ENDOSCOPIC TREATMENT OF UTERINE MALFORMATIONS PROF. ANTONIO PERINO CATTEDRA DI GINECOLOGIA OSTETRICIA E FISIOPATOLOGIA DELLA RIPRODUZIONE UMANA UNIVERSITA DEGLI STUDI DI PALERMO
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
Incidence of uterine malformations among patients willing to conceive during reproductive age F. Raga et al. Human Reprod. 1997
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 0 1 0 1 b 0 3 0 3 c 1 0 0 1 d 1 1 1 3 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 0 7 1 8 b 5 9 4 18 V Septate 20 (1.5) 17 (2) 6 (0.6) 43 (1.4) a 4 6 0 10 b 16 11 6 33 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
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%
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.
Uterine septum is the most common Mullerian fusion defect. Its overall incidence is estimated to be about 2 %. Ashton et al., 1988
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. 64 93 March et Israel 57 95 Daly et coll. 17 90
Formerly, the removal of an intrauterine septum was performed by transabdominal metroplasty McShane, 1983; Rock, 1992
Laparotomic Metroplasty Term-Pregnancy (%) Bret-Palmer or Tompkins 80 Jones 70
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
HYSTEROSCOPIC METROPLASTY MULTICENTRIC RETROSPECTIVE STUDY SCISSORS RESECTO. LASER TOT COLACURCI (NEAPLES) - 69-69 BUSACCA (MILAN) - 48-48 LA SALA (REGGIO EMILIA) 15 79-94 GUBBINI (BOLOGNA) 1 104-105 MENCAGLIA (FLORENCE) - 122-122 PERINO (PALERMO) 75 120 5 200 SCARSELLI (FLORENCE) - 22-22 TANTINI (FLORENCE) 12 101-113 TOTALE 103 665 5 773
INDICATIONS No cases = 636 410 29 197 Other (5%) Sterility (32%) Recurrent abortion (63%)
PRETREATMENT No cases = 557 PREOPERATIVE TREATMENT No cases = 636 200 150 100 50 0 12 111 245 189 Analogue (20%) Danazol (34%) None (44%) 1994 1996 1998 2000 2002 2004 2006 2008 E/P (3.1%) None Analogue Danazol E/P
INTRAOPERATIVE CONTROL No cases = 557 INTRAOPERATIVE CONTROL 200 150 100 50 0 180 104 No cases = 557 1994 1996 1998 2000 2002 2004 2006 2008 273 None None (49%) Laparoscopic (32%) USG (19%) Laparoscopy USG
INTRAOPERATIVE COMPLICATIONS MINOR Difficult dilatation n. 5 Bleeding n. 4 False way n. 1 MAJOR Perforations n. 8 E.P.A. n. 1
POSTOPERATIVE TREATMENT No cases = 636 58 9 None (89%) 566 E/P (9%) Other (2%)
FOLLOW-UP No cases = 636 3 69 124 ISG-HSC (11%) USG (19,5%) 440 HSC (69%) ISG (0,5%)
TOTAL PREGNANCIES (469) 8 45 13 42 361 Abortion >12 <28w (2%) Ongoing pregnancies (7%) Term pregnancies (80%) Preterm deliveries (2%) Abortion < 12w (9%)
Modality of delivery 155 206 Vaginal deliveries (57%) Caesarian sections (43%)
The septate uterus: a review of management and reproductive outcome Hayden A. Homer et al. Fertil Steril 2000
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. 17 40 34(85) 5(12.5) 1(2.5) De Cherney and Polan 15 NR >30 NR NR Israel and March 12 28 26(93) 0 2(7) De Cherney et al. 103 NR >206 NR NR Valle and Sciarra 12 42 30(71) 12(29) 0 Fayez 12 21 19(90) 2(10) 0 March and Israel 57 240 212(88) 21(9) 7(3) Perino et al. 24 27 24(89) 3(11) 0 Daly et al. 55 150 130(87) 13(9) 7(5) Choe and Baggish 14 38 31(82) 6(16) 1(3) Fedele et al. 71 >139 >139 NR NR Cararach et al. 62 176 160(91) 11(10) 1(1) Pabuccu et al. 49 108 96(89) 11(10) 1(1) Valle 115 299 258(86.3) 28(9.4) 13(4.3) TOTAL 658 1,062 933(88) 95(9) 34(3)
AFTER METROPLASTY No. of No. of No. of preterm term Author (ref.) No. of patients miscarriages (%) deliveries (%) deliveries (%) Chervenak and Neuwirth 2 0 0 2(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. 75 15(20) 5(7) 55(73) Choe and Baggish 12 1(8.3) 1(8.3) 10(83.3) Fedele et al. 65 10(16) 10(16) 45(69.2) Cararach et al. 41 12(29) 0 29(48) Pabuccu et al. 44 2(4.5) 2(4.5) 40(9.1) Valle 103 12(12) 7(7) 84(81) TOTAL 491 67(14) 29(6) 395(80)
Complete septate uterus, duplicated cervix, vaginal septum N cases: 24 Hysteroscopic procedure
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.
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
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
Versapoint instrumentations
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, 622 627
Table 1 Main characteristics of the patients Group A (resectoscope) (n 80) Group B (minihysteroscope) (n 80) Mean age (yrs) 28.1 4.8 29.1 4.5 95% CI 26.98 29.14 28.15 30.15 Mean duration of 2.8 0.9 3.1 1.1 infertility (yrs) 95% CI 2.58 3.06 2.83 3.33 Recurrent pregnancy loss (No.) Primary infertility (No.) 55 47 25 33
Table 2 Operative parameters Mean operative time (min) Group A (resectoscope) (n 80) Group B (minihysteroscope) (n 80) 23.4 5.6 15.7 4.7* 95% CI 22.11 24.63 14.83 16.92 Mean fluid absorption (ml) 486.4 169.9 222.1 104.9* 95% CI 448.55 524.20 198.77 245.48 Second surgery (No.) 2 4 *p.05 (difference between groups).
Table 3 Complications Group A (resectoscope) (n 80) Group B (minihysteroscope) (n 80) Intraoperative Cervical tears/traumas 3 --- Uterine false track 1 --- Uterine perforation --- --- Fluid overload --- --- Thermal injuries --- --- Significant blood loss 2 1 Postoperative Intrauterine synechiae 1 --- Uterine rupture in --- --- pregnancy Total 7 1* *p.05 (difference between groups).
Pregnancy rate (PR) in the study groups according to reproductive history.
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
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. 2009 Jun;91(6):2628-31.
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. 2009 Jun;91(6):2628-31.
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. 2009 Jun;91(6):2628-31.
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
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