Enhancing precision in hysteroscopic surgery: The role of intraoperative ultrasound.

Hysteroscopy stands as the gold-standard approach for managing intrauterine pathology. However, in complex clinical cases, hysteroscopic evaluation alone may prove insufficient for the safest and successful patient management. Intraoperative ultrasound (IOUS) has emerged as a valuable adjunct to hysteroscopic surgery, offering real-time visualization of endometrial cavity, uterine walls and instruments within the uterine cavity, enabling precise delineation of anatomical structures, and helping to assess the extent of pathology during intricate interventions. This review aims to comprehensively assess the applications, efficacy and utility of IOUS in hysteroscopic surgery. Available evidence indicates that in hysteroscopic myomectomy, IOUS significantly reduces the risk of uterine perforation, particularly in submucosal FIGO 2 myomas, and enhances the likelihood of a single-step procedure. During hysteroscopic metroplasty, ultrasound guidance decreases the chance of incomplete uterine septum resection. In the hysteroscopic management of severe Asherman syndrome, IOUS reduces the risk of uterine perforation or false passage. For cesarean scar pregnancy (CSP), ultrasound is crucial in defining the most appropriate surgical approach and is effective in guiding the hysteroscopic treatment of endogenic CSP. The use of IOUS in hysteroscopy proves valuable in complex cases where the risk of uterine perforation or incomplete procedure is increased.

Application of hysteroscopy in the treatment of Mullerian adenosarcoma of the cervix in an adolescent girl with 7 years of follow-up.

BACKGROUND: Mullerian adenosarcoma of the cervix is a rare biphasic tumor composed of a benign epithelial component and a malignant stromal component. Here, we report a rare case of Mullerian adenosarcoma of the cervix in an adolescent girl treated with hysteroscopic resection. CASE PRESENTATION: A 16-year-old girl presented to the Affiliated Hospital of North Sichuan Medical College in April 2017 with a one-year history of a painless vaginal mass. 10 hours prior to presentation, she had experienced rapid enlargement of the vaginal mass and mild vaginal bleeding. 16 hours after hospitalization, a mass measuring 14 × 10 × 4 cm was spontaneously expelled from the vagina. Histopathological examination of the mass confirmed a diagnosis of Mullerian adenosarcoma. On May 10, 2017, the patient underwent hysteroscopic resection of a cervical lesion and partial cervical resection. After nearly 7 years of follow-up, the tumor has not recurred. CONCLUSIONS: Mullerian adenosarcoma of the cervix is difficult to diagnose in adolescents. For young women affected by low-risk early-stage Mullerian adenosarcoma of the cervix, fertility preserving treatment using hysteroscopic resection with robust follow-up is a reasonable management option.

Comparison of hypotension between propofol and remimazolam-propofol combinations sedation for day-surgery hysteroscopy: a prospective, randomized, controlled trial.

BACKGROUND: A combination of remimazolam and propofol could produce more stable sedation. A good medication regimen should consider not only efficacy but also safety, especially hypotension. The aim of the current study was to compare the incidence and amount of hypotension by propofol versus remimazolam-propofol combinations in day-surgery hysteroscopy. METHODS: Patients were randomly assigned to receive either propofol (Group P, n = 125) or remimazolam-propofol combinations (Group RP, n = 125) at a 1:1 ratio. Intravenous injection of sufentanil 0.1ug/kg were administered before sedative medication. In group P, a bolus of 2.5 mg/kg propofol was administered. In group RP, intravenous anesthesia was commenced with 0.125 mg/kg remimazolam and 1 mg/kg propofol. After loss of consciousness, propofol was maintained at 6 mg/kg/h. The primary outcomes were the incidence and amount of hypotension during surgery. Hypotension was defined as a MAP less than 65mmHg for at least 1 min. The amount of hypotension was assessed by time-weighted average intraoperative MAP under a threshold of 65 mmHg. The secondary outcomes were various anesthesia related parameters and some adverse events. RESULTS: In group P, 25 patients (20.0%) experienced hypotension during hysteroscopy compared with 9 patients (7.2%) in group RP, for a difference of 12.8% (RR 2.778, 95%CI [1.352-5.709]). The combination of remimazolam and propofol resulted in significantly lower TWA (Time Weighted Average) threshold 0.14 (0.10-0.56) mmHg in group RP compared to 0.31 (0.15-0.67) mmHg in group P. The total dose of propofol was nearly double in group P compared to group RP. A significantly higher frequency of injection pain and low oxygen saturation was observed in the group P than that of the group RP. Hiccup was observed only in group RP. The incidences of body movement, bradycardia and vomiting were no significant difference between groups. CONCLUSION: The incidence and amount of hypotension by remimazolam-propofol combinations was significantly less than that by propofol sedation in day-surgery hysteroscopy. The optimization of medication regimen would attenuate the harm of hypotension and contribute to patients' rapid recovery in day surgery. TRIAL REGISTRATION: Chinese Clinical Trial Registry, ChiCTR2400079888 (date: 15/01/2024).

What is the impact of simulation on the learning of hysteroscopic skills by residents and medical students? A systematic review.

INTRODUCTION: Hysteroscopy is a critical procedure in gynecology for diagnosing and managing intrauterine pathology. Traditional hands-on training faces ethical and safety challenges, leading to an increased reliance on simulation training. This review systematically assesses the effectiveness of hysteroscopic simulation training in enhancing the technical skills of obstetrics and gynecology residents and medical students. METHODS: A PRISMA-guided literature search was conducted, covering English-language articles from January 2000 to December 2023. Studies were selected based on pre-defined criteria, focusing on the impact of simulation training on the targeted educational group. Metrics for evaluating skill improvement included machine-recorded metrics, Objective Structured Assessment of Technical Skills (OSATS), and global rating scales. RESULTS: The review included nine studies with varied designs, demonstrating significant improvements in hysteroscopic skills following simulation training. Virtual reality (VR) simulators showed substantial benefits in skill acquisition, while physical simulators provided valuable tactile feedback. However, long-term skill retention and the impact on non-technical skills were not adequately assessed. CONCLUSIONS: Simulation-based training effectively enhances hysteroscopic skills in medical students and residents. Further research is needed to explore long-term skill retention and the development of non-technical competencies. Robust studies, including randomized trials, are required for definitive validation.

Inhaled methoxyflurane (Penthrox®) as a novel pain relief for outpatient hysteroscopy and other gynaecological procedures.

OBJECTIVE: Penthrox® (methoxyflurane) is a convenient, portable, self-administered disposable single-use handheld inhaler licenced as an emergency, rapid-onset, short-acting, analgesic in adult trauma patients. Outpatient hysteroscopy is one of the commonest procedures in contemporary gynecology but it can be associated with significant pain leading to poor patient experience and failed procedures. We evaluated the feasibility and acceptability of Penthrox® in women undergoing outpatient hysteroscopic procedures and its potential efficacy to reduce pain and improve patient experience. STUDY DESIGN: We conducted a prospective observational cohort study on women undergoing hysteroscopy or other intrauterine procedures, such as coil fitting, endometrial biopsy, polypectomy, endometrial ablation and manual vacuum aspiration in an outpatient setting. Women were offered Penthrox® inhalers for pain control, instructed how to use it and asked to record the intra-procedural pain they expected and actually experienced using a 10 cm Visual Analogue Scale. The acceptability, side effects and ease of use of the Penthrox® device were also recorded. RESULTS: 122/146 (83.6 %) women chose to use Penthrox®. 116 out of the 122 (95.1 %) underwent an intrauterine procedure, including 59 hysteroscopic polypectomies and 34 global endometrial ablations. The average pain expected during the procedure was 6.0 (SD = 2.8) and the pain experienced during the procedure was 5.1 (SD = 2.8). The intended procedure was completed in 117 (96 %) women. Penthrox® was considered easy to use by 118 (97 %) women and 111 (91 %) would use it again, although 22 (18 %) women would prefer general anaesthesia in the future. No adverse events occurred but 88 (72 %) women reported mild, self-limiting side effects. CONCLUSION: Penthrox® appears safe, feasible and acceptable as a pain relief option during outpatient hysteroscopy and other intrauterine procedures. The effectiveness of Penthrox® should be evaluated against conventional pain control in an adequately powered multicentre randomised controlled trial.

Lung ultrasound diagnosis of pulmonary edema resulting from excessive fluid absorption during hysteroscopic myomectomy: a case report.

BACKGROUND: Hysteroscopic surgery is a safe procedure used for diagnosing and treating intrauterine lesions, with a low rate of intraoperative complications. However, it is important to be cautious as fluid overload can still occur when performing any hysteroscopic surgical technique. CASE PRESENTATION: In this case report, we present a unique instance where lung ultrasound was utilized to diagnose pulmonary edema in a patient following a hysteroscopic myomectomy procedure. The development of pulmonary edema was attributed to the excessive absorption of fluid during the surgical intervention. By employing lung ultrasound as a diagnostic tool, we were able to promptly identify and address the pulmonary edema. As a result, the patient received timely treatment with no complications. This case highlights the importance of utilizing advanced imaging techniques, such as lung ultrasound, in the perioperative management of patients undergoing hysteroscopic procedures. CONCLUSIONS: This case report underscores the significance of early detection and intervention in preventing complications associated with fluid overload during hysteroscopic myomectomy procedures.

Endometrial Adenocarcinoma After a Benign Biopsy Without Atypia: A Case Report.

Endometrial biopsy is a highly effective screening procedure used to determine endometrial cancer and its precursors. This is often used to rule out endometrial cancer, the most common gynecologic cancer in the United States, before a total hysterectomy. This is a case of a benign endometrial biopsy that was ultimately malignant in the post-operative pathology report. A 37-year-old female presents with a six-month history of dysmenorrhea, passage of large clots, and pelvic pain, seeking definitive treatment with a hysterectomy. The pre-operative assessment included ultrasound, hysteroscopic exam, and endometrial biopsy. The ultrasound demonstrated evidence of adenomyosis due to the heterogeneous appearance of the myometrium and an endometrial stripe of 36 mm. Endometrial biopsy using pipelle was performed alongside an in-office hysteroscopic exam, which had a hyperplastic appearance of the endometrium. The biopsy resulted in hyperplasia without atypia and scant polypoid endometrial tissue. The patient underwent a total laparoscopic hysterectomy and bilateral salpingectomy without complications. The post-operative pathology report indicated a grade 2 invasive endometrial adenocarcinoma extending through 75% of the myometrium. Incidental diagnosis of endometrial adenocarcinoma following total hysterectomy is rare and poses significant medical implications. Endometrial hyperplasia without atypia has a low risk of progressing to endometrial carcinoma over time.

The Correlation of Hysteroscopy and Histopathology in Evaluating Abnormal Uterine Bleeding: Observations From a Tertiary Care Center.

BACKGROUND: Abnormal uterine bleeding (AUB) is an important clinical entity, and its subtype, heavy menstrual bleeding (HMB), affects 14%-25% of women of reproductive age, potentially impairing their physical, emotional, social, and material quality of life. However, in addition to prior studies that supported the efficacy of hysteroscopy in identifying AUB, this study determined the overall pattern of abnormalities in AUB and correlated the diagnosis through hysteroscopy and histopathology. Additionally, a comparison of ultrasonography was done in this study. This study helps healthcare providers provide timely diagnosis and, thereby, timely interventions in treating different causes of AUB. METHODOLOGY: This hospital-based prospective observational study was conducted at a tertiary care center, including women aged 20-60 admitted with complaints of AUB between September 2022 and June 2024. Participants were selected based on their willingness to participate in the study. A statistical analysis was performed using relevant descriptive statistics and plotting the frequency and percentage. Cohen's kappa was applied to ascertain significant associations and patterns within the dataset.  Results: The study included 47 women who were admitted to the hospital for diagnostic hysteroscopy. A majority of clinical symptoms presented as menorrhagia (17, 36.2%). The hemoglobin (g/dL) ranged from 5.9 to 14.7. Overall, on hysteroscopy, 37 (78.7%) women had a normal uterus. On hysteroscopy, 36 (76.6%) participants showed a normal cervical canal and cervix. In terms of histopathology, a majority of the study population (21, 44.7%) had proliferative endometrium. In terms of the correlation between hysteroscopy and histopathology, the two methods agreed in 83% of cases and disagreed in 17% of cases. CONCLUSION: This study confirms that hysteroscopy is a crucial tool for assessing patients with AUB, particularly those with a thick endometrium, across all age groups. It does not replace other diagnostic methods; instead, it enhances them. Hysteroscopic-guided biopsy along with histopathology is now widely regarded as the most reliable method and new gold standard for assessing cases of AUB.

Tailoring the Diagnostic Pathway for Medical and Surgical Treatment of Uterine Fibroids: A Narrative Review.

Uterine leiomyomas are the most common benign uterine tumors in women and are often asymptomatic, with clinical manifestation occurring in 20-25% of cases. The diagnostic pathway begins with clinical suspicion and includes an ultrasound examination, diagnostic hysteroscopy, and, when deemed necessary, magnetic resonance imaging. The decision-making process should consider the impairment of quality of life due to symptoms, reproductive desire, suspicion of malignancy, and, of course, the woman's preferences. Despite the absence of a definitive cure, the management of fibroid-related symptoms can benefit from various medical therapies, ranging from symptomatic treatments to the latest hormonal drugs aimed at reducing the clinical impact of fibroids on women's well-being. When medical therapy is not a definitive solution for a patient, it can be used as a bridge to prepare the patient for surgery. Surgical approaches continue to play a crucial role in the treatment of fibroids, as the gynecologist has the opportunity to choose from various surgical options and tailor the intervention to the patient's needs. This review aims to summarize the clinical pathway necessary for the diagnostic assessment of a patient with uterine fibromatosis, presenting all available treatment options to address the needs of different types of women.

Predictors of Infused Distending Fluid Volume in Hysteroscopic Myomectomy.

Background and Objectives: The use of a bipolar resectoscope has become popular due to the lower risk of hyponatremia. However, gynecologists might overlook the risk of water intoxication. Water intoxication is associated with the infusion of distending fluid. We were interested in the prediction of the infused distending fluid volume in the era of bipolar hysteroscopy. Thus, the aim of this study was to identify the predictors of the infused distending fluid volume for hysteroscopic myomectomy. Materials and Methods: All consecutive women who underwent monopolar (n = 45) or bipolar (n = 137) hysteroscopic myomectomy were reviewed. Results: Myoma diameter (cm, coefficient = 680 mL, 95% confidence interval (CI) = 334-1025 mL, p <0.001) and bipolar hysteroscopy (coefficient = 1629 mL, 95% CI = 507-2752 mL, p = 0.005) were independent predictors of infused distending fluid volume. A myoma diameter ≥4.0 cm was the optimal cutoff value to predict the presence of >5000 mL of infused distending fluid. One woman in the bipolar group developed life-threatening water intoxication. Conclusions: Myoma diameter is associated with an increase in infused distending fluid volume, especially for myomas ≥4 cm. Meticulous monitoring of the infused distension fluid volume is still crucial to avoid fluid overload during bipolar hysteroscopic myomectomy.

Deciphering the diagnostic challenges of female genital tuberculosis: Insights from women pursuing conception at a tertiary care centre in northern India.

Female genital tuberculosis (FGTB) is asymptomatic or may present with a few symptoms among which infertility is the most common. The diagnosis of FGTB is challenging, as there is no single diagnostic test available.We researched 50 infertile patients by various special investigations and found 50% had tuberculosis, by various means. Endometrial biopsy and Hystero-laparoscopy are complementary procedures, and Cartridge Based Nucleic Acid Amplification Test is a useful new addition to the diagnostic armamentarium for endometrial and peritoneal samples.

Rapid and random-start endometrial preparation before outpatient hysteroscopic polypectomy in patients of perimenopausal age.

OBJECTIVE: This study aimed to assess the efficacy of randomly started oral dienogest/ethinylestradiol (DNG/EE) for swift endometrial preparation prior to outpatient hysteroscopic polypectomy in perimenopausal women. METHOD: A multicenter, prospective, randomized controlled trial was conducted in university hospitals. Eighty perimenopausal women scheduled for outpatient hysteroscopic polypectomy between January 2023 and March 2024 were randomly assigned to either intervention (n = 40) or control (n = 40) groups. Exclusion criteria included concomitant endometrial pathologies, recent therapy and adnexal diseases. The intervention group received oral DNG/EE 2 mg/0.03 mg/day started on any day of the menstrual cycle for 14 days. The control group underwent polypectomy between menstrual cycle days 8 and 11 without pharmacological treatment. RESULTS: Pre-procedure (p < 0.001) and post-procedure (p < 0.001) endometrial thickness were significantly reduced in the intervention group, along with a higher incidence of hypotrophic/atrophic endometrial patterns (p < 0.001). Surgical parameters also differed significantly between groups. CONCLUSION: DNG/EE treatment offers rapid, cost-effective endometrial preparation, enhancing surgical outcomes and patient satisfaction during outpatient polypectomy. TRIAL REGISTRATION: ClinicalTrials.gov NCT06316206.

Laparoscopy combined with hysteroscopy in the treatment of Robert's uterus accompanied by adenomyosis: A case report.

BACKGROUND: Gynaecologists should be aware of a rare obstructive Mullerian duct abnormality like Robert's uterus and perform further surgery when necessary. CASE SUMMARY: We report a 41-year-old mother of two children with Robert's uterus who was examined and treated by laparoscopy and hysteroscopy. Unlike the existing cases reported in the literature, this patient had a late onset of Robert's uterus symptoms. Due to right tubal ectopic pregnancy 3 years previously, the patient was treated with right salpingectomy and left tubal ligation but suffered aggravated left lower abdominal pain. She was examined and treated by laparoscopy and hysteroscopy, and is completely asymptomatic at 5-year follow-up. CONCLUSION: The typical obstructive Mullerian abnormality requires further surgery. Combined laparoscopy and hysteroscopy is an effective, minimally invasive technique with better recovery outcomes than traditional transabdominal procedures.

Submucosal cystic adenomyosis: a report of five cases and review of the literature.

AIM: To investigate the clinical characteristics, diagnosis, and clinical treatment of submucosal cystic adenomyosis. METHODS: The clinical data of five cases of patients with submucosal cystic adenomyosis in our hospital from January 2020 to June 2023 were retrospectively analyzed. RESULTS: The average age of the patients was 37.8 ± 4.5 years old, three of them experienced prolonged menstruation and heavy menstrual bleeding. All patients had a history of abnormal uterine bleeding and mild to moderate dysmenorrhea, with a VAS score of 2.8 ± 1.6. The average Carbohydrate antigen 125 (CA125) value was 29.9 ± 23.6U/ml. Two out of the five patients (40%) had CA125 values above the upper limit of normal. The nodules had a diameter of 3.2 ± 1.3 cm and a cavity size of 1.3 ± 0.7 cm. Color ultrasound revealed hypo or iso or anechoic echoic cysts, and blood flow signals were detected. The magnetic resonance imaging (MRI) findings varied among each patient. All the patients underwent hysteroscopy and resection of uterine cavity-occupying lesions, and no recurrence was observed. CONCLUSIONS: The clinical features of submucosal cystic adenomyosis include abnormal uterine bleeding and menstrual changes, and the degree of dysmenorrhea is generally not severe. The diagnostic utility of CA125 in submucosal cystic adenomyosis may be limited. The three-dimensional ultrasound and MRI are valuable preoperative examination methods currently. Hysteroscopy can not only diagnose submucosal cystic adenomyosis, but also treat it, and preserve the fertility function of the patient.

Comparison of Endometrial Polyp Characteristics in Transvaginal Sonography and Hysteroscopy in Predicting Endometrial Malignancies in Premenopausal and Postmenopausal Women.

Background: Hysteroscopy is known as the gold standard for endometrial polyps diagnosis and its findings on vascularity, size, and number of polyps can indicate malignancy, but it is a relatively expensive method with some complications. Ultrasound is a common part of the gynecological examination, and with technological advances, its ability to predict pathological outcomes has increased. This study aimed to determine the accuracy of ultrasound in diagnosing the characteristics of endometrial polyps. Materials and Methods: This diagnostic value study was performed on 300 premenopausal and postmenopausal women over 40 years of age with endometrial polyps referred to Alzahra and Beheshti hospitals in Isfahan. The characteristics of endometrial polyps were evaluated by transvaginal ultrasonography and hysteroscopy and biopsy specimens were sent for pathological evaluations. Results: In this study, 103 premenopausal women and 197 postmenopausal women were evaluated. Malignancy was confirmed by pathology in 4 premenopausal women (2%) and 2 postmenopausal women (2%). In both hysteroscopy and ultrasound methods, the frequency of vascularity was significantly different in postmenopausal and premenopausal women, but the other features of the polyp were not significantly different in them. Ultrasonic sensitivity in detecting the presence of vascularity, polyps larger than 1.5 mm, more than 1 polyp, and the presence of pedicle were 39.04, 57.38%, 91.93 and 94.95%, respectively, its specificity were 98.94, 36.47, 99.57 and 98.89% respectively. Conclusion: A comparison of the characteristics of polyps in both ultrasound and hysteroscopy methods shows that hysteroscopy has been more effective in diagnosing malignancy and ultrasound has not have acceptable sensitivity in diagnosing size and vascularity.

When is it necessary to perform biopsy in asymptomatic postmenopausal women with incidental finding of thickened endometrium?

OBJECTIVE: To determine the cutoff value for endometrial thickness (ET) that prompts a biopsy in asymptomatic postmenopausal women with an incidental finding of thickened endometrium, and to develop a risk prediction model. METHODS: This is a retrospective cohort analysis of the clinical records of the Hysteroscopic Center of Fu Xing Hospital, Capital Medical University, Beijing, China. We collected asymptomatic postmenopausal women who presented with an ET of ≥4 mm (double-layer) as an incidental finding. We stratified the participants into non-malignant and malignant groups based on pathology results and assessed differences between the two groups. A receiver operating characteristic curve (ROC) was used to identify the cutoff value of ET for predicting endometrial malignancy. Logistic regression models were also constructed to predict the risk of malignancy. RESULTS: A total of 581 consecutive eligible cases were included. The optimal cutoff value for ET was 8 mm, with a maximum area under the curve (AUC) of 0.755 (95 % CI: 0.645-0.865). In addition to ET, the regression model incorporated diabetes, blood flow signal, BMI, and hypertension to predict the risk of malignancy. A ROC curve constructed for the model yielded an AUC of 0.834 (95 % CI: 0.744-0.924). CONCLUSION: It is reasonable to offer hysteroscopy and visually-directed endometrial biopsy for asymptomatic postmenopausal women when ET is 8 mm or above. For those with an ET between 4 and 8 mm, further decision to perform biopsy should be determined on an individual basis, considering risk factors and blood flow signals of the endometrium.

Correlation of hysteroscopic findings of chronic endometritis with CD138 immunohistochemistry and their correlation with pregnancy outcomes.

PURPOSE: To investigate the correlation between hysteroscopic findings of chronic endometritis and CD138 immunohistochemistry positive in endometritis and to analyze the pregnancy outcomes and associated risk factors following embryo transfer in women diagnosed with chronic endometritis via hysteroscopy. METHODS: A retrospective observational study carried out at the Reproductive Medicine Center of Tangdu Hospital of Air Force Medical University, from January 2021 to December 2021, was performed by obtaining data from 194 medical records of women who underwent hysteroscopies for infertility and were diagnosed with chronic endometritis based on Delphi criteria. Spearman correlation analysis was used to evaluate the correlation between hysteroscopic findings and endometrial CD138 immunohistochemistry. The study also observed the differences in relevant indexes between the CD138-positive and CD138-negative groups after embryo transfer and analyzed factors influencing implantation failure using logistic regression analysis. RESULTS: The correlation analysis between hysteroscopic findings and CD138 immunohistochemistry showed that micropolyps were correlated with CD138 immunohistochemistry positivity. The correlation coefficient was 0.32 (P < 0.01). After embryo transfer, the clinical pregnancy rate of the CD138-positive group was lower compared to that of the CD138-negative group [64.79% (46/71) vs. 81.30% (100/123), P < 0.05]. The results of the multivariate logistic regression analysis revealed that age (P = 0.43) and CD138 immunohistochemistry positivity (P = 0.008) were the independent risk factors for predicting whether or not embryo implantation was successful. CONCLUSION: Hysteroscopic findings do not correlate strongly with endometrial CD138 immunohistochemistry, and chronic endometritis cannot be diagnosed by hysteroscopy alone. CD138 immunohistochemistry positivity is an independent factor contributing to the decrease in clinical pregnancy rate following embryo transfer.

Hysteroscopy: where did we start, and where are we now? The compelling story of what many considered the "Cinderella" of gynecological endoscopy.

Hysteroscopy has truly revolutionized the field of diagnostic and operative gynecology. It is presently regarded as the gold standard method for both the diagnosis and treatment of intrauterine diseases and it has fundamentally altered the way gynecologists treat patients with such conditions. These pathologies can now be diagnosed and treated in an outpatient setting, thanks to technological advancements and instrument downsizing. Two hundred years of development and notable innovation are now reflected in the present hysteroscopic practice. This review attempts to trace the boundaries-pushing history of hysteroscopy by highlighting the advancements in technology and the therapeutic and diagnostic benefits offered by this groundbreaking approach.

Hysteroscopic Management of Complete Vaginal and Uterine Septum with Double Cervix: Tips & Tricks for a Safe Surgery.

BACKGROUND: The septate uterus is the most common uterine abnormality, comprising 35% of all identified uterine malformations. According to the ESHRE/ESGE 2013 classification, the class U2bC2V1 is a rare congenital malformation characterized by a complete septate uterus with double cervix and nonobstructive longitudinal vaginal septum. STUDY OBJECTIVE: to share the decision-making process, the preoperative ultrasonographic assessment and our step-by-step hysteroscopic surgery technique to manage this complex malformation: including how to access the septate uterine cavity, the resection of the septum and its postoperative management. The goal of the surgical treatment is to restore the regular morphology of the vaginal canal and the uterine cavity with the right amount of myometrium. METHODS: we present video footage of a hysteroscopic approach at a tertiary care academic medical center for managing a 21-year-old patient with a symptomatic uterine septum with double cervix and nonobstructive longitudinal vaginal septum. RESULTS: Both the intraoperative and postoperative periods were uneventful: a complete resolution of the vaginal septum and creation of a single uterine cavity were obtained. CONCLUSION: Due to the significant anatomic variability of this condition, this type of surgery can be challenging. The goal of this video is also educational, aiming to illustrate a reproducible technique that can be utilized by younger or less experienced surgeons. In our experience, this hysteroscopic technique appears to be a valid option for patients with symptomatic Mullerian malformation or those with a history of recurrent miscarriages or unexplained infertility.

Good practice with fluid management in operative hysteroscopy.

Hysteroscopic surgery requires a balance of continuous controlled irrigation and aspiration to distend the endometrial cavity to a degree that provides the clear and stable visual environment necessary for diagnostic and therapeutic procedures. Whereas the preferred distending solution should be isotonic and isonatremic, radiofrequency (RF) electrosurgery with monopolar instrumentation can only be performed with non-ionic (hyponatremic) solutions. Absorption of as little as 500 mL and certainly more than 1000 mL of non-ionic solutions can result in fluid overload and/or dilutional hyponatremia with potentially serious adverse effects under certain conditions and patient characteristics. Both hysteroscopic RF electrosurgery with bipolar instrumentation and electro-mechanical morcellation and aspiration systems use isotonic and isonatremic solutions. Depending on the clinical context, absorption of more than 1500 mL of isonatremic solutions can also result in serious adverse effects. Automated fluid management systems are preferred and recommended, and surgeons should aim to maintain the maximum allowable intravasation of distending media below 1000 and 1500 mL for non-ionic and ionic fluids, respectively.