Mario Grasso

Does cold loop hysteroscopic myomectomy reduce intrauterine adhesions? A retrospective study

OBJECTIVE To estimate the prevalence and the characteristics of intrauterine adhesions after cold loop resectoscopic myomectomy. DESIGN Retrospective study. SETTING Endoscopic gynecologic center. PATIENT(S) 688 women with one or more G1-G2 myomas. INTERVENTION(S) Cold loop resectoscopic myomectomy and diagnostic hysteroscopy in all patients 2 months after surgery. MAIN OUTCOME MEASURE(S) Integrity of the uterine cavity and prevalence of intrauterine synechiae. RESULT(S) A total of 806 myomas were removed, ranging from a minimum of one to a maximum of five fibroids removed for each surgical procedure. Complications were reported in eight cases (1.16%). No hemorrhage, intravasation clinical syndrome, or perforation with the thermal loop were registered. Synechiae were found in 29 patients (4.23%): in 2 patients a new surgical hysteroscopic treatment was required to remove fibrous synechiae, and in 27 patients light adhesions were removed with the tip of the instrument in outpatient hysteroscopy. Neither intrauterine device nor anti-adherence mixtures were used at the end of surgery. CONCLUSION(S) The cold loop hysteroscopic myomectomy is a safe and effective procedure that seems to be associated with a lower rate of intrauterine adhesions in comparison with the reported literature. The issue appears to be of notable importance for fertility patients.

Is Cold Loop Hysteroscopic Myomectomy a Safe and Effective Technique for the Treatment of Submucous Myomas With Intramural Development? A Series of 1434 Surgical Procedures

STUDY OBJECTIVE To assess the safety and efficacy of cold loop hysteroscopic myomectomy in a large series of cases. DESIGN Retrospective study (Canadian Task Force Classification III). SETTING Arbor Vitae Center for Endoscopic Gynecology, Rome, Italy. PATIENTS A total of 1215 patients with 1 or more G1-G2 submucous myomas. INTERVENTION Cold loop hysteroscopic myomectomy. MEASUREMENT AND MAIN RESULTS A total of 1690 myomas were removed. A minimum of 1 to a maximum of 5 fibroids for each surgical procedure were totally removed. Out of 1215 patients, 1017 (83.7%) were treated with a single surgical procedure. Twelve intraoperative complications occurred (0.84%). No cases of uterine perforation with the thermal loop or clinical intravasation syndrome were reported. CONCLUSION Cold loop hysteroscopic myomectomy seems to represent a safe and effective procedure for the removal of submucous myomas with intramural development, while at the same time respecting the anatomic and functional integrity of the myometrium. The use of a cold loop in resectoscopic myomectomy is associated with a low rate of minor intraoperative complications and an absence of major complications. This could be of primary relevance with a view to fertility and future pregnancies.

Pain in diagnostic hysteroscopy: a multivariate analysis after a randomized, controlled trial

OBJECTIVE To study which variables are able to influence womens experience of pain during diagnostic hysteroscopy. DESIGN Multivariate analysis (phase II) after a randomized, controlled trial (phase I). SETTING Endoscopic gynecologic center. PATIENT(S) In phase I, 392 patients were analyzed. Group A: 197 women with carbon dioxide (CO2); group B: 195 women with normal saline. In phase II, 392 patients were assigned to two different groups according to their pain experience as measured by a visual analogue scale (VAS): group VAS>3 (170 patients); group VAS≤3 (222 patients). INTERVENTION(S) Free-anesthesia diagnostic hysteroscopy performed using CO2 or normal saline as distension media. MAIN OUTCOME MEASURE(S) Procedure time, VAS score, image quality, and side effects during and after diagnostic hysteroscopy. RESULT(S) In phase I the median pain score in group A was 2, whereas in group B it was 3. In phase II the duration of the procedure, nulliparity, and the use of normal saline were significantly correlated with VAS>3. A higher presence of cervical synechiae was observed in the group VAS>3. The multivariate analysis revealed an inverse correlation between parity and a VAS>3, whereas the use of normal saline, the presence of synechiae in the cervical canal, and the duration of the hysteroscopy were all directly correlated to a VAS score>3. CONCLUSION(S) Pain in hysteroscopy is significantly related to the presence of cervical synechiae, to the duration of the procedure, and to the use of normal saline; conversely, parity seems to have a protective role. CLINICAL TRIAL REGISTRATION NUMBER NCT01873391.

Pain during diagnostic hysteroscopy: what is the role of the cervical canal? A pilot study.

OBJECTIVE To evaluate whether a correlation exists between the pain perceived during diagnostic anesthesia-free hysteroscopy and the characteristics of the cervical canal. STUDY DESIGN Prospective observational pilot study of 255 women undergoing diagnostic hysteroscopy. Data analysis included characteristics of the patient and the cervical canal, and the pain experience during the procedure, assessed by visual analog score (VAS). A multiple logistic regression was then carried out in order to exclude confounding factors. RESULTS The degree of pain during hysteroscopy was equal to a median VAS score of 2 (range 0-10). Bivariate analysis between patients with VAS>3 and patients with VAS≤3 demonstrated a significant correlation between pain and the presence of synechiae in the cervical canal (P=0.022), the patients age (P=0.003) and parity (P=0.001). Multivariate analysis revealed that the presence of cervical synechiae (P=0.0001) [OR=4.99 (95% CI 2.13-11.70)] and parity (P=0.014) [OR=0.42 (95% CI 0.21-0.83)] were significantly correlated with pain. There was no significant correlation with the different angles of the cervical canal. CONCLUSION Cervical synechiae appear as a major factor influencing pain during hysteroscopy. While parity acts as a protective factor, the angle of the cervical canal does not seem to play an important role for pain during diagnostic hysteroscopy.

Is ‘cold loop’ hysteroscopic myomectomy a better option for reproduction in women with diffuse uterine leiomyomatosis? A case report of successful repeated pregnancies

Diffuse uterine leiomyomatosis (DUL) is a rare clinical entity with important reproductive consequences. To date, only four pregnancies have been reported after hysteroscopic myomectomy. Here we describe the case of a 28‐year‐old infertile woman with diffuse uterine leiomyomatosis, who presented infertility and metrorrhagia lasting for 2 years. A countless number of subserous, intramural and submucous myomas were ultrasonographically revealed. Diagnostic hysteroscopy described a uterine cavity completely subverted by the presence of myomas. A two‐step ‘cold loop’ hysteroscopic myomectomy was performed following the technique previously described. One month after the treatment, there were no submucous myomas. A regular uterine cavity free of synechiae was endoscopically confirmed. After the treatment, the patient carried to term three consecutive, uneventful pregnancies. This is the first report of repeated successful pregnancies following the ‘cold loop’ hysteroscopic technique in DUL. We believe that ‘cold loop’ resectoscopic myomectomy may provide new advantageous perspectives for women with DUL seeking pregnancy.

Is the cold loop hysteroscopic technique a myometrial sparing treatment for placenta accreta residuals in a puerperal uterus

Abstract Placenta accreta is a life-threatening obstetric pathology characterized by an abnormal invasion of chorionic villi into the uterine wall. The management represents a challenge for the gynecologist, especially in patients desiring to preserve their fertility. Several methods have been proposed to avoid hysterectomy. A case of a hysteroscopic conservative management with the cold loop technique in a puerpera with a large mass of placenta accreta residuals is described. The chorionic tissue was safely detached and it was subsequently removed by an electric cutting loop. Even in the absence of a clear cleavage plane, the thermal damage of surrounding healthy myometrium and dreadful complications as uterine perforation due to the electric cutting loop were avoided. The cold-loop hysteroscopic resection seems to be a safe and effective choice for the treatment of retained placenta accreta in patients desiring to preserve fertility. Moreover, it can also be proposed to patients who need to be treated immediately after delivery.

Intraoperative Effect of Preoperative Gonadotropin-Releasing Hormone Analogue Administration in Women Undergoing Cold Loop Hysteroscopic Myomectomy: A Randomized Controlled Trial

STUDY OBJECTIVE To evaluate the intraoperative effects of gonadotropin-releasing hormone (GnRH) analogue pretreatment in patients undergoing cold loop hysteroscopic myomectomy. DESIGN Randomized controlled trial (Canadian Task Force classification I). SETTING Arbor Vitae Center for Endoscopic Gynecology, Rome, Italy. PATIENTS A total of 99 patients were randomized and subsequently allocated to the GnRH analogue group or to the nonpharmacologic treatment control group. Fifteen patients were lost after allocation, and 42 patients per group underwent hysteroscopic myomectomy. INTERVENTIONS Cold loop hysteroscopic myomectomy. MEASUREMENTS AND MAIN RESULTS The control group accomplished the treatment in a 1-step procedure more frequently than the GnRH analogue group (92.85% and 73.8% of cases, respectively; p = .040). The completion of the treatment was more unlikely in case of G2 myomas (p = .006), whereas no differences were recorded for G1 and G0 myomas. The multivariate analysis showed a significant correlation between the multiple-step treatment and the use of GnRH analogue (odds ratio, 5.365; 95% confidence interval [CI], 1.018-28.284; p = .048), grading (odds ratio, 4.503; 95% CI, 1.049-19.329; p = .043), and size of myomas (odds ratio, 1.128; 95% CI, 1.026-1.239; p = .013). CONCLUSIONS Preoperative GnRH analogue administration did not facilitate the completion of cold loop hysteroscopic myomectomy in a single surgical procedure in G2 myomas and was correlated with a longer duration of the surgery. No significant benefits were found for G0 and G1 myomas. (ClinicalTrials.gov: NCT01873378.).

How to Overcome a Resistant Cervix for Hysteroscopy

Both in diagnostic and operative setting, the cervical canal is the way that surgeon has to take in order to access the uterine cavity. In the beginning, due to its anatomical characteristics, crossing the cervix represented the first problem that the pioneers of hysteroscopy had to face to reach the uterine cavity. In the last few decades hysteroscopy has developed in terms of technology and execution technique. Nevertheless, resistant cervix and pain, often related to it, still remain the most common causes of failure to complete the procedure in diagnostic and operative hysteroscopy. Several pathologies may affect the cervical canal, creating the condition for a resistant cervix. Nevertheless, behind a consistent number of resistant cervixes there is the lack of an adequate study of the cervical canal during diagnostic hysteroscopy, the poor knowledge of the pathologies that can be encountered and procedures incorrectly performed. The knowledge of characteristics and pathology of cervical canal as well as the hysteroscopic techniques conceived to solve such hindrances could help the surgeon to easily overcome a resistant cervix.

Risk Factors for the Completion of the Cold Loop Hysteroscopic Myomectomy in a One-Step Procedure: A Post Hoc Analysis

Introduction The aim of the study was to analyze which variables influenced the completion of a cold loop hysteroscopic myomectomy in a one-step procedure in a large cohort of patients. Materials and Methods A retrospective cohort study of 1434 cold loop resectoscopic myomectomies consecutively performed. The study population was divided into two groups according to the number of procedures needed to accomplish the treatment. Variables influencing the completion of hysteroscopic myomectomy in a one-step procedure were investigated. Results A total of 1434 resections were performed and 1690 myomas in total were removed. The procedure was accomplished in a one-step procedure in 1017 patients (83.7%), whereas 198 women (16.3%) needed a multiple-step procedure. The multivariate analysis showed that the size, the number of myomas, and the age of patients were significantly correlated with the risk of a multiple-step procedure. No correlation was revealed with the grading of myomas, parity, and the use of presurgical GnRH-agonist therapy. Conclusions In case of multiple fibroids, the intramural development of submucous myomas did not influence the completion of cold loop hysteroscopic myomectomy in a one-step procedure. The size of myomas and the age of patients were significantly correlated with the need to complete the myomectomy in a multiple-step procedure.

Hysteroscopic Aspects of Endometrial Ossification

Endometrialossificationisararediseasesometimesasso-ciatedwithinfertility,pelvicpain,andmenstrualirregularity[1]. This condition coudl be due to fetal bones retained aftera miscarriage or endometrial mature stromal cell metaplasia[2]. Diagnosis and treatment aregenerally made by hystero-scopy[3].A71-year-oldwomanwithabnormalendometrialthicknesswasadmittedtothehysteroscopicunit.Apreviousmiscarriage with dilatation and curettage and no irregularcycles or postmenopausal bleeding were reported.An office hysteroscopy was performed using CO