Dabao Xu

Etiology, treatment, and reproductive prognosis of women with moderate-to-severe intrauterine adhesions

To analyze data from the hysteroscopic adhesiolysis of moderate‐to‐severe intrauterine adhesions (IUAs), and to review the disease etiology, changes in menstruation, uterine recovery, and reproductive prognosis of women after comprehensive therapy.

Efficacy of estrogen therapy in patients with intrauterine adhesions: systematic review.

Hysteroscopic adhesiolysis has become the preferred option for management of intrauterine adhesions (IUA). Use of estrogen as perioperative adjuvant therapy has been suggested for preventing recurrent adhesions. The primary objective of this article was to review the literature for evidence of the efficacy of estrogen therapy in the management of IUA. All eligible studies were identified using computerized databases (PubMed, Scopus. and Web of Science) from their earliest publication date to July 2013. Additional relevant articles were identified from citations in these publications. Twenty-six studies were identified that reported use of hormone therapy as ancillary treatment after adhesiolysis. Of these studies, 19 used at least one of the following methods: intrauterine device, Foley catheter, hyaluronic acid gel, or amnion graft, in addition to hormone therapy as ancillary treatment. In 7 studies, hormone therapy was used as a single ancillary treatment. In 2 studies, no adjunctive therapy was used after adhesiolysis. Meta-analysis could not be performed because of the differences in treatment methods in these articles. There was a wide range of reported menstrual and fertility outcomes. Better menstrual and fertility outcomes were associated with use of estrogen in combination with other methods of ancillary treatment. At present, hormone therapy, in particular estrogen therapy, is beneficial in patients with IUA, regardless of stage of adhesions. However, estrogen therapy needs to be combined with ancillary treatment to obtain maximal outcomes, in particular in patients with moderate to severe IUA.

The definition, aetiology, presentation, diagnosis and management of previous caesarean scar defects

Caesarean sections are the most commonly performed surgical procedures involving the uterus in fertile women. Typically, this surgery involves a transverse incision in the anterior lower uterine segment. The incidence of caesarean sections is on the increase worldwide, and consequently, the complications associated with them are becoming more common. One such complication that is gaining more attention is previous lower uterine segment caesarean scar defect (PCSD). In this review, we sought to explore the definition, aetiology, presentation, diagnosis and management of PCSD.

Hysteroscopic Management of an Oblique Vaginal Septum in a Virgin Girl With a Rare Variant of Herlyn-Werner-Wunderlich Syndrome

STUDY OBJECTIVE To demonstrate a technique for hysteroscopic diagnosis and management of a rare variant of Herlyn-Werner-Wunderlich syndrome (HWWS) in a virgin girl. DESIGN Presentation of a rare variant of HWWS and a step-by-step description of the technique using videos, images, and title slides (educative video) (Canadian Task Force classification III). SETTING HWWS is a congenital anomaly of the urogenital tract, typically characterized by uterus didelphys, obstructed hemivagina, and ipsilateral renal agenesis. Of HWWS cases, 11.5% are a rare variant of the syndrome, with a septate bicollis uterus and obstructed hemivagina. HWWS is often diagnosed in adolescent girls and virgin patients. Early diagnosis and treatment should be achieved using a convenient, minimally invasive, and effective surgical approach to prevent complications. INTERVENTIONS A 14-year-old virgin girl had aggressive cyclic dysmenorrhea for 7 months. We made a diagnosis of the non-classic HWWS variant: septate uterus with double cervix, obstructed right hemivagina with hematocolpos, and unilateral renal agenesis. Diagnostic hysteroscopy indicated a flat hemivaginal septum, left cervix, and uterine cavity, but no right cervix or other associated channel. Hysteroscopic incision of the bulging oblique vaginal septum was performed medially from the most prominent point of the septum up to the left cervix and then down to the low edge of the oblique septum. An inflated Foley catheter was placed in the right hemivagina for 2 days to prevent adhesion of the incised septum. Surgery was successful, and the intact hymen was preserved. The patient has been symptom-free for 4 months after surgery. CONCLUSION Hysteroscopic incision of the oblique vaginal septum is a convenient, minimally invasive, and effective approach for treating HWWS in adolescents with cyclic dysmenorrhea and hematocolpos.

Two-stage resection of a disseminated mixed endometrial stromal sarcoma and smooth muscle tumor with intravascular and intracardiac extension

OBJECTIVE Mixed endometrial stromal and smooth muscle tumor (MESSMT)-a rare mesenchymal uterine tumor of the uterus with atypical clinical symptoms-is susceptible to misdiagnosis and missed diagnosis. We report a case of a disseminated MESSMT with intravenous and intracardiac extensions treated with staging surgery and review previously documented cases of such tumors with intracardiac extension. CASE REPORT The case involves a 45-year-old woman with disseminated MESSMT that originated in the uterus and progressed through the iliac vein, inferior vena cava, right atrium, and into the right ventricle, which closely resembled intravenous leiomyomatosis (IVL) grossly and microscopically. She presented with a 1-year history of dyspnea on exertion. IVL was highly suspected preoperatively based on computed tomography and magnetic resonance imaging findings. Two-stage surgeries were performed successfully. The postoperative pathology indicated a disseminated MESSMT. CONCLUSION This case illustrates the important role of pathology and immunohistochemistry in the differential diagnosis of a rare tumor that mimics the characteristics of IVL with intracardiac involvement and demonstrates the therapeutic strategy for this rare entity.

Retained permanent uterine suture after cesarean.

Currently, the standard practice in obstetrics is to use absorbable suture to close the myometrium at the time of cesarean delivery. We treated 14 patients with a retained permanent suture in a previous cesarean scar. With globalization and increased transit of people across borders it is possible that this complicationwill be seen in other countries. The average age of the patients was 27 years (21–38 years), and the period of time between the cesarean delivery and diagnosis was an average of 3.5 years (range 62 days to 11 years). A continuous liquid irrigation rigid hysteroscope (Karl-Storz, Tuttlingen,Germany)with 5 Fr instrument channel was used in this study. Five of the 14 patients who were diagnosed during hysteroscopy-guided early pregnancy termination were asymptomatic. The other 9 were symptomatic. Of the 9 symptomatic patients, 6 presented with irregular menstrual bleeding, 2 complained of prolonged periods, and 1 presented with bloody discharge. Among the 6 patients who suffered irregular bleeding, 1 had a history of passage of a permanent suture from the vagina, and 2 had undergone dilation and curettage (D&C) and were diagnosed with simple endometrial hyperplasia but failed to respond to hormone therapy. All 9 of the symptomatic patients failed to respond to antibiotics before removal of the retained suture and preoperative ultrasound failed to confirm the cause of the abnormal bleeding. All 14 patients were diagnosed by hysteroscopic visualization of permanent suture in the cesarean scar (Fig. 1). The sutures were removed under direct hysteroscopic visualization. Postoperative pathology revealed that among the 6 patients who presented with irregular menstrual bleeding, 3 had simple endometrial hyperplasia, 1 had endometritis, and 2 had both endometritis and endometrial polyps. In the 2 patients who presented with prolonged periods, 1 had endometrial polypoid hyperplasia and 1 had endometritis. The patient who presented with bloody discharge had endometritis. All 9 symptomatic patients were followed-up for 3 months after the surgery, and all recovered from abnormal bleeding. In order to determine the source of this aberrant operative procedure, we succeeded in communicating with 7 of the surgeons who had conducted the cesarean deliveries and learned that they had used permanent suture to close the myometrial layer of the uterus because of the cheaper cost or lack of absorbable suture. Removal of the suture is the critical component necessary to eliminate symptoms. Concurrent treatment, such as removal of endometrial polyps, use of hormones for cycle control, and use of antibiotics to control infection can be ancillary aids. Some patients might experience symptom recurrence because of the later extrusion of retained suture from the myometrium which was not seen during the initial surgery and patients should be informed of this possibility.

An unusual case of Herlyn‐Werner‐Wunderlich syndrome with a complete septate uterus and complicated urinary tract with rare ectopic ureteral opening

Herlyn-Werner-Wunderlich syndrome (HWWS) is a rare variant of Müllerian duct anomalies characterized by the combination of uterus didelphys, obstructed hemivagina, and ipsilateral renal agenesis [1]. Our case is unique because while most patients with HWWS have a didelphic uterus with symptoms of dysmenorrhea and irregular vaginal bleeding, our patient had a complete septate uterus with atypical symptoms due to communicating openings in the vaginal septum and between the two cervices. This article is protected by copyright. All rights reserved.

Hysteroscopy- and laparoscopy-based diagnosis and treatment of girls with unbroken hymen with an obstructing uterine septum: two case reports

IntroductionObstructing uterine septum is a rare uterine malformation. Patients with obstructing uterine septum are usually treated with laparouterotomy, causing obvious injury to both the uterus and body of the patients. Therefore, using the natural channel of the vagina is undoubtedly the best way to carry out the surgery. However, obstructing uterine septum usually occurs in puberty in girls without a history of sexual intercourse, thus iatrogenic damage to the hymen during the diagnosis and treatment cannot probably be avoided. However, Chinese people traditionally tend to use hymen intactness as a standard to judge whether an unmarried woman is chaste. Therefore, in China, to protect the hymen from damage during hysteroscopic diagnosis and treatment is of special significance for girls and women with unbroken hymens. None of the previously reported cases were treated with electrosurgical obstructing uterine septum excision based on B-ultrasound-guided hymen-protecting hysteroscopy and laparoscopy.Case presentationCase 1 patient was a virgo intacta 13-year-old Chinese girl. She was admitted due to an 8-day post-menstruation lower abdominal pain. With the guidance of B-ultrasound, we observed a 30mm×20mm mixed echogenicity mass in her uterine cavity. Case 2 patient was a virgo intacta 14-year-old Chinese girl. She was admitted to our hospital more than 6 months after secondary dysmenorrhea and 6 days after B-ultrasound-diagnosed uterine malformations. We observed a 30mm×25mm mixed echoic area in her uterine cavity with the guidance of B-ultrasound.Both patients were surgically treated without hymen damage with B-ultrasound-guided combined therapy of hysteroscopy and laparoscopy. A needle electrode with an 8mm diameter was placed into their uterine cavities under hysteroscopy. After obstructing uterine septum removal, their uterine cavities showed normal morphology. To protect their hymens, misoprostol was placed into their rectums to soften their cervices, so that the hysteroscope could be inserted into their cavities without damaging their hymens.ConclusionVirgo intacta women with obstructing uterine septum could be treated with electrosurgical obstructing uterine septum excision based on B-ultrasound-guided hymen-protecting hysteroscopy and laparoscopy.

Use of Suction Curettage in Operative Hysteroscopy

We investigated the efficiency of suction curettage used during operative hysteroscopy to facilitate removal of relatively large multiple endometrial polyps (MPs), single endometrial polyps (SPs), and submucous uterine myomas (SMs). Four hundred patients with MPs, 200 with SPs, and 60 with SMs were randomly selected into treatment group 1 (study group), and the same numbers of patients in each category was included in treatment group 2 (control group). In total, 1320 patients were recruited. The operator in group 1 used suction curettage to aid removal of the lesions, whereas the operator in group 2 used the conventional procedure. Operation times in the 2 treatment groups were recorded and compared. Surgical skills were described, and possible surgical complications were monitored. Mean (SD) operation time in patients with MPs, SPs, and SMs in group 1 vs group 2 was 4.5 (1.5) vs 15.0 (7.5) minutes, 5.5 (2.5) vs 12.0 (6.5) minutes, and 17.0 (4.5) vs 26.5 (8.5) minutes, respectively. Difference in operation time between the 2 treatment groups was significant (p<.001). No surgical complications occurred in either group. Suction curettage used to aid removal of relatively large MPs, SPs, and SMs during operative hysteroscopy is efficient, effective, and easy.