ENDOSCOPIC TREATMENT OF UTERINE MALFORMATIONS

Transcription

1 ENDOSCOPIC TREATMENT OF UTERINE MALFORMATIONS PROF. ANTONIO PERINO CATTEDRA DI GINECOLOGIA OSTETRICIA E FISIOPATOLOGIA DELLA RIPRODUZIONE UMANA UNIVERSITA DEGLI STUDI DI PALERMO

2 Mullerian duct malformations delineate a miscellaneous group of congenital anomalies that result from arrested development, abnormal formation, or incomplete fusion of the paramesonephric ducts. In many patients, uterine congenital anomalies have been related to menstrual disorders, infertility, recurrent pregnancy loss, prematurity and other obstetrics complications

3 Incidence of uterine malformations among patients willing to conceive during reproductive age F. Raga et al. Human Reprod. 1997

4 Type of malformation Fertile Infertile Sterile Total (n = 1289) (n = 868) (n = 1024) (n = 3181) II Unicornuate 2 (0.2) 5 (0.6) 1 (0.1) 8 (0.3) a b c d III Didelphys 1 (0.1) 6 (0.7) 1 (0.1) 8 (0.3) IV Bicornuate 5 (0.4) 16 (1.9) 5 (0.5) 26 (0.7) a b V Septate 20 (1.5) 17 (2) 6 (0.6) 43 (1.4) a b VI Arcuate 21 (1.6) 9 (1.0) 12 (1.1) 42 (1.3) VII Diethylstilboestrol 0 1 (0.1) 0 1 Total 49 (3.8) c 54 (6.3) b 25 (2.4) c 128 (4.0) F. Raga et al. Human Reprod. 1997

5 When class I and class VII uteri are thus ruled out, it was observed that septate and arcuate uteri represented 66% of the malformations, while the bicornuate, didelphys and unicornuate uteri constituited the remaining 33%

6 This picture is of clinical interest because of the fact that the former malformations can be easily managed by hysteroscopy, while the latter need more complicated procedures or have no surgical solution.

7 Uterine septum is the most common Mullerian fusion defect. Its overall incidence is estimated to be about 2 %. Ashton et al., 1988

8 Septate uterus has been linked to a high grade of fetal loss generally occurring during the first half of the pregnancy AUTHORS N. PATIENTS FETAL LOSS (%) Buttram et Gibbons - 88 Perino et coll March et Israel Daly et coll

9 Formerly, the removal of an intrauterine septum was performed by transabdominal metroplasty McShane, 1983; Rock, 1992

10 Laparotomic Metroplasty Term-Pregnancy (%) Bret-Palmer or Tompkins 80 Jones 70

11 Currently, operative hysteroscopy is proposed as the procedure of choice for the management of these disorders. DeCherney et al., 1986 March and Israel, 1987 Perino et al., 1987 Daly et al., 1989

12 HYSTEROSCOPIC METROPLASTY MULTICENTRIC RETROSPECTIVE STUDY SCISSORS RESECTO. LASER TOT COLACURCI (NEAPLES) BUSACCA (MILAN) LA SALA (REGGIO EMILIA) GUBBINI (BOLOGNA) MENCAGLIA (FLORENCE) PERINO (PALERMO) SCARSELLI (FLORENCE) TANTINI (FLORENCE) TOTALE

13 INDICATIONS No cases = Other (5%) Sterility (32%) Recurrent abortion (63%)

14 PRETREATMENT No cases = 557 PREOPERATIVE TREATMENT No cases = Analogue (20%) Danazol (34%) None (44%) E/P (3.1%) None Analogue Danazol E/P

15 INTRAOPERATIVE CONTROL No cases = 557 INTRAOPERATIVE CONTROL No cases = None None (49%) Laparoscopic (32%) USG (19%) Laparoscopy USG

16 INTRAOPERATIVE COMPLICATIONS MINOR Difficult dilatation n. 5 Bleeding n. 4 False way n. 1 MAJOR Perforations n. 8 E.P.A. n. 1

17 POSTOPERATIVE TREATMENT No cases = None (89%) 566 E/P (9%) Other (2%)

18 FOLLOW-UP No cases = ISG-HSC (11%) USG (19,5%) 440 HSC (69%) ISG (0,5%)

19 TOTAL PREGNANCIES (469) Abortion >12 <28w (2%) Ongoing pregnancies (7%) Term pregnancies (80%) Preterm deliveries (2%) Abortion < 12w (9%)

20 Modality of delivery Vaginal deliveries (57%) Caesarian sections (43%)

21 The septate uterus: a review of management and reproductive outcome Hayden A. Homer et al. Fertil Steril 2000

22 BEFORE METROPLASTY No. of No. of No. of preterm term Author (ref.) No. of patients No. of Pregnancies miscarriage s (%) deliveries (%) deliveries (%) Chervenak and Neuwirth 2 3 3(100) 0 0 Daly et al (85) 5(12.5) 1(2.5) De Cherney and Polan 15 NR >30 NR NR Israel and March (93) 0 2(7) De Cherney et al. 103 NR >206 NR NR Valle and Sciarra (71) 12(29) 0 Fayez (90) 2(10) 0 March and Israel (88) 21(9) 7(3) Perino et al (89) 3(11) 0 Daly et al (87) 13(9) 7(5) Choe and Baggish (82) 6(16) 1(3) Fedele et al. 71 >139 >139 NR NR Cararach et al (91) 11(10) 1(1) Pabuccu et al (89) 11(10) 1(1) Valle (86.3) 28(9.4) 13(4.3) TOTAL 658 1, (88) 95(9) 34(3)

23 AFTER METROPLASTY No. of No. of No. of preterm term Author (ref.) No. of patients miscarriages (%) deliveries (%) deliveries (%) Chervenak and Neuwirth (100) Daly et al. 9 2(22) 1(11) 6(67) De Cherney and Polan 11 2(18) 0 9(82) Israel and March 2 1(50) 0 1(50) De Cherney et al. >71 >8 1 NR Valle and Sciarra 10 2(20) 2(20) 6(60) Fayez 16 2(13) 0 14(87.5) March and Israel 56 8(14) 4(7) 44(79) Perino et al. 15 1(7) 0 14(93) Daly et al (20) 5(7) 55(73) Choe and Baggish 12 1(8.3) 1(8.3) 10(83.3) Fedele et al (16) 10(16) 45(69.2) Cararach et al (29) 0 29(48) Pabuccu et al. 44 2(4.5) 2(4.5) 40(9.1) Valle (12) 7(7) 84(81) TOTAL (14) 29(6) 395(80)

24 Complete septate uterus, duplicated cervix, vaginal septum N cases: 24 Hysteroscopic procedure

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26 Therefore hysteroscopic metroplasty results seem to be at least as good as those obtained after the abdominal metroplasty. However, hysteroscopic technique is associated with less morbidity, shorter hospital stay and the possibility of the vaginal route at delivery.

27 OFFICE HYSTEROSCOPY Recently technological improvements have led to the introduction of office hysteroscopes of small diameter (5 mm) fitted with mini-telescopes and bipolar electrodes working in saline solution. This technique allows a simple and safe treatment of intrauterine pathology including uterine septa

28 Type of hysteroscope For 5 FR. electrode continous flow rigid 5 mm hysteroscope with at least 5 FR. working channel For 24 FR. electrode Resectoscope 10 mm continuous flow

29 Versapoint instrumentations

30 Small-diameter hysteroscopy with Versapoint versus resectoscopy with a unipolar knife for the treatment of septate uterus: A prospective randomized study A. Perino et al. Journal of Minimally Invasive Gynecology (2007) 14,

31 Table 1 Main characteristics of the patients Group A (resectoscope) (n 80) Group B (minihysteroscope) (n 80) Mean age (yrs) % CI Mean duration of infertility (yrs) 95% CI Recurrent pregnancy loss (No.) Primary infertility (No.)

32 Table 2 Operative parameters Mean operative time (min) Group A (resectoscope) (n 80) Group B (minihysteroscope) (n 80) * 95% CI Mean fluid absorption (ml) * 95% CI Second surgery (No.) 2 4 *p.05 (difference between groups).

33 Table 3 Complications Group A (resectoscope) (n 80) Group B (minihysteroscope) (n 80) Intraoperative Cervical tears/traumas Uterine false track Uterine perforation Fluid overload Thermal injuries Significant blood loss 2 1 Postoperative Intrauterine synechiae Uterine rupture in pregnancy Total 7 1* *p.05 (difference between groups).

34 Pregnancy rate (PR) in the study groups according to reproductive history.

35 CONCLUSIONS Small-diameter hysteroscopy with bipolar electrode for the incision of uterine septum is as effective as resectoscopy with unipolar electrode regarding reproductive outcome and is associated with: shorter operating time lower complication rate

36 Hysteroscopic resection of the septum improves the pregnancy rate of women with unexplained infertility: a prospective controlled trial A. Mollo, P. De Franciscis, N. Colacurci, L. Cobellis, A. Perino, R. Venezia, C. Alviggi, and G. De Placido Results: Pregnancy rate (38.6% vs. 20.4%) and live birth rate were significantly higher in group A than in group B. The survival analysis showed that the probability of a pregnancy in the twelve-months follow up was significantly higher in patients undergone metroplasty than in women with unexplained infertility. The corresponding fecundity (10-week pregnancy) rates were 4.27 and 1.92 person-months in women who had undergone metroplasty and in women with unexplained infertility, respectively. Fertil Steril Jun;91(6):

37 Cumulative probability of a pregnancy in the 12 months after the control visit scheduled 1 month after the metroplasy in study group A (red line) and 1 month after the diagnostic laparoscopy in control group B (black line) Fertil Steril Jun;91(6):

38 Conclusions Hysteroscopic resection of the septum improves fecundity of women with septate uterus and otherwise unexplained infertility. Patients with septate uterus and no other cause of sterility have a significantly higher probability of conceiving after removal of the septum than patients affected by idiopathic sterility. Fertil Steril Jun;91(6):

39 CONCLUSION Of the utmost importance is to get clear indication of who, when and how to operate if a uterine malformation is diagnosed. Hysteroscopic metroplasty is now the reccomended treatment for most septate uteri due to its relative simplicity, low morbidity and excellent reproductive outcome

40 THANK YOU