Effectiveness of Hysteroscopic Techniques for Endometrial Polyp Removal: The Italian Multicenter Trial.

STUDY OBJECTIVE: To compare the effectiveness and safety of different techniques of hysteroscopic polypectomy. DESIGN: Multicenter, prospective observational trial (Canadian Task Force classification II-2). SETTING: Nineteen Italian gynecologic departments (university-affiliated or public hospitals). PATIENTS: Consecutive patients suffering from endometrial polyps (EPs). INTERVENTIONS: Hysteroscopic polypectomy, as performed through different techniques. MEASUREMENTS AND MAIN RESULTS: Included in the study were 1404 patients (with 1825 EPs). The setting was an ambulatory care unit in 40.38% of the cases (567 women), of whom 97.7% (554) did not require analgesia/anesthesia. In the remaining 59.62% of women (837 women), the procedures were performed in an operating room under mild sedation, local or general anesthesia. Minor complications occurred in 32 patients (2.27%), without significant differences between the techniques used (p = ns). Uterine perforation occurred in 14 cases, all performed in the operating room with some kind of anesthesia, only 1 with a vaginoscopic technique and the remaining during blind dilatation (odds ratio [OR], 19.98; 95% confidence interval [CI], 1.19-335.79; p = .04). An incomplete removal of EPs was documented in 39 patients. Logistic regression analysis showed that a higher risk of residual EPs was associated with the use of a fiber-based 3.5-mm hysteroscope (OR, 6.78; 95% CI, 2.97-15.52; p <.001), the outpatient setting (OR, 2.17; 95% CI, 1.14-4.14; p = .019), and EPs located at the tubal corner (OR, 1.98; 95% CI, 1.03-2.79; p = .039). No association between incomplete EP removal and EP size or number was recorded (p = ns), as well as with the other variables evaluated. CONCLUSION: Outpatient polypectomy was associated with a minimal but significantly higher risk of residual EPs in comparison with inpatient polypectomy. Conversely, inpatient polypectomy was associated with a considerably higher risk of uterine perforation and penetration in comparison with office hysteroscopy. Because of lower intraoperative risks and higher cost-effectiveness, office hysteroscopy may be considered, whenever possible, as the gold standard technique for removing EPs.

Decrease in uterine perforations with ultrasound image-guided applicator insertion in intracavitary brachytherapy for cervical cancer: A systematic review and meta-analysis.

PURPOSE: To estimate uterine perforations rates during intracavitary brachytherapy for cervical cancer with and without ultrasound (US) image guidance. MATERIALS AND METHODS: A systematic search of databases (PubMed and EMBASE) was performed. The pooled summary uterine perforation rate (detected by postinsertion CT or MRI) for the un-guided insertion group and the guided insertion group was calculated by using the random-effects model weighted by the inverse variance. RESULTS: A total of 690 articles were initially found, resulting in 12 studies that met the inclusion criteria. A total of 1757 insertions and 766 patients were included in the meta-analysis. The overall uterine perforation rate per insertion was 4.56% (95%CI: 2.35-8.67) and per patient was 7.39% (95%CI: 3.92-13.50). The pooled perforation rate per insertion without image guidance was 10.54% (95%CI: 6.12-17.57) versus 1.06% (95%CI: 0.41-2.67) with image guidance (p < 0.01). The pooled perforation rate per patient without guidance was 16.67% (95%CI: 10.01-26.45) versus 2.54% (95%CI: 1.21-5.24) with image guidance (p < 0.01). The ratio of perforations in the un-guided/guided groups was 9.94 and 6.56, per insertion and per patient, respectively. The most common sites of perforation were the posterior wall (>47 events) and the uterine fundus (24 events). None of the studies reported significant acute clinical consequences. Prophylactic antibiotic after perforation was used in 3 of the 4 studies that described the management. CONCLUSION: Using postinsertion CT or MRI to detect the perforation, the rate of uterine perforation per insertion in patients who received US-guided intracavitary brachytherapy insertion is 90% lower than with un-guided insertion.

Does a human chorionic gonadotropin level of over 20,000 IU/L four weeks after uterine evacuation for complete hydatidiform mole constitute an indication for chemotherapy for gestational trophoblastic neoplasia?

OBJECTIVE: To evaluate whether a human chorionic gonadotropin (hCG) level ≥20,000 IU/L four weeks after uterine evacuation for complete hydatidiform mole (CHM) is an appropriate indicator for initiating chemotherapy for the treatment of gestational trophoblastic neoplasia (GTN). STUDY DESIGN: Historical database review of 1228 women with CHM who received treatment and follow-up between January 2000 and June 2013 at four Brazilian trophoblastic disease centers. The primary outcome measure was the progression from CHM to GTN. The secondary outcomes were the occurrence of uterine perforation, staging of GTN, WHO/FIGO risk score, and treatment (use of single- or multiagent chemotherapy). RESULTS: An hCG level ≥20,000 IU/L four weeks after uterine evacuation for CHM, while occurring in only 6.1% of women, was the most important risk factor for the development of postmolar GTN (adjusted RR = 5.83; p < 0.01; CI: 3.47-9.79), with a sensitivity of 36.8%, a specificity of 98.6%, a positive predictive value of 80%, and a negative predictive value of 91.1%. On the other hand, there were no differences in postmolar GTN stage, prognostic score, or need for multiagent chemotherapy relative to hCG level ≥20,000 IU/L versus <20,000 IU/L. CONCLUSIONS: Although hCG level ≥20,000 IU/L four weeks after uterine evacuation for CHM was very predictive of development of post-molar GTN, delay in treatment until hCG plateau or increase did not affect outcomes, with no uterine perforations or treatment failures.

[COMPLICATIONS OF DIAGNOSTIC AND OPERATIVE HYSTEROSCOPY--REVIEW].

Hysteroscopy is a diagnostic or surgical mini-Invasive gynecologic operating procedure. The complications of this standard procedure are relatively rare. According to retrospective studies they are 0.95-13.6%. They occur more often by an operative rather than a diagnostic hysteroscopy. These complications could be divided into two groups of an approximately equal occurrence--due to a dilation and passing through the cervix uteri (cervical laceration, creative a false cervix uteri, perforation, bleeding, impossibility to pass through the inner orifice of the cervical canal, insufficiency of the cervix uteri) and due to the operative technique itself (uterine perforation, fluid overload, thermal or mechanical trauma of the inner urinaiy and gastrointestinal tract, infection, rupture of the uterus during a subsequent pregnancy). The most occurring complication is namely the uterine perforation--1-9%, the most severe could indeed be the fluid overload--0.01-11%. The gynecologist performing the hysteroscopy should be well grounded in the typical complications. Unveiling and performing a quick intervention of the latter could prevent unwanted consequences for the patient and the legal issues that could follow occur.

Prelabor uterine rupture after laparoscopic repair of uterine perforation.

Uterine rupture is an established risk of previous uterine trauma. Conventionally this has been considered most likely following prior classical or midline hysterotomies at cesarean section or subsequent to abdominal myomectomy in which the uterine cavity was breached. Although there are reports of such cases after laparoscopic procedures such as myomectomy the incidence is believed to be very small. We present an extreme case of uterine rupture at 27 weeks with a previous laparoscopically repaired uterine perforation.

Pseudolipomatosis affects specimens from endometrial biopsies.

Pseudolipomatosis refers to optically clear vacuoles that artifactually contaminate specimens, and it most commonly affects the gastrointestinal tract. Pseudolipomatosis closely resembles adult white fat and is of group "A" or "B" when vacuoles have mild or marked variation in size, respectively. Pseudolipomatosis has yet to be reported to occur in the endometrium. Pseudolipomatosis in the endometrium might be easily mistaken for extrauterine adipocytes and misdiagnosed as perforation. We retrospectively reviewed 50 consecutive specimens from endometrial biopsies to determine the prevalence of endometrial pseudolipomatosis and whether pseudolipomatosis was related to perforation. All 50 specimens contained pseudolipomatosis of group "B," and lacked extrauterine tissue. To our knowledge, all patients lacked clinical evidence of perforation at follow-up. Pseudolipomatosis commonly affects specimens from endometrial biopsies and is likely unrelated to perforation. Awareness of pseudolipomatosis is necessary to avoid misdiagnosing uterine perforation.

Spontaneous perforation of pyometra in a cervical cancer patient: a case report and literature review.

Pyometra is an uncommon condition with an incidence of less than 1% in gynaecologic patients. Spontaneous rupture of pyometra in cervical cancer presenting as generalized peritonitis is very rare. Only four cases have been described in the English literature to the best of our knowledge and from a PubMed search. The index case is an elderly postmenopausal female who was diagnosed with cervical cancer, started on radiotherapy and presented with features of generalized peritonitis. Contrast-enhanced CT revealed uterine perforation at the fundus with multiple abdominal and pelvic collections. A brief review of all the cases of ruptured pyometra in cervical cancer in the literature and a discussion of the role of imaging is presented.

Acute abdomen as initial presentation of gestational choriocarcinoma.

Choriocarcinoma is the most malignant tumor of gestational trophoblastic neoplasia. Choriocarcinoma presenting as postpartum hemorrhage and spontaneous uterine perforation with intra-abdominal hemorrhage is very rare. We present a 29-year-old woman with spontaneous uterine rupture due to choriocarcinoma following a live birth pregnancy. The long time interval (2 years) between the previous live birth pregnancy and the diagnosis of the disease, the acute onset of the disease by uterine rupture as the first symptom and the negative urine hCG test are presented and discussed in this case report.

Intrauterine fallopian tube incarceration: an uncommon complication of termination of pregnancy by vacuum aspiration.

A 34-year-old woman presented with an intermittent abdominal pain 5 years after voluntary vacuum aspiration for interruption of a first-trimester pregnancy. Magnetic resonance imaging demonstrated complete septate uterus and a cystic mass that infiltrated the posterior myometrial wall of the right side of the uterus. Laparoscopy and hysteroscopy revealed an intra uterine fallopian tube incarceration.

Appearance of uterine perforation by hysterosalpingography.

The appearance of a uterine perforation that occurred at the time of office hysteroscopy is shown via hysterosalpingogram and laparoscopy.

Extensive psammomatous calcification of the uterus and cervix associated with a uterine serous carcinoma.

This report describes a uterine serous carcinoma with bilateral ovarian metastasis, which was associated with widespread extensive psammomatous calcification of the uterine leiomyomata, the myometrium, and the cervical stroma. These psammoma bodies were not associated with tumour or epithelial elements. This psammomatous calcification is rare, with no previous reports of similar cases. The presence of psammoma bodies is probably related to the serous carcinoma, raising the possibility that psammoma body formation in serous carcinomas is the result of a factor secreted locally by the tumour, rather than the widely held theory that their formation is secondary to necrosis, with subsequent dystrophic calcification within a papillary neoplasm.

Intraperitoneal levonorgestrel-releasing intrauterine device following uterine perforation: the role of progestins in adhesion formation.

BACKGROUND: Intrauterine contraception is a widely used, highly effective means of birth control. Uterine perforation is a serious, albeit rare, complication of intrauterine device (IUD) use. Although uterine perforation by levonorgestrel-releasing (20 micro g/day) intrauterine system (LNG-IUS) has already been reported, the peritoneal adhesion potential of this IUD is unknown. METHODS: The medical files of all patients diagnosed with an intra-peritoneal IUD between the years 1990-2002 at Hadassah Medical Center were reviewed. Histopathological study of peritoneal adhesion tissue adjacent to levonorgestrel medicated IUD was conducted in one case. RESULTS: Eight cases of dislocated IUDs were found. Four cases used LNG-IUS and four other cases used copper-IUD. Laparoscopy for IUD removal disclosed mild local peritoneal adhesions between omentum and pelvic organs in all cases. No difference was noted in the appearance of the peritoneum in the presence of either a copper-IUD or LNG-IUS. Histological examination of peritoneal tissue encasing the levonorgestrel-intrauterine system revealed loose connective tissue with aggregates of submesothelial cells with a pseudo-decidual change. Immunohistochemical staining for progesterone receptor was negative. CONCLUSIONS: The peritoneal adhesions potential of LNG-IUS is low, similar to that of the copper-bearing IUD.

Uterine perforation associated with endometrial ablation.

Three cases of uterine perforation associated with endometrial ablation are presented. Possible predisposing factors in 2 cases were previous Caesarean section and difficulty in cervical dilatation. Adequate training for gynaecologists in hysteroscopy is essential before undertaking any type of operative hysteroscopy.

Uterine perforation during second-trimester abortion by cervical dilation and instrumental extraction: a review of 15 cases.

Review of the records of 15 women who had uterine perforations at the time of second-trimester abortion by dilation and evacuation showed that unexpected pain (but not excessive bleeding) was the most prominent sign. All patients required laparotomy, but in no case was laparotomy necessary as an emergency procedure. Laparoscopy was not helpful. Two-thirds had bowel injuries and two required hysterectomy. Errors in estimating gestational duration, inadequate cervical dilation, and failure to use sonography characterized these complicated cases.

A case report of unusual complication of myomatous uterus in pregnancy: spontaneous perforation of myoma after red degeneration.

An unusual complication of myomatous uterus in pregnancy is presented. It shows spontaneous perforation of a myoma after red degeneration, presenting as an acute abdomen. To our knowledge spontaneous perforation of a necrotising leiomyoma has not been reported earlier. A review of the literature is given.

Catastrophic injury secondary to the use of coaxial gas-cooled fibers and artificial sapphire tips for intrauterine surgery: a report of five cases.

Five women undergoing endometrial ablation with the Nd-YAG laser developed sudden gas embolism. In each case laser intrauterine contact surgery was carried out utilizing coaxial fibers with (three cases) and without (two cases) artificial sapphire tips but commonly cooled by air or nitrogen. Four of the five women died in a sequence of sudden cardiovascular collapse followed by irreversible cardiac arrest. One woman was critically ill and following prolonged hospitalization survived with neurological deficits.

Posttraumatic intrauterine omental implantation mimicking lipomatous lesion 16 years later.

A case of traumatic perforation of the uterus with subsequent omental implantation in the endometrial cavity clinically presenting 16 years later as an endometrial lipoma is discussed. This case should alert clinicians to the existence of such a complication to be included in their differential diagnosis of lipomatous lesions of the uterus.