Repair of a chronic myometrial defect with successful pregnancy outcome.

OBJECTIVE: To surgically demonstrate preconceptional laparoscopic repair of a chronic myometrial defect with mesh reinforcement, resulting in a successful pregnancy outcome. DESIGN: Video case report. The Institutional Ethical Committee was consulted, and the requirement for approval was waived because the video describes a modified surgical technique. The patient included in this video gave consent for publication of the video and posting of the video online, including on social media, the journal website, scientific literature websites (such as PubMed, ScienceDirect, Scopus, and others), and other applicable sites. SETTING: A referral advanced gynecological endoscopy center. PATIENT: A 27-year-old woman (P0A1) was diagnosed with myomas during pregnancy, resulting in miscarriage at 22 weeks. Laparotomy and myomectomy were performed 2 months later, and three 8-cm myomas were removed. The endometrial cavity opened posteriorly during surgery, and retained products of conceptions were removed. Periconceptional imaging done after two years showed few intramural myomas and a deficient myometrium in the posterior fundal region. Laparoscopy revealed a defect in the posterior fundal aspect of the uterus with leakage of dye, which was converted to laparotomy and myomectomy with the repair of the myometrial defect. After 1 year, follow-up magnetic resonance imaging showed thinned-out posterior myometrium with a focal area of absent myometrium in the midline and endometrial prolapse. The patient was advised on surrogacy, but she wanted to repair the defect again and try for pregnancy, so she was referred to our center. With the background of a few case reports using mesh to reinforce myometrial repair (1, 2), we counseled the patient about the myometrial repair with the additional use of mesh as an off-label use. INTERVENTION: The risk of uterine rupture after myomectomy is rare (<1%) (3), but it is a severe complication. High-risk cases, like significant myometrial defects or previous ruptures, may require surgical correction. Native repair may not achieve optimal results in all cases. Alternative approaches, like the additional use of mesh or biological materials, have been reported (4). In this case, we demonstrate the use of dual mesh for scar repair. Synthetic mesh over the uterus is used in laparoscopic procedures like sacrohysteropexy and cerclage. We used Parietex (Covidien, New Haven, CT, USA) mesh, a composite macroporous polyester mesh usually used for ventral hernia repair. It has an outer hydrophilic, absorbable collagen barrier that reduces adhesion formation. Laparoscopically, after adhesiolysis, a significant defect was demonstrated on the posterior wall of the uterus (Fig. 1). A complete resection of the fibrotic tissue along the edges of the scar defect was done to expose healthy myometrium. Myometrium was repaired in two layers, excluding the endometrium, with a V-Loc (Covidien, Dublin, Ireland) No. 1-0 suture. Parietex mesh was sutured over the repaired posterior myometrium to reinforce it (Fig. 2). MAIN OUTCOME MEASURES: The postoperative myometrial thickness on imaging and pregnancy outcome. RESULTS: Postoperative ultrasound scan after 6 weeks demonstrated restoration of posterior wall myometrial thickness of 14 mm. The patient was conceived through in vitro fertilization techniques 4 months after surgery. Antenatal follow-up was uneventful except for suspicion of posterior placenta accreta. She underwent an elective cesarean section with uterine artery embolization at 34 weeks and delivered a healthy infant weighing 1,950 g. Placental removal was uneventful. On inspection, the posterior surface of the uterus was intact without dehiscence, meshing in situ with minimal adhesions (Fig. 3). CONCLUSION: Myometrial scar defects can cause potential obstetric complications. Native repair of scar defects may not achieve optimal results, as in our case. Mesh repair of myomectomy scar defects can be used as an alternative approach, as exemplified in this case. However, further studies are required to establish the safety and efficacy of this approach.

Transvaginal ultrasound versus magnetic resonance imaging for preoperative assessment of myometrial infiltration in patients with low-grade endometrioid endometrial cancer: A systematic review and head-to-head meta-analysis.

PURPOSE: We aimed to compare the diagnostic performance of magnetic resonance imaging (MRI) and transvaginal ultrasound (TVS) for detecting myometrial invasion (MI) in patients with low-grade endometrioid endometrial carcinoma. METHODS: A comprehensive search of MEDLINE (Pubmed), Web of Science, Embase and Scopus (from January 1990 to December 2022) was performed for articles comparing TVS and MRI in the evaluation of myometrial infiltration in low-grade (grade 1 or 2) endometrioid endometrial carcinoma in the same group of patients. We used QUADAS-2 tool for assessing the risk of bias of studies. RESULTS: We found 104 citations in our extensive research. Four articles were ultimately included in the meta-analysis, after excluding 100 reports. All articles were considered low risk of bias in most of the domains assessed in QUADAS-2. We observed that pooled sensitivity and specificity for detecting deep MI were 65% (95% confidence interval [CI] = 54%-75%) and 85% (95% CI = 79%-89%) for MRI, and 71% (95% CI = 63%-78%) and 76% (95% CI = 67%-83%) for TVS, respectively. No statistical differences were found between both imaging techniques (p > 0.05). We observed low heterogeneity for sensitivity and high for specificity regarding TVS; and moderate for both sensitivity and specificity in case of MRI. CONCLUSIONS: The diagnostic performance of TVS and MRI for the evaluation of deep MI in women with low-grade endometrioid endometrial cancer is similar. However, further research is needed as the number of studies is scanty.

Evaluation of the role of intraoperative frozen section and magnetic resonance imaging in endometrial cancer.

OBJECTIVE: To evaluate the accuracy of preoperative endometrial biopsy and magnetic resonance imaging (MRI) of endometrial cancer compared with that of intraoperative frozen section. METHODS: This retrospective study included 264 patients who underwent surgery with intraoperative frozen section for endometrial cancer at our institution between 2014 and 2018. Diagnosis was determined by histologic type, grade, and myometrial invasion. Concordance rate, sensitivity, and specificity of preoperative diagnosis and intraoperative frozen diagnosis were calculated, in comparison to the final pathologic diagnosis. RESULTS: Preoperative and intraoperative diagnoses showed no statistically significant difference in determining histologic type and grade (P = 0.152). Intraoperative diagnosis showed higher sensitivity for endometrioid carcinoma grade 3 and other types, and higher specificity for grade 1. For myometrial invasion, intraoperative diagnosis showed significantly higher concordance rate than preoperative MRI findings (P < 0.01). Intraoperative diagnosis showed higher sensitivity and specificity in patients with and without myometrial invasion, respectively. CONCLUSION: Higher agreement between intraoperative and final diagnoses, especially in myometrial invasion, suggests that intraoperative frozen section is a good indicator for appropriate surgical procedure decision making.

Efficacy of transvaginal ultrasound versus magnetic resonance imaging for preoperative assessment of myometrial invasion in patients with endometrioid endometrial cancer: a prospective comparative study.

BACKGROUND: We compared the accuracy of preoperative transvaginal ultrasound (TVUS) versus magnetic resonance imaging (MRI) for the assessment of myometrial invasion (MI) in patients with endometrial cancer (EC), while definitive histopathological diagnosis served as a reference method. PATIENTS AND METHODS: Study performed at a single tertiary centre from 2019 to 2021, included women with a histopathological proven EC, hospitalized for scheduled surgery. TVUS and MRI were performed prior to surgical staging for assessment MI, which was estimated using two objective TVUS methods (Gordon's and Karlsson's) and MRI. Patients were divided into two groups, after surgery and histopathological assessment of MI: superficial (≤ 50%) and deep (> 50%). RESULTS: Sixty patients were eligible for the study. According to the reference method, there were 34 (56.7%) cases in the study with MI < 50%, and 26 (43.3%) with MI > 50%. Both objective TVUS methods and MRI showed no statistical significant differences in overall diagnostic performance for the preoperative assessment of MI. The concordance coefficient between both TVUS methods, MRI and histopathology was statistically significant (p < 0.001). Gordon's method calculating MI reached a positive predictive value (PPV) of 83%, negative predictive value (NPV) of 83%, 77% sensitivity, 88% specificity, and 83% overall accuracy. Karlsson's method reached PPV of 82%, NPV of 79%, 69% sensitivity, 88% specificity, and 80% overall accuracy. Accordingly, MRI calculating MI reached PPV of 83%, NPV of 97%, 97% sensitivity, 85% specificity, and 90% overall accuracy. CONCLUSIONS: We found that objective TVUS assessment of myometrial invasion was performed with a diagnostic accuracy comparable to that of MRI in women with endometrial cancer.

Novel laparoscopic surgery for the repair of cesarean scar defect without processing scar resection.

BACKGROUND: Cesarean scar defect (CSD), especially CSD with residual myometrium less than 3 mm is reported to be the highest risk agent associated with uterine rupture for subsequent pregnancy. Currently, laparoscopic resection and suture was the mainstay therapy method for CSD with a residual myometrium less than 3 mm in women with a desire to conceive. Besides, the women have CSD related symptoms, especially postmenstrual bleeding, should be recommended for CSD treatment. This study is to investigate the efficiency of this novel laparoscopic surgery for the repair of cesarean scar defect (CSD) without scar resection for residual myometrium thickening. METHOD: This retrospective clinical study enrolled 76 women diagnosed with CSD who had a residual myometrium thickness less than 3 mm and also had a desire to conceive, had undergone laparoscopic surgery for the repair of CSD in the time period March 2016 to March 2018. Two study cohorts were created among the 76 patients: 40 patients had undergone the novel laparoscopic repair of CSD without processing scar resection (Group A), whereas 36 patients had undergone the traditional laparoscopic resection and suture of CSD (Group B). RESULTS: Residual myometrium thickening occurred among all the 76 patients and the average residual myometrium thickness was increased to almost 6 mm, presenting no between-group difference. In Group A, all the CSD-related postmenstrual bleeding was resolved or improved, but one patient in Group B has no obvious change to postmenstrual bleeding. After CSD repair, 20 patients got pregnant naturally in Group A, and there was no cesarean scar pregnancy and uterine rupture. While, there were 9 cases of natural pregnancy in Group B. No uterine rupture occurred among these 9 pregnant women of Group B, but 1 case of pregnancy was terminated due to cesarean scar pregnancy. CONCLUSION: Laparoscopic repair without processing scar resection seems to be a feasible, safe and simple operative approach for CSD treatment, which can thicken residual myometrium and improve postmenstrual bleeding.

Hysteroscopic management of intramural ectopic pregnancy.

The uterine myometrium is the rarest location for an ectopic pregnancy resulting in the so-called 'intramural or intramyometrial ectopic pregnancy'. It presents a particular diagnostic and therapeutic challenge for the treating physician. If passed undiagnosed can lead to life-threatening uterine rupture, which may warrant hysterectomy, leaving the woman with irreversible infertility. Different treatment modalities have been proposed for the management of this condition. In this case report, we are describing a rare case of intramural ectopic pregnancy and reporting the use of hysteroscopy for the surgical management of this case for the first time in the literature.

Repair of the myometrial scar defect at repeat caesarean section: a modified surgical technique.

BACKGROUND: To investigate whether the existing surgical technique for uterine closure at repeat lower segment Caesarean section (LSCS) can be modified to achieve adequate residual myometrial thickness (RMT) to ensure scar integrity and reduce complications in future pregnancy. METHODS: Women with a significant scar defect at repeat LSCS had the anterior uterine wall closed by a single experienced obstetrician with a technique focused on recognition, mobilisation and apposition of the retracted myometrial edges at the boundary of the defect. This was aimed at anatomical restoration of the lower segment. The RMT at the scar area was assessed by postnatal pelvic ultrasound scan at three months. RESULTS: Thirty women with a history of at least one previous CS, incidentally found to have a large defect at operation underwent the technique with prior consent. A postnatal scan showed a mean residual myometrial thickness of 8.4 mm (SD ±1.3 mm; range 5.6-11.0 mm). The average operating time was 91 mins and the average blood loss 728 ml. Two women who underwent the repair have gone on to have a further uneventful CS. CONCLUSION: This modified technique resulted in scan evidence of an RMT indicative of uterine wall stability postnatally and offers the potential for reducing the risk of rupture and placenta accreta spectrum (PAS) in future pregnancy.

Anti-Müllerian hormone level may predict successful pregnancy after adenomyomectomy in patients with infertility due to adenomyosis.

ABSTRACT: We aimed to determine clinical factors predicting successful pregnancy by comparing pregnancy failure and success groups after adenomyomectomy. Additionally, we analyzed fertility outcomes after adenomyomectomy.The medical records of 43 patients who had undergone adenomyomectomy and received in vitro fertilization treatment from 2017 to 2020 were retrospectively reviewed. Patients were divided into pregnancy failure (n = 28) and pregnancy success (n = 15) groups. Patients' demographic factors were evaluated and compared between the groups.The age of patients was higher (39.0 [32.0-45.0] vs. 37.0 [33.0-42.0] years, P = .006) whereas the level of anti-Müllerian hormone (anti-Müllerian hormone [AMH]; 0.54 [0.01-8.54] vs. 2.91 [0.34-7.92] ng/mL, P = .002) lower in the pregnancy failure group compared to the pregnancy success group. The operative time was longer (220.0 [68.0-440.0] vs. 175.0 [65.0-305.0] min, P = .048) while the estimated blood loss higher (750 [100-2500] vs. 500 [50-2000] mL, P = .016) in the pregnancy failure group compared to the pregnancy success group. No significant difference was observed in body mass index, symptoms, cancer antigen 125, preoperative uterine volume, or type of adenomyosis. In the multivariate analysis, age and AMH were significant predictive factors for successful pregnancy.Ovarian reserve (age and AMH) and disease severity might be predictive factors for successful pregnancy in patients who have undergone adenomyomectomy. Adenomyomectomy should be considered for women desiring pregnancy and having appropriate ovarian reserve. Our results would be beneficial for patients and clinicians before deciding on adenomyomectomy. Larger prospective studies are required to confirm our findings.

Circular suture of the uterine serosa and myometrium layer around placental attachment site for refractory postpartum hemorrhage.

OBJECTIVE: The aim of the study was to analyze the clinical outcomes of circular suture at placental attachment site for refractory postpartum hemorrhage (PPH), which could block blood supply of the serosa and myometrium layer. METHODS: Eighty cases of refractory PPH were enrolled and retrospective analyzed in this study for further analysis from a consecutive single center database between 2010 and 2018. After undergoing circular suture of the uterine serosa and myometrium layer around placental attachment site, surgical and perioperative outcomes were recorded and analyzed. RESULTS: Among all the patients enrolled, 28 cases (35.0%) of refractory PPH were mainly caused by uterine inertia, 36 cases (45.0%) caused by ectopic placenta, and 2 cases (2.5%) caused by coagulation disorders. After circular suture of the uterine serosa and myometrium layer at placental attachment site, all the uterine active bleeding was controlled below 40 ml without recurrence. The perioperative results were similar between the vaginal and cesarean sections groups. CONCLUSIONS: Circular suture of the uterine serosa and myometrium at the placental attachment site could control refractory PPH with few postoperative complications. Circular suture around placenta site could be applied in time to protect the endometrium even in primary hospital.

Vascular Pseudoinvasion After Endometrial Ablation.

Vascular pseudoinvasion or displacement of tumor or normal endometrial tissue is a potential pitfall in uterine pathology. The proposed mechanisms of this phenomenon are mostly associated with the uterine manipulator used during minimally invasive hysterectomies. The aim of this report is to describe vascular pseudoinvasion in a still unreported setting, that of a postendometrial ablation hysterectomy, and to provide a summary of studies dealing with artifactual or nonmalignant myometrial vessel involvement by normal or neoplastic endometrial tissue.

Pregnancy outcomes after hysteroscopic surgery in women with cesarean scar syndrome.

Cesarean scar defect often causes postmenstrual abnormal uterine bleeding, dysmenorrhea, chronic pelvic pain, and infertility, which are collectively known as cesarean scar syndrome (CSS). Several studies have reported that hysteroscopic surgery can restore fertility in women with CSS. The study aimed to identify factors that influence subsequent pregnancy following hysteroscopic surgery. Therefore, we studied 38 women with secondary infertility due to CSS who underwent hysteroscopic surgery at Shiga University of Medical Hospital between July 2014 and July 2019. Our hysteroscopic procedure included inferior edge resection and superficial cauterization of the cesarean scar defect under laparoscopic guidance. Patients were followed up for 3 to 40 months after surgery. Surgery was successful in all cases and no complications were observed. Twenty-seven patients (71%) became pregnant (pregnant group), while 11 (29%) did not (non-pregnant group). Baseline characteristics of age, body mass index, gravidity, parity, previous cesarean section, presence of endometriosis, retroflex uterus, and preoperative residual myometrial thickness were not significantly different between the groups. However, the median residual myometrium thickness was significantly higher after surgery than before surgery in the pregnant group (1.9 [1.1-3.6] vs 4.9 [3.4-6.6] mm, P<0.0001), whereas this difference was not significant in the non-pregnant group. Of those who became pregnant, 85% conceived within 2 years of surgery. Although three pregnancies resulted in abortion and one is ongoing at the time of writing, 23 pregnancies resulted in healthy babies at 35-38 gestational weeks by scheduled cesarean sections with no obstetrical complications due to hysteroscopic surgery. The average birth weight was 3,076 g. Our findings support that hysteroscopic surgery is a safe and effective treatment for secondary infertility due to CSS. The thickness of the residual myometrium may be a key factor that influences subsequent pregnancy in women with CSS.

Assessment of thermal damage to myometrium during microwave ablation of uterine fibroids.

Thermal ablation techniques are increasingly used for the treatment of symptomatic uterine fibroids. Thermal protection of myometrial tissue adjacent to the fibroid from ablation is critical to maximally preserve the uterus. This study presents a bench top experimental setup, using ex vivo bovine muscle as a surrogate tissue, for evaluating collateral thermal damage in tissues during fibroid ablation. The study reports on the effect of applicator insertion angles (67.5° and 90°) into a mock fibroid on the efficacy of treatment. 6 experiments were performed (3 for each insertion angle) with 30 W applied power at 2.45 GHz. The heating duration was restricted to the time at which a thermal dose of 10 cumulative equivalent minutes at 43 °C (10 CEM 43) was accrued at the boundary of the mock fibroid. Results showed that the volume of ablation inside the mock fibroid dropped considerably from 66% to 17% when the applicator insertion angle was changed from 90º to 67.5º, suggesting that insertion angle plays an important role during microwave ablation of fibroid. The proposed setup provides a method for validating computational models for accurate and safe delivery of ablation to target tissues in fibroid treatment.

Focal adenomyosis of the outer myometrium and deep infiltrating endometriosis severity.

OBJECTIVE: To determine whether the presence of focal adenomyosis of the outer myometrium (FAOM) at preoperative magnetic resonance imaging is associated with the severity of deep infiltrating endometriosis. DESIGN: Observational cross-sectional study involving 255 symptomatic deep infiltrating endometriosis patients. Comparisons were performed according to the presence of FAOM. SETTING: University hospital. PATIENT(S): Women with a preoperative magnetic resonance imaging and complete surgical exeresis of endometriotic lesions with histologically documented deep infiltrating endometriosis. INTERVENTION(S): Surgical management for deep infiltrating endometriosis. MAIN OUTCOME MEASURE(S): The presence of multiple deep infiltrating endometriosis lesions, the mean number and location of deep infiltrating endometriosis lesions, and the mean total revised American Society for Reproductive Medicine scores. RESULT(S): The prevalence of FAOM at preoperative magnetic resonance imaging in the 255 patients with deep infiltrating endometriosis was 56.5%. The mean number of deep infiltrating endometriosis lesions was significantly higher in the FAOM(+) group than in the FAOM(-) group: 3.5 ± 2.1 vs. 2.2 ± 1.5. The mean total revised American Society for Reproductive Medicine score was higher in case of FOAM coexisting with deep infiltrating endometriosis. After adjusting for confounding factors, the presence of FAOM was significantly associated with multiple deep lesions. CONCLUSION(S): FAOM was significantly associated with greater deep infiltrating endometriosis severity. This needs to be integrated into the management strategy. Furthermore, a pathogenic link between deep infiltrating endometriosis and FAOM cannot be excluded.

A mouse model of placenta accreta spectrum.

INTRODUCTION: Placenta Accreta Spectrum (PAS) disorder is one of the leading causes of maternal morbidity and mortality due to uncontrollable hemorrhage. The greatest risk factor for development of PAS is prior uterine surgery, frequently cesarean delivery. Despite considerable clinical knowledge, animal models of PAS are lacking. To address this, we used two surgical approaches to create uterine scarring in peripartum and non-pregnant CD-1 mice. Il10-/- mice, with a pro-inflammatory phenotype were also studied. METHODS: In peripartum mice, a hysterotomy was performed to simulate a cesarean section. The second approach utilized endometrial curettage in non-pregnant mice. Sham-operated mice served as control. Following recovery, females were mated. On gestation day 16, pregnant females were euthanized, and the uterus was excised. Tissue was fixed, sectioned, and stained with H&E or cytokeratin immunohistochemistry. The cytokeratin-positive area extending beyond the trophoblast giant cells was measured by quantitative image analysis. Disruption of the circular (inner myometrium) smooth muscle was scored semi-quantitatively. RESULTS: In surgically scarred mice, trophoblast invasion was deeper relative to control mice, regardless of surgical method. The myometrium in experimental mice showed significant disruption compared to sham controls. Results from CD-1 and Il10-/- mice were similar, with the latter showing more severe pathology. DISCUSSION: While further refinement of surgical method is required, our data indicate that surgical uterine scarring in mice represents a promising model of PAS.

A case of unplanned pregnancy at 2 months after uterine curettage in a patient with a hydatidiform mole.

Whether an unplanned pregnancy should be terminated during follow-up of a hydatidiform mole is controversial. We report a patient who had an unplanned pregnancy with a hydatidiform mole at 2 months after uterine curettage when the human chorionic gonadotropin level had decreased to a negative value. Hydatidiform mole was confirmed by histopathology. Uterine curettage was performed twice and regular follow-ups were performed after surgery. The patient achieved a full-term pregnancy. The Apgar score of the newborn was 10 at 1, 5, and 10 minutes, and the newborn had no malformations. We conclude that the pregnancy outcome might be good in an unplanned pregnancy when the human chorionic gonadotropin level is negative.