- Email: [email protected]
Microsurgical resection of bilateral fallopian tube polyps
FERTILITY AND STERILITY Copyright © 1981 The American Fertility Society
Vol. 35, No.5, May 1981 Printed in U.SA.
MICROSURGICAL RESECTION OF BILATERAL FALLOPIAN TUBE POLYPS
JOHN J. STANGEL, M.D.*t:j: FRANK A. CHERVENAK, M.D.§ MARIANNA MOURADIAN-DAVIDIAN,
M.D.~
Section of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, New York Medical College, Departments of Obstetrics and Gynecology and Pathology, Westchester County Medical Center, Valhalla, New York 10595, and Department of Obstetrics and Gynecology, St. Lukes-Roosevelt Hospital Center, New York, New York 10019
A case of primary infertility with bilateral fallopian tube polyps has recently been presented to one of the authors (J. J. S.). The patient was operated upon at the Westchester County Medical Center. A microsurgical approach was used to resect the polyps. Such an approach has not been reported previously in the literature.
Fallopian tube polyps are an uncommon entity. The incidence varies from 1.2% to 2.77% for those lesions large enough to be seen on hysterosalpingography.1-3 Such polyps are usually located in the intramural or less commonly the proximal isthmic portion of the tube. Careful histologic studies of uterine mucosa have shown that endometrial polyps occur in the intramural portion of the tube in 11% of examined specimens. 4 The reported frequency of associated infertility in patients with fallopian tube polyps varies from 20% to 61.5%.2 Infertility is more common when the lesions are bilateral. 2 Surgical management for infertility has been uniformly poor in these cases. Removal of the affected segment of tube and subsequent uterine implantation of the distal portion of the tube has been the procedure performed; subsequent pregnancy has not been reported. It is important to note that most patients who have tubal polyps seen on hysterosalpingography are not infertile. Therefore, the observation of polyps radiographically is not an indication for immediate extirpation of the polyps.
CASE REPORT
The patient was a 25-year-old woman (gravidity 0, parity 0) who had had primary infertility for 1% years. The remainder of the history was unremarkable. Physical examination revealed an adult white female with no obvious abnormalities. Abdominal and pelvic examinations were within normal limits. The infertility evaluation revealed normal semen analysis, good results of the postcoital examination, biphasic basal body temperature, and a plasma progesterone level of 2.9 ng/ml. An endometrial biopsy performed on cycle day 25 of the following cycle showed a day-25 secretory endometrium. Hysterosalpingography using 10 ml of Sinografin revealed a bilateral filling defect in the proximal portions of both tubes near the uterotubal junction consistent with bilateral, symmetrically placed, intraluminal fallopian tube polyps. Spillage was demonstrated bilaterally (Fig. 1). Laparoscopy revealed normal-appearing uterus, ovaries, and distal tubes. At 4 mm from the uterotubal junctions, enlargements were noted which were 1% times the normal diameter of the
Received May 1, 1980; revised and accepted January 22, 1981. *Reprint requests: John J. Stangel, M.D., Department of Obstetrics and Gynecology, Westchester County Medical Center, Valhalla, New York 10595. tDepartment of Obstetrics and Gynecology, New York Medical Center. :j:Department of Obstetrics and Gynecology, Westchester County Medical Center. §Department of Obstetrics and Gynecology, St. LukesRoosevelt Hospital Center. ~Department of Pathology, Westchester County Medical Center.
580
Vol. 35, No.5·
581
COMMUNICATIONS-IN-BRIEF
FIG. 1. Preoperative hysterosalpingogram. The arrows indicate the bilateral intraluminal fallopian tube polyps.
fallopian tube. These enlargements had the appearance of intraluminal masses distending the fallopian tubes. Transcervical perfusion showed good filling and spillage bilaterally. Laparotomy was performed under the same anesthesia used for the laparoscopy. On palpation of the proximal portions of each tube, a small, slightly soft nodule in the area of the tubal mass was felt. With a needle microelectrode and unipolar cutting current, a linear incision was made in the antimesenteric area of the fallopian tube and carried down into the lumen of the fallopian tube. When the tubal lumen was entered, a polypoid structure pushed out through the incision. The incision was lengthened in a linear manner,
FIG. 2. Polypoid mass with a stalk showing varying-sized glands of endosalpingeal origin (hematoxylin and eosin, x 25).
so that the polyp was completely protruding through the incision. The polyp stalk was coagulated using bipolar current and microcoagulating forceps; with microscissors, the stalk was divided and the polyp was removed. The tubal incision was closed under the operating microscope in two layers with 9-0 monofilament nylon suture. Care was taken to approximate muscle to muscle without compromising the tubal lumen. The procedure was performed on the left and right fallopian tubes. Gross pathologic study revealed two polypoid masses measuring 7 x 6 x 4 mm and 6 x 5 x 4 mm, respectively. Histologically, varying-sized glands lined by columnar epithelium were seen in a cellular stroma (Figs. 2 and 3). The lining cells in many of the endosalpingeal glands were uniform. Occasional ciliated, somewhat broad-based cells simulating tubular epithelium were noted. Bundles of spindle cells resembling smooth muscle were seen at the stalk. Repeat hysterosalpingography using a similar perfusion technique 1 year later revealed bilaterally patent fallopian tubes with normal perfusion and spillage. There was no evidence of intraluminal polyps or other luminal defects (Fig. 4). Pregnancy has not yet occurred; however, the patient has developed irregular menses during the past 4 months and the current infertility may be due to oligo-anoVulation. At this time she is lost to follow-up. DISCUSSION
This is the first reported case of microsurgical resection of intraluminal fallopian tube polyps.
FIG. 3. Endosalpingeal glands lined by columnar and ciliated epithelium; some glands show a broad base (hematoxylin and eosin, x 450).
582
COMMUNICATIONS-IN-BRIEF
May 1981
subsequent regeneration or tubal constriction secondary to the operative procedure in the area of the. surgery. The possibility of intrinsic abnormal tubal physiology prior to surgery and continuing as a contributing factor in our patient's infertility cannot be ruled out. Previous reports have noted a higher incidence of menstrual irregularities and oligo-anovulation among patients with intraluminal fallopian tube polyps.2. 3 This association in our case is consistent with the previous reports,2.3 and oligo-anovulation may be a contributing factor in the continuing infertility. It is tempting to believe that, with adequate treatment of her anovulation, this patient's chances for pregnancy would increase significantly.
FIG. 4. Postoperative hysterosalpingogram showing bilateral tubal patency without the presence of polyps.
REFERENCES
This technique appears advantageous. and desirable, since it preserves tube length and the integrity and physiology of the uterotubal junction_ In previous surgical treatments utilizing tubal implantation, tube .length and the uterotubal junction had to be sacrificed. Hysterosalpingography performed 1 year postoperatively revealed normal. tubal filling and spillage with the absence of any intraluminal defects. This would rule out
1. Fernstrom I, Lagerlof B: Polyps in the intramural part of the fallopian tubes: ·a radiographic and clinical study. J Obstet Gynaecol Br Commonw 71:681, 1964 2. Bret AJ, Grepinet J: Polyps endometriaux de la portion intramurale de la trompe leur rapport avec la sterilite et endometriose. Sem Hop Paris 43:183, 1967 3. Gaudefroy M, Empereur-Buisson R, Sailly E: Les polypes endometriaux de la portion intramurale de la trompe. Rev Fr Gynecol 65:571, 1970 4. Lisa JR, Gioia JD,Rubin IC: Observations on the· interstitial·portion of the fallopian tube. Surg Gynecol Obstet 99:159, 1954
Vol. 35, No.5, May 1981 Printed in U.SA.
MICROSURGICAL RESECTION OF BILATERAL FALLOPIAN TUBE POLYPS
JOHN J. STANGEL, M.D.*t:j: FRANK A. CHERVENAK, M.D.§ MARIANNA MOURADIAN-DAVIDIAN,
M.D.~
Section of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, New York Medical College, Departments of Obstetrics and Gynecology and Pathology, Westchester County Medical Center, Valhalla, New York 10595, and Department of Obstetrics and Gynecology, St. Lukes-Roosevelt Hospital Center, New York, New York 10019
A case of primary infertility with bilateral fallopian tube polyps has recently been presented to one of the authors (J. J. S.). The patient was operated upon at the Westchester County Medical Center. A microsurgical approach was used to resect the polyps. Such an approach has not been reported previously in the literature.
Fallopian tube polyps are an uncommon entity. The incidence varies from 1.2% to 2.77% for those lesions large enough to be seen on hysterosalpingography.1-3 Such polyps are usually located in the intramural or less commonly the proximal isthmic portion of the tube. Careful histologic studies of uterine mucosa have shown that endometrial polyps occur in the intramural portion of the tube in 11% of examined specimens. 4 The reported frequency of associated infertility in patients with fallopian tube polyps varies from 20% to 61.5%.2 Infertility is more common when the lesions are bilateral. 2 Surgical management for infertility has been uniformly poor in these cases. Removal of the affected segment of tube and subsequent uterine implantation of the distal portion of the tube has been the procedure performed; subsequent pregnancy has not been reported. It is important to note that most patients who have tubal polyps seen on hysterosalpingography are not infertile. Therefore, the observation of polyps radiographically is not an indication for immediate extirpation of the polyps.
CASE REPORT
The patient was a 25-year-old woman (gravidity 0, parity 0) who had had primary infertility for 1% years. The remainder of the history was unremarkable. Physical examination revealed an adult white female with no obvious abnormalities. Abdominal and pelvic examinations were within normal limits. The infertility evaluation revealed normal semen analysis, good results of the postcoital examination, biphasic basal body temperature, and a plasma progesterone level of 2.9 ng/ml. An endometrial biopsy performed on cycle day 25 of the following cycle showed a day-25 secretory endometrium. Hysterosalpingography using 10 ml of Sinografin revealed a bilateral filling defect in the proximal portions of both tubes near the uterotubal junction consistent with bilateral, symmetrically placed, intraluminal fallopian tube polyps. Spillage was demonstrated bilaterally (Fig. 1). Laparoscopy revealed normal-appearing uterus, ovaries, and distal tubes. At 4 mm from the uterotubal junctions, enlargements were noted which were 1% times the normal diameter of the
Received May 1, 1980; revised and accepted January 22, 1981. *Reprint requests: John J. Stangel, M.D., Department of Obstetrics and Gynecology, Westchester County Medical Center, Valhalla, New York 10595. tDepartment of Obstetrics and Gynecology, New York Medical Center. :j:Department of Obstetrics and Gynecology, Westchester County Medical Center. §Department of Obstetrics and Gynecology, St. LukesRoosevelt Hospital Center. ~Department of Pathology, Westchester County Medical Center.
580
Vol. 35, No.5·
581
COMMUNICATIONS-IN-BRIEF
FIG. 1. Preoperative hysterosalpingogram. The arrows indicate the bilateral intraluminal fallopian tube polyps.
fallopian tube. These enlargements had the appearance of intraluminal masses distending the fallopian tubes. Transcervical perfusion showed good filling and spillage bilaterally. Laparotomy was performed under the same anesthesia used for the laparoscopy. On palpation of the proximal portions of each tube, a small, slightly soft nodule in the area of the tubal mass was felt. With a needle microelectrode and unipolar cutting current, a linear incision was made in the antimesenteric area of the fallopian tube and carried down into the lumen of the fallopian tube. When the tubal lumen was entered, a polypoid structure pushed out through the incision. The incision was lengthened in a linear manner,
FIG. 2. Polypoid mass with a stalk showing varying-sized glands of endosalpingeal origin (hematoxylin and eosin, x 25).
so that the polyp was completely protruding through the incision. The polyp stalk was coagulated using bipolar current and microcoagulating forceps; with microscissors, the stalk was divided and the polyp was removed. The tubal incision was closed under the operating microscope in two layers with 9-0 monofilament nylon suture. Care was taken to approximate muscle to muscle without compromising the tubal lumen. The procedure was performed on the left and right fallopian tubes. Gross pathologic study revealed two polypoid masses measuring 7 x 6 x 4 mm and 6 x 5 x 4 mm, respectively. Histologically, varying-sized glands lined by columnar epithelium were seen in a cellular stroma (Figs. 2 and 3). The lining cells in many of the endosalpingeal glands were uniform. Occasional ciliated, somewhat broad-based cells simulating tubular epithelium were noted. Bundles of spindle cells resembling smooth muscle were seen at the stalk. Repeat hysterosalpingography using a similar perfusion technique 1 year later revealed bilaterally patent fallopian tubes with normal perfusion and spillage. There was no evidence of intraluminal polyps or other luminal defects (Fig. 4). Pregnancy has not yet occurred; however, the patient has developed irregular menses during the past 4 months and the current infertility may be due to oligo-anoVulation. At this time she is lost to follow-up. DISCUSSION
This is the first reported case of microsurgical resection of intraluminal fallopian tube polyps.
FIG. 3. Endosalpingeal glands lined by columnar and ciliated epithelium; some glands show a broad base (hematoxylin and eosin, x 450).
582
COMMUNICATIONS-IN-BRIEF
May 1981
subsequent regeneration or tubal constriction secondary to the operative procedure in the area of the. surgery. The possibility of intrinsic abnormal tubal physiology prior to surgery and continuing as a contributing factor in our patient's infertility cannot be ruled out. Previous reports have noted a higher incidence of menstrual irregularities and oligo-anovulation among patients with intraluminal fallopian tube polyps.2. 3 This association in our case is consistent with the previous reports,2.3 and oligo-anovulation may be a contributing factor in the continuing infertility. It is tempting to believe that, with adequate treatment of her anovulation, this patient's chances for pregnancy would increase significantly.
FIG. 4. Postoperative hysterosalpingogram showing bilateral tubal patency without the presence of polyps.
REFERENCES
This technique appears advantageous. and desirable, since it preserves tube length and the integrity and physiology of the uterotubal junction_ In previous surgical treatments utilizing tubal implantation, tube .length and the uterotubal junction had to be sacrificed. Hysterosalpingography performed 1 year postoperatively revealed normal. tubal filling and spillage with the absence of any intraluminal defects. This would rule out
1. Fernstrom I, Lagerlof B: Polyps in the intramural part of the fallopian tubes: ·a radiographic and clinical study. J Obstet Gynaecol Br Commonw 71:681, 1964 2. Bret AJ, Grepinet J: Polyps endometriaux de la portion intramurale de la trompe leur rapport avec la sterilite et endometriose. Sem Hop Paris 43:183, 1967 3. Gaudefroy M, Empereur-Buisson R, Sailly E: Les polypes endometriaux de la portion intramurale de la trompe. Rev Fr Gynecol 65:571, 1970 4. Lisa JR, Gioia JD,Rubin IC: Observations on the· interstitial·portion of the fallopian tube. Surg Gynecol Obstet 99:159, 1954