How to be sure of a complete removal of Essure® implant? A radiological study of Essure® microinserts.

PURPOSE: Laparoscopic cornuectomy, one of the most performed surgical techniques to remove Essure® implants, is associated with a risk of fragmentation of the device. We aimed to assess the diagnostic accuracy of the intraoperative radiograph of the removed Essure® microinserts compared with intraoperative inspection of the device. STUDY DESIGN: In this French retrospective cohort study including 66 patients, two experienced gynecologists and two residents evaluated the intraoperative radiograph in a blind manner. Diagnostic accuracy was calculated for each observer. RESULTS: The global sensitivity and specificity for intraoperative radiograph to detect a residual fragment for both senior gynecologists and residents were, respectively 87.5 % (±3.3) and 80.0 % (+/12.2). Pooled positive (PPV) and negative predictive values (NPV) for intraoperative radiograph were respectively 99.2 % (±0.5) and 21.6 % (±6.4). There was a statistically significant difference in intraoperative radiograph analysis between senior gynecologists and residents (sensitivity: 91.4 %±0.8 vs 79.6 %±1.5, p = 0.02; specificity: 100% vs 50.0 %, p < 0.0001; PPV: 100 % vs 98.0 % ±0.1, p = 0.0007; NPV: 26.8 % ±1.8 vs 7.2 % ±0.5, p = 0.009). Sensitivity and specificity of the intraoperative inspection of the removal specimen was respectively 95.3 % and 100 % (PPV and NPV were, respectively 100 and 40 %). There were no statistically significant differences in diagnostic accuracy between intraoperative radiographs analysis and intraoperative inspection of the device for the senior gynecologists. CONCLUSIONS: Intraoperative radiograph of the removed Essure® implants analysis is a difficult skill needing specific training. Postoperative pelvic X-ray is still recommended in clinical practice after laparoscopic cornuectomy.

Interstitial pregnancy management: A multicentric analysis of 98 patients from the FRANCOGENT group comparing surgery and medical treatment.

OBJECTIVE: To evaluate the outcomes associated with each therapeutic option for patients diagnosed with interstitial pregnancy (IP). METHODS: We conducted a multicentric retrospective cohort study within the departments of Gynecology and Obstetrics involved in the Francogent research group. Women treated for an interstitial pregnancy between January 2008 to December 2019 were included. Three therapeutic options were evaluated: surgical treatment (ST); in situ methotrexate combined with systemic methotrexate (IS-MTX); and systemic methotrexate (IM-MTX). Success of first-line treatment was defined by hCG negativation (<5I U/L). Secondary outcomes included the need for secondary surgical procedure, secondary medical treatment, emergency surgery, postoperative complications, duration of hospitalization, and delay before hCG negativation. RESULTS: A total of 98 patients were managed for IP: 42 (42.9%) patients had IM-MTX; 34 (34.7%) had IS-MTX; and 22 (22.4%) had ST. First-line treatment was successful in all patients of the ST group (22/22, 100%), in 31% of patients within the IM-MTX group (13/42) and 70.6% (24/34) in the IS-MTX group. The sole parameter associated with the risk of treatment failure was the mode of methotrexate administration. The size of the gestational sac or the presence of fetal heartbeat was not associated with decreased medical treatment (IS or IM-MTX) efficiency. CONCLUSION: Either ST or IS-MTX are good options for IP treatment associated with high success rates. A single-dose regimen of IM-MTX is less efficient than IS-MTX or ST. Symptomatic patients with severity criteria should always undergo emergency surgery. IP remains a high-risk condition that should be managed, whenever possible, in referral centers to potentialize the chances of favorable outcomes.

Clinical improvement after Essure® devices removal: a systematic review.

PURPOSE: Essure® implant is a permanently implanted minimally invasive birth control device for women (female sterilisation) widely used between 2002 and 2018. Many adverse events were reported by patients. Increasingly removal procedures have been performed in symptomatic patients. However, there is a lack of in-depth studies on clinical improvement after Essure® removal. We aimed to review all clinical studies about symptoms and quality of life (QoL) after removal procedures. MATERIALS AND METHODS: A review of literature in electronic search in Medline and Embase databases from January 2002 to January 2022 using the following keywords: Essure; Essure removal; quality of life; symptomatology improvement. RESULTS: Out of 764 articles in the initial database, 18 clinical studies were eligible for inclusion in our literature review. Overall clinical improvement rates after removal ranged from 21% to 98%. All symptoms were less frequent after Essure® removal, although with large discrepancies between studies. Lack of improvement was reported between 1% to 15% of patients. Rate of patients with improvement of QoL after removal ranged from 58 to 98%. The pain was reported as significantly reduced after the surgery. CONCLUSIONS: In the available literature, Essure® removal in symptomatic patients may improve symptoms and quality of life. This should be discussed in the benefits and risks ratio before deciding on the best option of management.

Essure® removal in symptomatic patients may improve symptoms and quality of life.

Clinical and histopathological correlations in symptomatic patients with salpingectomy for Essure® implant removal: a cross-sectional study.

PURPOSE: Many concerns have been raised about adverse effects related to Essure® device. Several pathophysiological hypotheses have been proposed including allergic reactions, Autoimmune/Autoinflammatory Syndrome Induced by Adjuvants, galvanic corrosion with release of heavy metals and inflammation. In the present study, we aimed to focus on inflammation process by performing a histopathological evaluation of Fallopian tubes in symptomatic patients with Essure® removal. MATERIALS AND METHODS: A cross-sectional study with identification of the type of inflammatory response and characterisation of inflammatory cells in the surrounding tubal tissue around the Essure® (STTE) and at distance from the implant. Histopathological and clinical correlations were also investigated. RESULTS: In the STTE from 47 cases, acute inflammation was observed in 3/47 (6.4%) cases. Chronic inflammation with lymphocytes (42.5%, 20/47) was associated with a significant higher pre-operative pain score (p = .03). Fibrosis was noted in 43/47 (91.5%) cases. Fibrosis without lymphocytes (51.1%, 24/47) was statistically associated with significant reduced pain (p = .04). At distance from the Essure® implant, only chronic inflammation with lymphocytes was present in 10/47 (21.7%) cases. CONCLUSIONS: Inflammation response do not seem to be enough to explain all the Essure-related adverse outcomes, suggesting the involvement of other biological mechanisms. CLINICALTRIALS.GOV IDENTIFIER: NCT03281564.

Inflammation and fibrosis are found in the surrounding tubal tissue around the Essure^®. Inflammation process alone doesn't seem to be enough to explain symptomatology.

Bilateral Cornual Resection for Uterine-sparing Removal of Tubal Sterilization Devices.

STUDY OBJECTIVE: To describe a uterine-sparing minimally invasive surgical technique for laparoscopic resection of tubal occlusion devices using bilateral cornuectomy. DESIGN: This video reviews the background of the tubal occlusion device known as Essure and the indications and methods for surgical removal with a stepwise demonstration of a minimally invasive technique with narrated video footage. SETTING: The most cited reason for patients' desire for removal of the Essure device is pelvic pain. Both hysteroscopic and laparoscopic methods have been used for removal of these devices. Laparoscopy is indicated if it has been >3 months since insertion, if a coil is noted to be malpositioned, or if the patient desires continued permanent sterilization. Techniques for removal include salpingostomy, salpingectomy, and cornuectomy. Removal of the entire device is essential, given that any remaining coil or polyethylene terephthalate fibers may continue to cause symptoms. The coils of the device can easily be fractured; therefore, in our practice we perform a bilateral cornuectomy when uterine retention is desired Supplemental Videos 1 and 2, because fracture rates are higher with salpingectomy than cornuectomy. We demonstrate the steps of this method and highlight the critical aspects for surgeons to consider during the procedure. INTERVENTIONS: Laparoscopic bilateral cornuectomy approach to a uterine-sparing excision of Essure tubal occlusion devices to reduce the risk of coil retention and fracture: 1) Injection of dilute vasopressin at the uterine cornua for vasoconstriction and hemostasis 2) Circumferential dissection of the uterine cornua using monopolar energy 3) Confirmation of endometrial cavity entry using methylene blue 4) Excision of fallopian tube along mesosalpinx to include the fimbriated end 5) Closure of the myometrial layers using a unidirectional barbed suture in a running fashion CONCLUSION: In patients who desire uterine preservation, we recommend a minimally invasive technique of bilateral cornual resection for removal of tubal sterilization devices to avoid device fracture and inadvertent retention of coils.

Laparoscopic removal of Essure device techniques, perioperative findings and evaluation of patient's satisfaction: A case series.

OBJECTIVE: To evaluate perioperative outcomes and symptom resolution in women undergoing Essure removal. METHODS: Single centre cohort study at a large University Teaching Hospital in the UK. Symptoms and Quality of life (QoL) were assessed using a standardised questionnaire administered at 6-months and up to 10-years following removal of Essure® devices. RESULTS: 61 women underwent surgical removal of Essure® devices representing 61/1087 (5.6%) of all women undergoing this hysteroscopic form of sterilization. Patients who had Essure® removal were more likely to have a previous caesarean section [38% vs 18%; OR 0.4, 95% CI 0.2-0.6; P <0.001]. The main indication for removal was pelvic pain (49/61, 80%). Removal was achieved by laparoscopic bilateral salpingectomy/cornuectomy (44/61,71%) or hysterectomy (17/61, 28%). At surgery, perforated device was seen in 4/61 (7%) cases. 26/61 (43%) of patients had concomitant pelvic pathology; 12/26 (46%) had fibrous adhesions, 8/26 (31%) endometriosis, 4/26 (15%) adenomyosis, and 2/26 (8%) had endometriosis and adenomyosis. 10 patients underwent further procedure following removal for ongoing symptoms. 55/61 women (90%) responded to the post removal symptom questionnaire. Most respondents to the quality of life survey 42/55 (76%) reported total or some improvement. 42/53 (79%) had total or some improvement in pelvic pain, 9/13 (69%) in mental health and 10/12 (83%) in bleeding. CONCLUSION: Surgical removal of Essure® devices appears to improve symptoms thought to be attributable to the presence of these uterine implants in most women. However, patients should be counselled that one in five women may experience persistent or even worsening symptoms.

Interstitial Ectopic Pregnancy: Laparoscopic Cornuostomy.

STUDY OBJECTIVE: To demonstrate and discuss the technique of cornuostomy for surgical management of interstitial ectopic pregnancy. DESIGN: Stepwise demonstration of the technique with narrated video footage. SETTING: Tertiary referral center in Manchester, United Kingdom. INTERVENTION: Interstitial ectopic pregnancies are rare but are associated with a higher mortality rate than other ectopic pregnancies [1,2]. It occurs when the fertilized embryo implants in the interstitial portion of the fallopian tube traversing the vascularized myometrium. When undiagnosed they present late in the second trimester associated with rupture and catastrophic bleeding, with a mortality rate of 2% to 2.5%.2 Diagnosis requires a degree of vigilance from the ultrasound operator because it is commonly misdiagnosed as intrauterine pregnancies. Surgical management options include laparoscopic cornual resection or cornuostomy. There is no consensus on the optimal surgical technique but cornuostomy is a more conservative approach associated with less disruption to uterine anatomy and loss of myometrium [3,4]. A 22-year-old gravida 4 woman presented at 7 weeks' gestation with right iliac fossa pain. Initial serum human chorionic gonadotropin was 18 136 IU/L. Transvaginal ultrasound scan showed an empty endometrial cavity and an echogenic "donut"-shaped mass within the right interstitial space, within the uterine serosa but outside the endometrial cavity (Supplemental Video 1). At laparoscopy the diagnosis of a right interstitial ectopic pregnancy was confirmed (Supplemental Video 2). Vasopressin 20 IU diluted in 80 mL of normal saline was injected around the base of the ectopic pregnancy. Monopolar diathermy was used to incise the overlying serosa followed by hydrodissection to separate the ectopic gestational sac from the myometrial attachment. The resulting defect was inspected and closed in 2 layers. Total operating time was 46 minutes. CONCLUSION: Although there is no clear evidence to guide the management of all interstitial ectopic pregnancies, an individualized approach taking into account the woman's previous history and future fertility plans and wishes is essential. In this case, given the woman's previous contralateral salpingectomy and her wishes for a conservative approach, a laparoscopic cornuostomy was likely the best option.

Exophytic interstitial ectopic pregnancy removal: novel use of Endoloop for uterine cavity preservation.

OBJECTIVE: To demonstrate the unique use of Endoloop during laparoscopic removal of an exophytic interstitial ectopic pregnancy to ensure hemostasis, provide counter traction against a uterine manipulator, and reduce the likelihood of entry into the endometrium. DESIGN: Case report with intraoperative surgical footage. SETTING: Tertiary care referral center operating room. PATIENT(S): Single patient case report. INTERVENTION(S): A single patient with an ectopic pregnancy suspected using ultrasound and confirmed during surgery. MAIN OUTCOME MEASURE(S): Laparoscopic removal of the interstitial ectopic pregnancy via a wedge resection cornuectomy without endometrial involvement using a monopolar hook, Endoloop, and a William's cystoscopic needle for the injection of vasopressin. RESULT(S): The patient was a 32-year-old G7P1051 with a history of a left tubal ectopic pregnancy status post a laparoscopic left salpingectomy, 1 full-term vaginal delivery, 2 elective terminations, 2 early pregnancy losses, smoking (1 pack per day), and marijuana use (6 blunts per day). She initially presented in November 2020 with intermittent but worsening left lower quadrant abdominal pain and was found to have a left adnexal mass, raising concern for an ectopic pregnancy in the setting of a ß-human chorionic gonadotropin (ß-hCG) level of 6,411 mIU/mL, and no intrauterine pregnancy identified using transvaginal ultrasound. She was counseled on medical vs. surgical management and she elected to receive an injection of methotrexate in the emergency department (ED) before discharge with a scheduled follow-up visit at the clinic for standard ß-hCG trends. The patient did not attend her scheduled day 4 and 7 visits for ß-hCG levels or her 2-week appointment for ultrasound; so, she was called over the phone and asked to come to the ED as soon as possible for evaluation. Approximately 3 weeks after the injection of methotrexate, the patient was still experiencing intermittent left lower quadrant abdominal pain. A repeat ultrasound in the ED showed no intrauterine gestational sac, an endometrial thickness of 0.6 cm, a normal right ovary, a normal left ovary with a corpus luteum cyst, a small amount of free fluid in the cul-de-sac, and a left adnexal extraovarian complex cystic structure measuring 2.9 × 2.4 cm with a fetal pole. The fetal pole corresponded with a gestation period of 6 weeks and 3 days, based on a crown-rump length of 0.59 cm, and lacked cardiac activity. The ß-hCG level at this time was 1,124 mIU/mL, and the patient strongly desired surgical management for her ongoing abdominal pain and unresolved ectopic pregnancy. The patient's vital signs and complete blood count were within normal limits. The patient desired future fertility. A repeat transvaginal ultrasound before surgery showed the extraovarian nature of the ectopic pregnancy but could not specify whether it was intrauterine or intra-abdominal in the left adnexa; so, the decision was made to proceed with a diagnostic laparoscopy. After laparoscopic entry through Palmer's point using the Veress needle and then insertion of a 5-mm trocar under direct visualization, the left exophytic interstitial ectopic pregnancy was discovered, as depicted in the video. Given the patient's desire for future fertility, a wedge resection cornuectomy without the involvement of the endometrium was the ideal surgical approach. Subsequent trocar placement consisted of a 10-mm trocar in the umbilicus and a 5-mm trocar in the left lower quadrant. The Endoloop was initially inserted into the umbilical 10-mm trocar to allow for placement around the interstitial ectopic pregnancy to achieve hemostasis and act as a tourniquet. The Endoloop suture was passed into the abdomen and then pulled laterally using an atraumatic grasper through the left lower quadrant trocar to provide counter traction against a uterine manipulator that was deviating the uterus to the patient's right side. This created an excellent plane for dissection along the myometrial base of the interstitial pregnancy to prevent the removal of excess uterine tissue and decrease the likelihood of entry into the endometrial cavity. Injection of 4 units vasopressin (20u in 50 mL of normal saline) using a William's cystoscopy catheter through the umbilical port further ensured hemostasis along the base of the ectopic pregnancy during removal using a monopolar hook. The cystoscopy catheter was chosen for its length and flexible body to maximize maneuverability. Electrocautery was used as needed for hemostasis. After the removal of the ectopic pregnancy using the monopolar hook, the myometrium and serosa were reapproximated in a running 2-layered fashion using a V-Loc suture. The ectopic pregnancy was removed from the abdomen in a specimen retrieval bag through the 10-mm umbilical port. The 10-mm port was closed using a standard fascial closure device and then the skin of all the port sites was reapproximated using 4-0 Monocryl suture. Two important factors that favored this surgical technique over hysterectomy or standard cornuectomy included the patient's strong desire for future fertility and the exophytic nature of the interstitial pregnancy. Nevertheless, as the pregnancy increases in distance from the cornua, so does the likelihood that the pregnancy will be a normal intrauterine pregnancy, which greatly impacts counseling and management if the pregnancy is desired. Postoperative care was routine and the recommendation was made to wait at least 3 months to attempt another pregnancy and to undergo saline-infused sonography for the evaluation of the endometrial cavity; however, the patient never followed up. CONCLUSION(S): This video demonstrates the unique use of Endoloop and vasopressin through a William's cystoscopy injection needle during the laparoscopic removal of an exophytic interstitial ectopic pregnancy. The Endoloop helped to ensure hemostasis, provide counter traction against the uterine manipulator, and optimize visualization to reduce the likelihood of endometrial involvement in a patient who desired future fertility.

Technical notes surgical treatment of a ruptured interstitial pregnancy.

Non-tubal ectopic pregnancies represent fewer than 10% of all ectopic pregnancies. However, they are associated with a high rate of mortality due to late diagnosis and uterine horn rupture which requires radical emergency surgical management. Cornuectomy via laparoscopy is a treatment of choice. We provide here a simple description of laparoscopic cornuectomy using an Endo GIA stapling system: the Endo GIA® automatic forceps. It has the advantage of removing the mass, suturing, and achieving satisfactory haemostasis in a single step.

Surgical techniques for the removal of Essure® microinserts: a literature review on current practice.

PURPOSE: To evaluate the different techniques for Essure® microinserts removal and to assess the risk of fracture of the device and the intra- and post-operative complications in relation to surgical technique variants. METHODS: Electronic search in Medline, Scopus and Embase databases using the following keywords: Essure; Essure removal; Essure surgical technique. RESULTS: Out of 95 articles in the initial database, 17 studies were eligible for inclusion in our literature review. Several surgical techniques have been described in which the most frequent were laparoscopic salpingectomy (LS), laparoscopic cornuectomy (LC), laparoscopic or vaginal hysterectomy (LH, VH) with en-bloc salpingectomy. There were more fractures of the device with the LS procedure (6.25%) followed by the LC technique (2.77%), while there was no fracture with hysterectomy. However, peri-and post-operative complications were more severe and frequent with hysterectomy in comparison with the LC and LS procedures (respectively 8.1% Clavien Dindo grade 3 for the hysterectomy group, 1.11% for the LC procedure and 0.69% for the LS technique). CONCLUSION: Due to the lack of standardised surgical treatment guidelines, a system of care networks for symptomatic patients with adverse effects related to Essure® headed by specialised centres may offer a suitable and high-quality management with the appropriate removal techniques within two objectives: limiting the risk of fracture (with an en-bloc removal of the Essure® microinserts) and avoiding intra- and post-operative complications.

Patients' satisfaction following laparoscopic cornuectomy for removal of hysteroscopic sterilization devices.

OBJECTIVES: To evaluate patients' satisfaction and evolution of pre-operative symptoms at 6 months following laparoscopic cornuectomy for hysteroscopic sterilization implants removal. MATERIAL AND METHODS: Retrospective study including all patients undergoing laparoscopic cornuectomy for implants removal in a tertiary care setting from January 2017 to October 2018. All women suffered from persistent and treatment-resistant gynecologic and non-gynecologic complaints since sterilization procedure. Patents' satisfaction was evaluated with the PGI-I questionnaire at 2 and 6 months following surgery. RESULTS: Overall, 104 patients were enrolled. Main symptoms comprised asthenia (n = 80), chronic pelvic pain (n = 80), arthralgia (n = 70), abnormal uterine bleeding (n = 42) and headache (n = 40). Cornuectomy was feasible in all cases and led to complete devices removal in 101 women. Mean length of stay was 1.8 days, while outpatient management was feasible in 45.2 % of cases. One grade 3 complication occurred along the study period (hemoperitoneum requiring reoperation). Surgery was associated with a significant decrease in symptom occurrence, except for alopecia and weight loss. Patients' satisfaction was high: 91 % at 2 months and 97.6 % at 6 months reported an improvement in their health status compared to baseline situation. Satisfaction regarding each symptom was consistent with overall assessment, with most patients reporting significant improvement at both 2 and 6 months. CONCLUSION: Laparoscopic cornuectomy is feasible and associated with high mid-term satisfaction in patients suffering from adverse effects attributed to hysteroscopic sterilization implants.

Symptom related to Essure® and evolution after removal: Outcomes of retrospective cohort.

INTRODUCTION: The number of requests for Essure removal has grown continually over recent years. The objective is to describe the symptoms reported after Essure sterilization, methods of removal and results. MATERIAL AND METHODS: Retrospective and single-centre cohort (Regional university hospital of Lille, France) was conducted. All women, having consulted from December 2016 to February 2019 for symptoms related to Essure insertion, were included. All the symptoms were noted. A second group was created that included patients who underwent Essure removal to evaluate the benefits of surgery on these symptoms. RESULTS: The study included 98 patients. Most frequent symptoms were musculoskeletal pain (75 %), asthenia (63 %) and pelvic pain (55 %). Fifty-nine patients (60 %) underwent surgery. Surgery appeared beneficial with reduction of symptoms in 60 % of these patients, complete resolution in 33 % and no reduction of symptoms in 7%. Many symptoms were relieved by surgery with an overall decline of 96 % in menorrhagia, 94 % in metrorrhagia and 93 % in dyspareunia. However, other symptoms were not relieved by surgery like 100 % of sleep disorders, 70 % of abdominal pain cases and 57 % of memory impairment cases. CONCLUSION: Symptoms related to Essure insertion are numerous. Although surgery appears beneficial, some adverse effects remain. Therefore, a preoperative aetiologic assessment and information about risk of surgery failure are important.

Novel laparoscopic cornual resection of interstitial pregnancy using the Endo GIA™ Universal Stapler (Medtronic): A series of 12 cases.

BACKGROUND: The maternal mortality of interstitial pregnancy is five times greater than that of other ectopic gestations due to potential haemorrhage. Minimal access surgical techniques usually comprise cornual resection and cornuostomy, requiring laparoscopic suturing skills. AIM: To describe a case series using a laparoscopic automatic stapling device with reloadable cartridges to resect the cornu, enabling surgeons less familiar with intracorporeal suturing to avoid laparotomy when managing interstitial pregnancy. MATERIALS AND METHODS: Twelve cases of laparoscopic cornual resections for interstitial pregnancies with the Endo GIA™ Universal Stapler (Medtronic) were collected prospectively over eight years. Outcome measures include human chorionic gonadotropin beta subunit (hßCG) levels, successful laparoscopic completion, estimated blood loss, intra-and post-operative complications and length of stay. RESULTS: Median age and gestation at surgery were 31 years (range: 20-44) and eight weeks (range: 5-12), respectively. All involved live interstitial gestations, and 4/12 cases had significant haemoperitoneum at laparoscopy. The median blood loss was 300 mL (range 100-3500), and five women had blood loss >500 mL. The median serum hßCG level was 6429 IU/L (range: 1800-58690), and the median ectopic size was 4 cm (range 2-6). All cases were completed laparoscopically with no intra- or post-operative complications, although two women required blood transfusions. Median length of stay was 40 h. Further pregnancies could only be followed in 2/12 cases due to the migratory nature of our local population. CONCLUSION: We describe a case series of 12 laparoscopic cornual resections for interstitial pregnancies using Endo GIA™ Universal Stapler, which simultaneously staples and transects the tissues, thus minimising the need for laparoscopic intracorporeal suturing.

Two Surgical Techniques for Essure Device Ablation: The Hysteroscopic Way and the Laparoscopic Way by Salpingectomy with Tubal Interstitial Resection.

STUDY OBJECTIVE: To describe 2 different surgical techniques for Essure removal on the same patient: the hysteroscopic and laparoscopic techniques. DESIGN: An educational video approved by the local institutional review board (Canadian Task Force classification III). SETTING: A university hospital (University Hospital of Strasbourg, Strasbourg, France). PATIENT: A 46-year-old woman with many symptoms after Essure device implantation. An ultrasound found a right implant in the uterine cavity and a left intratubal implant. INTERVENTIONS: The first step was the hysteroscopic removal of the right implant. We viewed the 2 internal and external spirals, allowing the gripping of the whole device without risking any fragmentation or tubal lesion. The second step was bilateral salpingectomy with resection of the left interstitial tubal portion. We longitudinally incised the antimesial edge of the fallopian tube 2 to 3 cm from the tubal serous to the implant contact. A circumferential incision was performed at the uterine horn to circumscribe the interstitial tubal portion. The implant was released from the surrounding tissue. It was gently pulled to completely extract it and avoid spiral fragmentation. Then, we performed a bilateral total salpingectomy. An X-ray of the implants and pelvis was performed to ensure complete removal of the device. We made an X-stitch in the uterine horn to avoid the risk of fistula. CONCLUSION: More and more patients are asking for the removal of their implants. The surgical technique has to be adapted to the location of the implants and has to allow their complete removal to avoid leaving fragments that can cause the persistence of side effects.

Essure Removal for the Treatment of Device-Attributed Symptoms: An Expanded Case Series and Follow-up Survey.

STUDY OBJECTIVE: To evaluate perioperative outcomes and symptom resolution in women undergoing removal of the Essure device for device-attributed symptoms. DESIGN: Retrospective case series and follow-up patient survey (Canadian Task Force classification III). SETTING: Large academic medical center. PATIENTS: Fifty-two women who underwent laparoscopic or hysteroscopic Essure removal between 2012 and 2016. INTERVENTIONS: Women underwent one of four procedures: laparoscopic hysterectomy (LH) and bilateral salpingectomy (BS), laparoscopic BS and cornuectomy, laparoscopic Essure removal and BS, or hysteroscopic Essure removal and laparoscopic BS. MEASUREMENTS AND MAIN RESULTS: Fifty-two women who underwent Essure removal were asked to complete a survey regarding symptom resolution and quality of life following the procedure. Thirty-two women (61.5%) responded to the survey. Seventy-five percent (24/32) reported almost total or total improvement in quality of life, 56.3% (18/32) for sex life, 53.1% (17/32) for pelvic pain, and 65.6% (21/32) for daily activities. The majority of women reported some degree of improvement in all four domains queried (87.5%, 28/32). When asked about their symptoms in general, 31.3% (10/32) of women reported ongoing or worse symptoms after Essure removal. All procedures took approximately one hour (mean 65 min, SD 33 min), were associated with minimal blood loss (mean 31 mL, SD 17), and had no perioperative complications. CONCLUSION: Essure removal is a procedure that may be effective for treating most women with symptoms attributed to the device. Patients should be counseled that some symptoms may persist or even worsen following surgery.

Endoloop technique for laparoscopic cornuectomy: A safe and effective approach for the treatment of interstitial pregnancy.

Interstitial pregnancy (IP) occurs within the intramural portion of the tube and accounts for 2% of ectopic pregnancies. Surgery is considered the most definitive treatment for IPs, although there is no clear consensus regarding the optimal approach. In this paper we describe the advantages of cornual resection performed using the Endoloop technique and present three patients who were successfully treated using this approach. IP diagnosis was confirmed at two and three-dimensional ultrasound and laparoscopy in all cases. Fertility sparing surgery with cornuectomy by Endoloop ligature technique demonstrated low mean operating time and blood loss, and allowed the quick recovery and discharge of all patients. Laparoscopy has become the gold standard surgical approach for IP. Cornual resection or excision is the most commonly performed procedure. In our case series, the Endoloop technique showed excellent treatment outcomes in terms of effectiveness, blood loss, operative time, recovery and post-procedure fertility. Because of these features, Endoloop appears to be a suitable option for the laparoscopic management of IPs, both in elective and emergency settings.