The effect of laparoscopic resection of large niches in the uterine caesarean scar on symptoms, ultrasound findings and quality of life: a prospective cohort study.

OBJECTIVE: To evaluate the effectiveness of a laparoscopic niche resection on niche-related symptoms and/or fertility-related problems, ultrasound findings and quality of life. DESIGN: Prospective cohort study. SETTING: University hospital. POPULATION: Women with a large niche (residual myometrium <3 mm) and complaints of either postmenstrual spotting, dysmenorrhoea, intrauterine fluid accumulation and/or difficulties with embryo transfer due to distorted anatomy. METHODS: Women filled out questionnaires and a validated menstrual score chart at baseline and 6 months after the laparoscopic niche resection. At baseline and between 3 and 6 months follow up niches were evaluated by transvaginal ultrasound. MAIN OUTCOME MEASURES: The primary outcome was reduction of the main problem 6 months after the intervention. Secondary outcomes were complications, menstrual characteristics, dysmenorrhoea, niche measurements, intrauterine fluid, surgical outcomes, satisfaction and quality of life. RESULTS: In all, 101 women underwent a laparoscopic niche resection. In 80 women (79.2%) the main problem was improved or resolved. Postmenstrual spotting was significantly reduced by 7 days at 6 months follow up compared with baseline. Dysmenorrhoea and discomfort related to spotting was also significantly reduced. The residual myometrium was increased significantly at follow up. The intrauterine fluid was resolved in 86.9% of the women with intrauterine fluid at baseline; 83.3% of women were (very) satisfied. The physical component of quality of life increased, the mental component did not change. CONCLUSIONS: A laparoscopic niche resection reduced postmenstrual spotting, discomfort due to spotting, dysmenorrhoea and the presence of intrauterine fluid in the majority of women and increased the residual myometrium. TWEETABLE ABSTRACT: Laparoscopic niche resection reduces niche-related problems and enlarges the residual myometrium.

Fibroid vascularisation assessed with three-dimensional power Doppler ultrasound is a predictor for uterine fibroid growth: a prospective cohort study.

OBJECTIVE: To analyse fibroid vascularisation measured with three-dimensional (3D) power Doppler in relation to absolute fibroid volume change during 12 months of follow up and in relation to fibroid growth rate per year. DESIGN: A prospective cohort study was performed between March 2012 and March 2014. SETTING: Outpatient clinic of the VU medical centre, Amsterdam. POPULATION OR SAMPLE: All premenopausal women diagnosed with a maximum of two fibroids with expectant management were consecutively included. METHODS: Three-dimensional ultrasound including power Doppler was performed at baseline, 3, 6 and 12 months. Volume and vascular parameters were calculated using VOCAL software. MAIN OUTCOME MEASURES: The relationship between vascular index (VI) at baseline and fibroid volume over time was analysed using linear mixed model analyses for repeated measurements. Second, the relationship between VI at baseline and fibroid growth rate per year was calculated using linear regression analyses. Analyses were adjusted for possible confounders. RESULTS: In all, 66 women (mean age 42 years) completed 12 months of follow up without treatment. Baseline fibroid vascularisation (VI) measured with 3D power Doppler is correlated with fibroid volume at 12 months (P = 0.02 ). An increase of 1% in VI at baseline was associated with a 7.00-cm3 larger fibroid volume at 12 months. Furthermore, vascularisation was also associated with fibroid growth rate per year (P = 0.04). CONCLUSION: In women with uterine fibroids without therapy, baseline vascularisation (VI) measured with 3D power Doppler is correlated with absolute fibroid volume change at 12 months and with fibroid growth rate per year. TWEETABLE ABSTRACT: Fibroid vascularisation correlates with absolute fibroid volume change and fibroid growth rate per year.

Hysteroscopic resection of a uterine caesarean scar defect (niche) in women with postmenstrual spotting: a randomised controlled trial.

OBJECTIVE: To compare the effectiveness of a hysteroscopic niche resection versus no treatment in women with postmenstrual spotting and a uterine caesarean scar defect. DESIGN: Multicentre randomised controlled trial. SETTING: Eleven hospitals collaborating in a consortium for women's health research in the Netherlands. POPULATION: Women reporting postmenstrual spotting after a caesarean section who had a niche with a residual myometrium of ≥3 mm, measured during sonohysterography. METHODS: Women were randomly allocated to hysteroscopic niche resection or expectant management for 6 months. MAIN OUTCOME MEASURES: The primary outcome was the number of days of postmenstrual spotting 6 months after randomisation. Secondary outcomes were spotting at the end of menstruation, intermenstrual spotting, dysuria, sonographic niche measurements, surgical parameters, quality of life, women's satisfaction, sexual function, and additional therapy. Outcomes were measured at 3 months and, except for niche measurements, also at 6 months after randomisation. RESULTS: We randomised 52 women to hysteroscopic niche resection and 51 women to expectant management. The median number of days of postmenstrual spotting at baseline was 8 days in both groups. At 6 months after randomisation, the median number of days of postmenstrual spotting was 4 days (interquartile range, IQR 2-7 days) in the intervention group and 7 days (IQR 3-10 days) in the control group (P = 0.04); on a scale of 0-10, discomfort as a result of spotting had a median score of 2 (IQR 0-7) in the intervention group, compared with 7 (IQR 0-8) in the control group (P = 0.02). CONCLUSIONS: In women with a niche with a residual myometrium of ≥3 mm, hysteroscopic niche resection reduced postmenstrual spotting and spotting-related discomfort. TWEETABLE ABSTRACT: A hysteroscopic niche resection is an effective treatment to reduce niche-related spotting.