Hysteroscopic myomectomy: The guidelines of the International Society for Gynecologic Endoscopy (ISGE).

OBJECTIVE: With this publication, the International Society for Gynecologic Endoscopy (ISGE) aims to provide the clinicians with the recommendations arising from the best evidence currently available on hysteroscopic myomectomy (HM). STUDY DESIGN: The ISGE Task Force for HM defined key clinical questions, which led the search of Medline/PubMed and the Cochrane Database. We selected and analyzed relevant English-language articles, published from January 2005 to June 2021, including original works, reviews and the guidelines previously published by the European Society for Gynecological Endoscopy (ESGE) and the American Association of Gynecologic Laparoscopists (AAGL), in which bibliographies were also checked in order to identify additional references, using the medical subject heading (MeSH) term "Uterine Myomectomy" (MeSH Unique ID: D063186) in combination with ''Myoma" (MeSH Unique ID: D009214) and ''Hysteroscopy" (MeSH Unique ID: D015907). We developed the recommendations through multiple cycles of literature analysis and expert discussion. RESULTS: The ISGE Task Force did develop 10 grade 1A-C and 4 grade 2A-C recommendations. For planning HM, evaluation of the uterus with saline infusion sonohysterography (SIS) or combined assessment by transvaginal ultrasound (TVUS) and diagnostic hysteroscopy is recommended (Grade 1A). The use of STEPW (Size, Topography, Extension of the base, Penetration and lateral Wall position) classification system of submucosal leiomyoma (LM) is recommended to predict the complex surgeries, incomplete removal of the LM, long operative time, fluid overload and other major complications (grade 1B). For type 0 LMs, in addition to resectoscopy (slicing technique), morcellation is recommended, being faster and having a shorter learning curve with respect to resectoscopy (grade 1C). For type 1-2 LMs, slicing technique is currently recommended (grade 1C). A fluid deficit of 1000 mL also in case of bipolar myomectomy with saline solution, in healthy women of reproductive age, contains low risk for major complications. Lower thresholds (750 mL) for fluid deficit should be considered in the elderly and in women with cardiovascular, renal or other co-morbidities (Grade 1B). CONCLUSION: HM is the most effective conservative minimally invasive gynecologic intervention for submucous LM. The set of 14 ISGE recommendations can significantly contribute to the success of HM and the safety of patients for whom the choice of appropriate surgical technique, as well as the surgeon's awareness and measures to prevent complications are of the utmost importance.

Impaired inflammatory state of the endometrium: a multifaceted approach to endometrial inflammation. Current insights and future directions.

New insights into the complex and fine-regulated inflammatory mechanisms involved in the endometrium reveal multiple facets to the problem of endometrial inflammation. However, the entity termed chronic endometritis is to date restricted to infectious etiology and managed with antibiotics. Conversely, the concept of impaired inflammatory state of the endometrium (IISE) provides a more global approach to defective endometrial inflammation, considering both infectious and non-infectious etiology. A non-systematic review was done through a search on MEDLINE, EMBASE, Global Health, The Cochrane Library, Health Technology Assessment Database and Web of Science, research registers. Pertinent original and review articles, published in English or French until December 31, 2019, were selected. A compelling body of evidence demonstrates transient, repeated and persistent IISE to be a major factor of most problematic disorders in obstetrics/gynecology, such as endometrial polyps, unexplained infertility, miscarriage, placenta-related pathology and endometrial cancer. When scheduled accordingly, hysteroscopy can play a key role in the IISE assessment. Robust data suggests the pertinence of minimal-effective anti-inflammatory regimens for therapeutic IISE targeting. This review provides a comprehensive update on the multiple facets of inflammation in the endometrial physiology and pathology. Further research is needed to improve classification, diagnosis and treatment of IISE.

Hysteroscopic Diagnosis of Omentum Incarceration Subsequent to an Iatrogenic Uterine Perforation.

STUDY OBJECTIVE: To present and discuss the hysteroscopic aspects of incarcerated omentum through uterine perforation caused by previous dilation and curettage (D&C) for an incomplete first-trimester abortion. DESIGN: A case report. SETTING: Constantine University Hospital, Constantine, Algeria. PATIENT: A 40-year-old, gravida 3, para 2 patient, with a history of an incomplete first-trimester spontaneous abortion treated 6 months before by D&C requiring medical assistance because of moderate, chronic pelvic pain. No other clinical or biological alteration was found. The ultrasound showed intracavitary hyperechogenic formation infiltrating the myometrium posteriorly. INTERVENTIONS: Hysteroscopy revealed a fatlike lesion arousing suspicion of a residual trophoblast; the differential diagnosis included intramyometrial fat metaplasia as well [1]. A mechanical cold loop resection was initiated. Instrumental manipulation of the mass released yellow drops, probably of lipid nature, subsequently leading to the discovery of a uterine perforation giving passage to the omentum. Histologic examination confirmed fat tissue. There was immediate resolution of symptoms. Laparoscopic repair was subsequently performed and consisted of suturing the defect. There were no further complications. MEASUREMENTS AND MAIN RESULTS: Few cases of omentum incarceration in a perforated uterus diagnosed during laparotomy or by magnetic resonance imaging have previously been reported [2-4]. To our knowledge, this is the first case revealed through hysteroscopy. CONCLUSION: In women with a history of intracavitary interventions such as D&C, omentum incarceration should be considered when hysteroscopy demonstrates a fatlike formation and yellow droplets released by pressing or mobilizing the formation. Surgeons should be cautious, never using electrosurgery on formations whose origin arouses suspicion.