Response to ‘Letter to “Suprapubic pressure facilitates the procedure of office hysteroscopy: A randomized controlled trial”: Technical considerations’

Dear Editor, I would like to thank Tarek Shokeir, MD, for his interests in our study: ‘Suprapubic pressure facilitates the procedure of office hysteroscopy: A randomized controlled trial’ and wish to respond to their concerns as follows: Position of the uterus is very important factor in performing hysteroscopic procedures. During this study only anteverted uteri were included. Due to the fixation of the cervix (cervical ring, ligaments) by pressing uterine fundus impacts more the ‘free’ uterine corpus than the ‘fixated’ cervix. Of course the whole uterus (cervix and corpus) is moving but the utero-cervical angel closes more to the 180. The direction of the pressure is perpendicular to the abdominal wall, and the localization is suprapubic (fundus of the uterus). Maneuver should be applied during the insertion of the scope, at the first stage (some seconds) of the procedure. After entering the uterine cavity it should not be applied more

Uteromap – a standardized method for measurement of the uterus as part of the preoperative work-up

Background Uterine morphology is not uniform and ultrasound reports of gynecologic patients are diverse. However, in clinical situations (consultation, preoperative planning, during surgery) detailed parameters, dimensions, pathology location are important to reconstruct the situation. Our aim was to develop a new systematic way of ultrasound description of the uterus that is using predefined and standard values (Uteromap). This standardized method is more useful in planning the proper surgical procedure. Methods Normal gynecological ultrasonographic examination were performed in 30 cases, as the part of the gynecological examination in gynecologic ultrasound unit of a tertiary referral academic centre. All examinations and uterine descriptions were performed by expert sonographers. Then an independent examiner made the measurements according to the Uteromap. Briefly, Uteromap includes 9 values for general cases and 24 values for special pathologies. 3D volume served as controls, which was analyzed later off-line. Duration of both examinations were recorded, as well. Equipment used was Philips Affiniti. Results Compared to the 3D volume analysis, Uteromap records gave more accurate description and position of the focal uterine pathology and served more data about the uterus. The Uteromap parameters were reproducible in the 3D volumes. Duration of Uteromap measurements was not significantly longer after the tenth examination. Conclusions Standardized measurements using the Uteromap system during the transvaginal ultrasound examinations give more accurate description the uterine pathology morphometry. Uteromap is a reproducible and quick method for the accurate localization of focal uterine pathologies and description of malformations and minimize the interrater interpretations. It helps the surgeon to choose the proper way of surgery, to maintain the normal uterine cavity and wall

Visualization of Fibroid in Laparoscopy Videos using Ultrasound Image Segmentation and Augmented Reality

Though they rarely become malignant, the surgical removal of fibroids (uterine myomas) is commonly considered to prevent any possible future risks. As the least invasive intervention, endoscopic surgery is the most popular approach for this aim. However, since these compact tumors reside in the deep (muscle/connective) tissues of the uterus, they are hardly visible using only the video stream provided by the endoscopic camera. Thus, conform to the current general trend in human surgery, in this paper we propose a multimodal approach to make these tumors more visible during endoscopic interventions, namely, the reconstruction of the whole three-dimensional model of the uterus from ultrasound images and segmentation of the fibroids using this modality. Then, we map the result of the segmentation on the surface of the uterus, hence they become visible during endoscopic surgery. Similar efforts have already been made, considering the usage of MRI for this purpose, but ultrasound image acquisition is more widely available, faster, and cheaper next to the lower image quality. Our aim is to use the output of the 3D ultrasound imaging device during the laparoscopic surgery. Our segmentation pipeline processes the ultrasound images and consists of Otsu's thresholding using a special mask derived from image averages and morphological snakes to extract uterus boundary. As the final step, we project the segmented 3D model of the uterus with its lesion on an endoscope camera flow in real time to provide an augmented reality application

The use of hysteroscopy in endometrial cancer: old questions and novel challenges

Endometrial cancer is the most common gynecological malignancy with a relatively good overall prognosis. It traditionally has two subtypes: type 1 (endometrioid carcinoma) and type 2 (non-endometrioid carcinoma). The prognosis is excellent for stage I endometrioid cancer, with a 5-year survival rate of 96%. However, the prognosis is much worse for women with high-risk endometrial cancer. Effective preoperative staging is important in order to tailor treatment and achieve optimal long-term survival. The majority of asymptomatic polyps detected by ultrasound are treated surgically. Conventionally, dilatation and curettage was performed to obtain a histological diagnosis, but nowadays hysteroscopy with biopsy is starting to be considered as the gold standard. Hysteroscopic resection seems to reduce the risk of underdiagnosed (atypical endometrial hyperplasia) endometrial cancer. To avoid the spread of malignant cells, hysteroscopy should be performed with concern to keep intrauterine pressure low. In comparison with cervical injection, the hysteroscopic method has a better detection rate in the para-aortic area during sentinel lymph node mapping. In the assessment of cervical involvement, the accuracy of magnetic resonance imaging is significantly higher than the accuracy of hysteroscopy. In fertility-sparing cases, hysteroscopic endometrium resection with progesterone therapy is an acceptable option

Fallopian tubal obstruction is associated with increased pain experienced during office hysteroscopy: a retrospective study

This study aimed at evaluating the pain experienced during office hysteroscopy, with selective tubal cannulation and chromopertubation, by women with and without tubal obstruction in order to determine if such condition would be associated with increased pain during the examination. Women with a history of infertility underwent in-office hysteroscopy with selective chromopertubation using a continuous flow office hysteroscope with a 5 Fr operating channel fitted with a 4 Fr catheter for the injection of methylene blue dye. Experienced pain was recorded on a Visual Analog Scale (VAS) during diagnostic hysteroscopy after access to the uterine cavity. Of 90 women, 58 (66.4%) were found with at least one patent fallopian tube and inserted in the group “any”, meanwhile 32 (33.6%) were categorized into group “none” as both tubes were judged obstructed. There was no significant difference between groups in BMI and primary infertility rate, but the difference was significant concerning mean age (32.6 vs. 35.8; p < 0.001). The mean VAS score was 3.34 (± 1.07) in the group “any” and 4.25 (± 1.11) in “none”. Comparing the VAS score of the two groups, the difference was significant (p < 0.001). Tubal occlusion may have a potential role in the pain experienced by women undergoing in-office hysteroscopy. Women with bilateral tubal occlusion experienced a higher level of pain compared with patients with at least one patent fallopian tube. Operators may use milder intrauterine pressure of fluid distension medium when these patients are undergoing in-office hysteroscopy to reduce discomfort.L

The effect of localization and histological verification of endometrial polyps on infertility

Aim Our purpose is to investigate if transcervical resection of endometrial polyps improves the fertility in ovulatory infertile women, and whether polyp histology, intrauterine location, and the technique of polypectomy have any influence on the pregnancy rates. Methods In this retrospective study, clinical data of 87 ovulatory infertile women who underwent hysteroscopy and pol-ypectomy, and their 12-month follow-up have been analyzed. Subgroups according to the method of polyp removal (resec-toscope or curettage), the polyp localization (utero-tubal, anterior, posterior, lateral, multiple) and the histological result were interpreted. Results Mean age of patients was 33.99 ± 4.24 years. There were no differences in the BMI and basal FSH levels between the subgroups. Pregnancy was recorded in 30 (34.5%) within the next 12 months without any difference between the subgroups of polypectomy method applied. Posterior wall polyp resection increased the pregnancy chance (OR 5.02), but no other dif-ferences were observed in 1-year pregnancy rates to other localizations. Removal of polyps which had normal endometrial histology had lower pregnancy rates as compared to that of polyps with hyperplasia or endometrial polyp histology results (OR 0.25). Conclusions Polypectomy improved the conception rate in the subsequent year regardless of the intrauterine localization and the method of its surgical removal. Therefore, we can conclude that polypectomy should be considered in infertile women

From hysteroscopy to laparoendoscopic surgery: what is the best surgical approach for symptomatic isthmocele? A systematic review and meta-analysis

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Ulipristal Acetate Before Hysteroscopic Myomectomy

Purpose: The aim of this review is to provide an overview of the literature about the effects of ulipristal acetate (UPA) administration prior to hysteroscopic myomectomy. Methods: We performed a systematic literature search in PubMed/MEDLINE and Embase for original studies written in English (registered in PROSPERO - CRD42018092201), using the terms ‘hysteroscopy’ AND ‘ulipristal acetate’ published up to September 2018. Original articles about UPA treatment prior to hysteroscopic myomectomy (randomized, observational, retrospective studies) were considered eligible. Results: Our literature search produced 32 records. After exclusions, 4 studies were included showing the following results: a) hysteroscopic myomectomy is not negatively affected by UPA pretreatment; b) UPA increases the probability of successfully performing complete myomectomy even in highly complex procedures; c) UPA pretreatment decreases the duration of the procedure and improves patient satisfaction at 3-months post-surgery. Conclusions: UPA pretreatment does not seem to be associated with negative outcomes of hysteroscopic myomectomy and it can improve the surgical outcomes in difficult cases. Once the concerns on the potential hepatotoxicity of UPA are resolved, high-quality prospective randomized controlled trials should be implemented to investigate its efficacy and benefits in a larger patient cohort