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Metroplasty for the complete septate uterus: Does cervical sparing matter?
August 1996, Vol. 3, No. 4
TheJournal of the American Associationof Gynecologic Laparoscopists
Metroplasty for the Complete Septate Uterus: Does Cervical Sparing Matter? Paolo Vercellini, M.D., Olga De Giorgi, M.D., Ilenia Cortesi, M.D., Giorgio Aimi, M.D., Patrizia Mazza, M.D., and Pier Giorgio Crosignani, M.D. Abstract Study Objectives. To verify if section of the cervical septum facilitates hysteroscopic metroplasty of a complete septate uterus, and to determine if this technique is associated with intraoperative bleeding or postoperative obstetric complications. Design. Prospective, observational study, Setting. Academic department and tertiary care referral center for malformations of the female genital tract. Patients. Ten women with complete septate uterus. Interventions. The cervical portion of the septum was incised with Metzenbaum scissors and the corporeal portion with microscissors under hysteroscopic guidance. Measurements and Main Results. Mean +_SD operating time for the entire procedure was 24 +_7 minutes, with a mean distention fluid deficit of 480 +_ 190 ml. No significant bleeding was encountered during cervical septum incision. At follow-up hysteroscopy, the cervices were competent, and no women experienced second-trimester abortion or premature delivery. Conclusions. Section of the cervical septum with scissors is simple, rapid, and safe, facilitates corporeal hysteroscopic metroplasty, and may be considered a valid procedure to correct a completely septate uterus.
corrected, to avoid intraoperative, poorly controllable bleeding and cervical incompetence in subsequent pregnancies, l, 2 Techniques were proposed in which only the corporeal portion of the septum is sectioned and a communication between the two cavities is created at the isthmic level. 4' s This poses the problem of blind section during the first part of the operation, because orientation can only be guessed when the hysteroscope
Hysteroscopic metroplasty has become standard practice for the correction of septate uteri associated with recurrent abortions.l' 2This endoscopic approach is simple, rapid, and straightforward when the septum is partial, but may be problematic in the case of a complete septate uterus with two external orifices (American Fertility Society class Va3). In fact, according to current opinion, the cervical part of the septum should be spared when this type of malformation is
From the Clinica Ostetrica e Ginecologica "Luigi Mangiagalli," University of Milan, Milan, Italy, (all authors). Address reprint requests to Paolo Vercellini, M.D., Clinica Ostetrica e Ginecologica "Luigi Mangiagalli," dell'Universita di Milano, Via Commenda 12, 20122 Milan, Italy; fax 392 55 187 146. Presented at the 24th annual meeting of the American Association of Gynecologic Laparoscopists, Orlando, Florida, November 8-12, 1995.
509
Metroplas~, for the Complete Septate Uterus Vercellini et al
is in one uterine hemicavity, as both tubal ostia cannot be observed at the same time. Thus the incision may proceed toward the anterior or posterior wall, especially in the presence of abnormal uterine position or version, and perforations may o c c u r . 6' 7 We performed metroplasty including section of the cervical part of the septum in a prospective study of 10 women with complete septate uterus to evaluate the degree of difficulty of this modified technique, and to ascertain the frequency of intraoperative or obstetric complications. Materials and Methods Ten women with a complete septate uterus as shown by hysterosalpingography and ultrasonography with half-full bladder 8,9 were enrolled in a prospective, observational study of a modified metroplasty. Eight of them had a history of abortions and the other two were infertile. A longitudinal vaginal septum was present in eight patients (Figure 1). In three women it was excised between hemostatic clamps under general endotracheal anesthesia, and the anterior and posterior vaginal walls were sewn with a continuous synthetic absorbable suture. In five later cases the longitudinal vaginal septum was simply incised up to the cervix with monopolar coagulation (Figure 2), and bleeders were sealed with bipolar forceps. So as not to hamper subsequent maneuvers, vaginal sutures were placed only at the end of the entire procedure.
FIGURE 2. The vaginal septum is incised with scissors up to the cervix. Bipolar current is used for hemostasis.
Two single-tooth tenacula were placed on both lateral margins of the anterior cervical lips (Figure 3) and the two cervical canals were dilated one at a time up to 6 or 7 mm. To section the cervical septum, the two blades of a straight Metzenbaum scissors with blunt points were placed in the two cervical canals and two or three cuts were made in the septum (Figure 4). After removing the scissors, a rigid hysteroscope mounted with a 7-ram operating sheath was inserted in the unified cervical canal under laparoscopic control. The uterine cavity was distended with normal saline or a 1.5% glycine solution instilled under manometric monitoring with
FIGURE 3. Two single-tooth tenacula are placed on the anterior cervical lips, and after dilatation, the two blades of a straight scissors are placed in the two cervical canals.
FIGURE 1. A complete septate uterus (class Va) with a longitudinal vaginal septum dividing the upper two-thirds of the vaginal canal.
510
August 1996, Vol. 3, No. 4
The Journal of the American Association of Gynecologic Laparoscopists
uterus (Figure 6). Methylergonovine maleate 0.2 mg was injected intravenously at the end of the procedure. Fluid balance was calculated as the difference between the amount of solution instilled into the uterus and the amount recovered from the pelvic cavity with a suction cannula, from the hysteroscopic outflow channel, and from the plastic drapes that funneled fluids escaping through the cervix into a calibrated pouch. The operating time was defined as the interval between the start of cervical dilatation and removal of the hysteroscope. After the procedure the surgeon classified its degree of difficulty as none, minimal, moderate, or severe, and recorded any intraoperative and postoperative complications (uterine perforation, hemorrhage, fluid overload). A follow-up hysteroscopy was scheduled for all patients in the proliferative phase of the third postoperative cycle.
FIGURE 4. The cervical septum is sectioned up to the internal os with two or three cuts of the scissors.
Results
100 to 120 mm Hg pressure generated by a pneumatic cuff around a 3-L bag, and a vacuum of -30 to -40 mm Hg was applied for suction. To prevent excessive leakage of fluid around the hysteroscope, the two tenacula were repositioned on both sides of the insmunent, including the anterior and posterior cervical lips (Figure 5). When the apex of the partially sectioned uterine septurn was visualized, the operation was completed with rigid microscissors, as in the case of a partial septate
No significant bleeding occurred from any cervical septum after incision with Metzenbaum scissors. Care was taken not to extend sectioning far above the internal os. In fact, to avoid bleeding and permit optimum intrauterine visibility, the corporeal part of the septum must be-incised midway between the anterior and posterior uterine walls, and this can be accomplished only under direct observation. After insertion
FIGURE 5. A rigid operative hysteroscope is inserted in the unified cervical canal. To prevent excessive loss of
FIGURE 6. The apex of the partially sectioned uterine septum is visualized. The operation is completed with rigid microscissors, as in the case of a partial septate
fluid, the two tenacula are repositioned on both sides of the instrument, including the anterior and posterior cervical lips.
uterus.
511
Metroplasty for the Complete Septate Uterus Vercel/ini et al
of the hysteroscope, surgery was completed without difficulty or complications. Mean + SD operating time for metroplasty was 24 + 7 minutes with a mean distention fluid deficit of 480 + 190 ml (Table 1). No patient absorbed more than 1 L of solution and no symptoms or signs of fluid overload were observed. The degree of difficulty of the intervention was considered minimal in six cases and moderate in four. All women had an uneventful postoperative course and were discharged within 24 hours. At follow-up hysteroscopy the cervices were competent, allowing regular cavity distention. In three women we observed partial or total reappearance of the incised septum caudal to the internal os, reestablishing the cervical bipartition (Figures 7 and 8). The corporeal fundal septal remnants 1 cm or less deep, found in five patients, were sectioned. Six patients with complete septal incision conceived. Four carried the pregnancy to term and were delivered vaginally, one underwent cesarean section in another hospital at 38 weeks' for an unclear indication, and one aborted at the end of the second month of gestation. Prophylactic cervical cerclage was not performed.
FIGURE 7. Hysterosalpingograph shows two distinct hemicavities of the complete septate uterus.
that these may not be the most relevant outcome measures when studying the effects of the procedure. In fact, it is the possibility that a single incompetent cervix might be created from two separate cervical canals that underlies the recommendation to spare the cervical part of a complete uterine septum, 1' 2, 4, 5 although to our knowledge no obstetric complications secondary to cervical septal incision have been reported in the literature, and anatomic and obstetric outcomes in our patients do not support this opinion. The only
Discussion
Our results with a modified technique for correcting complete septate uterus compare favorably with those of classic hysteroscopic metroplasty in terms of operating time and distention fluid absorption, as we reported previously.7However, we consider TABLE 1. Clinical and Surgical Details of Modified Metroplasty for Complete Septate Uterus
Variable Operating time (min) Distention fluid deficit (ml) Degree of difficulty at intervention Minimal Moderate Postoperative recurrent cervical bipartition Postoperative fundal septal remnant Postoperative pregnancy outcome Vaginal delivery at term Cesarean section at term First-trimester abortion
Mean + SD or No. of Patients 24+7 480 _+ 190 6 4 4 5 FIG U RE 8. Hysterosalpingography after metroplasty with cervical septal incision shows recurrent bipartition of the cervical canal, unification of the corporeal cavities, and a minimally arcuate fundal contour.
4 1 1
512
August 1996, Vol. 3, No. 4
TheJournal of the American Association of Gynecologic Laparoscopists
abortion in the present series occurred early in the first trimester and may not have been attributable to cervical incompetence. Concern also has been expressed that a septate cervix may adversely affect vaginal delivery and that cesarean section may be necessary. ~ However, vaginal deliveries were uncomplicated in previous patients with partial septal section operated at our institution; the septum was displaced to one side by the descending fetal head and did not create any obstacle. 1~ Available data seem to suggest that sectioning or sparing the cervical septal portion has little if any effect on subsequent pregnancies. Unless a woman has a preoperative history of second-trimester abortion, we would not advise prophylactic cervical cerclage after a modified metroplasty. The observational nature of our study greatly limits the value of our findings. However, given the relative paucity of women with a complete septate uterus, it seems unrealistic to design a randomized clinical trial on section versus conservation of the cervical septum with obstetric outcome as the primary end point. Furthermore, readhesion of an incised cervical septum is not infrequent. The reason for different behavior of the cervical and corporeal parts of the septum is unclear; readhesion of the latter after incisional metroplasty is exceedingly rare. u It is possible that close juxtaposition of anterior and posterior severed portions in a very narrow space favors the formation of fibrin bridges. Moreover, the endometrium has higher mitotic capabilities and reparative potential compared with the endocervical mucosal lining. ~2A second possible risk of cervical septal sectioning might be problematic bleeding, but none of our patients developed this complication. Originally we started to section cervical septa because of difficulties creating the initial communication between the two corporeal cavities when the tissue to be cut was thick. In such cases the septal indentation produced by a probe introduced into the contralateral cavity 4 is not readily distinguishable, and distention of a pediatric Foley catheter bulb inserted in one cavity 5 may reduce the available operating space. For the corporeal part of the septum we routinely use microscissors because, in our opinion, this is the simplest, least expensive instrument and does not damage tissue beyond the visible limits of the section. 6,13 Most patients have a longitudinal vaginal septum dividing the upper one- or two-thirds of the vaginal
513
canal. The etiologic factor causing this type of malformation may prevent resorption of the medial aspects of the two mullerian ducts while sparing the vaginal portion deriving from the urogenital sinus. Consequently, we consider it sensible to correct this anomaly with a continuous incision from the caudal apex of the vaginal septum to the uterine fundus, completing the process that was stopped during embryogenesis. Along this line, the longitudinal vaginal septum can be simply incised without removing tissue. 14 Two women in our series were infertile. This cannot be considered an absolute indication for metroplasty, as it seems logical to correct a complete septate uterus during laparoscopy for infertility to reduce the high risk of abortion in case of future conception, either spontaneous or with assisted reproductive techniques.S~ ~5 In conclusion, based on our admittedly limited experience, section of the cervical septum with scissors is simple, rapid, and safe, it facilitates corporal hysteroscopic metroplasty, and it may be considered a valid alternative procedure to correct a complete septate uterus. Further studies with more patients are required to confirm our observations. References
1. Rock JA: Surgery for anomalies of the mullerian ducts. In Te Linde's operative gynecology, 7th ed. Edited by JD Thompson, JA Rock. Philadelphia, JB Lippincott, 1992, pp 603-646 2. Rock JA: Uterine reconstructive surgery. In Female reproductive surgery. Edited by JA Rock, AA Murphy, HW Jones Jr. Baltimore, Williams & Wilkins, 1992, pp 113-145 3. American Fertility Society: The American Fertility Society classification of adnexal adhesions, distal tubal occlusion, tubal occlusion secondary to tubal ligation, tubal pregnancies, mullerian anomalies and intrauterine adhesions. Fertil Steril 49:944-955, 1988 4. Daly DC, Tohan N, Walters C, et al: Hysteroscopic resection of the uterine septum in the presence of a septate cervix. Fertil Steril 39:560-563, 1983 5. Rock JA, Murphy AA, Cooper WH: Resectoscopic techniques for the lysis of a class V complete uterine septum. Fertil Steril 48:495-496, 1987 6. Vercellini P, Vendola N, Colombo A, et al: Hysteroscopic metroplasty with resectoscope or microscissors for the correction of septate uterus. Surg Gynecol Obstet 176:439-442, 1993
MetroplasV for the Complete Septate Uterus Vercellini et al
7. Vercellini R Ragni G, Trespidi L, et al: A modified technique for correction of the complete septate uterus. Acta Obstet Gynecol Scand 73:425-428, 1994
12. Padykula HA. Regeneration in the primate uterus. The role of stem cells. In Biology of the uterus, 2nd ed. Edited by RM Wynn, WP Jollie. New York, Plenum Medical Book Co., 1989, pp 279-288
8. Candiani GB, Ferrazzi E, Fedele L, et al: Sonographic evaluation of uterine morphology: A new scanning technique. Acta Eur Fertil 17:345-347, 1986
13. Candiani GB, Vercellini P, Fedele L, et al: Argon laser versus microscissor for hysteroscopic incision of uterine septa. Am J Obstet Gynecol 164:87-90, 1991
9. Fedele L, Ferrazzi E, Dorta M, et al: Ultrasonography in the differential diagnosis of "double" uteri. Fertil Steril 50:361-364, 1988
14. Buttram VC Jr, Reiter RC. Uterine anomalies. In Surgical treatment of the infertile female. Edited by VC Buttram Jr, RC Reiter. Baltimore, Williams & Wilkins, 1985, pp 149-199
10. Fedele L, Arcaini L, Parazzini E et al: Reproductive prognosis after hysteroscopic metroplasty in 102 women: Life-table analysis. Fertil Steril 59:768-772, 1993
15. Fedele L, Dorta M, Brioschi D, et al: Pregnancies in septate uteri: Outcome in relation to site of uterine implantation as determined by sonography. AJR 152:781-784, 1989
11. Candiani GB, Vercellini P, Fedele L, et al: Repair of the uterine cavity after hysteroscopic septal incision. Fertil Steril 54:991-995, 1990
514
TheJournal of the American Associationof Gynecologic Laparoscopists
Metroplasty for the Complete Septate Uterus: Does Cervical Sparing Matter? Paolo Vercellini, M.D., Olga De Giorgi, M.D., Ilenia Cortesi, M.D., Giorgio Aimi, M.D., Patrizia Mazza, M.D., and Pier Giorgio Crosignani, M.D. Abstract Study Objectives. To verify if section of the cervical septum facilitates hysteroscopic metroplasty of a complete septate uterus, and to determine if this technique is associated with intraoperative bleeding or postoperative obstetric complications. Design. Prospective, observational study, Setting. Academic department and tertiary care referral center for malformations of the female genital tract. Patients. Ten women with complete septate uterus. Interventions. The cervical portion of the septum was incised with Metzenbaum scissors and the corporeal portion with microscissors under hysteroscopic guidance. Measurements and Main Results. Mean +_SD operating time for the entire procedure was 24 +_7 minutes, with a mean distention fluid deficit of 480 +_ 190 ml. No significant bleeding was encountered during cervical septum incision. At follow-up hysteroscopy, the cervices were competent, and no women experienced second-trimester abortion or premature delivery. Conclusions. Section of the cervical septum with scissors is simple, rapid, and safe, facilitates corporeal hysteroscopic metroplasty, and may be considered a valid procedure to correct a completely septate uterus.
corrected, to avoid intraoperative, poorly controllable bleeding and cervical incompetence in subsequent pregnancies, l, 2 Techniques were proposed in which only the corporeal portion of the septum is sectioned and a communication between the two cavities is created at the isthmic level. 4' s This poses the problem of blind section during the first part of the operation, because orientation can only be guessed when the hysteroscope
Hysteroscopic metroplasty has become standard practice for the correction of septate uteri associated with recurrent abortions.l' 2This endoscopic approach is simple, rapid, and straightforward when the septum is partial, but may be problematic in the case of a complete septate uterus with two external orifices (American Fertility Society class Va3). In fact, according to current opinion, the cervical part of the septum should be spared when this type of malformation is
From the Clinica Ostetrica e Ginecologica "Luigi Mangiagalli," University of Milan, Milan, Italy, (all authors). Address reprint requests to Paolo Vercellini, M.D., Clinica Ostetrica e Ginecologica "Luigi Mangiagalli," dell'Universita di Milano, Via Commenda 12, 20122 Milan, Italy; fax 392 55 187 146. Presented at the 24th annual meeting of the American Association of Gynecologic Laparoscopists, Orlando, Florida, November 8-12, 1995.
509
Metroplas~, for the Complete Septate Uterus Vercellini et al
is in one uterine hemicavity, as both tubal ostia cannot be observed at the same time. Thus the incision may proceed toward the anterior or posterior wall, especially in the presence of abnormal uterine position or version, and perforations may o c c u r . 6' 7 We performed metroplasty including section of the cervical part of the septum in a prospective study of 10 women with complete septate uterus to evaluate the degree of difficulty of this modified technique, and to ascertain the frequency of intraoperative or obstetric complications. Materials and Methods Ten women with a complete septate uterus as shown by hysterosalpingography and ultrasonography with half-full bladder 8,9 were enrolled in a prospective, observational study of a modified metroplasty. Eight of them had a history of abortions and the other two were infertile. A longitudinal vaginal septum was present in eight patients (Figure 1). In three women it was excised between hemostatic clamps under general endotracheal anesthesia, and the anterior and posterior vaginal walls were sewn with a continuous synthetic absorbable suture. In five later cases the longitudinal vaginal septum was simply incised up to the cervix with monopolar coagulation (Figure 2), and bleeders were sealed with bipolar forceps. So as not to hamper subsequent maneuvers, vaginal sutures were placed only at the end of the entire procedure.
FIGURE 2. The vaginal septum is incised with scissors up to the cervix. Bipolar current is used for hemostasis.
Two single-tooth tenacula were placed on both lateral margins of the anterior cervical lips (Figure 3) and the two cervical canals were dilated one at a time up to 6 or 7 mm. To section the cervical septum, the two blades of a straight Metzenbaum scissors with blunt points were placed in the two cervical canals and two or three cuts were made in the septum (Figure 4). After removing the scissors, a rigid hysteroscope mounted with a 7-ram operating sheath was inserted in the unified cervical canal under laparoscopic control. The uterine cavity was distended with normal saline or a 1.5% glycine solution instilled under manometric monitoring with
FIGURE 3. Two single-tooth tenacula are placed on the anterior cervical lips, and after dilatation, the two blades of a straight scissors are placed in the two cervical canals.
FIGURE 1. A complete septate uterus (class Va) with a longitudinal vaginal septum dividing the upper two-thirds of the vaginal canal.
510
August 1996, Vol. 3, No. 4
The Journal of the American Association of Gynecologic Laparoscopists
uterus (Figure 6). Methylergonovine maleate 0.2 mg was injected intravenously at the end of the procedure. Fluid balance was calculated as the difference between the amount of solution instilled into the uterus and the amount recovered from the pelvic cavity with a suction cannula, from the hysteroscopic outflow channel, and from the plastic drapes that funneled fluids escaping through the cervix into a calibrated pouch. The operating time was defined as the interval between the start of cervical dilatation and removal of the hysteroscope. After the procedure the surgeon classified its degree of difficulty as none, minimal, moderate, or severe, and recorded any intraoperative and postoperative complications (uterine perforation, hemorrhage, fluid overload). A follow-up hysteroscopy was scheduled for all patients in the proliferative phase of the third postoperative cycle.
FIGURE 4. The cervical septum is sectioned up to the internal os with two or three cuts of the scissors.
Results
100 to 120 mm Hg pressure generated by a pneumatic cuff around a 3-L bag, and a vacuum of -30 to -40 mm Hg was applied for suction. To prevent excessive leakage of fluid around the hysteroscope, the two tenacula were repositioned on both sides of the insmunent, including the anterior and posterior cervical lips (Figure 5). When the apex of the partially sectioned uterine septurn was visualized, the operation was completed with rigid microscissors, as in the case of a partial septate
No significant bleeding occurred from any cervical septum after incision with Metzenbaum scissors. Care was taken not to extend sectioning far above the internal os. In fact, to avoid bleeding and permit optimum intrauterine visibility, the corporeal part of the septum must be-incised midway between the anterior and posterior uterine walls, and this can be accomplished only under direct observation. After insertion
FIGURE 5. A rigid operative hysteroscope is inserted in the unified cervical canal. To prevent excessive loss of
FIGURE 6. The apex of the partially sectioned uterine septum is visualized. The operation is completed with rigid microscissors, as in the case of a partial septate
fluid, the two tenacula are repositioned on both sides of the instrument, including the anterior and posterior cervical lips.
uterus.
511
Metroplasty for the Complete Septate Uterus Vercel/ini et al
of the hysteroscope, surgery was completed without difficulty or complications. Mean + SD operating time for metroplasty was 24 + 7 minutes with a mean distention fluid deficit of 480 + 190 ml (Table 1). No patient absorbed more than 1 L of solution and no symptoms or signs of fluid overload were observed. The degree of difficulty of the intervention was considered minimal in six cases and moderate in four. All women had an uneventful postoperative course and were discharged within 24 hours. At follow-up hysteroscopy the cervices were competent, allowing regular cavity distention. In three women we observed partial or total reappearance of the incised septum caudal to the internal os, reestablishing the cervical bipartition (Figures 7 and 8). The corporeal fundal septal remnants 1 cm or less deep, found in five patients, were sectioned. Six patients with complete septal incision conceived. Four carried the pregnancy to term and were delivered vaginally, one underwent cesarean section in another hospital at 38 weeks' for an unclear indication, and one aborted at the end of the second month of gestation. Prophylactic cervical cerclage was not performed.
FIGURE 7. Hysterosalpingograph shows two distinct hemicavities of the complete septate uterus.
that these may not be the most relevant outcome measures when studying the effects of the procedure. In fact, it is the possibility that a single incompetent cervix might be created from two separate cervical canals that underlies the recommendation to spare the cervical part of a complete uterine septum, 1' 2, 4, 5 although to our knowledge no obstetric complications secondary to cervical septal incision have been reported in the literature, and anatomic and obstetric outcomes in our patients do not support this opinion. The only
Discussion
Our results with a modified technique for correcting complete septate uterus compare favorably with those of classic hysteroscopic metroplasty in terms of operating time and distention fluid absorption, as we reported previously.7However, we consider TABLE 1. Clinical and Surgical Details of Modified Metroplasty for Complete Septate Uterus
Variable Operating time (min) Distention fluid deficit (ml) Degree of difficulty at intervention Minimal Moderate Postoperative recurrent cervical bipartition Postoperative fundal septal remnant Postoperative pregnancy outcome Vaginal delivery at term Cesarean section at term First-trimester abortion
Mean + SD or No. of Patients 24+7 480 _+ 190 6 4 4 5 FIG U RE 8. Hysterosalpingography after metroplasty with cervical septal incision shows recurrent bipartition of the cervical canal, unification of the corporeal cavities, and a minimally arcuate fundal contour.
4 1 1
512
August 1996, Vol. 3, No. 4
TheJournal of the American Association of Gynecologic Laparoscopists
abortion in the present series occurred early in the first trimester and may not have been attributable to cervical incompetence. Concern also has been expressed that a septate cervix may adversely affect vaginal delivery and that cesarean section may be necessary. ~ However, vaginal deliveries were uncomplicated in previous patients with partial septal section operated at our institution; the septum was displaced to one side by the descending fetal head and did not create any obstacle. 1~ Available data seem to suggest that sectioning or sparing the cervical septal portion has little if any effect on subsequent pregnancies. Unless a woman has a preoperative history of second-trimester abortion, we would not advise prophylactic cervical cerclage after a modified metroplasty. The observational nature of our study greatly limits the value of our findings. However, given the relative paucity of women with a complete septate uterus, it seems unrealistic to design a randomized clinical trial on section versus conservation of the cervical septum with obstetric outcome as the primary end point. Furthermore, readhesion of an incised cervical septum is not infrequent. The reason for different behavior of the cervical and corporeal parts of the septum is unclear; readhesion of the latter after incisional metroplasty is exceedingly rare. u It is possible that close juxtaposition of anterior and posterior severed portions in a very narrow space favors the formation of fibrin bridges. Moreover, the endometrium has higher mitotic capabilities and reparative potential compared with the endocervical mucosal lining. ~2A second possible risk of cervical septal sectioning might be problematic bleeding, but none of our patients developed this complication. Originally we started to section cervical septa because of difficulties creating the initial communication between the two corporeal cavities when the tissue to be cut was thick. In such cases the septal indentation produced by a probe introduced into the contralateral cavity 4 is not readily distinguishable, and distention of a pediatric Foley catheter bulb inserted in one cavity 5 may reduce the available operating space. For the corporeal part of the septum we routinely use microscissors because, in our opinion, this is the simplest, least expensive instrument and does not damage tissue beyond the visible limits of the section. 6,13 Most patients have a longitudinal vaginal septum dividing the upper one- or two-thirds of the vaginal
513
canal. The etiologic factor causing this type of malformation may prevent resorption of the medial aspects of the two mullerian ducts while sparing the vaginal portion deriving from the urogenital sinus. Consequently, we consider it sensible to correct this anomaly with a continuous incision from the caudal apex of the vaginal septum to the uterine fundus, completing the process that was stopped during embryogenesis. Along this line, the longitudinal vaginal septum can be simply incised without removing tissue. 14 Two women in our series were infertile. This cannot be considered an absolute indication for metroplasty, as it seems logical to correct a complete septate uterus during laparoscopy for infertility to reduce the high risk of abortion in case of future conception, either spontaneous or with assisted reproductive techniques.S~ ~5 In conclusion, based on our admittedly limited experience, section of the cervical septum with scissors is simple, rapid, and safe, it facilitates corporal hysteroscopic metroplasty, and it may be considered a valid alternative procedure to correct a complete septate uterus. Further studies with more patients are required to confirm our observations. References
1. Rock JA: Surgery for anomalies of the mullerian ducts. In Te Linde's operative gynecology, 7th ed. Edited by JD Thompson, JA Rock. Philadelphia, JB Lippincott, 1992, pp 603-646 2. Rock JA: Uterine reconstructive surgery. In Female reproductive surgery. Edited by JA Rock, AA Murphy, HW Jones Jr. Baltimore, Williams & Wilkins, 1992, pp 113-145 3. American Fertility Society: The American Fertility Society classification of adnexal adhesions, distal tubal occlusion, tubal occlusion secondary to tubal ligation, tubal pregnancies, mullerian anomalies and intrauterine adhesions. Fertil Steril 49:944-955, 1988 4. Daly DC, Tohan N, Walters C, et al: Hysteroscopic resection of the uterine septum in the presence of a septate cervix. Fertil Steril 39:560-563, 1983 5. Rock JA, Murphy AA, Cooper WH: Resectoscopic techniques for the lysis of a class V complete uterine septum. Fertil Steril 48:495-496, 1987 6. Vercellini P, Vendola N, Colombo A, et al: Hysteroscopic metroplasty with resectoscope or microscissors for the correction of septate uterus. Surg Gynecol Obstet 176:439-442, 1993
MetroplasV for the Complete Septate Uterus Vercellini et al
7. Vercellini R Ragni G, Trespidi L, et al: A modified technique for correction of the complete septate uterus. Acta Obstet Gynecol Scand 73:425-428, 1994
12. Padykula HA. Regeneration in the primate uterus. The role of stem cells. In Biology of the uterus, 2nd ed. Edited by RM Wynn, WP Jollie. New York, Plenum Medical Book Co., 1989, pp 279-288
8. Candiani GB, Ferrazzi E, Fedele L, et al: Sonographic evaluation of uterine morphology: A new scanning technique. Acta Eur Fertil 17:345-347, 1986
13. Candiani GB, Vercellini P, Fedele L, et al: Argon laser versus microscissor for hysteroscopic incision of uterine septa. Am J Obstet Gynecol 164:87-90, 1991
9. Fedele L, Ferrazzi E, Dorta M, et al: Ultrasonography in the differential diagnosis of "double" uteri. Fertil Steril 50:361-364, 1988
14. Buttram VC Jr, Reiter RC. Uterine anomalies. In Surgical treatment of the infertile female. Edited by VC Buttram Jr, RC Reiter. Baltimore, Williams & Wilkins, 1985, pp 149-199
10. Fedele L, Arcaini L, Parazzini E et al: Reproductive prognosis after hysteroscopic metroplasty in 102 women: Life-table analysis. Fertil Steril 59:768-772, 1993
15. Fedele L, Dorta M, Brioschi D, et al: Pregnancies in septate uteri: Outcome in relation to site of uterine implantation as determined by sonography. AJR 152:781-784, 1989
11. Candiani GB, Vercellini P, Fedele L, et al: Repair of the uterine cavity after hysteroscopic septal incision. Fertil Steril 54:991-995, 1990
514