Histological assessment of endometrial polyps resected by hysteroscopy.

OBJECTIVE: This study aimed to analyze the clinical data and pathologic aspects of endometrial polyps (EMPs) excised completely during surgical hysteroscopy and assess the connection between premalignant and malignant EMPs. PATIENTS AND METHODS: This retrospective study includes 489 participants who underwent hysteroscopy due to endometrial polyps, and the clinical features and histological findings of the resected polyps analyzed. RESULTS: Participants with EMPs were divided into six groups according to histologic findings. The histologic finding of most cases was simple benign endometrial polyp [397 patients (81.2%)]. Malignant polyp was detected in 3 patients (0.6%). The histologic findings according to age, menopausal status, and menstrual bleeding patterns at the time of presentation to the outpatient clinic were compared; however, no significant difference was observed. 237 patients were observed to have menometrorrhagia, which was the most prevalent symptom reported. The distribution of polyp sizes observed at hysteroscopy according to histologic findings was compared, but no significant difference was observed. CONCLUSIONS: EMPs are often benign but can include premalignant or malignant tissue changes. Hysteroscopy is used for direct observation of the uterine cervix and resection of existing polyps, considering the increasing frequency of its use as a diagnostic and treatment tool.

Recognizing uterine torsion as a differential diagnosis in pregnant cats with severe anemia to provide appropriate and timely care in the absence of a definitive presurgical diagnosis.

A pregnant female domestic longhair cat ~8 mo of age was referred to the Western College of Veterinary Medicine (Saskatoon, Saskatchewan) for a diagnostic evaluation of severe anemia (PCV: 10.8%) after a 2-day period of lethargy. A CBC, serum biochemistry profile, FeLV/FIV testing, and abdominal radiographs were completed and did not determine a cause for the anemia. Abdominal ultrasonography identified 1 viable and 6 nonviable and fetuses, anechoic fluid in the uterus, and a mild volume of peritoneal effusion. A whole-blood transfusion and C-section with ovariohysterectomy were performed even though a definitive presurgical diagnosis for the anemia had not yet been established. Exploratory surgery revealed a left uterine horn torsion with a necrotic base, severe congestion, and 7 nonviable fetuses. Following surgery, the queen made a full clinical recovery. Key clinical message: Uterine torsion can be easily overlooked as a cause of severe anemia due to the relative infrequency of this condition in cats and the low sensitivity of ultrasonography to provide a definitive presurgical diagnosis. Client communication must emphasize the need for a prompt surgical intervention to establish the diagnosis and to save the cat, despite poor rates of neonatal survival. Once the animal is stabilized after surgery, further diagnostic tests and procedures are indicated if the cause of anemia has not yet been identified.

Reconnaître la torsion utérine comme un diagnostic différentiel chez les chattes gestantes souffrant d'anémie sévère afin de fournir des soins appropriés et opportuns en l'absence d'un diagnostic pré-chirurgical définitif. Une chatte domestique à poils longs, âgée d'environ 8 mois, a été référée au Western College of Veterinary Medicine (Saskatoon, Saskatchewan) pour une évaluation diagnostique d'anémie sévère (hématocrite : 10,8 %) après une période de léthargie de 2 jours. Une formule sanguine complète, un profil biochimique sérique, des tests FeLV/FIV et des radiographies abdominales ont été réalisés et n'ont pas permis de déterminer la cause de l'anémie. L'échographie abdominale a identifié 1 foetus viable et 6 non viables, du liquide anéchoïque dans l'utérus et un léger volume d'épanchement péritonéal. Une transfusion de sang total et une césarienne avec ovariohystérectomie ont été réalisées même si le diagnostic pré-chirurgical définitif de l'anémie n'avait pas encore été établi. La chirurgie exploratoire a révélé une torsion de la corne utérine gauche avec une base nécrotique, une congestion sévère et 7 foetus non viables. Après l'opération, la chatte s'est complètement rétablie cliniquement.Message clinique clé:La torsion utérine peut facilement être négligée comme cause d'anémie sévère en raison de la rareté relative de cette affection chez le chat et de la faible sensibilité de l'échographie pour fournir un diagnostic pré-chirurgical définitif. La communication avec le client doit souligner la nécessité d'une intervention chirurgicale rapide pour établir le diagnostic et sauver le chat, malgré de faibles taux de survie néonatale. Une fois l'animal stabilisé après la chirurgie, d'autres tests et procédures de diagnostic sont indiqués si la cause de l'anémie n'a pas encore été identifiée.(Traduit par Dr Serge Messier).

Short-term reproductive outcomes analysis and prediction of the modified uterine stent treatment for mild to moderate intrauterine adhesions: experience at a single institution.

BACKGROUND: To evaluate the efficacy of modified uterine stent in the treatment of mild-to-moderate intrauterine adhesions and explore the relative indicators affecting prognosis prediction. METHODS: A total of 115 patients with mild-to-moderate intrauterine adhesions received a modified uterine stent placement after hysteroscopy adhesiolysis. The second-look hysteroscopy operated after 3 months surgery, and the third-look hysteroscopy operated after 6 months surgery if necessary. The stent was removed when the cavity shape was repaired, then the reproductive outcomes were followed up one year. RESULTS: Menstrual blood volume, endometrial thickness and volume had increased significantly after 3 months surgery. The rates of cavity repaired were 86.96% (100/115) after 3 months surgery and 100% (115/115) after 6 months surgery cumulatively. Endometrial thickness after 3-months surgery was positively associated with uterine cavity shape repaired (P<0.01). The receive operating characteristic (ROC) curve showed the rate of uterine cavity shape repaired predicted by the model was 0.92, based on the endometrial thickness after 3-months surgery. The rate of pregnancy was 86.09% (99/115) in one year, while the rate of miscarriage accounted for 26.26% (26/99). The median time interval between stent removal and subsequent conception was 3 months. It showed adhesion recurrence was the risk factor for subsequent pregnancy (P<0.01). CONCLUSIONS: A modified uterine stent placement under hysteroscopy was an effective approach for mild-to-moderate intrauterine adhesions, which is easy to operate and worthy for clinical promotion. Endometrial thickness measured by ultrasonography probably has predictive value in adhesion recurrence and subsequent pregnancy. TRIAL REGISTRATION: ChiCTR2100051524. Date of registration (retrospectively registered): 26/09/2021.

Comparing the efficacy and pregnancy outcome of intrauterine balloon and intrauterine contraceptive device in the prevention of adhesion reformation after hysteroscopic adhesiolysis in infertile women: a prospective, randomized, controlled trial study.

STUDY OBJECTIVE: To evaluate the efficacy and pregnancy outcomes of intrauterine balloon and intrauterine contraceptive devices in the prevention of adhesion reformation following hysteroscopic adhesiolysis in infertile women with moderate to severe intrauterine adhesion. DESIGN: A prospective, randomized, controlled trial study. SETTING: A tertiary university hospital. PATIENTS: A total of 130 patients with moderate (American Fertility Society [AFS] score of 5-8) and severe (AFS score of 9-12) intrauterine adhesions were recruited. INTERVENTIONS: 86 patients were evenly allocated to group treated with an IUD for 1 month and group treated with an IUD for 2 months. 44 patients were allocated to group treated with a Foley catheter balloon.(IUD: Yuangong IUD). MEASUREMENTS AND MAIN RESULTS: The primary outcome measures were the AFS score, endometrial thickness, and pregnancy outcome. After hysteroscopy, the AFS score was significantly decreased(P<0.05), whereas endometrial thickness was significantly increased across the three groups(P<0.001). Notably, the decline in the AFS score in the balloon group was greater than that in the IUD-1-month group and IUD-2-month group(P<0.01), with no significant difference between the IUD groups(P = 0.298). Lastly, In addition, the extent of the increase in endometrial thickness(P = 0.502) and the pregnancy outcomes(P = 0.803) in the three groups were not significantly different. CONCLUSION: Inserting a balloon or placing an IUD for one or two months can effectively lower the risk of adhesion recurrence and restore the shape of the uterine cavity. While the therapeutic effect of the balloon was superior to that of the IUD, no significant differences were observed in the one-month and two-month IUD groups. TRIAL REGISTRATION: This research was registered in the Chinese Clinical Trial Registry ( http://www.chictr.org.cn/enIndex.aspx ); Clinical trial registry identification number: ChiCTR-IOR-17,011,943 ( http://www.chictr.org.cn/showprojen.aspx?proj=17979 ). Date of trial registration: July 11, 2017.

Minimally invasive treatment of uterine necrosis with favorable outcomes: an uncommon case presentation and literature review.

BACKGROUND: Uterine necrosis is a rare condition and is considered a life-threatening complication. However, cases of uterine necrosis were rarely reported, particularly those caused by infection. In terms of treatment, no minimally invasive treatment for uterine necrosis has been reported, and total hysterectomy is mostly considered as the treatment option. OBJECTIVE: The article specifically focuses on minimally invasive treatments and provides a summary of recent cases of uterine necrosis. CASE PRESENTATION: We report the case of a 28-year-old patient gravid 1, para 0 underwent a cesarean section after unsuccessful induction due to fetal death. She presented with recurrent fever and vaginal discharge. The blood inflammation markers were elevated, and a CT scan revealed irregular lumps with low signal intensity in the uterine cavity. The gynecological examination revealed the presence of gray and white soft tissue, approximately 5 cm in length, exuding from the cervix. The secretions were found to contain Fusobacterium necrophorum, Escherichia coli, and Proteus upon culturing. Given the patient's sepsis and uterine necrosis caused by infection, laparoscopic exploration uncovered white pus and necrotic tissue openings in the anterior wall of the uterus. The necrotic tissue was removed during the operation, and the uterus was repaired. Postoperative pathological findings revealed complete degeneration and necrosis of fusiform cell-like tissue. Severe uterine necrosis caused by a multi-drug resistant bacterial infection was considered after the operation. She was treated with antibiotics for three weeks and was discharged after the infection was brought under control. The patient expressed satisfaction with the treatment plan, which preserved her uterus, maintained reproductive function, and minimized the extent of surgery. CONCLUSION: Based on the literature review of uterine necrosis, we found that it presents a potential risk of death, emphasizing the importance of managing the progression of the condition. Most treatment options involve a total hysterectomy. A partial hysterectomy reduces the extent of the operation, preserves fertility function, and can also yield positive outcomes in the treatment of uterine necrosis, serving as a complement to the overall treatment of this condition.

Effects of endometrial versus non-endometrial suturing on isthmocele development; a randomized controlled trial.

OBJECTIVE: Incomplete healing after cesarean section (CS) can result in isthmocele formation. When suturing the uterus, fully folding the wound lips may embed the endometrial layer into the myometrium, leading to isthmocele development. Hence, this study aimed to compare the effects of endometrial and non-endometrial suturing on isthmocele development. MATERIAL AND METHODS: This randomized controlled trial included 274 patients. Women who underwent primary CS were randomly allocated to one of the two study groups: endometrial suturing and non-endometrial suturing. The primary outcome was isthmocele rate at postpartum 6 months. Secondary outcomes were the volume of the isthmocele, thickness of the residual myometrium, menstrual irregularities (intermenstrual spotting), and the relationship between the isthmocele and uterine position. RESULTS: A total of 159 patients (81 in the endometrial suturing group and 78 in the non-endometrial suturing group) were analyzed. The incidence of isthmocele was significantly lower in the non-endometrial suturing group than in the endometrial suturing group (12 [15.4%] vs. 24 [29.6%] patients; p = 0.032). Menstrual irregularities, such as intermenstrual spotting, were significantly higher in the endometrial suturing group than in the non-endometrial group (p = 0.019). CONCLUSION: Uterine closure with non-endometrial suturing was associated with significantly lower isthmocele development and less intermenstrual spotting compared to that with endometrial suturing.

Manually driven versus motor driven hysteroscopic tissue removal system for polypectomy: Long-term results.

OBJECTIVE: The aim of this follow-up study is to compare a manually driven hysteroscopic tissue removal system (ResectrTM 9 Fr) with a motor driven system (TruclearTM) in terms of long-term clinical outcomes such as abnormal uterine bleeding and polyp recurrence. STUDY DESIGN: This is a follow-up of a multicenter randomized controlled trial comparing a manually and motor driven hysteroscopic tissue removal system for polypectomy. This prospective cohort study was performed at Ghent University Hospital (Ghent, Belgium) and Catharina Hospital Eindhoven (Eindhoven, the Netherlands). The trial was registered at Clinicaltrials.gov (Trial ID = NCT05337605, April 2022). Seventy-five women with abnormal uterine bleeding who participated in the randomized controlled trial and had pathological confirmation of the diagnosis of an endometrial polyp, were contacted. Fifty-five women (70.67 %) were willing to participate in this follow-up study. The primary outcome was the recurrence and/or persistence of abnormal uterine bleeding and the time to the recurrence of abnormal uterine bleeding. Secondary outcomes were polyp recurrence and time to polyp recurrence, symptom relief, satisfaction score regarding symptom relief and general satisfaction score regarding the surgical procedure. RESULTS: In the manually driven group, the mean time to the recurrence or persistence of abnormal uterine bleeding was 26 months (95 % CI 20 - 32). In the motor driven group, the mean time to the recurrence or persistence of abnormal uterine bleeding was 29 months (95 % CI 23- 34). A log-rank test showed a non-significant difference between both groups (P =.77). There was no significant difference in polyp recurrence (P =.22) or symptom relief between the two groups (P =.67). Additionally, the groups did not differ in satisfaction scores regarding symptoms or polypectomy (P =.16 and P =.61, respectively). CONCLUSION: This long-term follow-up study showed no statistically significant difference in the recurrence and persistence of abnormal uterine bleeding between a manually and motor driven hysteroscopic tissue removal system for polypectomy.

Intrauterine interventions options for preventing recurrence after hysteroscopic adhesiolysis: a systematic review and network meta-analysis of randomized controlled trials.

PURPOSE: Recurrence of adhesions after hysteroscopic adhesiolysis is a challenging clinical problem without a unified management approach. Therefore, we conducted a network meta-analysis that considered both direct and indirect comparisons between interventions to identify optimal strategies for preventing recurrence. METHODS: We searched for research trials published up to July 2023 from PubMed, Embase and the Cochrane Database. We selected randomized controlled trials comparing the use of different interventions for the prevention of adhesion recurrence, with no language or regional restrictions. We used random-effects models to assess odds ratios (OR) and mean difference (MD) with 95% confidence intervals (CI). Adverse events associated with the interventions were also assessed. This study was registered on PROSPERO, CRD42023449068. RESULTS: Data from 21 randomized controlled trials involving 2406 patients were synthesized, including interventions with balloon, amnion, platelet-rich plasma (PRP), intrauterine device (IUD), hyaluronic acid (HA), platelet-rich fibrin (PRF), and granulocyte colony-stimulating factor (G-CSF). The top 5 interventions for change in AFS scores were: PRP + Balloon (MD = 5.44; 95% CI, 2.63-8.25), Amnion + Balloon (MD = 5.08; 95% CI, 2.71-7.44), IUD + Balloon (MD = 4.89; 95% CI, 2.49-7.30), HA + Balloon (MD = 3.80; 95% CI, 1.78-5.82), and G-CSF + Balloon (MD = 3.84; 95% CI, 1.05-6.63). There were no statistically significant differences between interventions in the recurrence rate of moderate-to-severe uterine adhesions and the clinical pregnancy rate. Most interventions were safe. CONCLUSIONS: To our knowledge, this is the most comprehensive network meta-analysis to date of interventions for preventing postoperative intrauterine adhesion recurrence. Our results indicate that PRP + Balloon seems to be the most effective approach.

Uterovesical fistula and its treatment in Sub-Saharan Africa.

AIM:  Aim of the study to summarize the current information on diagnostic and treatment options for uterovesical fistula as a consequence of iatrogenic complication. Methods: Literature review of available information on surgical treatment options for uterovesical fistula resulting from previous caesarean section and comparison with our own experience in the developing world. Conclusion: Uterovesical fistula is an abnormal communication between the bladder and uterus. The cause of this pathology in most cases is an iatrogenic complication, most commonly arising after a caesarean section. The incidence of this pathology varies significantly geographically. In developed countries, these fistulas are rather rare. On the other hand, in developing countries, uterovesical fistulas are more common with a significant impact on the subsequent life of the patient due to generally inaccessible health care.

Intrauterine adhesion in ultrasound-guided manual vacuum aspiration (USG-MVA) versus electric vacuum aspiration (EVA): a randomised controlled trial.

BACKGROUND: Intrauterine adhesion (IUA) can arise as a potential complication following uterine surgery, as the surgical procedure may damage the endometrial stratum basalis. The objective of this study was to assess and compare the occurrence of IUA in women who underwent ultrasound-guided manual vacuum aspiration (USG-MVA) versus electric vacuum aspiration (EVA) for managing first-trimester miscarriage. METHODS: This was a prospective, single-centre, randomised controlled trial conducted at a university-affiliated tertiary hospital. Chinese women aged 18 years and above who had a delayed or incomplete miscarriage of ≤ 12 weeks of gestation were recruited in the Department of Obstetrics and Gynaecology at the Prince of Wales. Recruited participants received either USG-MVA or EVA for the management of their miscarriage and were invited for a hysteroscopic assessment to evaluate the incidence of IUA between 6 and 20 weeks after the surgery. Patients were contacted by phone at 6 months to assess their menstrual and reproductive outcomes. RESULTS: 303 patients underwent USG-MVA or EVA, of whom 152 were randomised to 'USG-MVA' and 151 patients to the 'EVA' group. Out of the USG-MVA group, 126 patients returned and completed the hysteroscopic assessment, while in the EVA group, 125 patients did the same. The incidence of intrauterine adhesion (IUA) was 19.0% (24/126) in the USG-MVA group and 32.0% (40/125) in the EVA group, showing a significant difference (p < 0.02) between the two groups. No significant difference in the menstrual outcomes at 6 months postoperatively between the two groups but more patients had miscarriages in the EVA group with IUA. CONCLUSIONS: IUAs are a possible complication of USG-MVA. However, USG-MVA is associated with a lower incidence of IUA postoperatively at 6-20 weeks. USG-MVA is a feasible, effective, and safe alternative surgical treatment with less IUA for the management of first-trimester miscarriage. TRIAL REGISTRATION: The study was registered with the Centre for Clinical Research and Biostatics- Clinical Trials Registry (CCRBCTR), which is a partner registry of the WHO Primary Registry-Chinese Clinical Trials Registry (ChiCTR) (Unique Trial Number: ChiCTR1900023198 with the first trial registration date on 16/05/2019).

A retrospective cohort study to examine factors affecting live birth after hysteroscopic treatment of intrauterine adhesions.

OBJECTIVE: To evaluate independent factors that affect the chance of live birth (LB) after hysteroscopic adhesiolysis in patients with intrauterine adhesions. DESIGN: Retrospective cohort study. SETTING: Hysteroscopic center of Fuxing Hospital in Beijing, China. PATIENT(S): Patients diagnosed with Asherman syndrome between June 2020, and February 2022. INTERVENTION(S): Hysteroscopic adhesiolysis is followed by a second look hysteroscopy to assess the outcome and follow-up for a year. MAIN OUTCOME MEASURE(S): Live birth rate (LBR) without the use of assisted reproductive technologies at 12-month follow-up. RESULT(S): Of the 544 women included in the cohort, the pregnancy rate at the end of 1 year of follow-up was 47.6% (95% confidence interval [CI] 45.5%-49.7%), and the LBR was 41.0% (95% CI 38.9%-43.1%). Stepwise multiple logistic regression analysis identified three independent predictors of LB in decreasing order of significance: increase in menstrual flow after surgery (odds ratio [OR] 3.69, 95% CI 1.77-8.21), postoperative endometrial thickness in the midluteal phase (OR 1.53, 95% CI 1.31-1.80), and the severity of recurred adhesion at second-look hysteroscopy (OR 0.62, 95% CI 0.50-0.76). Among subjects with good independent prognostic factors, namely, increased menstrual flow after surgery, postoperative endometrial thickness in the midluteal phase >6 mm, and no or minimal recurrence of adhesions at second-look hysteroscopy, the LBR was 69.0% (95% CI 65.4%-72.6%). On the other hand, in women (n = 26) without any of the three good prognostic factors, none had a successful LB (0). CONCLUSION(S): Overall, the LBR after treatment for Asherman syndrome was 41.0%. The prognosis is dependent on three outcome measures after surgery, namely, improvement in menstrual flow, postoperative endometrial thickness, and the minimal degree of recurrent adhesions at second-look hysteroscopy.

The predictive value of serum IL-17A and IL-6 expression in postoperative recurrence in patients with intrauterine adhesion.

BACKGROUND: The recurrence rate of intrauterine adhesions (IUA) was high. At present, there are few studies on the relationship between proinflammatory factors IL-17A and IL-6 and IUA. The expression of serum IL-17A and IL-6 in IUA patients and their predictive value for postoperative recurrence were retrospectively analyzed. METHODS: A total of 90 IUA patients who underwent hysteroscopic adhesion lysis in our hospital from January 2020 to January 2023 were selected as the IUA group. Patients were divided into mild, moderate, and severe IUA groups. At the same time, 60 cases of secondary infertility patients with normal endometrium were selected as the control group. The clinical baseline characteristics and serum levels of IL-17A and IL-6 were compared between control group and IUA group. To analyze the correlation and predictive value of IL-17A and IL-6 expression levels with the recurrence rate of IUA patients. RESULTS: The preoperative levels of IL-17A and IL-6 in the IUA group were significantly higher than those in the control group. The higher the levels of inflammatory factors IL-17A and IL-6, the deeper the degree of IUA. Multivariate analysis showed that pregnancy, curettage history, IL-17A, and IL-6 levels were risk factors for IUA recurrence. In addition, the specificity and area under the curve of combining baseline data with postoperative serum IL-17A and IL-6 for predicting IUA were higher than those predicted separately. CONCLUSION: The expression levels of serum IL-17A and IL-6 can be used as a value index to evaluate postoperative recurrence in IUA patients.

Hysteroscopy-assisted suction curettage for early pregnancy loss: does it reduce retained products of conception and postoperative intrauterine adhesions?

OBJECTIVE: To describe the feasibility of hysteroscopy-assisted suction curettage for early pregnancy loss and to investigate whether it reduces the rates of retained products of conception (RPOC) and intrauterine adhesions (IUA). DESIGN: Prospective single-arm cohort study. SETTING: University-affiliated Department of Obstetrics and Gynecology. PATIENTS: Women admitted for surgical evacuation of early pregnancy loss were invited to participate in the study. INTERVENTION: Vaginal misoprostol was administered for cervical ripening preoperatively. Under general anesthesia, a diagnostic hysteroscopy was performed to identify the pregnancy's implantation wall, followed by ultrasound-guided suction and curettage directed to the implantation wall, and then diagnostic hysteroscopy to verify complete uterine cavity emptying. Postoperative IUA were evaluated by follow-up office hysteroscopy. MAIN OUTCOME MEASURE: Identification of the pregnancy's implantation wall on hysteroscopy, and intra-, and postoperative complications associated with the procedure. The evaluation of postoperative IUA was limited due to the COVID-19 pandemic-related restrictions on elective procedures. RESULTS: Forty patients were included in the study group. Their mean age was 34.0 ± 6.6 years, and their mean gestational age was 8.9 ± 1.6 weeks. The implantation wall was clearly visualized on hysteroscopy in 33 out of 40 cases (82.5%). The mean operative time was 17.2 ± 8.8 min, and no intraoperative complications occurred. Suspected RPOC were diagnosed intraoperatively by hysteroscopy and removed in 4 cases, and the histologic examination confirmed the presence of RPOC in three of them. Follow-up office hysteroscopy was performed in nine women: mild IUA was diagnosed in one case and a normal cavity was confirmed in eight cases. A new pregnancy was reported at the time of follow-up in 15 cases, while 12 women declined to attend the follow-up hysteroscopy and four were lost to follow-up. CONCLUSIONS: Hysteroscopy-assisted suction curettage for early pregnancy loss is a safe, short, and inexpensive procedure, which allows the identification of the pregnancy's wall in most cases and may reduce the rates of RPOC.

Comparative outcomes between transvaginal endoscopic hysterectomy and total laparoscopic hysterectomy in patients with benign uterine disease: A single-center, retrospective, cohort, interrupted time-series study.

OBJECTIVES: To compare the surgical outcomes of total laparoscopic hysterectomy (TLH) and transvaginal endoscopic hysterectomy (TVEH) for benign uterine diseases. METHODS: This retrospective, cohort, interrupted time-series study included patients who underwent TLH between January 2013 and September 2016 and TVEH between October 2016 and June 2020. Median difference regression was used to compare the hospital length of stay (LOS) and operative time between the groups. Risk difference regression was used to analyze the proportion of patients who developed postoperative fever or vaginal stump infection. RESULTS: Of the total 171 patients enrolled, 101 and 70 underwent TVEH and TLH, respectively. The mean ages of patients in the TVEH and TLH groups were 46.49 and 46.17 years, respectively. No conversion was observed. Ureteric injury occurred in one patient in the TVEH group, whereas there was no organ injury in any of the patients in the TLH group. Compared with those in the TLH group, patients in the TVEH group had a significantly shorter median operative time, shorter hospital LOS, lower morphine use, and lower postoperative febrile morbidity rates. However, no significant difference was observed in the rate of vaginal stump infection between the groups. CONCLUSION: Given the shorter operative time, shorter hospital LOS, less febrile morbidity, and lower morphine use in patients with TVEH than in those with TLH, TVEH should be considered as an alternative hysterectomy procedure for benign uterine diseases.

Diffuse uterine leiomyomatosis: a rare discovery.

PURPOSE: This case report aims to present a rare and challenging clinical scenario involving diffuse uterine leiomyomatosis (DUL), an infrequently encountered benign uterine pathology. The primary objective is to describe this unique case's clinical presentation, diagnostic challenges, and subsequent management. METHODS: A detailed analysis of the patient's medical history, diagnostic evaluations, and treatment approach was conducted. A relevant literature review on DUL was also performed. This case report includes high-resolution images and figures, showcasing MRI scans, surgical procedures, and histopathology slides related to the case. RESULTS: The case report outlines the clinical journey of a patient with DUL, an exceptionally rare uterine condition characterized by the uncontrolled proliferation of smooth muscle cells forming nodules and fascicles. This case illustrates the diagnostic complexities associated with DUL, as it mimics other uterine pathologies such as leiomyomas or adenomyosis. The patient's clinical presentation included abnormal uterine bleeding, heavy menstrual bleeding, fertility issues, and dysmenorrhea, leading to initial misdiagnoses. Surgical intervention eventually addressed the condition with corresponding images illustrating the procedures. CONCLUSION: This case report highlights DUL's rarity and diagnostic challenges. Clinicians must be vigilant when encountering similar clinical presentations, ensuring a comprehensive diagnostic workup to differentiate DUL from other uterine pathologies. Enhanced awareness among healthcare providers and further research into DUL's pathophysiology is essential for accurate diagnosis and timely management. The presented case underscores the need for tailored approaches to managing DUL and expanding the knowledge base surrounding this puzzling uterine disorder.

Hysteroscopic Lysis of Complex Uterine Adhesions After Interventional Radiology-Guided Access.

OBJECTIVE: To demonstrate a novel surgical technique using hysteroscopic lysis of adhesions after interventional radiology (IR)-guided access in patients with severe intrauterine adhesions and challenging uterine access. DESIGN: This video illustrates the technique of the safe division of intrauterine adhesions after IR-guided access. SETTING: Conventional hysteroscopic adhesiolysis might be inadequate or risky in cases of severely narrowed or obstructed uterine flow tract, possibly resulting in incomplete adhesiolysis, false passages, or uterine perforation. This video presents 2 cases from a tertiary center involving a multidisciplinary team of a reproductive surgeon and an interventional radiologist. The first case involves a 38-year-old with severe Asherman syndrome, who experienced unsuccessful attempt to treat adhesions that was complicated by a false passage. The second case involves a 39-year-old with recurrent severe Asherman syndrome and a history of unsuccessful attempts at hysterosalpingogram and conventional hysteroscopic lysis of adhesions. INTERVENTIONS: In the IR suite, the patient was put in a lithotomy position on the fluoroscopy table. A vaginal speculum was inserted exposing the cervix. The procedure was performed using intravenous sedation and topical anesthetic spray applied to the cervix. Using fluoroscopy, a balloon cannula was inserted through the cervix, followed by contrast injection to assess uterine access. If there is no route, transvaginal ultrasound-guided needle cannulation of the main portion of the uterine cavity would be performed, approximating as closely as possible to the expected route of the cervical canal. A guidewire followed by a locked loop catheter was advanced through adhesions into the uterine cavity. The catheter was left protruding from the cervix to guide the hysteroscope. The patient was then transferred to the operating room for the hysteroscopic procedure. Under the guidance of the intrauterine catheter, the adhesions were carefully lysed using cold scissors. The endometrial cavity and tubal openings were inspected to ensure complete adhesiolysis and exclusion of any other copathologies. CONCLUSION: IR guidance can provide a safe and effective approach to hysteroscopic lysis of adhesions in patients with challenging intrauterine adhesions and difficult uterine access, such as patients with severe Asherman syndrome, intractable cervical stenosis, uterine wall agglutination, previous adhesiolysis failure, marked fixed retroverted retroflexed uteri, and previous false passage or uterine perforation.

Fertility and anatomical outcomes following hysteroscopic adhesiolysis: An 11-year retrospective cohort study to validate a new classification system for intrauterine adhesions (Urman-Vitale Classification System).

OBJECTIVE: To propose a new classification system (Urman-Vitale Classification System) for intrauterine adhesions (IUAs) and to evaluate anatomical and fertility outcomes after hysteroscopic adhesiolysis accordingly. METHODS: A retrospective analysis of consecutive patients treated over 11 years by a single operator in a tertiary care hospital. Women with sonographic suspicion of IUAs were scheduled for hysterosalpingography (HSG) and hysteroscopy for confirmation and treatment. IUAs were divided into five classes according to symptoms, ultrasound, HSG findings, and postsurgical hysteroscopic appearance. Hysteroscopic adhesiolysis was performed using a bipolar cutting electrode in an office setting. Evaluated outcomes were restoration of the uterine cavity, clinical pregnancy, pregnancy loss, and live birth rates. RESULTS: A total of 227 patients (479 procedures) were included. Mean number of hysteroscopies increased in frequency with class of adhesions from Class 1 to Class 5 (1.0 ± 0.2 vs 2.3 ± 0.5; P = 0.001). Full restoration of the cavity was achieved in 100% of patients with Class 1 compared with 18.5% for Class 5 (43/43 vs 5/27; P = 0.001). Clinical pregnancy (Class 1 vs Class 4: P = 0.034; 1 vs 5: P = 0.006; 2 vs 5: P = 0.024) and live birth (Class 1 vs Class 4: P = 0.001; 1 vs 5: P = 0.006; 2 vs 4: P = 0.007; 2 vs 5: P = 0.0208) rates decreased with increasing severity of IUAs. Pregnancy loss rate was related to IUA severity (Class 1 vs Class 4: P = 0.012; 1 vs 5: P = 0.003: 2 vs 4: P = 0.014; 2 vs 5: P = 0.021). CONCLUSION: A classification based on symptoms, imaging findings, and postsurgical macroscopic appearance of the uterine cavity could be useful in predicting prognosis and fertility in women with IUAs.

Incidence of intrauterine adhesion after ultrasound-guided manual vacuum aspiration (USG-MVA) for first-trimester miscarriages: a prospective cohort study.

PURPOSE: Ultrasound-guided manual vacuum aspiration (USG-MVA) is a feasible and effective outpatient treatment to treat early pregnancy loss. METHODS: This was a prospective observational study at a university-affiliated hospital. All women undergoing either a USG-MVA or electric vacuum aspiration (EVA) were invited to return 3-6 months later for follow-up at which women completed a questionnaire to document their post-evacuation menstrual and reproductive history, and underwent a hysteroscopy if they were not pregnant. The severity of intrauterine adhesion (IUA), if present, was graded (Stage I-III) according to the American fertility society classification. RESULTS: A total of 292 women had a hysteroscopy after their initial surgical evacuation, USG-MVA 169(57.9%) versus EVA 123(42.1%). Women undergoing EVA as opposed to a USG-MVA had a 12.9% higher incidence of IUA (24.1% vs. 37.0%, p = 0.042) equivalent to 1.84 times higher risk (95% CI 1.01-3.34; p = 0.048). Women having EVA continued to show an increased but not statistically significant trend towards an increased risk of IUA after adjusting for the type of miscarriage (aOR = 1.3; 95% CI 0.66-2.50; p = 0.46). CONCLUSION: There were no significant differences in their reproductive outcomes and fewer women post-USG-MVA complained of hypomenorrhea. IUA may still occur in women undergoing USG-MVA but it is lower than the rate in women undergoing EVA. Clinical trials registry The trial was registered with the Centre for Clinical Research and Biostatistics - Clinical Trials Registry (CCRBCTR), a partner registry of the WHO Primary Registry-Chinese Clinical Trials Registry (ChiCTR) with a Unique Trial Number: CUHK_CCRB00541 on 22 Dec 2016.

Perioperative outcomes of transvaginal natural orifice transluminal endoscopic surgery and transumbilical laparoendoscopic single-site surgery in hysterectomy: A comparative study.

OBJECTIVE: This study aimed to compare the perioperative outcomes of patients who underwent hysterectomy for benign gynecologic diseases using transvaginal natural orifice transluminal endoscopic surgery (vNOTES) or transumbilical laparoendoscopic single-site surgery (TU-LESS). METHODS: A total of 314 patients who underwent hysterectomy for benign uterine disease at West China Second University Hospital between October 2018 and December 2021 were enrolled in this retrospective study. vNOTES (n = 157) and TU-LESS (n = 157) recipients were matched 1:1 in terms of uterine volume. The operation time, blood loss, postoperative decrease in hemoglobin, uterus weight, postoperative hospital stay, postoperative pain score at 12 h, postoperative indwelling catheter time, and other clinical indicators were compared between the two groups. RESULTS: All 314 patients successfully completed the surgery, and the two groups had similar baseline characteristics, with no statistical difference. Regarding intraoperative outcomes, the operation time was shorter in the vNOTES group than in the TU-LESS group (80 vs 100 min, P = 0.04), and there were no significant differences in intraoperative blood loss, intraoperative blood transfusion rate, postoperative decrease in hemoglobin, or uterine weight. Concerning postoperative outcomes, vNOTES hysterectomy was significantly superior to TU-LESS hysterectomy in terms of the length of hospital stay (3 vs 4 days, P < 0.001), visual analog scale score for pain at 12 h after surgery (P = 0.04), postoperative indwelling catheter time (39.5 vs 64.0 h, P < 0.001), and postoperative exhaust time (24.0 vs 42.0 h, P < 0.001). There were no significant differences in postoperative complications between the two groups. CONCLUSION: vNOTES and TU-LESS seem safe and feasible for hysterectomy, but vNOTES hysterectomy was more conducive to the postoperative rehabilitation of patients, with less trauma, less pain, and better cosmetic effects than TU-LESS hysterectomy. As an emerging surgical approach, more studies, including large-sample, multicenter, randomized controlled trials, are needed to validate our findings.