Ron Sagiv

Role of Sonography in the Diagnosis of Retained Products of Conception

Objective. To present our experience with clinical and sonographic diagnosis of retained products of conception and to evaluate its correlation with histopathologic findings. Methods. This was a retrospective study on 156 patients admitted for retained products of conception. Women were referred because of 1 or more of the following: abdominal pain, bleeding, and fever. The status of the cervix was evaluated by bimanual examination. The diagnosis of retained products of conception was made when a sonographic finding of hyperechoic or hypoechoic material was seen in any part of the uterine cavity or the presence of a thickened endometrial stripe greater than 8 mm and an irregular interface between the endometrium and myometrium was found. One hundred twenty‐one women (77.6%) were admitted after dilation and curettage for abortion, and 35 (22.4%) were admitted after spontaneous labor. Results. Histopathologic reports confirmed the diagnosis of retained products of conception in 86 (71%) of 121 women in the postabortion group and in 17 (48.5%) of 35 women in the postpartum group. The overall false‐positive rate for sonographic diagnosis was 34%. For women after abortion and after delivery, the false‐positive rates were 28.9% and 51.5%, respectively. Conclusions. Reliance on common signs and symptoms to diagnose retained products of conception as well as the use of sonography is associated with an unacceptably high false‐positive rate, mainly after delivery. A more conservative approach to the treatment of retained products of conception is suggested.

Laparoscopic management of extremely large ovarian cysts.

OBJECTIVE: To assess the feasibility and outcome of laparoscopic surgery for the management of extremely large ovarian cysts. METHODS: From July 2000 to December 2003, 21 patients with extremely large ovarian cysts were managed laparoscopically. The masses were cystic or complex, reached the umbilicus or higher, and were not associated with ascites or enlarged pelvic or para-aortic lymph nodes on computed tomography scan. Serum CA 125 levels were within the normal range or mildly elevated (< 130 mIU/mL). The mean and median ages of the patients were 45 ± 20 and 46 years, respectively (range 17–89 years). Seven women were postmenopausal and the rest were premenopausal. The patients underwent cystectomy or adnexectomy depending on each patients age and obstetric history. RESULTS: Two laparoscopies were converted to laparotomy, one because of ovarian malignancy and the second because of technical difficulties related to morbid obesity and severe intra-abdominal adhesions. The postoperative recovery was uneventful in all women. CONCLUSION: With proper patient selection, the size of an ovarian cyst is not necessarily a contraindication for laparoscopic surgery. LEVEL OF EVIDENCE: III

A new approach to office hysteroscopy compared with traditional hysteroscopy: a randomized controlled trial.

OBJECTIVE: To compare a “no touch” approach to diagnostic hysteroscopy without anesthesia with traditional diagnostic hysteroscopy after intracervical injection of mepivacaine hydrochloride 3%. METHODS: A total of 130 women undergoing diagnostic hysteroscopy were included in the study and were randomized, using a computer-generated randomization list to one of two treatment groups in a ratio of 2:1. Eighty-three women underwent hysteroscopy without speculum, tenaculum, or anesthesia. Forty-seven women received intracervical anesthesia with 10 mL of 3% mepivacaine hydrochloride solution injected at two sites (3:00 and 9:00 positions) and underwent traditional hysteroscopy. Hysteroscopy was performed using a rigid 3.7-mm hysteroscope and a medium of 0.9% saline, and the image was transmitted to a screen visible to the patient. A visual analog scale (VAS) consisting of a 10-cm line was used to assess the intensity of pain experienced during and after the procedure. Overall patient satisfaction was assessed during, immediately after, 15 minutes later, and 3 days after hysteroscopy. RESULTS: The mean pain score was significantly lower in the group without the use of speculum, tenaculum, or anesthesia (VAS1: 3.8±2.7 versus 5.34±3.23, P=.01; VAS2: 3.02±2.50 versus 4.57±3.30, P=.008). Patient satisfaction rate was similar in both groups. CONCLUSION: Patients reported significantly less pain with the altered approach to diagnostic hysteroscopy compared with patients undergoing the traditional procedure with anesthesia. This new approach can therefore be considered as a useful hysteroscopic technique. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT00319410 LEVEL OF EVIDENCE: II-1

Can we rely on blind endometrial biopsy for detection of focal intrauterine pathology

OBJECTIVEnTo compare the diagnostic power of random endometrial biopsy with hysteroscopy for intrauterine lesions.nnnSTUDY DESIGNnA retrospective cohort study of 639 women evaluated by diagnostic office hysteroscopy and endometrial biopsy (Novak curette) was carried out between 10/1997-6/2000. Reasons for evaluation were postmenopausal bleeding, abnormal uterine bleeding, ultrasound or hystero-salpingography findings, intrauterine device removal, suspected retained products of conception, infertility, late abortions and recurrent abortions.nnnRESULTSnThe womens mean age was 43.4+/-13.3 years (range, 18-88). The most prevalent indication for investigation was abnormal uterine bleeding (n=218, 34.1%), followed by sonographic or hystero-salpingographic findings (n=167, 26.1%). Hysteroscopy revealed a normal uterine cavity in 367 (57.4%) women. Endometrial polyps and submucosal fibroids were the most common hysteroscopic findings (in 151 [23.6%] and 72 [11.3%], respectively). The hysteroscopic findings were compared with the pathology results in 558 cases. The sensitivity of the Novak curette for detection of endometrial polyps and submucosal fibroids was only 8.4% and 1.4%, respectively. The positive predictive value (30.9%) and the negative predictive value (57.9%) for both lesions were likewise low. On the other hand, hysteroscopy was not effective in diagnosing the 27 cases of hyperplasia (26 simple and one complex) all without atypia.nnnCONCLUSIONnRandom endometrial sampling alone is not effective for diagnosing focal lesions of the uterine cavity and should be combined with other modalities, preferably diagnostic hysteroscopy.

Vaginal removal of prolapsed pedunculated submucous myoma: a short, simple, and definitive procedure with minimal morbidity

ObjectiveOur objective was to evaluate the outcome of vaginal removal of prolapsed pedunculated submucous myomas over a 10-year period.Study designRetrospective observational study. Fifty-two patients were admitted with the diagnosis of prolapsed pedunculated submucous myoma. Six patients were excluded because of an a priori decision for abdominal hysterectomy. In 46 patients an attempt for vaginal myomectomy under general anesthesia was done.ResultsVaginal myomectomy was successful in 44 patients (95.6%). There were no immediate complications. Histological diagnosis of leiomyoma was confirmed in 34 cases (73.9%) and in the remainders intrauterine pathology was endometrial polyp. Total abdominal hysterectomy was performed in additional 6 patients (13.7%) 3xa0months to 5xa0years following vaginal myomectomy.ConclusionsVaginal myomectomy is the treatment of choice for prolapsed pedunculated submucous myoma. The associated morbidity is minimal.

Midtrimester abortion in patients with a previous uterine scar

OBJECTIVEnTo investigate whether extraamniotic prostaglandin E2 (PGE2) for midtrimester pregnancy interruption in women with a scarred uterus has any adverse effects compared to those without an uterine scar.nnnSTUDY DESIGNnTwo hundred and sixty-two women who underwent second trimester (16-27 gestational weeks) termination of pregnancy were enrolled in this study. Thirty-one women with a uterine scar were compared with 231 patients without a scarred uterus. Extraamniotic PGE2 was applied in serial doses of 200 mcg every 2 h up to 20 doses. Intravenous infusion of oxytocin was added in cases when the fetus was not expelled. Curettage was performed in the majority of the patients.nnnRESULTSnThe two groups were similar for indications for pregnancy termination, maternal age and gestational age. Gravidity and parity were significantly higher in the group with an uterine scar. The mean induction to abortion time and the complication rate were similar in both groups. No uterine rupture was observed.nnnCONCLUSIONnExtraamniotic PGE2 for midtrimester termination of pregnancy is a safe procedure with a low complication rate, even in patients with an uterine scar.

Laparoscopic surgery performed in advanced pregnancy compared to early pregnancy

PurposeThe aim of our study was to assess the clinical and obstetric outcomes of laparoscopic surgeries performed during advanced pregnancy compared to those performed in early pregnancy.MethodsWe retrospectively reviewed all cases of patients who underwent laparoscopic surgery during pregnancy in our institution between 1996 and 2013.ResultsWe reviewed cases of 117 pregnant women who underwent laparoscopic surgery during the study period. There were no conversions to laparotomy. 71 surgeries were performed in the first trimester (group 1, mean gestational age 7.7xa0±xa01.9xa0weeks) and 46 were performed in the second and third trimesters (group 2, mean gestational age 18.1xa0±xa04.3xa0weeks). More patients in group 1 underwent surgery for suspected adnexal torsion (pxa0<xa00.001), while more patients in group 2 underwent surgery for presumptive cholecystitis (pxa0=xa00.014) and persistent ovarian mass (pxa0=xa00.011). The interval between admission and surgery differed significantly between the groups and was longer in group 2 compared to group 1 (18.2xa0±xa024.0 vs. 6.8xa0±xa010.6xa0h, pxa0=xa00.001). No difference was found between the two groups regarding surgical complications, histopathological findings and pregnancy outcomes.ConclusionIn our experience, laparoscopic surgery in advanced pregnancy was found to be feasible and safe as in early pregnancy, without any adverse effects on pregnancy outcome.

Interstitial pregnancy management and subsequent pregnancy outcome

We report on management and subsequent fertility outcome of interstitial pregnancy in a retrospective cohort study (Canadian Task Force classification II‐3) at a university affiliated teaching hospital. Of 706 women with extrauterine pregnancy, 14 consecutive women with interstitial pregnancy were treated by methotrexate, laparotomy or laparoscopy between 1997 and 2007. The first four women, with significant hemoperitoneum, were treated by laparotomy. Of the next 10 women, four were selected for medical treatment with methotrexate. Only one case was treated successfully. The other six women had laparoscopic treatment. Of nine laparoscopies, one was converted to laparotomy due to excessive blood loss during the procedure. Of nine women desiring a child, three were infertile, whereas six conceived with an intrauterine pregnancy. A change from diagnosis later in pregnancy and laparotomy to more conservative treatment, mainly by laparoscopy, suggests a possibly better subsequent pregnancy rate.

Clinical characteristics and the risk for malignancy in postmenopausal women with adnexal torsion

OBJECTIVEnTo compare clinical characteristics and management of adnexal torsion in postmenopausal patients as compared to premenopausal ones.nnnMETHODSnA retrospective 22 year cohort of all cases of surgically verified adnexal torsion in postmenopausal and premenopausal patients, comparing presentation, imaging, surgical procedure and histology.nnnRESULTSnThirty five cases of adnexal torsion among postmenopausal patients were compared to 302 cases among premenopausal ones. Complex ovarian masses and larger ovarian diameter were more common among postmenopausal patients (7.8 vs. 6.8 cm, p=0.003). The admission to surgical interval differed substantially between the groups (75.5h in postmenopausal patients vs. 24.4 in the premenopausal ones, p<0.001). The main surgical indication for postmenopausal patients was pelvic mass investigation (54.3% vs 11.6%, p<0.001), and more premenopausal patients underwent surgery with a clinical suspicion of adnexal torsion (77.1% vs. 40%, p<0.001). Extensive surgery including bilateral salpingo-oophorectomy with or without total abdominal hysterectomy was more commonly performed in postmenopausal patients, as opposed to conservative surgery, including detorsion and cystectomy/fenestration or detorsion only, in premenopausal surgeries. Cancer was diagnosed in 3% of postmenopausal patients with adnexal torsion.nnnCONCLUSIONnAdnexal torsion in postmenopausal women is rare, but presents similarly, results in more delayed and extensive surgery and involves malignancy in 3%.

Improved Patient Compliance using Pediatric Cystoscope during Office Hysteroscopy

STUDY OBJECTIVEnTo evaluate the use of a pediatric cystoscope in office diagnostic hysteroscopy.nnnDESIGNnRetrospective review (Canadian Task Force classification II-2).nnnSETTINGnMaccabi Outpatient Womens Health Center.nnnPATIENTSnOne thousand three hundred and thirty-five women; 959 (71.8%) premenopausal and 376 (28.2%) menopausal.nnnINTERVENTIONnOffice diagnostic hysteroscopy using 2.3-mm diameter pediatric cystoscope, without premedication or anesthesia.nnnMEASUREMENTS AND MAIN RESULTSnHysteroscopy was successfully completed in 1298 patients (97.3%). The main reason for failure was cervical stenosis. Menopausal status was the only statistically significant factor correlating with increased failure rate. The analysis demonstrates that for every year of age, the OR for success decreases by 0.965, and success rises by 1.29 for every delivery the woman had. In menopausal women, the OR for success decreases by 0.45. Dilatation of the cervix was required in six women (0.46%), and local anesthesia was needed in only two women. One uterine perforation was recorded, and eight women (0.006%) developed vasovagal reflex or severe abdominal cramps. Post procedural oral analgesia was needed in 108 (8%) of the women.nnnCONCLUSIONnThe combination of a very small diameter continuous flow pediatric cystoscope, together with its ability to deliver high-quality images of the uterine cavity, make this instrument an excellent option for office diagnostic hysteroscopy.