after procedures revealed complete restoration and functional adequacy of endometrium. Long-term results available in 575 patients showed endometrial ablation or resection to be effective in achieving amenorrhea or hypomenorrhea in 73.1%, with no recurrences; 76.3% of women wishing to conceive succeeded, of whom 69.9% had fullterm pregnancies. Conclusion. Hysteroscopic management of intrauterine conditions is an advantageous altemative to laparotomic or radical surgery, and beneficial for patients' health and quality of life.
rectovaginal endometriosis was present. Intrafascial TLH was performed with bipolar coagulation and transection of both round ligaments and simultaneous opening of the uterovesical peritoneal fold. Windows were created in both broad ligaments. The posterior layer of broad ligament was peeled to uterosacral ligaments, with partial transection if possible. Uterine vessels were dissected and sutured close to the cervix at the level of the internal os. Upper pedicles were ligated and cut. Cutting of vessels and circular transection of pelvic fascia and vaginal walls simultaaaeously with uterosacral-cardinal complex were performed with a monopolar cutter, pushing the vaginal fornix upward with the uterine manipulator. Two or more figure-of-eight sutures were placed on the vaginal cuff, including peritoneum of posterior cul-de-sac and uterosacral ligaments. In multiparous women or those with a tendency to pelvic floor relaxation, prophylactic McCall or Moscovitz procedure was performed. No conversions to laparotomy or vaginal approach were necessary. The only vaginal manipulation was morcellation of myomas. Average operating time was 82.4 + 10.8 minutes. Blood loss did not exceed 155 ml. No intraoperative or postoperative complications occurred. Conclusion. Laparoscopic intrafascial technique appeared safe for important structures such as ureters and bowel, controlled blood loss by initial securing of vessels even in women with significantly distorted pelvic anatomy due to enlarged and deformed uterus and associated endometriosis, and was effective in preserving supporting pelvic structures.
7. Laparoscopic Supracervical Hysterectomy for the Large Uterus AJ Adolph, WK Winer, TL Lyons. Center for Women's Care and Reproductive Surgery, Atlanta, Georgia.
6. Technical Aspects and Results of TLH LV Adamyan, VI Kulakov, SI Kiselev. Scientific Center for Obstetrics, Gynecology, and Perinatology, Moscow, Russia.
Objective. To review outcomes of laparoscopic supracervical hysterectomy (LSH) performed in women with large uteri. Measurements and Main Results. A retrospective chart review was carried out for all patients undergoing LSH for uteri weighing greater than 300 g between 1997 and 2001. Videotapes of surgeries were reviewed. Of 329 hysterectomies, 54 uteri (16.4%) weighed more than 300 g and 67% more than 500 g. Symptoms of menorrhagia and pressure were present in 79.6% of women. Leiomyomata were present in all women.
Objective. To evaluate retrospectively technical aspects and results of TLH in 1000 patients with uterine myomas and/or adenomyosis, and peritoneal or rectovaginal endometriosis. Measurements and Main Results. Uterine size ranged from 8 to 20 gestational weeks (average 12.8 wks, weight 458 g). In 132 women myomas up to 8 cm in diameter were localized between ligaments or in the lower uterine segment. In 141 patients peritoneal or
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