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Hysteroscopic and Laparoscopic Management of Uterine and Vaginal Anomalies
Ola Famuyide, MBBSJanuary 30, 2016
Objectives
• Enumerate common classifications congenital uterine anomalies (CUA)
• Enumerate detailed peri-operative evaluation including diagnostic work-up
• Describe critical steps involved in surgical correction of common anomalies
• Describe surgical outcomes following correction
Embryology of the Female Reproductive System
https://www.youtube.com/watch?v=BIdQjHHXF4I
American Fertility Society Classification of Uterine Anomalies (1988)
ESHRE/ESGE Consensus on the Classification of Female Genital Tract Congenital Anomalies (2013)
Grimbizis G et al Human Reproduction 2013;28(8):2032-44
Prevalence of CUA in Unselected and High Risk Populations: A Systematic ReviewOverall prevalence of 4-7% in normal population and up to 16-25% in recurrent pregnancy losses
Chan YY et al. Human reproduction Update 20011; 17(6):761-771
Clinical Implications of Congenital Uterine Anomalies
•1st Trimester abortion: RR 1.56 (CI 1.17-2.08)•2nd Trimester abortion: RR 2.31 (CI 1.63-3.27)
Venetis C et al. Reproductive Biomedicine Online 2014; 29:665-683
Is there evidence for treating asymptomatic women with uterine septum?
• What to do with the 23 yo nulligravid found to have a septum during US for AUB?
• Good prospective longitudinal observational studies lacking
Tonguc EA et al. Int J Gynecol Obstet 2011; 113:128-130
Diagnosis
•Based on ability to evaluate the vagina, endometrial cavity, contour of the fundus and adnexa (possibly renal system)
•Optimal tests: 3D US, MRI, SonohystogramHysteroscopy +Laparoscopy (laparotomy)
•Sub-optimal: 2D US, hysteroscopy alone, HSG, or laparoscopy alone
Chan YY et al. Human reproduction Update 20011; 17(6):761-771
Pre-operative Renal Anatomy Evaluation
•Associated renal abnormalities in 30% of CUA
• Commonest with müllerian agenesis types II and III and obstructed hemivagina
• Unclear if septate uterus is associated with a higher risk than normal population
• Renal agenesis constitutes 67% of all abnormalities
Hall-Craggs M, Kirkham A, Creighton S. Journal of Pediatric Urology 2013; 9: 27-32
Obstructed Müllerian Anomalies
•Hemivagina, transverse septum, etc.
•Highly associated with ectopic ureters and ureteric remnants
•Accurate knowledge of ureteric course is critical
•Refer!
Uterine Septum Pre-operative Counseling
•Goal is complete septum resection 10mm or less
•Risks of surgery
• Perforation, fluid overload, cervical laceration, incomplete resection
• Misoprostol for cervical prep
• Timing of surgery/endometrial prep
Operative Technique- Incomplete septum
Didelphis or Complete Septum- Chalk or Cheese?
• 25 yo nulligravid planning referred from pre-conceptual counseling for “double cervix”
• 2D-US showed 2 endocervical and 2 endometrial cavities; ?uterine didelphis
Operative Technique-Complete Septum
Immediate Post-Operative Management
•Goal is prevention of endometrial synechia or significant residual septum
• Estrogen therapy (Premarin 2-3mg daily for 6 weeks)
• Intrauterine contraceptive device
• Nothing
Mayo Data (Unpublished)
•Women treated for uterine septum(January 2002 – December 2015) (N = 45)• Age (years) = 28.8 ± 7.6• Clinical characters:
Indication of surgery Number (%)
Gynecologic indications 15 (33.3%)
Abnormal uterine bleeding 11 (24.4%)
Chronic pelvic pain/dysmenorrhea 4 (8.9%)
Incidental 16 (35.5%)
Obstetric indications 14 (31.1%)
Miscarriage 9 (20%)
Preterm labour 3 (6.7%)
Primary infertility 1 (2.2%)
History of malpresentation 1 (2.2%)
Type of septum Number (%)
Isolated uterine septum - Incomplete septum- Complete septum- Not determined
36 (80%)13 (28.9%)6 (13.3%)17 (37.7%)
Utero-vaginal septum 9 (20%)
Mayo Data (Unpublished)
•Complications: No major complications
•Pregnancy outcomes:Among the 13 women who had hysteroscopic metroplasty for obstetric indications: 9 (69%) had full term pregnancy 4 (31%) were lost to follow-up
Outcomes Data
Venetis C et al. Reproductive Biomedicine Online 2014; 29:665-683
Less Commonly- Non Communicating Uterine Horn (type II)
Summary
•CUA are relatively common 4-7%
•Commonest, correctable CUA are septated uterus
•Refer obstructed lesions, in particular, hemivagina or transverse septum
•Hysteroscopic metroplasty is the preferred treatment of choice with excellent outcomes