Jackie Hollett-Caines

Fertility and pregnancy outcomes following hysteroscopic septum division.

OBJECTIVES We sought to evaluate retrospectively the efficacy of hysteroscopic metroplasty in a population of women with a history of recurrent pregnancy loss or infertility who were also known to have a uterine septum. METHODS Hysteroscopic metroplasty was performed on 26 women with a uterine septum and a history of either recurrent pregnancy loss or infertility. The metroplasty was performed using a Versapoint bipolar needle device (in 23% of cases) or a resectoscopic knife electrode with cutting current (in 77% of cases). The main outcome measures were rates of clinical pregnancy and live birth. RESULTS Nineteen women had a hysteroscopic metroplasty because of recurrent pregnancy loss. Postoperatively, the pregnancy rate was 95%, and the live birth rate was 72%. The seven infertile patients had pregnancy and live birth rates of 43% and 29%, respectively. CONCLUSION Hysteroscopic metroplasty using either the Versapoint bipolar needle device or a knife electrode is both safe and effective. In women with recurrent pregnancy loss, future fertility is not impaired, and live birth rates are significantly improved.

Uterine artery occlusion: what is the evidence?

Symptomatic uterine fibroids are a relatively common gynecologic condition. In the past, fibroids were exclusively treated by myomectomy and/or hysterectomy. With the advent of uterine artery embolization or uterine artery occlusion, there now exist minimally invasive approaches to fibroid therapy especially for women in whom surgery is contraindicated or for those who wish to retain their uterus and possibly fertility. Fertility and pregnancy outcomes after these minimally invasive therapies are currently being evaluated.

Laparoscopic Mobilization of the Rectosigmoid and Excision of the Obliterated Cul-de-sac

STUDY OBJECTIVE To evaluate the feasibility and surgical and clinical outcomes of laparoscopic excision of anterior recto-sigmoid wall endometriosis and en bloc dissection of the obliterated cul-de-sac. DESIGN Retrospective cohort (Canadian Task Force classification II-2). SETTING University-affiliated teaching hospital. PATIENTS Eighty-one women with infertility and/or chronic pelvic pain. Intervention. Laparoscopic excision of all endometrial implants and uterosacral ligaments, and dissection of the cul-de-sac using a horseshoe-shaped approach to mobilize, but not resect, the rectosigmoid. MEASUREMENTS AND MAIN OUTCOMES Eleven women (24%) had endometriomas. Cumulative pregnancy rates in 34 women with primary infertility and 12 with secondary infertility were 62% and 42%, respectively. Eighty-eight percent of 61 women with pain reported significant improvement of symptoms. CONCLUSION Laparoscopic excision of cul-de-sac and rectovaginal endometriosis by this approach is feasible and safe when performed by an experienced surgeon, and results in high rates of cumulative pregnancy and relief of pain. Some patient variables may give higher rates of success for pregnancy than others.

Transvaginal Doppler-Guided Uterine Artery Occlusion for the Treatment of Symptomatic Fibroids: Summary Results From Two Pilot Studies

OBJECTIVE To evaluate the feasibility, safety, and short-term efficacy of bilateral uterine artery occlusion, using a transvaginal Doppler-guided vascular clamp as a minimally invasive therapy for symptomatic uterine leiomyomas. METHODS We conducted two prospective, non-randomized, phase I pilot studies (Canadian Task Force Classification II-2) at a university-affiliated teaching hospital. Between June 2004 and May 2005, 30 premenopausal women with symptomatic uterine leiomyomas underwent bilateral uterine artery occlusion using a transvaginal Doppler-guided vascular clamp. Bilateral uterine artery occlusion was performed for 5.8 +/- 1.4 hours in the first 17 patients (Group 1) and from 6 to 9 hours (mean 7.05 +/- 1.0 hours) in the latter 13 patients (Group 2). Outcome measures included dominant fibroid volume (cm(3)), uterine volume (cm(3)), and improvement of menorrhagia at one, three, and six months. RESULTS Bilateral occlusion of the uterine arteries was achieved in all 30 patients. In Group 1, the Ruta Menorrhagia Severity Scores decreased from baseline by 16%, 22% and 39% at one, three, and six months respectively. The dominant fibroid (DF) and uterine volumes decreased by 24% and 16% respectively at six months. In Group 2, the Ruta scores changed from baseline by +3%, -24%, and -42% at one, three, and six months respectively. The DF and uterine volumes decreased by 29% and 16%, respectively at six months. CONCLUSION Following bilateral uterine artery occlusion using a transvaginal Doppler clamp, the dominant fibroid volume decreased by an average of 24%, uterine volume decreased by 12%, and menorrhagia symptoms were reduced by up to 42%. Uterine artery occlusion may provide the gynaecologist with an alternative to uterine artery embolization (UAE). The system is simple, easy to apply, and short-term efficacy may be equivalent to UAE.

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.

Uterine artery embolization for uterine arteriovenous malformation in five women desiring fertility: pregnancy outcomes.

Uterine arteriovenous malformations (AVM) are rare and can be classified as either congenital or acquired. Acquired AVMs may result from trauma, uterine instrumentation, infection or gestational trophoblastic disease. The majority of acquired AVMs are encountered in women of reproductive age with a history of at least one pregnancy. Traditional therapies of AVMs include medical management of symptomatic bleeding, blood transfusions, uterine artery embolization (UAE) or hysterectomy. In this retrospective case series, we report our experience with AVM and UAE in five symptomatic women of reproductive age who wished to preserve fertility. Patients were 18-32 years old, and had 1-3 previous pregnancies prior to initial presentation. All patients were followed until their deliveries. All five patients delivered live births. Three of the five patients required two embolization procedures and one of these women required a subsequent hysterectomy. Two deliveries were at term and had normal weight babies and normal placenta. One woman had cerclage placed and developed chorioamnionitis at 34 weeks but had a normal placenta. Two pregnancies were induced <37 weeks for pre-eclampsia/b intrauterine growth restriction ± abnormal umbilical artery dopplers. The low birthweight were both <2000 g. Both placentas showed accelerated maturity and infarcts. All estimated blood losses were recorded as <500 cc. In conclusion, UAE may not be as effective at managing AVM as previously thought and should be questioned as an initial therapy in symptomatic women of reproductive age desiring fertility preservation.

Resolution of Catamenial Epilepsy after Goserelin Therapy and Oophorectomy: Case Report of Presumed Cerebral Endometriosis

Endometriosis can develop in every organ and tissue in the female body except perhaps the spleen. The mechanism of distal metastasis is thought to be hematogenous or lymphatic spread from the uterus. Endometriotic lesions in the central nervous system are rare. Herein, we report the case of a woman with abnormal uterine bleeding who developed catamenial neurologic signs and symptoms. Computed tomography scans and magnetic resonance images demonstrated a circumscribed lesion in the left centrum semiovale of the brain. All neurologic symptoms resolved completely after treatment with gonadotropin-releasing hormone agonist for 3 months and subsequent laparoscopic bilateral oophorectomy. The patient was thought to have cerebral endometriosis, a rare phenomenon, although several cases have been reported in the literature. Temporal association of neurologic signs and symptoms with menstruation that resolves with medical or surgical menopause is highly suggestive of cerebral endometriosis.

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.

Leiomyosarcoma Diagnosed Six Years After Laparoscopic Electromyolysis

BACKGROUND Making a histologic diagnosis of leiomyosarcoma in the specimen from a hysterectomy performed for suspected benign fibroids is rare. Currently, there are no reliable diagnostic tools to diagnose uterine sarcomas preoperatively. CASE A 38-year-old woman presented with menorrhagia and a uterine fibroid measuring 6.0 cm x 8.1 cm x 6.2 cm on ultrasonography. The patient underwent a laparoscopic myolysis with 50% shrinkage of the fibroid volume at follow-up after six months. Six years after myolysis, the patient presented with right lower quadrant pain and a rapidly enlarging uterus. Hysterectomy and bilateral salpingo-oophorectomy was performed and a diagnosis of leiomyosarcoma was histologically confirmed. CT scan was performed biannually after hysterectomy. One year after surgery, the patient presented with radiologic evidence of a right pulmonary nodule. The nodule was excised thoracoscopically and histologic examination demonstrated metastatic leiomyosarcoma. One year later, another pulmonary lesion appeared in the left lung and was excised thoracoscopically. Again, histological assessment showed metastatic leiomyosarcoma. This patient has remained healthy and asymptomatic for two years since the last thoracoscopic excision of the leiomyosarcoma metastasis. CONCLUSION The current trend in treatment for symptomatic fibroids is therapy sparing the uterus. Such treatment includes both medical therapy and fibroid necrosing therapies such as vascular occlusion, embolization, and thermal coagulation technologies. Women considering uterus-sparing treatment should be advised of the potential risk of uterine malignancy, even though that risk is quite minimal (< 0.5%). A delay in the diagnosis of uterine malignancy may ultimately compromise long-term survival.

Post-Uterine Artery Embolization Pain and Clinical Outcomes for Symptomatic Myomas Using Gelfoam Pledgets Alone Versus Embospheres Plus Gelfoam Pledgets: A Comparative Pilot Study

BACKGROUND To evaluate the efficacy and post-procedural pain associated with uterine artery embolization (UAE) using Gelfoam alone versus Embospheres plus Gelfoam in women with symptomatic uterine fibroids. METHOD We conducted a prospective, non-randomized pilot study. Fluoroscopy-guided trans-femoral artery UAE was performed using Gelfoam pledgets alone or Embospheres (500 to 700 mg) plus Gelfoam under conscious sedation and local anaesthesia. This was followed by patient-controlled analgesia (PCA) using a morphine pump overnight. Post-procedural pain was assessed by the mean amount of self-administered morphine delivered by PCA pump (mL) from 0 to 19 hours in each group. The mean volumes of the uterus and the dominant fibroid were calculated by ultrasound at baseline, three months, six months, and 12 months. RESULTS A total of 17 women participated in the study. Bilateral uterine artery occlusion was performed in eight women using Gelfoam alone, and in nine women using Embosphere + Gelfoam. One woman in the Embosphere + Gelfoam group developed a puncture-site hematoma requiring further intervention one week later. The mean (SD) amount of morphine self-administered by PCA pump at time 0, 1, and 2 hours was 3.4 mg (3.1), 2.9 mg (2.2), and 2.4 mg (3.3) in the Gelfoam-only group and 6.1 mg (3.0), 9.6 mg (7.1), and 5.3 mg (4.4) in the Embosphere + Gelfoam group, respectively. After three hours, the amount of morphine used was equal in both groups. The mean (SD) total dose of morphine used was 29.5 mg (18.6) in the Gelfoam group and 41.1 mg (19.3) in the Embosphere + Gelfoam group (P = 0.228). At 12 months, the reduction in median total uterine volume and median dominant fibroid volume in each group was equal. CONCLUSION Clinical outcomes were equivalent after uterine artery embolization using Gelfoam alone versus Gelfoam + Embospheres. Although the amount of immediate post-procedure pain may be less with Gelfoam alone, we could not demonstrate this objectively using morphine use as a measure of pain.