Intrauterine device extraction through laparoscopic hysterotomy.

CASE REPORT: A 52-year-old woman with an intrauterine device placed more than 10 years before consulted our department after a failed attempt to its removal in the outpatient area. While performing the colposcopy a completely fibrosed cervical canal permitted no access to the uterine cavity. The IUD was confirmed to still be placed intrauterine by pelvix x-ray and an endovaginal sonography. Due the risk for future infections, a device extraction was recommended, although the patient categorically refused a hysteroscopic approach as an hysterectomy. After discussing all available options the patient agreed on a laparoscopic approach with uterine conservation. It was performed through a vertical hysterotomy with the electrocautery hook and the incision closed using intracorporeal vycril stitches. The patient was dismissed 48 h after surgery. A sonographic control was carried 6 months later revealing no evidence of scar complication. DISCUSSION: Hysteroscopy with or without sonographic intraoperative control to avoid uterine perforation, remains the recommended treatment in case of retained IUD. Difficult cases with a fibrotic cervix can be dilated with a scalpel under general anaesthesia before hysteroscopy to retrieve the coil. Laparoscopic approach is usually being used as a minimally invasive procedure for the extraction of IUD that are misplaced or migrate to the peritoneal cavity. In very seleted cases, laparoscopy can be a useful tool in case other approaches are ineffective or rejected by the patient.

A phase III randomised trial of trans-abdominal ultrasound in improving application quality and dosimetry of intra-cavitary brachytherapy in locally advanced cervical cancer.

INTRODUCTION: Intra-cavitary brachytherapy (ICB) remains an integral part of radiotherapy treatment in cervical cancer. Two-dimensional X ray point-based planning remains common and blind insertion leads to uterine perforations and higher toxicity. We conducted a randomised controlled trial of using trans-abdominal ultrasound in performing ICB to reduce perforation and organ at risk doses. PATIENT AND METHODS: The present study is a phase III open label randomised controlled trial of ultrasound guided ICB conducted on invasive cervical cancer patients. Patients were randomised by a simple computer-generated randomization chart into Arm A (No Ultrasound guidance) and Arm B (ICB with ultrasound guidance). The uterine perforation rates, tandem length change rates, bladder doses, rectal dose and procedure times were compared. Fischer exact test was used to compare the arms and p value <0.05 considered significant. RESULTS: A total of 160 patients were randomised. With US assistance, the uterine perforation rate was 1.25% (n = 1). In the non-US assistance arm the perforation rate was 12.5% (n = 10) (p = 0.005). Mean time to complete the entire procedure was significantly shortened from 26 min to 19 min favouring the US arm (p = 0.001). Dosimetric assessment between the two groups showed significant decrease in dose received by the various organs at risk with US assistance. CONCLUSION: The present study confirms significant improvement in application quality as well as dosimetry with reduction in procedure time. Trans-Abdominal US should be routinely used for ICB procedures, particularly in resource limited settings.

Intraoperative Ultrasound Guidance During Curettage After Second-Trimester Delivery is Associated With a Higher Rate of Complications.

OBJECTIVE: The use of intraoperative ultrasound guidance for second-trimester elective dilation and curettage reduces the incidence of uterine perforation. However, the role of intraoperative ultrasound guidance during curettage following second-trimester delivery has not been evaluated. We aim to evaluate the effect of intraoperative ultrasound guidance during curettage following second-trimester delivery. METHODS: We conducted a retrospective cohort study that included patients who had a second-trimester delivery at up to 236/7 weeks gestation and underwent uterine curettage after the fetus was delivered. RESULTS: Overall, 273 patients were included. Of them, 194 (71%) underwent curettage without intraoperative ultrasound guidance, while 79 (29%) underwent the procedure utilizing intraoperative ultrasound guidance. The overall rate of a composite adverse outcome was higher among those undergoing curettage under intraoperative ultrasound guidance compared with no ultrasound guidance (31 [39.2%] vs. 40 [20.6%]; OR 2.4; 95% CI 1.4-4.4, P = 0.002). Placental morbidity (10 [12.6%] vs. 11 [5.6%]; OR 1.9; 95% CI 1.01-5.9, P = 0.04) and infectious complications (6 [7.5%] vs. 5 [2.5%]; OR 3.1; 95% CI 1.01-10.4, P = 0.05) were more frequent among those undergoing curettage with intraoperative ultrasound guidance. In a multivariate logistic regression analysis, intraoperative ultrasound guidance was the only independent factor positively associated with the occurrence of an adverse outcome (adjusted OR 1.93; 95% CI 1.1-3.4, P = 0.02). Procedure time was longer when ultrasound guidance was used (9:52 vs. 6:58 min:s; P < 0.001). CONCLUSION: Intraoperative ultrasound guidance during curettage after second-trimester delivery is associated with a higher complication rate than no guidance.

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.

Ultrasound guidance during hysteroscopic myomectomy in G1 and G2 Submucous Myomas: for a safer one step surgery.

OBJECTIVE: Hysteroscopic myomectomy is the gold standard method for treatment of submucous fibroids. Hysteroscopic myomectomy techniques for removal of submucous fibroids still have controversies. In this study we aimed to describe usefulness of ultrasound guidance in hysteroscopic myomectomy for a safe and effective removal of submucous G1 and G2 fibroids. STUDY DESIGN: This is a multicentre study. 64 symptomatic patients with submucous fibroid underwent ultrasound guided hysteroscopic myomectomy. First we excised intrauterine dome of fibroid until reaching the level of cavity wall by the method of resectoscopic (electrosurgical resection using a loop electrode) slicing. Next remnant intramural node was squeezed by uterine contractions induced. After we had excised the intrauterine dome of fibroid by slicing method, we formed cavitation for the intramural part (newly raised myoma dome). The cavity was filled with distension solution and we evaluated the margins of the uterus and the margins of the myoma by sonographically. Then the myoma was excised under ultrasonographic guidance by transabdominal probe. We obtained a regular uterine cavity. RESULTS: Mean operation time was 42±7min. Mean Mannitol volume was 4.3±1.7l and the mean intraoperational fluid deficit was 500ml. Not in any case uterine perforation was occurred. All fibroids removed totally. In 8 (19%) cases intrauterine synechiae detected and all these synechiaes were incised by a scissor during hysteroscopy. CONCLUSION: There is still no single technique proven to be unequivocally superior to the others for treating fibroids with intramural development (G1-G2). Ultrasound guided hysteroscopy seems to be an effective and safe method for resection of G1 and G2 fibroids.

Feasibility of a new two-step procedure for office hysteroscopic resection of submucous myomas: results of a pilot study.

OBJECTIVE: To assess the feasibility of a new two-step technique for office hysteroscopic resection of submucous myomas. STUDY DESIGN: Between January 2010 and December 2011, all consecutive patients of reproductive age with symptomatic lesions sonographically diagnosed as single mainly intracavitary (G1 or G2) myoma ≤4.0 cm were eligible to participate in a prospective study. They underwent a two-step hysteroscopic procedure, which included preparation of partially intramural myomas with incision of the endometrial mucosa and the pseudocapsule covering the myoma in the first step, and excision of the myoma by means of diode laser four weeks later. All procedures were performed on an outpatient basis and without anesthesia. RESULTS: A total of 43 women (mean age 36.7 years) were included. The two-step myomectomy technique was successfully performed in 34 (79.1%) patients. All myomas ≤18 mm were successfully enucleated as compared with 85% of 19-30 mm, and 0% of ≥30 mm (P<0.001). Also, myomas located in the anterior/posterior walls and those located in the fundus/lateral walls were enucleated in 87.9% and 50% of cases, respectively (P=0.020). Success of surgery was not influenced by the initial type of myoma. CONCLUSION: The new two-step hysteroscopic myomectomy carried out as an outpatient procedure and without anesthesia is feasible for the excision of symptomatic submucous fibroids.

Success rates of intrauterine inoculations of layers via the vagina.

Intrauterine inoculation of layer hens has been documented previously in the literature; however, its efficiency has only been assessed on a very small scale. Attempts were therefore made to inoculate 14 experimental groups each consisting of 10 commercial table egg-producing hens intrauterinely with methylene blue. The effect of four variables-oviposition (natural, hormonally induced or not), position of the hen at inoculation (vertical/horizontal), technique to access the uterus (three methods) and inoculation device (four types)-on the success rate of intrauterine inoculation of layers of different breed and age was studied. Immediately after inoculation, hens were euthanized and the presence of methylene blue and perforations in the oviduct were examined. Successful inoculation rates ranged from 0/10 to 10/10. The 100% success rate was obtained in birds without an egg in the uterus, which were restrained in a horizontal position and inoculated with a hard catheter after exposure of the uterovaginal junction. The second best score was obtained in hens inoculated shortly after natural oviposition, maintained in a vertical position and using a corkscrew-shaped saliva ejector after exposure of the vaginal orifice (7/10). In all other groups the success rate was 5/10 or less. Vaginal perforation occurred in none to eight birds per group. It is concluded that intrauterine inoculation of laying hens is only reliable in birds without an egg in the uterus after exposure of the uterovaginal junction. All other methods proved unreliable and often caused vaginal perforations. However, intravaginal inoculation can be performed with 100% accuracy providing the vaginal orifice is exposed.

A new experimental three-dimensional, reticular intrauterine device (3-DRIUD) composed of nitinol and silicone rubber.

BACKGROUND: The aim of this study was to explore a new three-dimensional, reticular intrauterine device (3-DRIUD) composed of nitinol and silicone rubber and to observe the contraceptive effect of the device in rats. STUDY DESIGN: Two contraceptive experiments were performed. In the first, female rats underwent bilateral placement of a 20.0-35.0-mm 3-DRUID (experimental group, n=30) via an abdominal incision or a sham operation with no IUD (control group, n=30). Two weeks after the operation was performed, the rats from either group were caged together with male rats. The contraceptive effects of the 3-DRIUD were observed at 1 to 3 months postoperation, after which the 3-DRIUDs were removed. One month after this second operation, the rats from the two groups were again coupled with fertile male rats. In a second experiment, female rats underwent bilateral placement of a 10.0-mm 3-DRUID (n=5) via an abdominal incision or a two-dimensional IUD (2-DIUD, n=20) and mated 1 month after surgery. The single-pipeline IUD was placed in 10 rats, while the enfolded-pipeline IUD was placed in 10 different rats. RESULTS: In the first experiment, none of the females in the experimental 3-DRIUD group became pregnant (0/30, 0%) after 3 months, compared to 28/30 (93.3%, p<.0001) rats in the control group. After the 3-DRIUDs were removed from the experimental group after 3 months, 27/30 (90%) became pregnant, compared with 29/30 (97%, p>.05). The litter size (mean±SD) did not differ between groups (10.9±1.5 3-DRUID, 11.2±1.1 control, p>.05). In the second experiment, five rats had a 10.0-mm 3-DRUID (which was one third the length of one uterine horn) inserted into the bilateral uterine horns, and three of the five rats became pregnant. All 20 rats were pregnant 1 month after the insertion of the 2-DIUD. Thus, the contraceptive rate for the 2-DIUD group was 0. CONCLUSIONS: The primary contraceptive mechanism effect of the new 3-DRIUD in rodents appears to be a result of occupying physical space in the uterus.

Should uterine tandem applicators ever be placed without ultrasound guidance? No: a brief report and review of the literature.

BACKGROUND: Brachytherapy is an integral component of the curative treatment of locally advanced cervical cancer. Optimal applicator placement is associated with improvements in local control and treatment-related toxicity. Uterine perforation by the tandem is common and often undetected by orthogonal radiographs. The role of ultrasound in guiding tandem placement remains controversial. METHODS: A 55-year-old woman with International Federation of Gynecology and Obstetrics stage IIB cervix cancer underwent placement of a Fletcher-Suit-Delcos tandem and ovoids applicator. Postoperative computed tomography was used for treatment planning. RESULTS: The applicator appeared to be appropriately placed on clinical exam and orthogonal radiographs. Postoperative computed tomography revealed the tandem had perforated the anterior uterine wall. In a second procedure, the tandem was placed correctly under intraoperative ultrasonography. CONCLUSIONS: A review of the literature finds a relatively high rate of uterine perforation of the uterus that is undetected by orthogonal radiographs or clinical examination. Multiple reports support the use of real-time ultrasound for patients with especially challenging anatomy. As this report illustrates, uterine perforation is possible in any patient. Therefore, routine real-time ultrasonography should be considered for all uterine tandem insertions.

Ultrasound-guided tandem placement for low-dose-rate brachytherapy in advanced cervical cancer minimizes risk of intraoperative uterine perforation.

OBJECTIVES: Tandem placement as part of low-dose-rate (LDR) brachytherapy boost for cervical cancer may be complicated by uterine perforation. The objective of this study was to describe a 10-year experience of using intraoperative ultrasound guidance in an attempt to minimize the risk of uterine perforation. METHODS: Operative and inpatient records were reviewed to identify cases in which intraoperative ultrasound guidance was employed in order to assist tandem placement, and to determine whether clinical or radiographic findings subsequently suggested uterine perforation. Demographic factors were collected in order to determine the baseline risk of perforation within this population. RESULTS: Between 1998 and 2008, 71 patients underwent 110 ultrasound-guided placements of tandem applicators. The median age was 48 (range, 26-88) years, and 20% were older than 60 years. Disease stage was FIGO IB1 (n = 10), IB2 (n = 13), IIA (n = 4), IIB (n = 19), IIIA (n = 2), IIIB (n = 16), IVA (n = 5) and IVB (n = 2). The median gravidity was 3 (range 1-10) and median parity was 3 (range 0-10). Seven patients had a preimplant history of pelvic infection, four had a history of intrauterine contraceptive device use, and 10 had a prior history of Cesarean section delivery. Only one patient experienced infection that may have been attributable to tandem placement-associated uterine perforation. At median survivor follow-up of 34 months, 19 patients had died. The estimated 3-year disease-free and overall survival rates for the entire population were 60% and 66%, respectively. CONCLUSIONS: Within the present population, intraoperative ultrasound guidance of tandem placement was associated with no confirmed cases of uterine perforation.

Complications of hysteroscopic and uterine resectoscopic surgery.

Adverse events associated with hysteroscopic procedures are in general rare, but, with increasing operative complexity, it is now apparent that they are experienced more often. A spectrum of complications exist ranging from those that relate to generic components of procedures such as patient positioning and anesthesia and analgesia, to a number that are specific to intraluminal endoscopic surgery (perforation and injuries to surrounding structures and blood vessels). The response of premenopausal women to excessive absorption of nonionic fluids deserves special attention. There is also an increasing awareness of uncommon but problematic sequelae related to the use of monopolar uterine resectoscopes that involve thermal injury to the vulva and vagina. The uterus that has previously undergone hysteroscopic surgery can behave in unusual ways, at least in premenopausal women who experience menstruation or who become pregnant. Better understanding of the mechanisms involved in these adverse events, as well as the use or development of several devices, have collectively provided the opportunity to perform hysteroscopic and resectoscopic surgery in a manner that minimizes risk to the patient.

Safety of late second-trimester pregnancy termination by laminaria dilatation and evacuation in patients with previous multiple cesarean sections.

OBJECTIVE: To assess whether there is an increased perioperative risk in termination of late second-trimester pregnancy after multiple cesarean sections by laminaria dilatation and evacuation. STUDY DESIGN: During the period between January 2002 and June 2008, 636 consecutive patients underwent late second-trimester (17-24 weeks) pregnancy terminations by dilatation and evacuation. Patients were divided into 3 subgroups: those with no previous cesarean section (n = 545), those with 1 previous cesarean section (n = 59), and those with several previous cesarean sections (n = 32). RESULTS: There were no significant differences in major perioperative complications, such as anesthetic complications, need for blood transfusion, and cervical lacerations comparing the 3 subgroups. Importantly, there were neither cases of uterine perforation nor retained products of conception in the 3 subgroups. CONCLUSION: Late second-trimester pregnancy termination after multiple cesarean sections by laminaria dilatation and evacuation is probably not associated with an increased perioperative risk. Larger studies are needed to empower this study.

Managing bleeding, fluid absorption and uterine perforation at hysteroscopy.

Hysteroscopy is the current gold standard for evaluating intrauterine pathology, including submucous fibroids, polyps, hyperplasia and cancer. However, there are still problems and complications connected to hysteroscopy. Fluid overload of 1-2l occurs in approximately 5.2% and >2l in 1% of cases. This article discusses the physiology, implications and treatment of these cases. Uterine perforation is encountered in nearly 1% of cases. We describe the precautions to avoid this perforation and the methods to treat it. The article also discusses excessive bleeding, which occurs in 3% of operative hysteroscopies and describes strategies to avoid and to deal with this complication. Emergency hysterectomy and other surgical interventions are rarely indicated and are seen in 2% of cases. Finally, death due to septicaemia or fluid overload has been reported only very rarely (0.1%). These different complications are discussed in detail.

A survey of uterine perforation following dilatation and curettage or evacuation of retained products of conception.

STUDY: Of 11,914 women who underwent dilatation and curettage over a 7-year period (1995-2002) at Princess Badea Teaching Hospital in Irbid, North Jordan, 23 patients sustained a uterine perforation. In 22 cases, the operator was a trainee. Previous gynaecological surgery had been performed in only 2 of these 23 women. CONCLUSION: Operator inexperience seemed to be the only risk factor in this very common operation.

[Brachytherapy in cervix cancers: development of techniques and concepts]. / Curiethérapie dans les cancers du col utérin: évolution des techniques et des concepts.

Brachytherapy plays an important role in the treatment of patients with cervical carcinoma. Technical modalities have evolved during the last years and have benefited from imaging modalities development, specially MRI. Imaging modalities contribute to a better knowledge of tumoral extension and critical organs. Ultrasound during brachytherapy has led to the almost complete eradication of uterine perforation. In the future, a more systematic use of systems allowing optimization may induce a better dose distribution in the tumor as well as in the critical organs. Recent data provided information in favor of a better analysis in the relative role of dose-rate, total dose and treated volume and their influence on the local control and complication incidence. Concomitant radiochemotherapy represents a standard in the treatment of patients with tumoral size exceeding 4 cm. Some questions still remain: is concomitant chemotherapy of benefit during brachytherapy? Is there any place for complementary surgery, specially in patients with complete response after external irradiation with concomitant chemotherapy and brachytherapy? In order to answer the former question, a phase III randomized trial is going to start, with the Fédération Nationale des Centres de Lutte Contre le Cancer as a promoter.

Large uterine defect found at cesarean section. A case report.

BACKGROUND: Uncomplicated uterine perforation has been considered a benign event. Since the advent of operative hysteroscopy, there have been several reports of uterine rupture during pregnancy in patients who have undergone that procedure when complicated by known or unsuspected uterine perforation. Large fundal defects without rupture have also been reported. CASE: A 23-year-old, white woman was admitted for labor induction at 42 weeks' gestation. After an unsuccessful attempt at labor induction, a cesarean section (C/S) was performed. At that time a large (5-cm) fundal defect was noted. A thorough history suggested that the defect was probably the result of unsuspected perforation of the uterus during dilatation and currettage for a late first-trimester fetal death. A follow-up hysterosalpingogram was done and consultation obtained regarding future management. A course of expectant management with C/S prior to the onset of labor was advised. Three years later, after an uncomplicated pregnancy, a repeat C/S was done at 38 weeks' gestation. CONCLUSION: Patients with a history of operative hysteroscopy or difficult curettage may have sustained known or unsuspected perforations of the uterus with subsequent scarring or defect, placing them at some risk of uterine rupture during pregnancy. Patients should be counseled regarding these risks, and assessment by hysterography might be helpful.

[Clinical study on 235 cases performed under hysteroscopy combined with laparoscopy].

OBJECTIVE: To evaluate the clinical value of using hysteroscopy combined with laparoscopy in gynecologic disease. METHODS: From January 1995 to January 2001, two hundred thirty five operations were performed under hysteroscopy combined with laparoscopy. This paper focuses on their indications, method and complications as well as management. RESULTS: Among the 235 cases, all of them were performed more than two procedures inside uterine and pelvic cavity. Hysteroscopy underwent on all cases for the lesion of uterine cavity except one changed laparotomy due to heavy bleeding. These hysteroscopy included some complicated operations such as transcervical resection of septum, transcervical resection of adhesion, transcervical resection of embryo bones and IUD pieces embedded endometrium as well as transcervical resection of myoma that the size was bigger than 4.5 centimeter or intramural and broad peduncle one. Seven cases with incomplete uterine perforation and three cases with uterine perforation were found by laparoscopy during hysteroscopic procedures and treated under laparoscopy. In addition, other laparoscopic procedures such as cystectomy, adhesiolysis, myomectomy, hydrotubation, salpingostomy and oophorectomy etc. Were also performed. There were no complications caused by hysteroscopy combined with laparoscopy. CONCLUSIONS: Hysteroscopy combined with laparoscopy can be performed under one anesthesia and managed the lesions in both uterine and pelvic cavity that could not be treated previously with single hysteroscopy or laparoscopy. Hysteroscopy combined with laparoscopy can find out and treat uterine perforation timely and reduce complications.