Outpatient hysteroscopy is effective for uterine cavity evaluation following failed office-based endometrial biopsy.

BACKGROUND: Failure to obtain an office-based endometrial biopsy for abnormal uterine bleeding is not uncommon. Although operating room-based procedures are traditionally considered the gold standard assessment tool in these circumstances, outpatient hysteroscopy is a less invasive, more cost-effective, and safer alternative. However, there is no contemporary Canadian literature on the effectiveness of an outpatient approach for this specific population. OBJECTIVE: We aim to evaluate the effectiveness and outcomes of outpatient hysteroscopy for uterine cavity evaluation for patients who have failed an in-office endometrial biopsy attempt. METHODS: We conducted a retrospective cohort study of all patients referred to an academic outpatient hysteroscopy unit between January 2015 and January 2018, who underwent an outpatient hysteroscopy following failed endometrial biopsy. Data were collected from electronic medical records. RESULTS: Of the 407 consecutive patients who underwent an outpatient hysteroscopic procedure, 68 met inclusion criteria. Postmenopausal bleeding was the most common indication for initial biopsy, and most failures were attributed to cervical stenosis. Outpatient hysteroscopies were successfully completed in 96% of cases (n = 65/68). Failure resulted from either anxiety and discomfort (n = 2), or severe intrauterine adhesions (n = 1). Overall, 10% of patients subsequently required an operating room-based hysteroscopy, either to complete a myomectomy or polypectomy, or to allow general anesthesia. Outpatient hysteroscopy identified endometrial hyperplasia and cancer in 4.5% and 3% of patients, respectively. CONCLUSION: Outpatient hysteroscopy following unsuccessful office endometrial biopsy attempts appears to be a feasible, safe, and cost-effective investigation strategy that may prevent the need for an operating room-based procedure in 90% of cases.

Hysteroscopic management of a stenotic cervix.

OBJECTIVE: To demonstrate an approach to the hysteroscopic management of a stenotic cervix. DESIGN: Step-by-step explanation of the techniques using video and animation (educational video). SETTING: Academic tertiary level referral center. PATIENT(S): Patients with cervical stenosis, inclusive of both reproductive age and postmenopausal women. Gynecologists require intrauterine access for many procedures, but a stenotic cervix can obstruct surgery. Blind dilation of a stenotic cervix can lead to a cervical laceration or uterine perforation, with concomitant complications. INTERVENTION(S): The hysteroscopic management of a stenotic cervix includes optimizing the surgical environment, performing vaginoscopy and "no-touch" hysteroscopy, and revision of the cervical canal. Revision can be performed using microscissors, micrograspers, or a cutting loop electrode. Partial cervical canal excision to aid in hysteroscopy access should be reserved in women who are not interested in future pregnancy or those who are postmenopausal. Outpatient hysteroscopy uses smaller instruments and shows operative success with patient satisfaction. Although these techniques are demonstrated in an outpatient hysteroscopy setting, they can be adapted for use in an operating theater. MAIN OUTCOME MEASURE(S): The individual steps and approach are emphasized. RESULT(S): Intrauterine access can be achieved with various techniques. CONCLUSION(S): The "see-and-treat" approach demonstrated in this video can allow access into the uterine cavity despite a stenotic cervix.

Surgery for endometriosis: beyond medical therapies.

Endometriosis-associated pelvic pain and subfertility may be managed medically in many cases; however, the surgical management of this insidious disease remains a necessary part of the treatment algorithm. Laparoscopy for diagnosis alone is rarely indicated with the advancements in preoperative imaging. When surgery is performed, the ideal goal would be a therapeutic and effective surgical intervention based on the preoperative evaluation. Surgery for women with pain due to endometriosis may be indicated in patients who cannot or do not wish to take medical therapies; acute surgical or pain events; deep endometriosis; during concomitant management of other gynecologic disorders; and patients seeking fertility with pain. The role of surgery for endometriosis-related subfertility may be considered in those with hydrosalpinges undergoing IVF; management of ovarian endometriomas in specific circumstances; and when a patient requests surgery as an alternative to assisted reproductive technology (ART). Surgery for ovarian endometriomas requires special attention due to the risk of potential harm on future fertility. Finally, a combined approach of surgery followed by postoperative medical therapy offers the best long-term outcomes for recurrence of disease and symptoms. A patient-centered approach and a goal-oriented approach are essential when determining the options for care in this population.

Lymphatic injury at sacrocolpopexy: an unusual complication.

BACKGROUND: Lymphorrhea is a rare condition with a paucity of reports in the gynaecologic literature. The most frequent causes are invasive procedures and surgical interventions. CASE: A multiparous woman underwent a total abdominal hysterectomy with prophylactic bilateral salpingectomy and abdominal sacrocolpopexy for pelvic organ prolapse. During retroperitoneal dissection, clear fluid discharge was encountered. Ureteric injury was subsequently ruled out. A sample of the fluid was taken to confirm lymphatic injury. Ligation suture and closing the peritoneum slowed fluid drainage. CONCLUSION: To our knowledge, this is the first reported lymphatic injury in association with a urogynaecologic procedure. Gynaecologists should be aware of this potential complication and should have an approach to diagnosis and management. This case highlights the importance of intraoperative consultation.

Contexte : La lymphorrhée est un trouble rare n'ayant fait l'objet que de très peu de signalements au sein de la littérature gynécologique. Les interventions effractives et les interventions chirurgicales en constituent les causes les plus fréquentes. Cas : Une femme multipare a subi une hystérectomie abdominale totale (s'accompagnant d'une salpingectomie bilatérale prophylactique) et une sacrocolpopexie abdominale (pour contrer le prolapsus des organes pelviens). Au cours de la dissection rétropéritonéale, un écoulement de liquide transparent a été constaté. La présence d'une lésion urétérale a par la suite été écartée. Un échantillon de ce liquide a été prélevé afin de confirmer la présence d'une lésion lymphatique. La mise en place de ligatures et la fermeture du péritoine ont ralenti le drainage du liquide. Conclusion : À notre connaissance, il s'agit du premier signalement d'une lésion lymphatique associée à une intervention urogynécologique. Les gynécologues devraient être à l'affût de cette complication potentielle et disposer d'une approche envers son diagnostic et sa prise en charge. Ce cas souligne l'importance de la consultation peropératoire.

The connexin43 C-terminal region mediates neuroprotection during stroke.

Connexin43 plays an important role in neuroprotection in experimental stroke models; reducing the expression of this gap junction protein in astrocytes enhances injury upon middle cerebral artery occlusion (MCAO). Because the C-terminal region of connexin43 isimportant for channel activity, we carried out MCAO stroke experiments in mice expressing a truncated form of connexin43 (Cx43DeltaCT mice). Brain sections were analyzed for infarct volume, astrogliosis, and inflammatory cell invasion 4 days after MCAO. Adult cortices and astrocyte cultures were examined for connexin43 (Cx43) expression by immunohistochemistry and Western blot. Cultured astrocytes were also examined for dye coupling, channel conductance, hemichannel activity, and Ca wave propagation. The Cx43DeltaCT mice exhibit enhanced cerebral injury after stroke. Astrogliosis was reduced and inflammatory cell invasion was increased inthe peri-infarct region in these mice compared with controls; Cx43 expression was also altered. Lastly, cultured astrocytes from Cx43DeltaCT mice were less coupled and displayed alterations in channel gating, hemichannel activity, and Ca wave properties. These results suggest that astrocytic Cx43 contributed to the regulation of cell death after stroke and support the view that the Cx43 C-terminal region is important in protection in cerebral ischemia.