Intramural Myomectomy Using a Combination of Hysteroscopy and Laparoscopy

Thanks to advances in hysteroscopic surgery and improvements in instrumentation, hysteroscopy can now be performed for intramural myomas. Twelve women with submucous or intramural myomas with a diameter ranging from 3.5 to 5.8 cm received preoperative preparation with 5 months of gonadotropin-releasing hormone analogs. The uterine cavity was distended with sorbitol-mannitol solution infused by an electronic pump. Hysteroscopic resection was performed with a 26F resectoscope and electrosurgical monopolar unit under laparoscopic control in all patients. Four women required a second procedure to complete the resection of myoma. No major complications occurred.

Risks of Virus Transmission During Diagnostic Hysteroscopy

The high frequency of asymptomatic carriers of viral infections represents a major risk for transmission. Viral agents can be transmitted through blood or biologic fluids during diagnostic hysteroscopy. Routine disinfection methods to clean hysteroscopes cannot be considered adequate to prevent transmission. Hepatitis C and B viruses require 1-hour sterilization in glutaric aldehyde or gas sterilization (ethylene oxide) to be decontaminated. Human immunodeficiency virus decontamination of instruments is easier and safer. Blood test screening of patients positive for hepatitis B and C should be performed in all candidates for endoscopic gynecologic procedures to avoid the possibility of virus transmission.

[Hysteroscopic evaluation of the endometrium in 63 postmenopausal patients treated with tamoxifen for breast cancer]. / Valutazione isteroscopica dell'endometrio in 63 pazienti in post-menopausa trattate con tamoxifene per carcinoma della mammella.

This retrospective analysis intends to evaluate by histeroscopy the endometrial findings in a group of 63 patients in post-menopausal treated with tamoxifen for breast cancer. Our patients assumed tamoxifen for a different period between 6 and 120 months. Patients have been divided in two groups: I) patients undergoing hysteroscopy because of some clinical symptoms; II) patients who undergoing hysteroscopy as a routine examination. The most important observation of this work is the correlation between the presence of negative endometrium and low risk hyperplasia (LRH) associated to: symptomatology and duration of therapy. In the group of asymptomatic patients the LRH is found only after 3 years of treatment, while in the group of symptomatic patients, LRH is present within the first two years of treatment; beyond this period high risk hyperplasia (HRH) and endometrial carcinoma have been diagnosed. We also observed a higher incidence of endometrial polyps in this population than among the non treated group and among the symptomatic patients. From these data we conclude that hysteroscopy follow-up has to be performed in the group of patients treated with tamoxifen and that it would be necessary to have a hysteroscopy before the beginning of therapy and that this one has to be repeated once a year through the treatment. Obviously the symptomatic patients have to undergo hysteroscopy as soon as possible as a higher incidence of HRH and endometrial carcinoma has been detected in this group of patients.

Preoperatory treatment with Triptorelin LA in hysteroscopic metroplastic.

Septate uterus is the intracavitary pathology which is most associated with infertility and/or preterm labor; therefore, it is primary indication for hysteroscopic metroplasty. By the introductio of the resectoscope in gynaecological endoscopy the surgical technique has been revolutioned. GnRHa therapy before surgery has showed some advantages related to surgical results, surgery time, intraoperative bleeding and endometrial detachment, and amount of fluids used for uterine cavity distention. The treatment before hysteroscopic metroplasty for partial septus has not influenced positive results, while for uterine septus that reached the inferior third of the cavity or moreover, it provided better condition for this procedure.

Can hysteroscopic evaluation of endometrial carcinoma influence therapeutic treatment?

235 cases of primary endometrial adenocarcinoma (AC) (age range, 37-94; mean age, 61 years) were collected during the period 1980-1992. Hysteroscopic examination of both the endometrial cavity and the cervical canal was performed in every patient prior to hysterectomy, and evaluations of cancer extension in the endometrium (focal: 97 pts; partial: 82 pts; massive: 47 pts; unevaluable: 9 pts) and of endocervical involvement (positive: 45 pts) were compared to the histological findings and survival rates. The chi 2 test was used for statistical analysis, and statistical significance was considered where the p value was < 0.05. Endometrial extension was poorly related to the depth of myometrial invasion (M1 = depth of invasion to < 1/2 myometrium, M2 = invasion to > 1/2 myometrium): focal AC: M1 57.8%, M2 42.2%; partial AC: M1 40.2%, M2 59.8%; massive AC: M1 51.1%, M2 48.9%; (p = 0.5). Endocervical involvement was unrelated to endometrial extension. No correlation was found between AC histological grade (G1-G3) and entity of endometrial extension, whereas grade showed a significant correlation with myometrial invasion (G1 M1: 69.1%; G3 M1: 41.0%; p = 0.002) and survival rates (G1 90.4%, G2 88.5%, G3 69.4%; p = 0.01). Five-year survival figures showed no evident correlation with cancer extension (focal AC: 86.5%; partial AC: 87.8%; massive AC: 86.3%; p = 0.9) whereas myometrial invasion showed a statistical significance (M1: 91.4%, M2: 79.7%; p = 0.03). Three patterns of invasion were defined: pushing (P), infiltrative (I) and diffuse (D) isolated cells. There were significant differences between the various growth patterns and survival rates (P 90.7%; I 84.3%; D 45.4%; p = 0.0001). False negative rate of the hysteroscopic diagnosis of cervical involvement was 7.9% (18 cases); however, in 6 of these cases only deep cervical invasion was found.

GnRH agonist analogs and hysteroscopic resection of myomas.

OBJECTIVES: The purpose of this study was to evaluate the effects of pretreatment with GnRH analogs and hysteroscopic resection of submucous myomas previously deemed to be contraindicated for this approach. METHODS: Twenty-five patients were included in this study. Patients were assessed by ultrasonography and diagnostic hysteroscopy. They were treated with depot GnRH analogs for 3 months and then scheduled for hysteroscopic surgery. RESULTS: After GnRH therapy the diameter was 61 +/- 10% of the initial diameter. In one patient, therapy was almost ineffective. Hysteroscopic surgery was possible in all 25 patients. Seven patients presented an intramural myoma that was not possible to remove entirely during the first attempt. After dessication and 2 supplementary months of GnRH analog therapy, a second surgical attempt was successful in complete removal of the tumor in all except one case. In one patient hysterectomy 15 days after hysteroscopic surgery was necessary for incoercible bleeding due to a deep adenomiosis. CONCLUSIONS: A combined medical and surgical approach seems to reduce the limit of hysteroscopic surgery and avoid open myomectomy or hysterectomy in a well selected group of patients.

Our experience with direct intraperitoneal insemination (DIPI) as a treatment for infertile couples.

The therapeutic value of Direct Intraperitoneal Insemination (DIPI) is of particular interest in cases of unexplained infertility and failed AID. The same technique is less likely to be successful where functional or morphological semen abnormalities or multifactorial infertility exist. The Authors report their own experience with DIPI as a treatment on 76 couples with a long-standing infertility.

Is hysteroscopy of value in the investigation of female infertility?

A prospective multicentre study was designed to ascertain the value of hysteroscopy in the evaluation of female infertility. The study comprises 619 CO2 hysteroscopies in women complaining of infertility. Four hundred and ninety nine examinations (80%) were performed without anaesthesia or cervical dilatation. Twenty eight cases of malformation were diagnosed. Adhesions were found in 68 patients (11%), polypi in 56 (9.1%) and submucous fibroids in 51 (8.2%). Endometrial hyperplasia was diagnosed by hysteroscopy in 67 patients, but there was only 42% histological correlation. Examination of the tubal ostia by hysteroscopy revealed 26 patients (4%) with unilateral tubocornual polyps and one with bilateral polyps. The correlation with hysterosalpingography (HSG) in 185 patients was poor. In 20% where the HSG was reported as normal there were hysteroscopically demonstrable lesions whereas there were false positive findings at HSG in 35% of cases. Hysteroscopy is the only technique which provides an accurate clinical evaluation of the uterine cavity although it does not provide significant information about the cervical canal or fallopian tubes.

Levo-norgestrel-nova-T and precancerous lesions of the endometrium.

The authors report the preliminary data on the topical treatment of endometrial hyperplasia by an intrauterine device releasing Levo-norgestrel (LNG-Nova-T), in a series of 31 patients. The patients examined so far by endometrial biopsies performed at predetermined intervals showed a complete histological regression of the hyperplasia, regardless of its pattern.

Hysteroscopy and endometrial biopsy.

The role of hysteroscopy for a complete evaluation of luteal phase is discussed by the authors. They affirm that for a thorough evaluation a hysteroscopy may be usefully performed simultaneously to the endometrial biopsy.

Hysteroscopy for evaluation of tubal ostium pathology.

A comparison between hysterosalpingography and hysteroscopy in the evaluation of tubal ostium pathology is presented by the authors. They stress in particular the role of hysteroscopy in this evaluation.

Hyperprolactinemia and 5-alpha-reductase activity.

A number of experimental data indicate that hyperprolactinemia inhibits the activity of 5-alpha-reductase; however, no information is available about the time required for this enzyme to re-activate after prolactinemia has returned to normal values. In the present study, five normal caucasian men, whose fertility had previously been proven, were given HCG (5000 IU/day by intramuscular route for three days) both in basal conditions and after sulpiride-induced hyperprolactinemia (dosage = 200 mg/day for ten days). In both conditions, the plasma levels of prolactin (PRL), testosterone (T), dihydro-testosterone (DHT), 17-beta-estradiol (E2), and dehydroepiandrosterone sulfate (DHAS) were monitored during the treatment with HCG and for an additional 24 hrs after HCG discontinuation. All hormones were assayed by RIA. Our results demonstrate that hyperprolactinemia causes a marked decrease (58%) of DHT, a less marked decrease (39%) of T, an increase (43%) of DHAS whereas only a small increase (2%) of E2 was observed. Steroids were shown to behave differently after the HCG tests performed in the two experimental conditions. In particular, the levels of DHT had a much more pronounced increased after HCG in the second test than in the first; in contrast, both DHAS and E2 had a less marked response after the second test. Our data, on the one hand, confirm that 5-alpha-reductase is inhibited by hyperprolactinemia; on the other hand, the hyperprolactinemia-induced block of this enzyme appears to be rapidly reversible because the enzyme is reactivated within 48-72 hrs after normalization of prolactin levels. (Normal values of prolactin were on the average achieved on the 4th day after sulpiride discontinuation).(ABSTRACT TRUNCATED AT 250 WORDS)

Plasma concentrations of FSH and testosterone in male infertile patients.

We studied the statistical distribution of the plasma concentrations of FSH and testosterone in patients with oligoazoospermia as compared with normospermic subjects. The plasma concentration of FSH was determined in 429 patients with oligoazoospermia and 282 normospermic subjects ("controls"). In 118 out of these 429 patients and in 47 of the 282 controls, the plasma concentration of testosterone was also measured. The plasma concentrations of FSH differed significantly depending on the patients' values of spermatic concentration. The most significant difference was observed between azoospermic patients and controls, whereas the difference between patients with mild oligospermia and controls was not significant. Conversely, the plasma concentrations of testosterone did not correlate with the values of spermatic concentration and even the difference between azoospermic patients and controls did not reach the significance level. In addition, testosterone plasma concentrations did not differ between two sub-groups of patients who were defined depending on whether the plasma concentration of FSH was normal or high. Our findings confirm the inverse relation between plasma FSH levels and spermatic concentration which had already been observed in previous studies. However, a considerable overlap in the plasma concentrations of FSH has been found between sub-groups of patients with different spermatic concentrations. This overlap limits the clinical usefulness of the measurement of FSH concentration inasmuch as normal FSH plasma levels may often be associated with any value of spermatic concentration. Also, our data confirm that the measurement of testosterone plasma levels provides little clinical usefulness in male infertile patients.

[Clinical experience with a new type of intra-tubal device]. / Etude clinique d'un nouveau modele de dispositif intra-tubaire.

PIP: 3 types of hysteroscopic sterilization are in various stages of investigation at present: destruction of the interstitial portion of the tube with electrocoagulation or cryonecrosis, injection of sclerosing agents or liquid silicone, and mechanical devices. A nylon intratubal device measuring 4 cm long by 1 mm in diameter tested in a multicenter study was designed to prevent migration into the uterine cavity and had a nylon ring at the proximal extremity to facilitate removal of the device. The flexible middle part permitted insertion of the device without trauma. The proliferative phase of the cycle was the optimal time for insertion since the tubal orifices were most easily observed at that time. Among contraindications to use of the device were retroverted uterus, pelvic inflammatory disease, insufficiently large tubal opening, and sinuosity of the interstitial segment. 166 women aged 33.5 years of age on average and with an average parity of 2.4 children participated in a test of the method between March 1982 and February 1984. Bilateral insertion on the 1st attempt was possible for 149 women, 7 women required a 2nd attempt because of bleeding or poor visualization, and the others had functional or anatomic contraindications to use of the method. 29 insertions were done under paracervical local anesthesia and 6 under general anesthesia. Hysterographic control 1 month after insertion revealed 4 expulsions, 2 of which were bilateral. 1471 cycles without other contraception have been followed. 1 pregnancy occurred 6 months after insertion; in this case hysteroscopy showed that the device was in place. Microhysteroscopy permits a direct approach to the uterine cavity which can be done on an outpatient basis without general anesthesia. The surgical nylon of the device is inert and biocompatible, and microhysteroscopic controls have not demonstrated inflammatory tissue reactions. The flexibility of the device assures an insertion without risk of perforation. Although the method has been studies in 1471 cycles, further research is needed before conclusions can be drawn about its efficacy. Observations in 6 patients who underwent hysterectomy after use of the intratubal device showed a moderate reaction of neighboring tissue, but no evidence that the device could not be easily removed and permeability of the interstitial portion of the tubes recovered. Preliminary results support development of the method, but some difficulties in its use must still be overcome.^ieng

Hysteroscopic evaluation of intrauterine progesterone contraceptive system as a treatment for abnormal uterine bleeding.

Intrauterine Progesterone Contraceptive System has been used in twenty patients aged 45 to 52, affected by dysfunctional uterine bleeding due to glandular hyperplasia (6 cases), focal glandular hyperplasia (8 cases), cystic hyperplasia (4 cases) and adenomatous hyperplasia (2 cases). Hysteroscopy and endometrial biopsy were performed every two months after insertion of IPCS. Complete regression or clear improvement were observed in all cases. The question if regression may be considered permanent or temporary remains to be answered.

PIP: An intrauterine progesterone contraceptive system has been used in 20 patients aged 45-52 affected by dysfunctional uterine bleeding due to glandular hyperplasia (6 cases), focal glandular hyperplasia (8 cases), cystic hyperplasia (4 cases), and adenomatous hyperplasia (2 cases). Hysteroscopy and endometrial biopsy were performed every 2 months after insertion of the system. Complete regression or clear improvement were observed in all cases. The question if regression may be considered permanent or temporary remains to be answered.

Dynamic echohysteroscopy: new perspectives for diagnostic sonography in female infertility.

Dynamic echohysteroscopy is a new diagnostic method which can be applied to the clinical problems of infertility, providing informations on the morphology of the internal genitals. The Authors underline the clinical validity of this diagnostic technique, even though more experience is required in order to define a better standardization of the method.

Clinical evaluation in vivo and in vitro of cervical mucus in IUD users: differences between women wearing copper and progesterone releasing IUDs.

This is a report of the variations of cervical mucus of women wearing different kinds of IUDs, before and after the insertion. We could not find significant variations of the clinical patterns in women wearing copper IUDs, but noticeable variations were found in progesterone releasing device users.

PIP: Modifications of cervical mucus associated with IUD use were investigated in 5 women fitted with a copper IUD and 5 women with a progesterone-releasing device. Also investigated was the survival and viability of sperm in users of these 2 types of IUDs. Mucus was collected from study subjects before IUD insertion and 3 months after insertion; the quantity, spinnbarkheit, cellularity, and ferning capacity were assessed. A capillary tube test was also performed, and penetration depth, penetration density, motility duration, and migration reduction were evaluated. Women with a copper IUD in place showed no significant changes in cervical mucus measures after insertion. In contrast, insertion of the progesterone-releasing device significantly modified the spinnbarkheit and the cellularity of the mucus, with a dramatic increase of leukocyes. Similarly, although the copper IUD did not produce significant variations in penetration test parameters, insertion of the progesterone-releasing IUD was associated with a significant decrease in sperm concentrations penetrated at 1 cm, a marked drop in sperm motility and survival, and a significant decrease in the reduction of migration. These results indicate that progesterone-releasing IUDs produce important changes in cervical mucus and reduce sperm penetration and survival. It is hypothesized that the negative effect on the cervical mucus may be a principal mechanism of action of the progesterone-releasing contraceptive device.

Pre-neoplastic lesions of vulvar cancer.

The monitoring of potentially neoplastic lesions is based on the determination of the histopathologic characteristics of the lesion, which is done either by large surgical resection of the lesions "in toto" or by biopsy of the lesion. Chronic vulvar dystrophy may develop into carcinoma, the supposed likelihood varying according to the various Authors. The lesion which is histologically defined as atypical keratoacanthoma is the most frequent precursor of carcinoma. Most Authors agree in believing that lichen scleroatrophic does not often develop into carcinoma. It is, nevertheless, the most frequent precursor of leukoplakia which is, on the other hand, a risk lesion. However, any chronic vulvar irritation may increase the risk of cancer and must therefore be carefully monitored by multiple biopsies to be examined at regular intervals.