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The significance of hysteroscopic treatment of congenital uterine malformations
RBMOnline - Vol 4. Suppl. 3. 52–54 Reproductive BioMedicine Online; www.rbmonline.com/Article/223 on web 1 October 2001
The significance of hysteroscopic treatment of congenital uterine malformations Nicola Colacurci1, Pasquale De Franciscis, Felice Fornaro, Nicola Fortunato, Antonio Perino Institute of Gynaecology and Obstetrics, School of Medicine, Second University of Naples, Naples, Italy 1Correspondence: e-mail [email protected]
Abstract Hysteroscopic surgery replaced abdominal metroplasty and is today the treatment of choice for congenital uterine malformations. This is not just because of its reproductive results, which are comparable to those achieved with the abdominal approach, but mainly because of several post-operative benefits (reduced morbidity, convalescence and costs, and no scar tissue on the abdominal and uterine walls), improved reproductive performance (no reduction in uterine volume, shorter interval to conception after operation) and the mode of delivery (avoiding Caesarean section). Decisions on when and how to treat uterine septa, in relation to the type of malformation, are discussed. In particular, indications for treatment have been broadened to include not only the septate uterus associated with adverse reproductive outcome, but also patients before any potential obstetric accidents, especially in those with declining fecundity (>35 years), with reproductive problems (unexplained infertility) and before assisted reproductive techniques, as well as in women with no actual desire of pregnancy. Two types of hysteroscopic treatment are available: resectoscopic and office hysteroscopic surgery. The indications for resectoscopic surgery are broad-based septa and complete septa with single or double cervix. The resectoscope allows an excellent continuous flow system, providing continuous washing of the uterine cavity and a clear view, removing bubbles and debris during the procedure. However, an exact measurement of fluid balance must be performed to avoid excessive fluid intravasation. Laparoscopic or sonographic monitoring is mandatory. Treatment of limited-based small septa whose apex is easily visible can be achieved with an outpatient approach using office minihysteroscopic surgery and the vaginoscopic technique. The intra-operative check of the fundus is performed by ultrasonography. No preparation of the endometrium is required, except for large, broad-based septa, and hormonal therapy and intrauterine devices are not utilized post-operatively. The post-operative follow-up consists of a hysteroscopic check performed 1–3 months after surgery. Keywords: congenital uterine malformations, hysteroscopy, Mullerian defects, resectoscope, septate uterus, surgery
Introduction
52
Uterine anomalies caused by Müllerian fusion defects are the most common types of malformations of the reproductive system, including a large group of congenital pathologies (didelphic, bicornuate, septate uterus), among which the septate uterus accounts for approximately 80–90% (Simon et al., 1991) and is associated with the poorest reproductive performance (fetal survival rates 6–28%, miscarriage rate >60%). Hysteroscopy is nowadays considered the gold standard for the assessment of uterine pathology because it allows a direct vision of the volume and morphology of the cavity, the evaluation of tubal ostia symmetry and the immediate recognition of a concomitant pathology. Several studies have stressed the relevance of hysteroscopy, not only as a first level diagnostic examination of female infertility but also before performing any assisted reproduction cycle. The findings of intrauterine abnormalities at hysteroscopic evaluation prior to IVF in women with normal hysterosalpingographic features clearly demonstrate the superiority of hysteroscopy (Goldenberg et al., 1991; Golan et al., 1992). Also, it is the experience of the present authors that the routinely hysteroscopic evaluation increases the implantation rate in normo-ovulatory women >35 years, with normal spermiogram of the partner, undergoing their first IVF treatment, when compared with women not undergoing hysteroscopy because of the detection and removal of minimal septa and other intrauterine pathologies. However,
hysteroscopy per se does not allow a definitive diagnosis of the type of uterine malformation, because it does not provide information about the external morphology of the uterus. Therefore, other diagnostic tests are necessary: a concomitant laparoscopy could be used, both to distinguish between a septate and a bicornuate uterus and to complete the diagnostic workup of infertility, providing the opportunity to treat either the malformation at the same time as its diagnosis or any coexisting pathology (endometriosis, adherences, tubal occlusion). Some less invasive tests, such as transvaginal ultrasonography or sonohysterography, are routinely used to evaluate external uterine morphology (Randolph et al., 1986; Ayida et al., 1997) and can provide additional information on tubal patency and adnexal pathology. Three-dimensional ultrasonography (Raga et al., 1996) has shown an accuracy of 92% for the diagnosis of septate uterus and 100% for bicornuate uterus in a sample of patients subsequently undergoing laparoscopy; however, its clinical applicability is limited. Magnetic resonance imaging has been used (Carrington et al., 1990) to obtain information on the relative content of myometrial and fibrous tissue in the septum, to determine the appropriate surgical approach, but the specificity does not reach 100%, the costs remain high and the interpretation depends on the radiologist’s experience. Hysteroscopic surgery represents the treatment of choice for the septate uterus. However, other uterine malformations with lower incidence of reproductive problems more rarely require
Hysteroscopic treatment of congenital uterine malformations - N Colacurci et al.
surgical treatment, generally consisting of a laparotomy and only in few cases laparoscopy. Traditionally, the septate uterus has been treated by abdominal metroplasty with wedge resection (Jones procedure) or by incision of the septum (Tompkins procedure), with excellent results when the patients were carefully selected. In 1974, Edstrom introduced the hysteroscopic treatment of the septate uterus, based on the concept of the transcervical observation of the septum and its resection through a hysteroscopy. When analysing personal (Colacurci et al., 1996; Colacurci et al., 1998b) and international data (Daly et al., 1983; Fayez 1986; Heinonen 1997), the reproductive results (full-term pregnancy rates) obtained with hysteroscopic metroplasty are comparable to those achieved with the abdominal approach. However, hysteroscopy is today the only feasible intervention, because of several post-operative benefits (reduced morbidity, no scar tissue on the abdominal and uterine walls, shorter convalescence and faster return to normal activity, significant cost savings), improved reproductive performance (no reduction in the volume of the uterine cavity, shorter interval to conception after operation) and the mode of delivery (avoiding Caesarean section). Despite the fact that the effectiveness of hysteroscopic treatment of the septate uterus has been elucidated by several studies (Daly et al., 1983; Fedele et al., 1993; Colacurci et al., 1996; Colacurci et al., 1998b; Hickok 2000), some problems still exist: the main debated points are regarding when and how to treat uterine septa (the choice of hysteroscopic technique in relation to the type of malformation).
When It is widely accepted that the diagnosis of a septate uterus needs surgical correction when an association with adverse reproductive outcome is demonstrated. In women with a reproductive history of two or more fetal losses during the first or second trimester of pregnancy, the extremely favourable prognosis after hysteroscopic metroplasty (Acien 1997; Homer et al., 2000), with data showing a fall in overall miscarriage rates from 88 to 5.9% is a clear indication for intervention. In women with only one miscarriage, a conservative approach is advocated by some authors (Homer et al., 2000), given a high delivery rate (80–90%) in the next pregnancy. In recent years, there has been an increase in the indication of treating women with a primary infertility history at the time of the ‘balance laparoscopy’ or before performing an assisted reproduction technique. It is preferable to perform a metroplasty before any potential obstetric accidents, especially in patients with declining fecundity (>35 years), and this attitude has been reinforced by the introduction of microsurgical techniques. Furthermore, it has been proposed that metroplasty should be performed not only in women with reproductive problems (unexplained infertility) (Hickok 2000; Mencaglia and Tantini, 1996), in cases of recurrent miscarriage and before assisted reproductive treatment (Daly et al., 1989, Mencaglia and Tantini, 1996), but also in women who do not desire to be pregnant.
How Two types of hysteroscopic treatment are available: resectoscopic and office hysteroscopic surgery. Whichever
method is chosen, the aim is to produce a satisfactory cavity, stopping the procedure when bleeding occurs from small vessels of the fundal myometrium and when tubal ostia can be viewed clearly and simultaneously under panoramic vision. The resectoscopic procedure is performed using a 27 F endoscope and electrosurgery with monopolar loops or fibreoptic laser energy (neodymium:yttrium.aluminiumgarnet, ITP/53, argon, cripton laser) and requires cervical dilatation and distension of the uterine cavity with sorbitolmannitol or glycine solutions. The technique consists of incising the septum across the apex, gradually shortening it, and then incising along each side of the septum alternately and gradually thinning it, until a short notch remains that is incised beginning at one cornual end and progressing to the other. Residual septa can be found at a post-operative hysteroscopic check, but a fundal notch less than 1 cm does not adversely affect reproductive performance (Colacurci et al., 1996; Fedele et al., 1996). The resectoscope allows an excellent continuous flow system, providing continuous washing of the uterine cavity and a clear view, removing bubbles and debris during the procedure. Electrolyte-free fluid can be used as a distending medium, and an exact measurement of the fluid balance must be performed to avoid excessive fluid intravasation, fluid overload and hyponatriemia. Bleeding is usually not significant, due to the coagulating effect of the electrical energy, but peripheral coagulation of the adjacent normal endometrium may occur. Laparoscopic or sonographic monitoring is mandatory for septal resection to observe the symmetry of both uterotubal cornes by transilluminution (laparoscopic check) or the thickness of the fundal uterine wall (USG check) in order to avoid damage to the myometrium and immediate complications, such as perforation. Personal experiences (Colacurci et al., 1996; Colacurci et al., 1998a,b) and international data (Daly et al., 1983; Fedele et al., 1993; Hickok, 2000) demonstrate that resectoscopic removal of uterine septum is safe and effective, with low cost and incidence of complications. Indications for resectoscopic surgery are broad-based septa and complete septa with single (unicolle uterus) or double cervix (bicolle uterus). Two techniques are available for treating complete septa involving the cervical canal: some authors perform only the dissection of the corporal part, sparing the cervical portion (Romer and Lober, 1997; Rock et al., 1999) to reduce the risk of secondary cervical incompetence; in these cases, a probe is introduced into one of the cervices to perform an indentation just above the internal cervical os, and the operative hysteroscope is introduced into the other cervix to produce with a thin knife electrode a small window, through which the probe is inserted. When sufficient space has been created to observe the opposed cavity, the probe is withdrawn and the hysteroscopic incision begins at his level after occluding the other cervical os with the balloon of a Foley catheter in order to prevent loss of the distending medium. Other authors (Vercellini et al., 1996) treat all complete septa in one-step surgery, including both the uterine and the cervical portion, reporting no complications in the hysteroscopic surgery or in pregnancy with vaginal delivery (Mencaglia and Tantini, 1996; Nisolle and Donnez, 1996; Donnez and Nisolle, 2000). In cases of double cervix with septate vagina, the removal of the vaginal septum must be performed first (Donnez and Nisolle, 2000). A few cases of hysteroscopic surgery of exceptional anomalies are reported; examples of appropriate treatment proposed are ‘excluded’ non-communicating horns (Donnez and Nisolle, 2000) and
53
Hysteroscopic treatment of congenital uterine malformations - N Colacurci et al.
hemicavities (Perino et al., 1995). In addition, complete management, including a precise knowledge of eventual urinary tract malformations, is required.
Conclusion In recent years, new technologies have modified the hysteroscopic approach to many intrauterine pathologies responsible for infertility. In particular, the office minihysteroscopy using saline solution as distending medium, the vaginoscopic approach, the 5 Fr channel for introducing microscissors or bipolar electrode working in saline solution, all allow an outpatient approach for the treatment of many intrauterine pathologies. An outpatient approach is used by the authors for the limited-based small septa, whose apex is easily visible. The development of an anaesthesiological protocol using paracervical block (mepivacaine 2%), with or without intravenous conscious sedation (atropine 0.01 mg/kg, fentanyl 0.1 mg, midazolam 2.5 mg), allows resectoscopic procedures to be carried out in day surgery. Microscissors or versapoint procedures need only intravenous premedication, but not a paracervical block, and can be performed in an outpatient setting. A further advantage of microscissors is that there is no risk of thermal endometrial damage, which may interfere with embryo implantation. The limitation of this type of outpatient surgery is the lack of laparoscopic check, since the patient is unlikely to accept a concomitant minilaparoscopy. However, accurate monitoring by ultrasound guarantees a good diagnosis of the malformation and safe removal of the septum. The pre- and post-operative guidelines are the same as those used for resectoscopic or microscissor metroplasty: no preparation of the endometrium, because the intervention is scheduled in the early proliferative phase, and no advantage has been demonstrated to the use of progestins, danazol or gonadotrophin-releasing hormone (GnRH) analogues (Colacurci et al., 1998a). The only cases in which pretreatment of patients is recommended are those with large broad-based septa, in order to obtain an atrophic endometrium to make it easier to see through the endoscope and to increase the likelihood of a successful procedure. The post-operative follow-up consists of an hysteroscopic check performed 1–3 months after surgery, and hormonal therapy and intrauterine devices are not administered.
References
54
Acien P 1997 Shall we operate on mullerian defects? Incidence of mullerian defects in fertile and infertile women. Human Reproduction 12, 1372–1376. Ayida G, Chamberlain P, Barlow D, Kennedy S 1997 Uterine cavity assessment prior to in vitro fertilization: comparison of transvaginal scanning, saline contrast hysterosonography and hysteroscopy. Ultrasound in Obstetrics and Gynecology 10, 59–62. Carrington BM, Hricak H, Nuruddin RN et al. 1990 Mullerian duct anomalies: MR imaging evaluation. Radiology 176, 715–720. Colacurci N, De Placido G, Mollo A et al. 1996 Reproductive outcome after hysteroscopic metroplasty. European Journal of Obstetrics, Gynecology and Reproductive Biology 66, 147, 150. Colacurci N, De Franciscis P, Mollo A et al. 1998a Preoperative GnRH analogue in hysteroscopic metroplasty. Panminerva Medica 40, 41–44. Colacurci N, De Placido G, Perino A et al. 1998b Hysteroscopic metroplasty. Journal of the American Association of Gynecologic Laparoscopists 5, 171–174.
Daly DC, Maier D, Soto-Albors C 1989 Hysteroscopic metroplasty: six years’ experience. Obstetrics and Gynecology 73, 201–205. Daly DC, Walters CA, Soto-Albors CE, Riddick DH 1983 Hysteroscopic metroplasty: surgical technique and obstetric outcome. Fertility and Sterility 39, 623–628. Donnez J, Nisolle M 2000 Endoscopic laser treatment of uterine malformations. Human Reproduction 15, 1381–1387. Fayez JA 1986 Comparison between abdominal and hysteroscopic metroplasty. Obstetrics and Gynecology 68, 399–403. Fedele L, Arcaini L, Parazzini F et al. 1993 Reproductive prognosis after hysteroscopic metroplasty in 102 women: life-table analysis. Fertility and Sterility 59, 768–772. Fedele L, Bianchi S, Marchini M et al. 1996 Residual uterine septum of less than 1 cm after hysteroscopic metroplasty does not impair reproductive outcome. Human Reproduction 11, 727–729. Golan A, Ron-El R, Herman A et al. 1992 Diagnostic hysteroscopy: its value in an in vitro fertilization/embryo transfer unit. Human Reproduction 7, 1433–1434. Goldenberg M, Bider D, Ben-Rafael Z et al. 1991 Hysteroscopy in a program of in vitro fertilization. Journal of In Vitro Fertilization and Embryo Transfer 8, 336–338. Heinonen PK 1997 Reproductive performance of women with uterine anomalies after abdominal or hysteroscopic metroplasty or no surgical treatment. Journal of the American Association of Gynecologic Laparoscopists 4, 311–317. Hickok LR 2000 Hysteroscopic treatment of the uterine septum: a clinician’s experience. American Journal of Obstetrics and Gynecology 182, 1414–1417. Homer HA, LI TC, Cooke ID 2000 The septate uterus: a review of management and reproductive outcome. Fertility and Sterility 73, 1–14. Mencaglia L, Tantini C 1996 Hysteroscopic treatment of septate and arcuate uterus. Gynaecological Endoscopy 5, 151–154. Nisolle M, Donnez J 1996 Endoscopic treatment of uterine malformations. Gynaecological Endoscopy 5, 155–160. Perino A, Chianchiano N, Simonaro C, Cittadini E 1995 Endoscopic management of a case of ‘complete septate uterus with unilateral haematometra’. Human Reproduction 10, 2171–2173. Raga F, Bonilla-Musoles F, Blanes J, Osborne NG 1996 Congenital Mullerian anomalies: diagnostic accuracy of three-dimensional ultrasound. Fertility and Sterility 65, 523–528. Randolph JR, Ying YK, Maier DB et al. 1986 Comparison of realtime ultrasonography, hysterosalpingography, and laparoscopy/hysteroscopy in the evaluation of uterine abnormalities and tubal patency. Fertility and Sterility 46, 828–832. Rock JA, Roberts CP, Hesla JS 1999 Hysteroscopic metroplasty of the Class Va uterus with preservation of the cervical septum. Fertility and Sterility 72, 942–945. Romer T, Lober R 1997 Hysteroscopic correction of a complete septate uterus using a balloon technique. Human Reproduction 12, 478–479. Simon C, Martinez L, Pardo F et al. 1991 Mullerian defects in women with normal reproductive outcome. Fertility and Sterility 56, 1192–1193. Vercellini P, de Giorgi O, Cortesi I et al. 1996 Metroplasty for the complete septate uterus: does cervical sparing matter? Journal of the American Association of Gynecologic Laparoscopists 3, 509–514.
The significance of hysteroscopic treatment of congenital uterine malformations Nicola Colacurci1, Pasquale De Franciscis, Felice Fornaro, Nicola Fortunato, Antonio Perino Institute of Gynaecology and Obstetrics, School of Medicine, Second University of Naples, Naples, Italy 1Correspondence: e-mail [email protected]
Abstract Hysteroscopic surgery replaced abdominal metroplasty and is today the treatment of choice for congenital uterine malformations. This is not just because of its reproductive results, which are comparable to those achieved with the abdominal approach, but mainly because of several post-operative benefits (reduced morbidity, convalescence and costs, and no scar tissue on the abdominal and uterine walls), improved reproductive performance (no reduction in uterine volume, shorter interval to conception after operation) and the mode of delivery (avoiding Caesarean section). Decisions on when and how to treat uterine septa, in relation to the type of malformation, are discussed. In particular, indications for treatment have been broadened to include not only the septate uterus associated with adverse reproductive outcome, but also patients before any potential obstetric accidents, especially in those with declining fecundity (>35 years), with reproductive problems (unexplained infertility) and before assisted reproductive techniques, as well as in women with no actual desire of pregnancy. Two types of hysteroscopic treatment are available: resectoscopic and office hysteroscopic surgery. The indications for resectoscopic surgery are broad-based septa and complete septa with single or double cervix. The resectoscope allows an excellent continuous flow system, providing continuous washing of the uterine cavity and a clear view, removing bubbles and debris during the procedure. However, an exact measurement of fluid balance must be performed to avoid excessive fluid intravasation. Laparoscopic or sonographic monitoring is mandatory. Treatment of limited-based small septa whose apex is easily visible can be achieved with an outpatient approach using office minihysteroscopic surgery and the vaginoscopic technique. The intra-operative check of the fundus is performed by ultrasonography. No preparation of the endometrium is required, except for large, broad-based septa, and hormonal therapy and intrauterine devices are not utilized post-operatively. The post-operative follow-up consists of a hysteroscopic check performed 1–3 months after surgery. Keywords: congenital uterine malformations, hysteroscopy, Mullerian defects, resectoscope, septate uterus, surgery
Introduction
52
Uterine anomalies caused by Müllerian fusion defects are the most common types of malformations of the reproductive system, including a large group of congenital pathologies (didelphic, bicornuate, septate uterus), among which the septate uterus accounts for approximately 80–90% (Simon et al., 1991) and is associated with the poorest reproductive performance (fetal survival rates 6–28%, miscarriage rate >60%). Hysteroscopy is nowadays considered the gold standard for the assessment of uterine pathology because it allows a direct vision of the volume and morphology of the cavity, the evaluation of tubal ostia symmetry and the immediate recognition of a concomitant pathology. Several studies have stressed the relevance of hysteroscopy, not only as a first level diagnostic examination of female infertility but also before performing any assisted reproduction cycle. The findings of intrauterine abnormalities at hysteroscopic evaluation prior to IVF in women with normal hysterosalpingographic features clearly demonstrate the superiority of hysteroscopy (Goldenberg et al., 1991; Golan et al., 1992). Also, it is the experience of the present authors that the routinely hysteroscopic evaluation increases the implantation rate in normo-ovulatory women >35 years, with normal spermiogram of the partner, undergoing their first IVF treatment, when compared with women not undergoing hysteroscopy because of the detection and removal of minimal septa and other intrauterine pathologies. However,
hysteroscopy per se does not allow a definitive diagnosis of the type of uterine malformation, because it does not provide information about the external morphology of the uterus. Therefore, other diagnostic tests are necessary: a concomitant laparoscopy could be used, both to distinguish between a septate and a bicornuate uterus and to complete the diagnostic workup of infertility, providing the opportunity to treat either the malformation at the same time as its diagnosis or any coexisting pathology (endometriosis, adherences, tubal occlusion). Some less invasive tests, such as transvaginal ultrasonography or sonohysterography, are routinely used to evaluate external uterine morphology (Randolph et al., 1986; Ayida et al., 1997) and can provide additional information on tubal patency and adnexal pathology. Three-dimensional ultrasonography (Raga et al., 1996) has shown an accuracy of 92% for the diagnosis of septate uterus and 100% for bicornuate uterus in a sample of patients subsequently undergoing laparoscopy; however, its clinical applicability is limited. Magnetic resonance imaging has been used (Carrington et al., 1990) to obtain information on the relative content of myometrial and fibrous tissue in the septum, to determine the appropriate surgical approach, but the specificity does not reach 100%, the costs remain high and the interpretation depends on the radiologist’s experience. Hysteroscopic surgery represents the treatment of choice for the septate uterus. However, other uterine malformations with lower incidence of reproductive problems more rarely require
Hysteroscopic treatment of congenital uterine malformations - N Colacurci et al.
surgical treatment, generally consisting of a laparotomy and only in few cases laparoscopy. Traditionally, the septate uterus has been treated by abdominal metroplasty with wedge resection (Jones procedure) or by incision of the septum (Tompkins procedure), with excellent results when the patients were carefully selected. In 1974, Edstrom introduced the hysteroscopic treatment of the septate uterus, based on the concept of the transcervical observation of the septum and its resection through a hysteroscopy. When analysing personal (Colacurci et al., 1996; Colacurci et al., 1998b) and international data (Daly et al., 1983; Fayez 1986; Heinonen 1997), the reproductive results (full-term pregnancy rates) obtained with hysteroscopic metroplasty are comparable to those achieved with the abdominal approach. However, hysteroscopy is today the only feasible intervention, because of several post-operative benefits (reduced morbidity, no scar tissue on the abdominal and uterine walls, shorter convalescence and faster return to normal activity, significant cost savings), improved reproductive performance (no reduction in the volume of the uterine cavity, shorter interval to conception after operation) and the mode of delivery (avoiding Caesarean section). Despite the fact that the effectiveness of hysteroscopic treatment of the septate uterus has been elucidated by several studies (Daly et al., 1983; Fedele et al., 1993; Colacurci et al., 1996; Colacurci et al., 1998b; Hickok 2000), some problems still exist: the main debated points are regarding when and how to treat uterine septa (the choice of hysteroscopic technique in relation to the type of malformation).
When It is widely accepted that the diagnosis of a septate uterus needs surgical correction when an association with adverse reproductive outcome is demonstrated. In women with a reproductive history of two or more fetal losses during the first or second trimester of pregnancy, the extremely favourable prognosis after hysteroscopic metroplasty (Acien 1997; Homer et al., 2000), with data showing a fall in overall miscarriage rates from 88 to 5.9% is a clear indication for intervention. In women with only one miscarriage, a conservative approach is advocated by some authors (Homer et al., 2000), given a high delivery rate (80–90%) in the next pregnancy. In recent years, there has been an increase in the indication of treating women with a primary infertility history at the time of the ‘balance laparoscopy’ or before performing an assisted reproduction technique. It is preferable to perform a metroplasty before any potential obstetric accidents, especially in patients with declining fecundity (>35 years), and this attitude has been reinforced by the introduction of microsurgical techniques. Furthermore, it has been proposed that metroplasty should be performed not only in women with reproductive problems (unexplained infertility) (Hickok 2000; Mencaglia and Tantini, 1996), in cases of recurrent miscarriage and before assisted reproductive treatment (Daly et al., 1989, Mencaglia and Tantini, 1996), but also in women who do not desire to be pregnant.
How Two types of hysteroscopic treatment are available: resectoscopic and office hysteroscopic surgery. Whichever
method is chosen, the aim is to produce a satisfactory cavity, stopping the procedure when bleeding occurs from small vessels of the fundal myometrium and when tubal ostia can be viewed clearly and simultaneously under panoramic vision. The resectoscopic procedure is performed using a 27 F endoscope and electrosurgery with monopolar loops or fibreoptic laser energy (neodymium:yttrium.aluminiumgarnet, ITP/53, argon, cripton laser) and requires cervical dilatation and distension of the uterine cavity with sorbitolmannitol or glycine solutions. The technique consists of incising the septum across the apex, gradually shortening it, and then incising along each side of the septum alternately and gradually thinning it, until a short notch remains that is incised beginning at one cornual end and progressing to the other. Residual septa can be found at a post-operative hysteroscopic check, but a fundal notch less than 1 cm does not adversely affect reproductive performance (Colacurci et al., 1996; Fedele et al., 1996). The resectoscope allows an excellent continuous flow system, providing continuous washing of the uterine cavity and a clear view, removing bubbles and debris during the procedure. Electrolyte-free fluid can be used as a distending medium, and an exact measurement of the fluid balance must be performed to avoid excessive fluid intravasation, fluid overload and hyponatriemia. Bleeding is usually not significant, due to the coagulating effect of the electrical energy, but peripheral coagulation of the adjacent normal endometrium may occur. Laparoscopic or sonographic monitoring is mandatory for septal resection to observe the symmetry of both uterotubal cornes by transilluminution (laparoscopic check) or the thickness of the fundal uterine wall (USG check) in order to avoid damage to the myometrium and immediate complications, such as perforation. Personal experiences (Colacurci et al., 1996; Colacurci et al., 1998a,b) and international data (Daly et al., 1983; Fedele et al., 1993; Hickok, 2000) demonstrate that resectoscopic removal of uterine septum is safe and effective, with low cost and incidence of complications. Indications for resectoscopic surgery are broad-based septa and complete septa with single (unicolle uterus) or double cervix (bicolle uterus). Two techniques are available for treating complete septa involving the cervical canal: some authors perform only the dissection of the corporal part, sparing the cervical portion (Romer and Lober, 1997; Rock et al., 1999) to reduce the risk of secondary cervical incompetence; in these cases, a probe is introduced into one of the cervices to perform an indentation just above the internal cervical os, and the operative hysteroscope is introduced into the other cervix to produce with a thin knife electrode a small window, through which the probe is inserted. When sufficient space has been created to observe the opposed cavity, the probe is withdrawn and the hysteroscopic incision begins at his level after occluding the other cervical os with the balloon of a Foley catheter in order to prevent loss of the distending medium. Other authors (Vercellini et al., 1996) treat all complete septa in one-step surgery, including both the uterine and the cervical portion, reporting no complications in the hysteroscopic surgery or in pregnancy with vaginal delivery (Mencaglia and Tantini, 1996; Nisolle and Donnez, 1996; Donnez and Nisolle, 2000). In cases of double cervix with septate vagina, the removal of the vaginal septum must be performed first (Donnez and Nisolle, 2000). A few cases of hysteroscopic surgery of exceptional anomalies are reported; examples of appropriate treatment proposed are ‘excluded’ non-communicating horns (Donnez and Nisolle, 2000) and
53
Hysteroscopic treatment of congenital uterine malformations - N Colacurci et al.
hemicavities (Perino et al., 1995). In addition, complete management, including a precise knowledge of eventual urinary tract malformations, is required.
Conclusion In recent years, new technologies have modified the hysteroscopic approach to many intrauterine pathologies responsible for infertility. In particular, the office minihysteroscopy using saline solution as distending medium, the vaginoscopic approach, the 5 Fr channel for introducing microscissors or bipolar electrode working in saline solution, all allow an outpatient approach for the treatment of many intrauterine pathologies. An outpatient approach is used by the authors for the limited-based small septa, whose apex is easily visible. The development of an anaesthesiological protocol using paracervical block (mepivacaine 2%), with or without intravenous conscious sedation (atropine 0.01 mg/kg, fentanyl 0.1 mg, midazolam 2.5 mg), allows resectoscopic procedures to be carried out in day surgery. Microscissors or versapoint procedures need only intravenous premedication, but not a paracervical block, and can be performed in an outpatient setting. A further advantage of microscissors is that there is no risk of thermal endometrial damage, which may interfere with embryo implantation. The limitation of this type of outpatient surgery is the lack of laparoscopic check, since the patient is unlikely to accept a concomitant minilaparoscopy. However, accurate monitoring by ultrasound guarantees a good diagnosis of the malformation and safe removal of the septum. The pre- and post-operative guidelines are the same as those used for resectoscopic or microscissor metroplasty: no preparation of the endometrium, because the intervention is scheduled in the early proliferative phase, and no advantage has been demonstrated to the use of progestins, danazol or gonadotrophin-releasing hormone (GnRH) analogues (Colacurci et al., 1998a). The only cases in which pretreatment of patients is recommended are those with large broad-based septa, in order to obtain an atrophic endometrium to make it easier to see through the endoscope and to increase the likelihood of a successful procedure. The post-operative follow-up consists of an hysteroscopic check performed 1–3 months after surgery, and hormonal therapy and intrauterine devices are not administered.
References
54
Acien P 1997 Shall we operate on mullerian defects? Incidence of mullerian defects in fertile and infertile women. Human Reproduction 12, 1372–1376. Ayida G, Chamberlain P, Barlow D, Kennedy S 1997 Uterine cavity assessment prior to in vitro fertilization: comparison of transvaginal scanning, saline contrast hysterosonography and hysteroscopy. Ultrasound in Obstetrics and Gynecology 10, 59–62. Carrington BM, Hricak H, Nuruddin RN et al. 1990 Mullerian duct anomalies: MR imaging evaluation. Radiology 176, 715–720. Colacurci N, De Placido G, Mollo A et al. 1996 Reproductive outcome after hysteroscopic metroplasty. European Journal of Obstetrics, Gynecology and Reproductive Biology 66, 147, 150. Colacurci N, De Franciscis P, Mollo A et al. 1998a Preoperative GnRH analogue in hysteroscopic metroplasty. Panminerva Medica 40, 41–44. Colacurci N, De Placido G, Perino A et al. 1998b Hysteroscopic metroplasty. Journal of the American Association of Gynecologic Laparoscopists 5, 171–174.
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