Silvia Bramante

Efficacy of a polyethylene oxide-sodium carboxymethylcellulose gel in prevention of intrauterine adhesions after hysteroscopic surgery.

STUDY OBJECTIVES To assess the efficacy of a polyethylene oxide-sodium carboxymethylcellulose gel (Intercoat; Gynecare, division of Ethicon, Inc., Somerville, NJ) in preventing the development of de novo intrauterine adhesions (IUAs) after hysteroscopic surgery and to rate the patency of the internal uterine ostium at 1-month follow-up diagnostic hysteroscopy. DESIGN Randomized controlled study (Canadian Task Force classification I). SETTING University hospital. PATIENTS One hundred ten patients diagnosed during office hysteroscopy as having single or multiple lesions suitable for surgical treatment or resistant dysfunctional uterine bleeding requiring endometrial ablation. INTERVENTIONS Patients were randomized to 2 groups. Group 1 underwent hysteroscopic surgery plus intrauterine application of Intercoat gel, and group 2 underwent hysteroscopic surgery only (control group). Follow-up office hysteroscopy was performed at 1 month after surgery to assess the rate and severity of IUA formation and to rate the patency of the internal uterine ostium after the surgical intervention. MEASUREMENTS AND MAIN RESULTS Compared with the group 2, group 1 demonstrated a significant reduction in the incidence (6% vs 22%; p <.05) of de-novo IUAs. Application of the gel seemed to reduce the severity of IUAs, with fewer moderate and severe IUAs at follow-up in group 1 in comparison with group 2 (33% vs 92%). Furthermore, group 1 demonstrated significant improvement in the degree of patency of the internal uterine ostium (41.9% of cases) in comparison with diagnostic office hysteroscopy performed at enrollment (p <.05). In contrast, in group 2, worsening of patency of the internal uterine ostium was recorded in 18.2% of cases (p <.05). CONCLUSIONS Intercoat gel seems to prevent de novo formation of IUAs and to improve the patency of the internal uterine ostium at follow-up hysteroscopy. However, larger studies are needed to confirm these findings.

Challenging the cervix: strategies to overcome the anatomic impediments to hysteroscopy: analysis of 31,052 office hysteroscopies

OBJECTIVE To report our experience on 10,156 cases of cervical stenosis (CS) diagnosed at office hysteroscopy. DESIGN Retrospective study. SETTING Ambulatory clinics of diagnostic and operative hysteroscopy of two university teaching hospitals (Naples and Bari). PATIENT(S) A total of 31,052 patients undergoing office hysteroscopy. INTERVENTION(S) All of the paper and electronic reports of the office hysteroscopies performed from January 1996 to September 2014 were reviewed. Hysteroscopies were classified as successful (i.e., when access to and visualization of the entire uterine cavity was possible during the same procedure), incomplete (i.e., when access to uterine cavity was possible, but the entire uterine cavity could not be examined), or failed (i.e., when access to uterine cavity was not possible). CS was classified on the basis of localization: stenosis of external cervical ostium (ECO; type I); stenosis of distal third of cervical channel and the internal cervical ostium (ICO; type II); stenosis of the ICO (type III), and combined stenosis of ECO and ICO (type IV). MAIN OUTCOME MEASURE(S) The success rate at overpassing CS (including both successful and incomplete hysteroscopies) was the primary outcome measure. Secondary outcome measures were frequency and localization of CS in fertile and postmenopausal women and the frequency of use of technical maneuvers and/or miniaturized mechanical or bipolar instruments to overcome them. RESULT(S) All hysteroscopies were performed with the use of a 5- or 4-mm rigid continuous-flow office operative hysteroscope by operators with different levels of expertise. The hysteroscopy technique used was standardized between the two centers and among all of the surgeons throughout the years. An access to the uterine cavity with a complete evaluation of the whole endometrial surface was possible in 93.9% of cases (29,152 patients). The main reasons of the 1,320 (4.3%) incomplete and 580 (1.9%) failed hysteroscopies were pain and CS, respectively. CS was identified in 10,156 women (32.7% of all procedures) and was significantly more frequent in postmenopausal than in fertile women (70.1% vs. 29.9%), except for type I stenosis, which was more frequent in fertile than in postmenopausal women. Type IV CS (44.3%) was the most commonly detected. Overall, CS was managed successfully with minimal discomfort in 98.5% of cases with technical maneuvers and miniaturized mechanical and/or bipolar instruments. Adhesiolysis with the distal tip of the hysteroscope by rotating the scope on the endocamera was the significantly more used strategy to overpass all types of CS (39.8% of cases), generally used in combination with miniaturized operative instruments (79.2%). Bipolar electrodes were more used in cases of type I and type IV stenosis (39.7%) compared with the other types of CS. CONCLUSION(S) CS and pain represent the main reasons for failed hysteroscopy. Recent technical and technologic innovations, together with increased operator experience and optimal pain management, have made it possible to overcome even severe CS with the use of office hysterosocpy, thus significantly reducing the rate of failed procedures and the need for operating room and general anesthesia.

“Tubal Ostium Sunshine”: Hysteroscopic Sign of Chronic Salpingitis

Fallopian tube abnormalities including tubal occlusion, acute and chronic salpingitis, hydrosalpinx, peritubal adhesions, and salpingitis isthmica nodosa are major causes of female infertility, accounting for 30% to 40% of all cases. A tubemay be obstructed as a result of inflammation or a previous surgery. Most commonly, fallopian tube occlusion is due to an infection such as pelvic inflammatory disease, typically caused by a sexually transmitted agent such as Chlamydia trachomatis or Neisseria gonorrhoeae. Occlusion may occur at any site along the course of the tube. When the blockage involves the ampullary portion, the tube may dilate, thus forming a hydrosalpinx. Currently, hysterosalpingography and laparoscopy are the criterion standard in assessment and management of fallopian tube occlusion. However, several new techniques have been recently introduced. Several authors have investigated the role of hysteroscopy in assessing the status of the fallopian tubes. A recent

Reproductive outcome after auto-crosslinked hyaluronic acid gel application in infertile patients who underwent laparoscopic myomectomy

Autocrosslinked hyaluronic acid gel is useful for preventing postsurgical adhesion formation in infertile patients who have undergone laparoscopic myomectomy, and it increases the pregnancy rate more than laparoscopic myomectomy alone. Moreover, pregnancy rate is significantly higher with the use of subserous sutures.