Fawaz Edris

Miscellaneous Uterine Malignant Neoplasms Detected during Hysteroscopic Surgery

STUDY OBJECTIVES To estimate the incidence of incidental miscellaneous uterine malignant neoplasms other than endometrioid adenocarcinoma detected during routine resectoscopic surgery in women with abnormal uterine bleeding (AUB) and to examine the effect of hysteroscopic surgery on long-term clinical outcome. DESIGN Prospective cohort study (Canadian Task Force classification II-3). SETTING University-affiliated teaching hospital. PATIENTS Women with AUB. INTERVENTION From January 1, 1990, through December 31, 2008, one of the authors (G.A.V.) and several fellows performed primary hysteroscopic surgery at St. Josephs Health Care in 3892 women with AUB. Of the 7 with malignant disease, one underwent hysteroscopic partial (n = 1) or complete (n = 6) rollerball electrocoagulation or endomyometrial resection. After diagnosis of uterine cancer, the women were counseled about the disease and management in accord with established clinical practice guidelines. Follow-up with office visits and telephone interviews ranged from 2 to 8 years (median, 6 years). MEASUREMENTS AND MAIN RESULTS Of the 3892 women, 4 had undiagnosed and 3 had suspected miscellaneous uterine malignant neoplasms including 1 endometrial stromal sarcoma, 2 carcinosarcomas, 2 atypical polypoid adenomyomas of the endometrium, 1 minimal deviation adenocarcinoma of the cervix, and 1 smooth-muscle tumor of uncertain malignant potential. At 2 to 8 years of follow-up, 1 patient died accidentally after 1 year, 1 died of carcinomatosis of either coexisting breast cancer or a carcinosarcoma (postmortem examination was declined) after 1 year, and 5 were alive and well. CONCLUSION Resectoscopic surgery in women with miscellaneous uterine malignant lesions not adversely affect 5-year survival and long-term prognosis.

Comparison of Clinical Outcomes with Low-Voltage (Cut) Versus High-Voltage (Coag) Waveforms during Hysteroscopic Endometrial Ablation with the Rollerball: A Pilot Study

STUDY OBJECTIVE To compare efficacy of rollerball endometrial ablation with low-voltage (cut) versus high-voltage (coag) waveforms. DESIGN Pilot comparative clinical study (Canadian Task Force Classification II-1). SETTING University-affiliated teaching hospital. PATIENTS Fifty premenopausal women with menorrhagia. INTERVENTION Women with menorrhagia were allocated randomly to thermal destruction of the endometrium by a 5-mm rollerball with unmodulated cutting current or modulated coagulating current. Complication rate, clinical outcomes, and need for reintervention were evaluated. MEASUREMENTS AND MAIN RESULTS At 2 years of follow-up, the reintervention rate was 26.3% in the cutting waveform group versus 31.4% in the coagulating waveform group. This difference was not statistically significant. Hysterectomy was performed in 3 (14%) women in the cutting waveform group and 5 (20%) women in the coagulating waveform group. There were no complications in either group. CONCLUSION Both cutting and coagulating waveforms are equally effective for hysteroscopic endometrial ablation with the rollerball.

Single Operator Ultrasound Guided Transabdominal Oocyte Retrieval in Patients with Ovaries Inaccessible Transvaginally: A Modified Technique

Objectives: To described the feasibility, relative safety and efficacy of a modified transabdominal ultrasoundguided follicular-aspiration technique. Methods: Retrospective cohort study in a private In-Vitro Fertilization (IVF) center. Amongst 816 IVF cycles over 3 years, 13 women (13 cycles) with inaccessible ovaries through the vagina required transabdominal retrieval. In 3 cases, both ovaries were aspirated transabdominally. Under conscious sedation and local analgesia, the same operator scanned the abdomen with one hand and retrieved the oocytes with the other; using a standard 17-gauge aspiration needle and without the use of a needle-guide. All but one ovary required one puncture. Research board of ethics approval was obtained. Results: The mean and standard deviation (± SD) number of oocytes retrieved transabdominally and transvaginally were 8.4 (± 4.8) and 10.5 (± 6.8), respectively (P=0.93). The mean (± SD) fertilization rate and “good quality” embryos was 78.1% (± 16.2) and 51.9% (± 19.8), respectively. Of the 13 patients, 12 had Embryo Transfer (ET). One patient developed ovarian hyperstimulation syndrome and her embryos were cryopreserved. Of the 12 patients, one had an ectopic pregnancy and 6 (50%) had at least one intrauterine gestational sac. Two patients conceived with a twin and four with a singleton. One of the twin cases aborted at 19 weeks due to an incompetent cervix, and one singleton pregnancy had a miscarriage at 8 weeks of gestation. The other four patients (33.3%) delivered at term, and all babies are alive and well. Of the remaining 5 patients, one conceived from a frozen ET, and delivered a healthy baby at term. Conclusion: This modified technique, performed by a single operator under conscious sedation and local analgesia, allowed maximal retrieval of oocytes through a single ovarian puncture in women undergoing IVF-ET with inaccessible ovaries transvaginally. It is safe and feasible.