Hysteroscopic Isthmoplasty: Step-by-Step Technique.

STUDY OBJECTIVE: To demonstrate our technique for surgical hysteroscopy performed with a standard-size resectoscope or miniresectoscope in 3 cases of isthmocele. DESIGN: Step-by-step demonstration of the technique using slides, pictures, and video (educative video) (Canadian Task Force classification III). SETTING: Isthmocele is a characteristic semidiverticular anomaly of the anterior isthmic wall of the uterus, located at the site of a previous cesarean delivery scar. The etiopathogenesis of isthmocele remains poorly understood, although several hypotheses have been proposed. Factors that may possibly play a role in niche development include a very low incision through cervical tissue, inadequate suturing technique during closure of the uterine scar, surgical interventions that increase adhesion formation, and patient-related factors that impair wound healing or increase inflammation or adhesion formation. The treatment of isthmocele focuses on relieving symptoms (i.e., postmenstrual spotting, suprapubic pelvic pain, dysmenorrhea, dyspareunia, and infertility), and, consequently, asymptomatic cases should not be treated. Various surgical approaches have been described to treat isthmocele-related symptoms, including hysteroscopy, laparoscopy, vaginal, robotic, and combined techniques. INTERVENTION: Our local Institutional Review Board approved the study protocol. The procedures were performed in operative room using a 26 Fr and 16 Fr continuous-flow resectoscope under general anesthesia. The surgical technique involves resection of the fibrotic tissue of the lower margin and then the upper margin of the pouch using a cutting loop, until the underlying muscular tissue is reached, followed by resection of the inflamed and necrotic tissue of the base of the pouch. Similar surgical maneuvers are performed on the contralateral side (right anterolateral wall) for complete ablation of the isthmic region (inverted ablation). CONCLUSION: According to the most recent literature, hysteroscopic hystmoplasty appears to be a safe and effective treatment option in cases of isthmocele with a niche at least 2 mm deep and a residual myometrial thickness of at least 3 mm to improve postmenstrual bleeding. When residual myometrial thickness is <3 mm, the hysteroscopic approach is not recommended, mainly because of the risk of bladder injury. In these symptomatic cases, laparoscopic or vaginal repair may be considered.

Cervico-isthmic pregnancy successfully treated with bipolar resection following methotrexate administration: case report and literature review.

Cervico-isthmic pregnancy is a rare form of ectopic pregnancy associated with a high morbidity and mortality rate. Recent advances in high-resolution ultrasound have made the diagnosis of early cervico-isthmic pregnancies easier. Early diagnosis allows a more conservative therapeutic approach that avoids hysterectomy and preserves fertility. Here is reported a case of viable cervico-isthmic pregnancy successfully treated with resectoscopy after failed systemic and local (hysteroscopic) methotrexate administration. The resectoscopic excision of the cervico-isthmic pregnancy was carried out with the technique of slicing, using a 27 bipolar resectoscope with a 4-mm loop. The procedure was successful with the complete removal of the ectopic pregnancy, while maintaining satisfactory haemostasis. A literature review shows that no consensus exists for the treatment of cervico-isthmic pregnancies. We report a case of viable cervico-isthmic pregnancy successfully treated with resectoscopy after failed systemic and local (hysteroscopical) methotrexate administration. The resectoscopic excision of cervico-isthmic pregnancy was carried out with the technique of slicing, using a 27 bipolar resectoscope with a 4-mm loop. The procedure was successful with the complete removal of the ectopic pregnancy, while maintaining satisfactory haemostasis.

Monofilament vs multifilament suture for uterine closure at the time of cesarean delivery: a randomized clinical trial.

BACKGROUND: Different factors may influence the closure of the uterine wall, including suture material. Suture materials may indeed influence tissue healing and therefore the development of scar defects. OBJECTIVE: To test whether uterine closure using synthetic absorbable monofilament sutures at the time of cesarean delivery would reduce the rate of cesarean scar defects compared with uterine closure using synthetic absorbable multifilament sutures. STUDY DESIGN: Parallel-group, nonblinded, randomized clinical trial of women with singleton pregnancies undergoing cesarean delivery at term in a single center in Italy. The inclusion criteria were singleton pregnancy, first or second cesarean delivery, scheduled and emergent or urgent cesarean deliveries, and gestational age between 37 0/7 and 42 0/7 weeks. Eligible participants were randomly allocated in a 1:1 ratio to either the monofilament group (polyglytone 6211 [Caprosyn]; Covidien, Dublin, Ireland) or the multifilament suture group (coated polyglactin 910 suture with Triclosan [Vicryl Plus]; Ethicon, Inc, Raritan, NJ). The primary outcome was the incidence of cesarean scar defect at ultrasound at the 6-month follow-up visit. The secondary outcomes were residual myometrial thickness and symptoms. RESULTS: Overall, 300 women were included in the trial. Of the randomized women, 151 were randomized to the monofilament group and 149 to the multifilament group. However, 27 women were lost to follow-up: 15 in the monofilament group and 12 in the multifilament group. Of note, 6 months after delivery, the incidence rates of cesarean scar defect were 18.4% (25 of 136 patients) in the monofilament group and 23.4% (32 of 137 patients) in the multifilament group (relative risk, 0.79; 95% confidence interval, 0.41-1.25; P=.31). The mean residual myometrial thicknesses were 7.6 mm in the monofilament group and 7.2 mm in the multifilament group (mean difference, +0.40 mm; 95% confidence interval, -0.23 to 1.03). There was no between-group substantial difference found in the incidence of symptoms, including pelvic pain, painful periods, and dyspareunia. CONCLUSION: In singleton pregnancies undergoing primary or second cesarean delivery, the use of synthetic absorbable monofilament sutures at the time of uterine wall closure was not associated with a reduction in the rate of cesarean scar defect 6 months after delivery compared with the use of synthetic absorbable multifilament sutures.

Office myomectomy.

Small myomas have a high potential to grow and either to become symptomatic or to cause complications in women of reproductive age. Furthermore, although the risk of malignancy is rare, even the most experienced operator cannot replace the histological analysis to exclude malignancy or premalignant lesions. Such small symptomatic and asymptomatic totally or partially intracavitary myomas may be treated effectively and safety in office setting. The aim of this paper is to describe the currently available hysteroscopic techniques to treat myomas <1.5 cm also with a minimal intramural component without anaesthesia or analgesia in ambulatory setting reducing patient's discomfort.