Motti Goldenberg_New horizons in hysteroscopy.ppt [Uyumluluk ...

P.O. Number Terms Rep Ship Via F.O.B. ProjectQuantity Item Code Description Price Each AmountNEW HORIZONS INHYSTEROSCOPIC SURGERYM. Goldenberg, MDSheba Medical CenterTel-Hashomer, IsraelTotal

•TheHysteroscopic Management ofIntamural Fibroids•Focal Scar Ablation for the Treatment ofMenorrhagia post Cesarean Section•HysteroscopicTreatment of ResidualTrophoblastic Tissue

THE HYSTEROSCOPICMANAGEMENT OFINTRAMURAL FIBROIDS

Type 2Intra MuralType 0Type 1

•Menorrhagia•Infertility?

Do women with intramural fibroidssuffer from decreased fertility?Can we hope to improve fertility byremoving intramural fibroids?AdhesionsScarred myometriumIUA

•Review of 150 papers 1990-2002•6 papers concerning Intramural myomaswithout cavity distortion

“Intramural myomata without intra cavitaryinvolvement definitely have an impact onpregnancy outcome in assistedreproduction.Surgical removal must be consideredespecially in patients with previous failedassisted reproductive treatment."

•Hysteroscopy:• No scar (less chance of uterine rupture)• No peritoneal adhesions• Rapid recovery• No need for C/S•Laparoscopy• One stage• Allows pelvic assessment

• MEDIA• BIPOLAR/MONOPOLAR ENERGY• SALINE vs GLYCIN• IMAGING DURING THE PROCEDURE• NONE• LAPAROSCOPY• ABDOMINAL US• VAGINAL US• RECTAL US• PRE-OPERATIVE HORMONAL TREATMENT• ONE OR TWO STEPS

• Yang JH, Lin BL• J Am Assoc Gynecol Laparosc. 2001 Nov;8(4):501-5•MEASUREMENTS AND MAIN RESULTS:•Median myoma diameter 3.3 cm•Myometrial thickness between the myoma andserosa increased gradually and significantlyBefore 6.7 mm,During 8.9 mm,Immediately after 16.1 mm (p

•One-step hysteroscopic myomectomymay be performed to remove deeplyinfiltrating submucous myomas whenmyometrial thickness at the implantationsite is as thin as 5 mm.Lower fear of perforation

• Midline Resection• Long Strokes, Capsule to Capsule• Collapse of lateral walls• Camera horizontal• Avoiding the capsule• Bipolar Resectoscope• Vessel coagulation• Low pressure• Constant orientations• 3D US

Did we complete the myomectomy?Did we reach the myometrium?!

Myomas treated hysteroscopically All submucosal myomas two step procedure are considered Single Intramural < 5 cm that lies close tothe endometrium

Stewart KS, Evans TWBr J Obstet Gynaecol. 1975

Cecilia FabresJournal of Minimally Invasive Gynecology,2005

CharacteristicAge (yrs)Parity (no.)Previous cesarean sections (no.)Interval from last cesareansection to hysteroscopy (yrs)Mean(range)(41–29)(6–1)(6–1)(8–1)3632.753.6

MEASUREMENTS AND MAIN RESULTS: The mean number ofprevious cesarean-section deliveries was 2.75.Infertility work-up in the 11 patients revealed 9 with unknown infertility,1 with male infertility, and 1 with failed tubal reversal surgery. Nine ofthem became pregnant between 14- and 24-months of follow-up.Eighty-four percent of patients (20/24) remained asymptomatic(without bleeding disturbances) after surgery.CONCLUSIONS: Previous cesarean delivery scar defect may bethe cause of intermenstrual bleeding, and it is possible that it alsomay impair fertility, but it can be successfully treated byhysteroscopic surgery.

Tahara M, Shimizu T, Shimoura H.Fertil Steril. 2006 Aug;86(2):477-9. Epub2006 Jun 12.

• We evaluated the effectiveness of combined hormonaltherapy (estrogen and progesterone tablets containing0.5 mg of norgestrel and 0.05 mg of ethynyl estradiol) inpatients with recurring vaginal bleeding after cesareansection. Several cycles of the hormonal therapyeliminated the problem of abnormal vaginal bleeding, andthe patients were satisfied with the treatment

•48 Patients•Median 2.4 CS•All had intramenstrual bleeding

•All treated surgically•18 (37.5%) roller ball•30 (62.5%) resectoscope

•Symptoms improved in 8/18 (44.5%) of the rollerballgroup

•Symptoms improved in 24/30 (80%) of theresectoscope group (P

•Woman is forbidden to her husband•7 “clean” days should be counted•Any spot mandates additional 5 days break

Office Diagnostic Hysteroscopy

Resectoscopic Approach

Resectoscopic Approach

•Death 4 weeks post balloon, El-Nashar Obstetgynecol 2009•Vesico-Uterine fistula, Rooney Obstet Gynecol2010

Car

- Post abortion:-D&C-D&E-Suspected Complete Abortion-Misoprostol (PGE1) Treatment- Post Partum:-Normal Delivery-Cesarean Section

• Incidence :1-2 % of TOP’s• More common with uterine anomaly• Presentation: Abdominal painVaginal bleedingFever• Diagnosis: TVS, Hydrosonography, Diag. hysteroscopy

•Observation•Medical-Methergine-Misoprostol (PGE1)•Surgical- Vacuum / Curettage

•Curettage: Blind procedure – Non selective• Residual trophoblastic tissue may persist even aftercurettage• Unnecessary removal of normal endometrium• Repeated curettage increases the risk of intrauterineadhesions -Asherman’s Syndrome

DiagnosisReassurance thatall tissue isremovedCurettageAbility to see andtreat uterinemalformationsD&CPossibleNoNon selective,EntireendometiumNoHysteroscopyDefinitiveYesSelective removal.EndometriumuntouchedYes

Managing residual trophoblastic tissue.Hysteroscopy for Directing Curettage.Goldenberg M ,Schiff E ,Achiron R ,Lipitz S ,Mashiach S.J Reprod Med 1997: 42:26-8OBJECTIVE: To describe our experience with selectiveremoval of residual intrauterine trophoblastic tissue viahysteroscopy.METHODS: Eighteen patients, 16 postabortion and 2postpartum, underwent a hysteroscopic procedure forremoval of residual trophoblastic tissueRESULTS: Complete removal of the suspected residualtissue was achieved in all patients.

STUDY OBJECTIVE: To assess the efficacy of andreproductive outcome after selective curettage ofresidual trophoblastic tissue directed byhysteroscopy compared with conventional,nonselective, blind curettage.PATIENTS: Seventy patients after curettage ordelivery, with clinical and ultrasonographic signsof suspected residual trophoblastic tissue.

RESULTS:24 women underwent traditional curettage46 underwent hysteroscopic selective curettage.Five (20.8%) patients who underwent traditionalcurettage later required operative hysteroscopydue to persistent residual tissue.None of those who underwent hysteroscopyneeded a second operation.No complicationsReproductive outcome similar in both groups

•General anesthesia.•Dilatation to Hegar 8-9•Distention medium: Saline 0.9%!!•Pressure of 60-100 mmHg.•Hysteroscopy with 26F continuous-flowresectoscope. The entire uterine cavity isvisualized.

•The adherent residual tissue is located.•Selective, directed removal with the loopNo electrical currentis used!!

Selective curettage of residualtrophoblastic tissue directed byhysteroscopy is preferable tononselective, blind curettage.