Ultrasound-Guided Polypectomy: Evaluation of a Novel Technique to Remove Endometrial Polyps in the Office.

OBJECTIVE: To present a novel technique for office resection of pedunculated endometrial polyps under ultrasound guidance. METHODS: A prospective trial was conducted at an academic center where women with abnormal uterine bleeding (AUB) who were diagnosed an endometrial polyp following saline infusion sonogram (SIS), were offered polyp removal under ultrasound guidance using a universal grasping forceps (2.5 mm × 25 cm). The primary outcome was to evaluate the feasibility of this technique for complete removal of the polyp. The secondary outcomes were to evaluate the patients' pain score, satisfaction score using visual analogue score (VAS), and efficacy of the technique in alleviating symptoms in patients with AUB due to polyps. RESULTS: Thirty patients participated, with a mean age of 54.8 ± 11 years. Average polyp volume was 1.87 cm3 and mean duration for polypectomy was 11 minutes 31 seconds. The median pain score immediately post-procedure was 5 (0-9). We were unable to complete the procedure in two patients due to patient discomfort and poor visualization. Complete removal of polyp was ensured by checking for a thin endometrial echo at the end of the procedure and by performing SIS at 3-months post-procedure. Of the 22 patients who returned for follow-up, 19 (86.36%) showed no evidence of polyp on SIS and all reported resolution of AUB symptoms. The median satisfaction score at the follow-up was 10/10. Adequate pathology samples were obtained from all cases, diagnosing malignancy in one and endometrial hyperplasia in one patient. CONCLUSION: This technique offers safe and effective removal of pedunculated endometrial polyps in an office setting, avoiding the need for general anesthesia. It can be offered as a therapeutic option at the initial point of contact, providing symptom relief and tissue diagnosis while reducing costs and patient visits.

Association between Preoperative Adenomyosis Detection Rate during Pelvic Ultrasonography and the Specialty of the Reading Physician.

STUDY OBJECTIVE: To compare the detection rate of adenomyosis when ultrasound is performed by a radiologist compared with a gynecologic expert sonologist. DESIGN: A retrospective, single-center study. SETTING: A university teaching hospital. PATIENTS: All women above 18 years of age with a positive histopathology diagnosis of adenomyosis obtained in a hysterectomy specimen from October 1, 2011, to October 1, 2017, were screened for inclusion. Cases without a preoperative pelvic ultrasound report, those with coexisting premalignant/malignant conditions, and patients presenting to the clinic with symptoms other than abnormal uterine bleeding, dysmenorrhea, or abdominal pain were excluded. A total of 412 cases were included in the final analysis. MEASUREMENTS AND MAIN RESULTS: The preoperative ultrasound was performed by a radiologist in 241 patients (59%) and by an expert gynecologic sonologist in 171 patients (42%). Patients' age, body mass index, race, ethnicity, parity, and history of prior cesarean section were comparable between the 2 groups. The adenomyosis detection rate was significantly higher in the expert gynecologic sonologist group compared with radiologists (95 [56%] vs 29 [12%], p <.01). After controlling for patients' race, body mass index, prior cesarean sections, and presence of myomas using multivariable logistic regression, gynecologic expert sonologists were 7.8 times more likely to detect adenomyosis than radiologists (odds ratio = 7.84; 95% confidence interval, 4.58-13.44). Regardless of medical specialty, the presence of myomas significantly decreased the detection of adenomyosis compared with the absence of myomas (odds ratio = 0.23; 95% confidence interval, 0.13-0.39). CONCLUSION: The detection rate of adenomyosis was significantly higher when ultrasound was performed by expert gynecologic sonologists compared with radiologists. The presence of myomas significantly decreased detection rates regardless of specialty. Ultrasound evaluation for detecting adenomyosis should be preferentially performed by gynecologic expert sonologists.

Risk of complications in patients with conservatively managed ovarian tumours (IOTA5): a 2-year interim analysis of a multicentre, prospective, cohort study.

BACKGROUND: Ovarian tumours are usually surgically removed because of the presumed risk of complications. Few large prospective studies on long-term follow-up of adnexal masses exist. We aimed to estimate the cumulative incidence of cyst complications and malignancy during the first 2 years of follow-up after adnexal masses have been classified as benign by use of ultrasonography. METHODS: In the international, prospective, cohort International Ovarian Tumor Analysis Phase 5 (IOTA5) study, patients aged 18 years or older with at least one adnexal mass who had been selected for surgery or conservative management after ultrasound assessment were recruited consecutively from 36 cancer and non-cancer centres in 14 countries. Follow-up of patients managed conservatively is ongoing at present. In this 2-year interim analysis, we analysed patients who were selected for conservative management of an adnexal mass judged to be benign on ultrasound on the basis of subjective assessment of ultrasound images. Conservative management included ultrasound and clinical follow-up at intervals of 3 months and 6 months, and then every 12 months thereafter. The main outcomes of this 2-year interim analysis were cumulative incidence of spontaneous resolution of the mass, torsion or cyst rupture, or borderline or invasive malignancy confirmed surgically in patients with a newly diagnosed adnexal mass. IOTA5 is registered with ClinicalTrials.gov, number NCT01698632, and the central Ethics Committee and the Belgian Federal Agency for Medicines and Health Products, number S51375/B32220095331, and is ongoing. FINDINGS: Between Jan 1, 2012, and March 1, 2015, 8519 patients were recruited to IOTA5. 3144 (37%) patients selected for conservative management were eligible for inclusion in our analysis, of whom 221 (7%) had no follow-up data and 336 (11%) were operated on before a planned follow-up scan was done. Of 2587 (82%) patients with follow-up data, 668 (26%) had a mass that was already in follow-up at recruitment, and 1919 (74%) presented with a new mass at recruitment (ie, not already in follow-up in the centre before recruitment). Median follow-up of patients with new masses was 27 months (IQR 14-38). The cumulative incidence of spontaneous resolution within 2 years of follow-up among those with a new mass at recruitment (n=1919) was 20·2% (95% CI 18·4-22·1), and of finding invasive malignancy at surgery was 0·4% (95% CI 0·1-0·6), 0·3% (<0·1-0·5) for a borderline tumour, 0·4% (0·1-0·7) for torsion, and 0·2% (<0·1-0·4) for cyst rupture. INTERPRETATION: Our results suggest that the risk of malignancy and acute complications is low if adnexal masses with benign ultrasound morphology are managed conservatively, which could be of value when counselling patients, and supports conservative management of adnexal masses classified as benign by use of ultrasound. FUNDING: Research Foundation Flanders, KU Leuven, Swedish Research Council.

Using the cone biopsy to compare colposcopy clinics in new york and london.

OBJECTIVE: To assess whether there were significant differences in cytologic and colposcopic assessments associated with conization specimens at a colposcopy clinic in New York compared with a colposcopy clinic in London. MATERIALS AND METHODS: A retrospective histopathologic survey of patients evaluated at the Mt. Sinai Hospital Colposcopy Clinic (MSH) in New York City and the Royal Free Hospital Colposcopy Clinic (RFH) in London between January 1, 1997, and December 31, 1998, was reviewed. Study groups included all patients who underwent conization at either clinic. Referral cytologic results, colposcopic findings, and conization histologic results were compared. RESULTS: Two hundred three cases from MSH and 457 cases from RFH were reviewed. Most patients undergoing conization in either clinic were referred with Pap smears suggesting high-grade squamous intraepithelial lesions (MSH, 77%; RFH, 77%). Colposcopic biopsy was performed on all patients at MSH. At RFH, colposcopic-directed punch biopsy was not performed on 35% of the patients who would have been treated regardless of biopsy results. There is a significant difference in the distribution of cone histologic diagnosis between the two clinics (p = .02); there are proportionally more women diagnosed with high-grade disease in RFH than in MSH, where there are more normal and low-grade cone histologic results. According to the kappa coefficients, there is only slight agreement between the Pap smear cytologic results and punch biopsy with the conization histologic results for either clinic (MSH, kappa = 0.13; RFH, kappa = 0.19), with the RFH performing slightly better. CONCLUSIONS: This study shows exact agreement between cytologic and final conization diagnosis and colposcopic biopsy and final conization as 47% to 64%. Treatment decisions and outcomes are different between the two clinics, with the RFH clinic performing fewer biopsies and having more procedures yielding high-grade disease. Recommendations regarding changing colposcopic practices could best be made after a prospective study.