[Analysis of the application effect and safety of transnasal humidified rapid insufflation ventilatory exchange technique in hysteroscopic diagnostic and therapeutic surgery].

Objective: To investigate the effect and safety of transnasal humidified rapid insufflation ventilatory exchange (THRIVE) technique in hysteroscopic diagnostic and therapeutic surgery. Methods: This study was a randomized controlled trial. A total of 100 female patients undergoing hysteroscopy surgery at Beijing Tongren Hospital from September to December 2023 were selected and randomly divided into two groups by the random number table method: the THRIVE group and the mask oxygen group, with 50 patients in each group. Patients in both groups were given total intravenous anesthesia with propofol combined with remifentanil and preserved spontaneous respiration. The THRIVE group was given oxygen by the THRIVE device with an oxygen flow rate of 50 L/min, while the mask oxygen group was given oxygen by the mask with an oxygen flow rate of 5 L/min; the oxygen concentration of both groups was set at 100%. The general condition of the patients, vital signs during the operation, the amount of anesthesia drugs used and the operation time were recorded. The primary observation index was the incidence of hypoxic events in the two groups; the secondary observation indexes were the incidence and time of intraoperative apnea as well as the corresponding oxygenation interventions and the incidence of non-hypoxic adverse events. Results: The age of the THRIVE group was (42±14) years, and the age of the mask oxygen group was (43±15) years. The duration of surgery in the THRIVE group was (15.9±3.4) min, which was statistically lower than that of the mask oxygen group (16.3±4.5) min (P=0.041), and there were no differences observed in the duration of awakening time and anesthesia time (both P>0.05). There was no significant difference in the dosage of propofol, remifentanil, and intraoperative vasoactive drugs between the two groups (all P>0.05). The SpO2 of the patients in the THRIVE group at the end of the operation was (99.7±1.1) %, which was higher than that of the mask-oxygen group (99.1±1.1) % (P<0.05). There was no difference in SpO2 of the two groups at the other time points (all P>0.05). There were no differences in HR and MAP of two group patients at each time point (all P>0.05). The incidence of hypoxic events in the THRIVE group was 12.0% (6/50), which was lower than that of 28.0% (14/50) in the mask oxygen group (P=0.045). The difference in the incidence and duration of apnea between the two groups was not statistically significant (all P>0.05). There were no cases of temporary need for laryngeal mask or tracheal intubation during surgery in both groups. There was no statistically significant difference in the incidence of intraoperative body movement, dizziness, nausea and vomiting between the two groups (all P>0.05), and no cardiac, cerebral, renal or other important organ insufficiency occurred in the two weeks after surgery. Conclusion: THRIVE technology can provide effective oxygenation for patients undergoing hysteroscopic diagnosis and treatment, maintain patients' circulatory stability, and improve the safety and efficiency of surgery.

Histological assessment of endometrial polyps resected by hysteroscopy.

OBJECTIVE: This study aimed to analyze the clinical data and pathologic aspects of endometrial polyps (EMPs) excised completely during surgical hysteroscopy and assess the connection between premalignant and malignant EMPs. PATIENTS AND METHODS: This retrospective study includes 489 participants who underwent hysteroscopy due to endometrial polyps, and the clinical features and histological findings of the resected polyps analyzed. RESULTS: Participants with EMPs were divided into six groups according to histologic findings. The histologic finding of most cases was simple benign endometrial polyp [397 patients (81.2%)]. Malignant polyp was detected in 3 patients (0.6%). The histologic findings according to age, menopausal status, and menstrual bleeding patterns at the time of presentation to the outpatient clinic were compared; however, no significant difference was observed. 237 patients were observed to have menometrorrhagia, which was the most prevalent symptom reported. The distribution of polyp sizes observed at hysteroscopy according to histologic findings was compared, but no significant difference was observed. CONCLUSIONS: EMPs are often benign but can include premalignant or malignant tissue changes. Hysteroscopy is used for direct observation of the uterine cervix and resection of existing polyps, considering the increasing frequency of its use as a diagnostic and treatment tool.

To Compare the Anesthetic Effect of Remimazolam and Propofol in Painless Hysteroscopic Minimally Invasive Surgery.

OBJECTIVE: Hysteroscopic surgery will stimulate the autonomic nerves innervating the uterus, causing intense discomfort and pain in the examined person, and in severe cases, it will cause blood pressure drop, heart rate slowing, arrhythmia and even cardiac arrest, so most patients need anesthetic intervention. This study to retrospectively compare the anesthetic effect of remimazolam and propofol in minimally invasive painless hysteroscopic surgery and to explore the safety and efficacy of remimazolam. METHODS: The clinical data of 110 female patients who underwent painless hysteroscopic minimally invasive surgery in our hospital from January 2023 to June 2023 were collected. The patients were divided into the remimazolam group (group R, n = 55) and the propofol group (group P, n = 55) according to the main anesthetic drugs used during the operation. The changes in heart rate (HR), mean arterial pressure (MAP), blood oxygen saturation (SpO2), and respiratory rate (RR) at the time of entry (T0), modified vigilance/sedation score (MOAA/S) 0 (T1), cervical dilation (T2), end of the operation (T3) and anesthesia recovery (T4) were compared between the two groups. Anesthesia induction time, operation time, and anesthesia recovery time were compared between the two groups, and the incidence of intraoperative and postoperative adverse reactions was compared between the two groups. RESULTS: HR, MAP, and SpO2 in group R were significantly higher than those in group P at T1, T2, T3, and T4 (p < 0.05), and there was no significant difference in RR between the two groups (p > 0.05). HR, MAP, and SpO2 at T1 and T2 were significantly lower than those at T0 in group R (p < 0.05), and RR at different time points in the group had no significant difference (p > 0.05). HR, MAP, and SpO2 at T1, T2, T3, and T4 were significantly lower than those at T0 in group P (p < 0.01), and RR at different time points in the same group had no significant difference (p > 0.05). The anesthesia induction time in group R was more prolonged than in group P, and the anesthesia recovery time in group R was shorter than in group P (p < 0.05). The incidences of hypotension, bradycardia, low oxygen saturation, respiratory depression, and injection pain in group R were significantly lower than those in group P (p < 0.05). CONCLUSION: Intravenous induction of remimazolam at 6 mg·kg-1·h-1 and maintenance of anesthesia at 1-2 mg·kg-1·h-1 have less effect on hemodynamics, faster recovery time and lower incidence of adverse reactions compared with propofol when used in minimally invasive hysteroscopic surgery. Remimazolam can be safely and effectively used in this kind of surgery.

Short-term reproductive outcomes analysis and prediction of the modified uterine stent treatment for mild to moderate intrauterine adhesions: experience at a single institution.

BACKGROUND: To evaluate the efficacy of modified uterine stent in the treatment of mild-to-moderate intrauterine adhesions and explore the relative indicators affecting prognosis prediction. METHODS: A total of 115 patients with mild-to-moderate intrauterine adhesions received a modified uterine stent placement after hysteroscopy adhesiolysis. The second-look hysteroscopy operated after 3 months surgery, and the third-look hysteroscopy operated after 6 months surgery if necessary. The stent was removed when the cavity shape was repaired, then the reproductive outcomes were followed up one year. RESULTS: Menstrual blood volume, endometrial thickness and volume had increased significantly after 3 months surgery. The rates of cavity repaired were 86.96% (100/115) after 3 months surgery and 100% (115/115) after 6 months surgery cumulatively. Endometrial thickness after 3-months surgery was positively associated with uterine cavity shape repaired (P<0.01). The receive operating characteristic (ROC) curve showed the rate of uterine cavity shape repaired predicted by the model was 0.92, based on the endometrial thickness after 3-months surgery. The rate of pregnancy was 86.09% (99/115) in one year, while the rate of miscarriage accounted for 26.26% (26/99). The median time interval between stent removal and subsequent conception was 3 months. It showed adhesion recurrence was the risk factor for subsequent pregnancy (P<0.01). CONCLUSIONS: A modified uterine stent placement under hysteroscopy was an effective approach for mild-to-moderate intrauterine adhesions, which is easy to operate and worthy for clinical promotion. Endometrial thickness measured by ultrasonography probably has predictive value in adhesion recurrence and subsequent pregnancy. TRIAL REGISTRATION: ChiCTR2100051524. Date of registration (retrospectively registered): 26/09/2021.

Comparing the efficacy and pregnancy outcome of intrauterine balloon and intrauterine contraceptive device in the prevention of adhesion reformation after hysteroscopic adhesiolysis in infertile women: a prospective, randomized, controlled trial study.

STUDY OBJECTIVE: To evaluate the efficacy and pregnancy outcomes of intrauterine balloon and intrauterine contraceptive devices in the prevention of adhesion reformation following hysteroscopic adhesiolysis in infertile women with moderate to severe intrauterine adhesion. DESIGN: A prospective, randomized, controlled trial study. SETTING: A tertiary university hospital. PATIENTS: A total of 130 patients with moderate (American Fertility Society [AFS] score of 5-8) and severe (AFS score of 9-12) intrauterine adhesions were recruited. INTERVENTIONS: 86 patients were evenly allocated to group treated with an IUD for 1 month and group treated with an IUD for 2 months. 44 patients were allocated to group treated with a Foley catheter balloon.(IUD: Yuangong IUD). MEASUREMENTS AND MAIN RESULTS: The primary outcome measures were the AFS score, endometrial thickness, and pregnancy outcome. After hysteroscopy, the AFS score was significantly decreased(P<0.05), whereas endometrial thickness was significantly increased across the three groups(P<0.001). Notably, the decline in the AFS score in the balloon group was greater than that in the IUD-1-month group and IUD-2-month group(P<0.01), with no significant difference between the IUD groups(P = 0.298). Lastly, In addition, the extent of the increase in endometrial thickness(P = 0.502) and the pregnancy outcomes(P = 0.803) in the three groups were not significantly different. CONCLUSION: Inserting a balloon or placing an IUD for one or two months can effectively lower the risk of adhesion recurrence and restore the shape of the uterine cavity. While the therapeutic effect of the balloon was superior to that of the IUD, no significant differences were observed in the one-month and two-month IUD groups. TRIAL REGISTRATION: This research was registered in the Chinese Clinical Trial Registry ( http://www.chictr.org.cn/enIndex.aspx ); Clinical trial registry identification number: ChiCTR-IOR-17,011,943 ( http://www.chictr.org.cn/showprojen.aspx?proj=17979 ). Date of trial registration: July 11, 2017.

Manually driven versus motor driven hysteroscopic tissue removal system for polypectomy: Long-term results.

OBJECTIVE: The aim of this follow-up study is to compare a manually driven hysteroscopic tissue removal system (ResectrTM 9 Fr) with a motor driven system (TruclearTM) in terms of long-term clinical outcomes such as abnormal uterine bleeding and polyp recurrence. STUDY DESIGN: This is a follow-up of a multicenter randomized controlled trial comparing a manually and motor driven hysteroscopic tissue removal system for polypectomy. This prospective cohort study was performed at Ghent University Hospital (Ghent, Belgium) and Catharina Hospital Eindhoven (Eindhoven, the Netherlands). The trial was registered at Clinicaltrials.gov (Trial ID = NCT05337605, April 2022). Seventy-five women with abnormal uterine bleeding who participated in the randomized controlled trial and had pathological confirmation of the diagnosis of an endometrial polyp, were contacted. Fifty-five women (70.67 %) were willing to participate in this follow-up study. The primary outcome was the recurrence and/or persistence of abnormal uterine bleeding and the time to the recurrence of abnormal uterine bleeding. Secondary outcomes were polyp recurrence and time to polyp recurrence, symptom relief, satisfaction score regarding symptom relief and general satisfaction score regarding the surgical procedure. RESULTS: In the manually driven group, the mean time to the recurrence or persistence of abnormal uterine bleeding was 26 months (95 % CI 20 - 32). In the motor driven group, the mean time to the recurrence or persistence of abnormal uterine bleeding was 29 months (95 % CI 23- 34). A log-rank test showed a non-significant difference between both groups (P =.77). There was no significant difference in polyp recurrence (P =.22) or symptom relief between the two groups (P =.67). Additionally, the groups did not differ in satisfaction scores regarding symptoms or polypectomy (P =.16 and P =.61, respectively). CONCLUSION: This long-term follow-up study showed no statistically significant difference in the recurrence and persistence of abnormal uterine bleeding between a manually and motor driven hysteroscopic tissue removal system for polypectomy.

Review of Asherman syndrome and its hysteroscopic treatment outcomes: experience in a low-resource setting.

BACKGROUND: Asherman syndrome is one of the endometrial factors that influence a woman's reproductive capacity. However, in our context, it needs to be well-documented. This study aimed to evaluate the clinical characteristics and hysteroscopic treatment outcomes of Asherman syndrome. METHOD: A retrospective follow-up study from January 1, 2019, to December 31, 2022, was conducted on cases of Asherman syndrome after hysteroscopic adhesiolysis at St.Paul's Hospital in Addis Ababa, Ethiopia. Clinical data were collected via telephone survey and checklist. Epidata-4.2 and SPSS-26 were employed for data entry and analysis, respectively. RESULT: A total of 177 study participants were included in the final analysis. The mean patient age was 31 years (range: 21-39) at the initial presentation, and 32.3 years (range: 22-40) during the phone interview. The majority of the patients (97.7%) had infertility, followed by menstrual abnormalities (73.5%). Among them, nearly half (47.5%) had severe, 38.4% had moderate, and 14.1% had mild Asherman syndrome. The review identified no factor for 51.4% of the participants. Endometrial tuberculosis affected 42 patients (23.7%). It was also the most frequent factor in both moderate and severe cases of Asherman syndrome. Only 14.7% of patients reported menstrual correction. Overall, 11% of women conceived. Nine patients miscarried, three delivered viable babies, and six were still pregnant. The overall rate of adhesion reformation was 36.2%. Four individuals had complications (3 uterine perforations and one fluid overload) making a complication rate of 2.3%. CONCLUSION: Our study revealed that severe forms of Asherman syndrome, which are marked by amenorrhea and infertility, were more common, leading to incredibly low rates of conception and the resumption of regular menstruation, as well as high recurrence rates. A high index of suspicion for Asherman syndrome, quick and sensitive diagnostic testing, and the development of a special algorithm to identify endometrial tuberculosis are therefore essential. Future multi-centered studies should focus on adhesion preventive techniques.

Evaluation of whether there is residual polyp tissue after hysteroscopic morcellation at Cam and Sakura City Hospital: a retrospective cohort study.

BACKGROUND: In polypectomy with mechanical hysteroscopic morcellators, the tissue removal procedure continues until no polyp tissue remains. The decision that the polypoid tissues were removed completely is made based on visual evaluation. In a situation where the polyp tissue was visually completely removed and no doubt that the polyp has been completely removed, short spindle-like tissue fragments on the polyp floor continue in most patients. There are no studies in the literature on whether visual evaluation provides adequate information at the cellular level in many patients in whom polypoid tissues have been determined to be completely removed. The aim of the present study was to analyze the pathological results of the curettage procedure, which was applied following the completion of polyp removal with operative hysteroscopy, and to evaluate whether there was residual polyp tissue in the short spindle-like tissue fragments that the mechanical hysteroscopic morcellator could not remove. The secondary aims of this study were to compare conventional loop resection hysteroscopy with hysteroscopic morcellation for the removal of endometrial polyps in terms of hemoglobin/hematocrit changes, polypectomy time and the amount of medium deficit. METHODS: A total of 70 patients with a single pedunculate polypoid image of 1.5-2 cm, which was primarily visualized by office hysteroscopy, were included in the study. Patients who had undergone hysteroscopic polypectomy were divided into two groups according to the surgical device used: the morcellator group (n = 35, Group M) and the resectoscope group (n = 35, Group R). The histopathological results of hysteroscopic specimens and curettage materials of patients who had undergone curettage at the end of operative hysteroscopy were evaluated. In addition, the postoperative 24th hour Hb/HCT decrease amounts in percentage, the polypectomy time which was measured from the start of morcellation, and deficit differences were compared between groups. RESULTS: In total, 7 patients in the morcellator group had residual polyp tissue detected in the full curettage material. The blood loss was lower in the morcellator group than in the resectoscope group (M, R; (-0.07 ± 0.08), (-0,11 ± 0.06), (p < 0.05), respectively). The deficit value of the morcellator group were higher (M, R; (500 ml), (300 ml), (p < 0.05), respectively). The polypectomy time was shorter in the morcellator group (M, R; mean (2.30 min), (4.6 min), (p < 0.05)). CONCLUSIONS: Even if the lesion is completely visibly removed during hysteroscopic morcellation, extra caution should be taken regarding the possibility of residual tissue. There is a need for new studies investigating the presence of residual polyp tissue.

Hysteroscopic Transillumination as a Guide for Laparoscopic Excision of Rudimentary Uterine Horn: A Winning Duo.

STUDY OBJECTIVE: Anatomic anomalies of the female reproductive genital tract affect approximately 5.5% of women [1]. The hemiuterus or class U4 by the European Society of Human Reproduction and Embryology / European Society for Gynaecological Endoscopy 2013 classification is a rare congenital malformation defined as a unilateral uterine development, with a contralateral part that could be either incompletely formed or absent. This class is divided into 2 subclasses depending on the presence or not of a functional rudimentary cavity (U4a/U4b) [2]. This work aimed to share our experience performing an hysteroscopic and laparoscopic combined technique to surgically manage this uterine malformation exploiting the hysteroscopic transillumination. DESIGN: A step-by-step explanation of surgical technique with narrated video footage. SETTING: Tertiary Level Academic Hospital "IRCCS Azienda Ospedaliero - Universitaria di Bologna" Bologna, Italy. INTERVENTIONS: A 32-year-old woman with a symptomatic (severe dysmenorrhea and chronic pelvic pain) suspected U4a uterine malformation diagnosed at our center was scheduled for laparoscopic removal of the right uterine horn and ipsilateral salpingectomy exploiting the contemporary hysteroscopic transillumination guidance. We selected this approach to avoid possible complications owing to the anatomic anomalies that are very common in these cases [3,4]. After coagulation and section of the right round ligament at the uterine angle and opening of the right broad ligament, access to the retroperitoneum was obtained to directly visualize the entire course of ureter and the uterine artery. The right uterine artery was coagulated and sectioned at the uterus. Then, the hysteroscope was introduced to the uterine fundus and the light source brightness was increased up to 100% to allow an adequate transmural visualization of the uterine defect from the laparoscope. Once the defect edge was well highlighted, the right uterine horn was isolated and removed using a monopolar hook, taking care to preserve an adequate amount of myometrium. A double layer running suture with barbed absorbable thread (V-Loc) for reconstructive purposes was performed. The specimen was retrieved inside an endobag to allow a safe extraction. Right salpingectomy was then performed. CONCLUSION: Considering the great anatomic variability of this condition, this type of surgery is not always simple. Indeed, the borders between the uterus and the rudimentary uterine horn are often not perfectly recognizable; this can lead to accidental removal of healthy myometrium and increase the risk of perioperative bleeding [5]. In our experience, the combined hysteroscopic and laparoscopic combined technique allows the surgeon to better delimit the borders of the hemiuterus, providing a more conservative and safer surgery. Hysteroscopic transillumination offers the possibility to modulate the radicality in the resection of the rudimentary horn and in the final treatment of dysmorphism.

Single Euploid Embryo Transfer Outcomes After Uterine Septum Resection.

STUDY OBJECTIVE: To study pregnancy outcomes after single euploid embryo transfer (SEET) in patients who underwent prior uterine septum resection to those with uteri of normal contour, without Müllerian anomalies or uterine abnormalities including polyps or fibroids, and without a history of prior uterine surgeries. DESIGN: Retrospective cohort study. SETTING: Single academic affiliated center. PATIENTS: 60 cycles of patients with prior hysteroscopic uterine septum resection who underwent an autologous SEET between 2012 and 2020 were used as the investigational cohort. A 3:1 ratio propensity score matched control cohort of 180 single euploid embryo transfer cycles from patients without a history of uterine septa were used as the control group. INTERVENTIONS: No interventions administered. MEASUREMENTS AND MAIN RESULTS: Pregnancy, clinical pregnancy loss, ongoing clinical pregnancy, and live birth rates in patients with a history of uterine septum resection compared with matched patients without Müllerian anomalies or uterine surgeries. Patients with a prior uterine septum had significantly lower rates of chemical pregnancy (58.33% vs 77.2%, p = .004), implantation (41.67% vs 65.6%, p = .001), and live birth (33.33% vs 57.8%, p = .001) per transfer. No statistical difference in clinical pregnancy loss rates was found when comparing septum patients with controls (8.33% vs 7.8%, p = .89). CONCLUSION: Patients with a history of hysteroscopic resection who undergo in vitro fertilization are more susceptible to suboptimal clinical outcomes compared with patients with normal uteri. Early pregnancy loss rates in patients with a uterine septum are higher than in those without; however, after resection, the rates are comparable. Patients born with septate uteri require assessment of surgical intervention prior to SEET, and to optimize their reproductive outcomes.

Hysteroscopic Metroplasty Using Holmium: YAG Laser for Treatment of Septate Uterus.

STUDY OBJECTIVE: To demonstrate the safety, efficacy, and ease of hysteroscopic metroplasty using holmium:YAG (Ho:YAG) laser for treatment of septate uterus. DESIGN: Stepwise demonstration of surgical technique with narrated video footage. SETTING: Septate uterus is the most common type of uterine anomaly. The incidence of uterine septum in women presenting with infertility and recurrent abortions is 15.4% [1,2]. Hysteroscopic septal incision is associated with improvement in live-birth rate in these women [3]. Hysteroscopic metroplasty for septate uterus can be done with the use of scissors and energy sources such as monopolar and bipolar electrosurgery and lasers. Ho:YAG laser is commonly used by urologists for various surgeries because of its "Swiss Army Knife" action of cutting, coagulation, and vaporization [4]. Ho:YAG laser is known for its precision. It causes lesser depth of tissue injury and necrosis and minimal collateral thermal damage compared with the electrosurgical devices and other lasers used for hysteroscopic surgery [5-8]. This is advantageous in hysteroscopic metroplasty given that it reduces the risk of uterine perforation during surgery and hence uterine rupture in the subsequent pregnancy. Reduced collateral damage to the surrounding endometrium helps promote early endometrial healing and prevent postoperative intrauterine adhesions. A 28-year-old patient with history of 2 spontaneous abortions came to our hospital for investigations. 3D transvaginal sonography of the patient showed presence of partial septate uterus with a fundal indentation of 1.5 cm (Supplemental video 1). INTERVENTION: Diagnostic hysteroscopy followed by septal incision using Ho: YAG laser was planned. We used a 2.9 mm BETTOCCHI Hysteroscope (Karl Storz SE & Co.) with a 5 mm operative sheath. Normal saline was used as the distending medium and the intrauterine pressure was maintained at 80 to 100 mm Hg. The procedure was done under total intravenous anesthesia using propofol injection. Vaginoscopic entry into the uterus (without any cervical dilatation) showed evidence of a partial uterine septum with tubal ostia on either side of the septum. A 400 micron quartz fiber was passed through a laser guide into the 5-Fr working channel of the operative hysteroscope. Ho:YAG laser (Auriga XL 50-Watt, Boston Scientific) with power settings of 15 watts (1500 mJ energy at 10 Hz) was used. Incision of the septum was started at the apex of the septum in the midline and continued in a horizontal manner from side to side toward the base (Supplemental video 2). Incision of the septum is continued till the tip of the hysteroscope can move freely from one ostium to the other (Supplemental video 3). The operative time was 12 minutes. There were no intra- or postoperative complications. Postoperative estrogen therapy was given for 2 months in the form of estradiol valerate 2 mg (tablet, Progynova, Zydus Cadila) 12 hourly orally for 25 days and medroxyprogesterone acetate 10 mg (tablet, Meprate, Serum Institute of India, Ltd) 12 hourly orally added in the last 5 days [9]. 3D transvaginal ultrasound was done on day 8 of menses. It showed a triangular uterine cavity with a very small fundal indentation of 0.37 cm. A second look hysteroscopy that was done on day 9 of menses showed an uterine cavity of good shape and size [10]. Few fundal adhesions were seen and they were incised using Ho:YAG laser. The patient conceived 5 months after the primary surgery and delivered by cesarean section at 38 weeks, giving birth to a healthy baby of 2860 grams. There were no complications during her pregnancy and delivery. A comparative study is essential to prove its advantages over other energy sources for this surgery. CONCLUSION: Hysteroscopic metroplasty using Ho:YAG laser for treatment of septate uterus is a simple, precise, safe, and effective procedure. VIDEO ABSTRACT.

Hysteroscopy-assisted suction curettage for early pregnancy loss: does it reduce retained products of conception and postoperative intrauterine adhesions?

OBJECTIVE: To describe the feasibility of hysteroscopy-assisted suction curettage for early pregnancy loss and to investigate whether it reduces the rates of retained products of conception (RPOC) and intrauterine adhesions (IUA). DESIGN: Prospective single-arm cohort study. SETTING: University-affiliated Department of Obstetrics and Gynecology. PATIENTS: Women admitted for surgical evacuation of early pregnancy loss were invited to participate in the study. INTERVENTION: Vaginal misoprostol was administered for cervical ripening preoperatively. Under general anesthesia, a diagnostic hysteroscopy was performed to identify the pregnancy's implantation wall, followed by ultrasound-guided suction and curettage directed to the implantation wall, and then diagnostic hysteroscopy to verify complete uterine cavity emptying. Postoperative IUA were evaluated by follow-up office hysteroscopy. MAIN OUTCOME MEASURE: Identification of the pregnancy's implantation wall on hysteroscopy, and intra-, and postoperative complications associated with the procedure. The evaluation of postoperative IUA was limited due to the COVID-19 pandemic-related restrictions on elective procedures. RESULTS: Forty patients were included in the study group. Their mean age was 34.0 ± 6.6 years, and their mean gestational age was 8.9 ± 1.6 weeks. The implantation wall was clearly visualized on hysteroscopy in 33 out of 40 cases (82.5%). The mean operative time was 17.2 ± 8.8 min, and no intraoperative complications occurred. Suspected RPOC were diagnosed intraoperatively by hysteroscopy and removed in 4 cases, and the histologic examination confirmed the presence of RPOC in three of them. Follow-up office hysteroscopy was performed in nine women: mild IUA was diagnosed in one case and a normal cavity was confirmed in eight cases. A new pregnancy was reported at the time of follow-up in 15 cases, while 12 women declined to attend the follow-up hysteroscopy and four were lost to follow-up. CONCLUSIONS: Hysteroscopy-assisted suction curettage for early pregnancy loss is a safe, short, and inexpensive procedure, which allows the identification of the pregnancy's wall in most cases and may reduce the rates of RPOC.

Comparison of vaginoscopic hysteroscopy and traditional hysteroscopy: A systematic review and meta-analysis.

BACKGROUND: Outpatient hysteroscopy is a safe, feasible, and optimum procedure for the diagnosis and management of intrauterine pathologies. OBJECTIVE: To determine the best approach of outpatient hysteroscopy (vaginoscopic vs traditional) in terms of pain, duration of procedure, feasibility, safety, and acceptability. SEARCH STRATEGY: PubMed, Embase, Google Scholar, and Scopus were searched from January 2000 to October 2021. No filters or restrictions were applied. SELECTION CRITERIA: Randomized controlled trials comparing vaginoscopic hysteroscopy with traditional hysteroscopy in an outpatient setting. DATA COLLECTION AND ANALYSIS: Two authors independently performed a comprehensive literature search and collected and extracted data. The summary effect estimate was determined using both fixed effects and random-effects models. RESULTS: Seven studies with 2723 patients (vaginoscopic [n = 1378] and traditional hysteroscopy [n = 1345]) were included. Vaginoscopic hysteroscopy was associated with a significant reduction in intraprocedural pain (standardized mean difference, -0.05 [95% confidence interval (CI), -0.33 to -0.23], I2 = 0%), procedural time (standardized mean difference, -0.45 [95% CI, -0.76 to -0.14], I2 = 82%), and fewer side effects (relative risk, 0.37 [95% CI, 0.15-0.91], I2 = 0%). The procedure failure rate was similar in both approaches (relative risk, 0.97 [95% CI, 0.71-1.32], I2 = 43%). Complications were mostly documented with traditional hysteroscopy. CONCLUSION: Vaginoscopic hysteroscopy reduces the pain and duration compared with traditional hysteroscopy.

Fertility, pregnancy and perioperative outcomes after operative hysteroscopy for uterine septum: a network meta-analysis.

INTRODUCTION: Septate uterus is a congenital malformation associated with adverse reproductive and pregnancy outcomes. It remains controversial whether hysteroscopic septoplasty should be recommended for the treatment of septate uterus, and it is also unclear if different hysteroscopic methods have more favorable outcomes. This study aims to compare the available hysteroscopic techniques of septoplasty for fertility, reproductive, and perioperative outcomes. METHODS: This systematic review and meta-analysis was conducted following PRISMA guidelines. We searched Medline, Scopus, and Cochrane databases up to April 2023 without language restrictions. Eligible studies had to compare two or more different methods of hysteroscopic septoplasty in women with septate uterus and report on fertility and pregnancy outcomes after a follow-up. Perioperative outcomes were also examined. Data extraction was performed by two independent reviewers using a standardized form. Risk of bias was assessed using the Newcastle-Ottawa Quality Assessment Form and Revised Cochrane risk-of-bias tool (RoB 2). RESULTS: Out of 561 studies identified, 9 were included in the systematic review and meta-analysis. The comparison of different hysteroscopic septoplasty techniques based on the energy used showed higher pregnancy rates after mechanical septoplasty in comparison to electrosurgery, while miscarriage and live birth rates were comparable. Laser vs. electrosurgery and mechanical techniques of septoplasty had comparable pregnancy, miscarriage, and live birth rates. The network meta-analysis after comparing every different method used showed significantly higher clinical pregnancy rate in scissor group in comparison to resectoscope. No significant differences were found among the techniques regarding miscarriage rate and live birth rate. CONCLUSION: In summary, this systematic review and network meta-analysis suggests that hysteroscopic septoplasty with scissors is associated with higher pregnancy rates compared to resectoscope. However, the limited evidence available and small sample sizes in the included studies indicate that these findings should be interpreted with caution. Further studies are required to determine the effectiveness of various hysteroscopic techniques and guide clinical decision-making in the management of this condition.

Uterine cervical stenosis: from classification to advances in management. Overcoming the obstacles to access the uterine cavity.

BACKGROUND: To date hysteroscopy is the gold standard technique for the evaluation and management of intrauterine pathologies. The cervical canal represents the access route to the uterine cavity. The presence of cervical stenosis often makes entry into the uterine cavity difficult and occasionally impossible. Cervical stenosis has a multifactorial etiology. It is the result of adhesion processes that can lead to the narrowing or total obliteration of the cervical canal. PURPOSE: In this review, we summarize the scientific evidence about cervical stenosis, aiming to identify the best strategy to overcome this challenging condition. METHODS: The literature review followed the scale for the quality assessment of narrative review articles (SANRA). All articles describing the hysteroscopic management of cervical stenosis were considered eligible. Only original papers that reported data on the topic were included. RESULTS: Various strategies have been proposed to address cervical stenosis, including surgical and non-surgical methods. Medical treatments such as the preprocedural use of cervical-ripening agents or osmotic dilators have been explored. Surgical options include the use of cervical dilators and hysteroscopic treatments. CONCLUSIONS: Cervical stenosis can present challenges in achieving successful intrauterine procedures. Operative hysteroscopy has been shown to have the highest success rate, particularly in cases of severe cervical stenosis, and is currently considered the gold standard for managing this condition. Despite the availability of miniaturized instruments that have made the management of cervical stenosis more feasible, it remains a complex task, even for experienced hysteroscopists.

Clinical efficacy and risk factors for suction curettage and hysteroscopy in patients with type I and II cesarean scar pregnancy.

OBJECTIVE: To investigate the clinical efficacy and evaluate risk factors for suction curettage (SC) and hysteroscopy in the treatment of type I and II cesarean scar pregnancy (CSP). METHODS: This was a retrospective study including 100 women diagnosed with type I/II CSP. Patients were treated with either ultrasound-guided SC (SC group) or hysteroscopy resection (surgery group). The success rates, mean operation time, hospitalization duration, hospitalization cost, risk factors, adverse events, and complications were analyzed. RESULTS: The success rate of the SC and surgery groups were 85% and 100%, respectively, and the difference was statistically significant (P = 0.032). There was one case of type I CSP and eight cases of type II CSP that failed SC treatment. No failed cases were found in the surgery group. Analysis of the causes of treatment failure revealed that diameter of the gestational sac was a risk factor for SC failure (odds ratio, 19.66 [95% confidence interval {CI}, 1.70-227.72], P = 0.017). Comparing the clinical outcomes between the SC and surgery groups, although the mean operation time of the SC group was significantly shorter than the surgery group (15 [CI, 15-20] vs. 30 [CI, 27-40], P = 0.001), the cost and duration of hospitalization were significantly lower in the surgery group than that in the SC group. No significant differences were observed for adverse events and complications between the two groups (P > 0.05). CONCLUSION: Hysteroscopy is an effective and economical method for treating type I/II CSP. Moreover, SC is not recommended for patients with type I/II CSP with a gestation age ≥8 weeks.

Hysteroscopic Lysis of Complex Uterine Adhesions After Interventional Radiology-Guided Access.

OBJECTIVE: To demonstrate a novel surgical technique using hysteroscopic lysis of adhesions after interventional radiology (IR)-guided access in patients with severe intrauterine adhesions and challenging uterine access. DESIGN: This video illustrates the technique of the safe division of intrauterine adhesions after IR-guided access. SETTING: Conventional hysteroscopic adhesiolysis might be inadequate or risky in cases of severely narrowed or obstructed uterine flow tract, possibly resulting in incomplete adhesiolysis, false passages, or uterine perforation. This video presents 2 cases from a tertiary center involving a multidisciplinary team of a reproductive surgeon and an interventional radiologist. The first case involves a 38-year-old with severe Asherman syndrome, who experienced unsuccessful attempt to treat adhesions that was complicated by a false passage. The second case involves a 39-year-old with recurrent severe Asherman syndrome and a history of unsuccessful attempts at hysterosalpingogram and conventional hysteroscopic lysis of adhesions. INTERVENTIONS: In the IR suite, the patient was put in a lithotomy position on the fluoroscopy table. A vaginal speculum was inserted exposing the cervix. The procedure was performed using intravenous sedation and topical anesthetic spray applied to the cervix. Using fluoroscopy, a balloon cannula was inserted through the cervix, followed by contrast injection to assess uterine access. If there is no route, transvaginal ultrasound-guided needle cannulation of the main portion of the uterine cavity would be performed, approximating as closely as possible to the expected route of the cervical canal. A guidewire followed by a locked loop catheter was advanced through adhesions into the uterine cavity. The catheter was left protruding from the cervix to guide the hysteroscope. The patient was then transferred to the operating room for the hysteroscopic procedure. Under the guidance of the intrauterine catheter, the adhesions were carefully lysed using cold scissors. The endometrial cavity and tubal openings were inspected to ensure complete adhesiolysis and exclusion of any other copathologies. CONCLUSION: IR guidance can provide a safe and effective approach to hysteroscopic lysis of adhesions in patients with challenging intrauterine adhesions and difficult uterine access, such as patients with severe Asherman syndrome, intractable cervical stenosis, uterine wall agglutination, previous adhesiolysis failure, marked fixed retroverted retroflexed uteri, and previous false passage or uterine perforation.

Fertility and anatomical outcomes following hysteroscopic adhesiolysis: An 11-year retrospective cohort study to validate a new classification system for intrauterine adhesions (Urman-Vitale Classification System).

OBJECTIVE: To propose a new classification system (Urman-Vitale Classification System) for intrauterine adhesions (IUAs) and to evaluate anatomical and fertility outcomes after hysteroscopic adhesiolysis accordingly. METHODS: A retrospective analysis of consecutive patients treated over 11 years by a single operator in a tertiary care hospital. Women with sonographic suspicion of IUAs were scheduled for hysterosalpingography (HSG) and hysteroscopy for confirmation and treatment. IUAs were divided into five classes according to symptoms, ultrasound, HSG findings, and postsurgical hysteroscopic appearance. Hysteroscopic adhesiolysis was performed using a bipolar cutting electrode in an office setting. Evaluated outcomes were restoration of the uterine cavity, clinical pregnancy, pregnancy loss, and live birth rates. RESULTS: A total of 227 patients (479 procedures) were included. Mean number of hysteroscopies increased in frequency with class of adhesions from Class 1 to Class 5 (1.0 ± 0.2 vs 2.3 ± 0.5; P = 0.001). Full restoration of the cavity was achieved in 100% of patients with Class 1 compared with 18.5% for Class 5 (43/43 vs 5/27; P = 0.001). Clinical pregnancy (Class 1 vs Class 4: P = 0.034; 1 vs 5: P = 0.006; 2 vs 5: P = 0.024) and live birth (Class 1 vs Class 4: P = 0.001; 1 vs 5: P = 0.006; 2 vs 4: P = 0.007; 2 vs 5: P = 0.0208) rates decreased with increasing severity of IUAs. Pregnancy loss rate was related to IUA severity (Class 1 vs Class 4: P = 0.012; 1 vs 5: P = 0.003: 2 vs 4: P = 0.014; 2 vs 5: P = 0.021). CONCLUSION: A classification based on symptoms, imaging findings, and postsurgical macroscopic appearance of the uterine cavity could be useful in predicting prognosis and fertility in women with IUAs.

Pain and anxiety management with virtual reality for office hysteroscopy: systemic review and meta-analysis.

PURPOSE: Office hysteroscopy (OH) is a commonly performed procedure, although it might be associated with some degree of pain and anxiety. Our aim was to determine the effects of virtual reality on pain and anxiety levels felt by patients undergoing OH. METHODS: MEDLINE, Embase, Google Scholar, Cochrane Library, clinicaltrials.gov, ProQuest, Grey literature, and manual searching of references within studies found in the initial search were systematically searched using the terms 'Virtual Reality' and 'Hysteroscopy' without time or language limitations. The review considered all studies assessing the impact of virtual reality (VR) over OH outcomes, and prospective randomized trials were included in the meta-analysis. Retrospective and case - control studies were excluded from the meta-analysis. RESULTS: We identified 17 studies, of which four randomized controlled studies were included in the meta-analysis (327 participants, 168 in the VR group and 159 in the control group). On a 0-10 scale, pain sensation and maximal pain sensation during the operation were not statistically different between study and control groups (relative risk (RR) = -0.64, 95% C.I (-1.57)0.29) and (RR = -0.93, 95% C.I (-3.33) - 1.47), respectively. Anxiety measurement was statistically lower in the study group (RR = -1.73, 95% C.I (-2.79) - ( -0.67)). CONCLUSIONS: The available data suggest that VR techniques do not decrease the pain sensation during OH however, they do contribute to a reduction in the anxiety levels experienced by patients. PROSPERO registration number CRD42023432819.