We review the current evidence about the treatment modalities of intrauterine adhesions (IUA) or Asherman's Syndrome (AS). Systematic approach, audit and well-structured research is mandatory in order to establish the best treatment for the individual needs of patients. The clinical practice changed significantly over the last 20 years with technological advances in hysteroscopy and imaging techniques. Hysteroscopic treatment seems effective and safe. IUA or AS is a rather uncommon finding in general gynaecological practice. The referral to a tertiary centre will help to centralise the most difficult cases and create the opportunity to study more in detail the efficacy of each treatment modality and to compare the different treatment techniques.
Objectives To study the feasibility, safety and efficacy of the newly designed Purohit technique for vaginal hysterectomy. Design Prospective observational study. Setting Urban private hospital. Methods The study involved 214 consecutive patients without prolapse. Inclusion criteria were: all benign disease of the uterus with a uterus of up to 20 weeks’ gestational size; patients were also included who had relative contraindications to the vaginal hysterectomy route, and who needed removal of movable adnexal cyst (5–7 cm) or oöphorectomy. Patients with endometriosis were excluded. Initially, vaginal hysterectomy was attempted in all patients included in the study, by means of the Purohit vaginal hysterectomy technique. Uterine arteries were secured by means of the Purohit uterine artery technique. Outcome measures These were: intraoperative and postoperative complications, duration of operation, need for laparoscopic assistance, postoperative pain, duration of hospital stay and readmission. Results The mean (± SD) weight of the removed uteri was 191.91 ± 101.52 g (range 40–950). Vaginal hysterectomy was successfully completed in 213 consecutive patients (99.53%), and failed in only one patient (0.46%) in whom laparoscopic assistance was needed to release the upper ligaments. Morcellation was required in 13.55%. Vaginal salpingo-oöphorectomy was completed without difficulty in all 24 attempted procedures, including two patients with twisted ovarian cyst. Intraoperative bleeding was less than 100 ml in 87.85% of patients; 0.93% required blood transfusion. The mean haemoglobin loss was 0.5 g dl −1 (0.2–4.0). No major electrical injury occurred. The mean (± SD) operating time was 60.6 ± 26.53 min (25–180). Mild postoperative pain was experienced by 98.59% of patients, and the mean hospital stay was 2.7 ± 1 days (1–10). In the second postoperative week, 2.33% of patients developed haematocele above the vault of size 20–100 ml; two patients required readmission for drainage of the haematocele. Conclusion The Purohit technique is safe, and 99.53% of women with benign disease of a uterus of up to 20 weeks’ gestational size, excluding endometriosis, underwent vaginal hysterectomy, with or without salpingo-oöphorectomy, carried out by means of this technique.
ABSTRACT Objective To compare flexible and rigid hysteroscopy in an outpatient hysteroscopy clinic. Design A randomized, single‐blinded prospective study. Setting A one‐stop, outpatient hysteroscopy clinic in a district general hospital. Subjects 96 women referred to the clinic with abnormal uterine bleeding. Main outcome measures Patient pain scores, local anaesthetic usage, need for cervical dilation, quality of view, correlation of clinical and histological findings, duration of procedure, operator's assessment of the ease of the procedure. Results Data from 83 women were analysed; three declined to enter the study, one failed to complete the pain scores and nine also had an operative hysteroscopy. Immediate median pain scores were statistically lower in the flexible hysteroscopy group, 1.2 vs. 3.6 ( P = 0.001). The difference persisted 30 min after the procedure (0.4 vs. 1.1, P = 0.031). Pain experienced with endometrial biopsy was similar in the two groups (2.5 vs. 3.0, P = 0.16). There were no statistical differences between the two study arms with regard to procedure duration, quality of view, need for cervical dilation, anaesthetic usage or operator assessment of the ease of the procedure. There was agreement in clinical and histological diagnoses in all cases. The operators’ assessment of patients’ pain level correlated highly with patient pain scores. There were no statistically significant differences in any end‐point between the two operators. Conclusion Flexible hysteroscopy is associated with lower levels of patient discomfort than rigid hysteroscopy. Other study variables were comparable for the two types of hysteroscopy.
ABSTRACTObjective To record circulatory volume changes, hyponatraemia, decrease in plasma osmotic pressure, changes in blood picture and coagulation profile in correlation with the size of myoma during hysteroscopic myomectomy.Design A cross‐sectional prospective comparative study.Setting Gynaecologic Endoscopy Unit, Assiut University Hospital, Assiut, Egypt.Subjects Fifty patients undergoing hysteroscopic myomectomy where a balanced general anaesthetic technique was used.Interventions Patients were divided into two groups according to the size of the submucous myoma. Group A included 25 patients having small submucous myomas (3 cm or less). Group B included those having larger myomas (more than 3 cm). Hysteroscopic myomectomy was done using glycine 1.5% as an irrigating solution for all cases. Haemodynamic measurements included pulse, mean arterial blood pressure and central venous pressure (CVP). Cardiodynamic measurements using non‐invasive thoracic electrical bioimpedence (TEB) included cardiac output (CO), cardiac index (CI), stroke volume (SV), stroke index (SI), end diastolic volume (EDV), end diastolic index (EDI), ejection fraction (EF), peak flow (PF), peak flow index (PFI) and systemic vascular resistance (SVR), arterial blood gases (PaO2, PaCO2), oxygen saturation by pulse oximeter and end tidal CO2 by capnogram. Serum sodium and potassium concentration, blood osmolarity, prothrombin time (PT), prothrombin concentration (PC), partial thromboplastine time (PTT), haemoglobin concentration (HB), haematocrite value (HCT) and platelet count (PLT) were also measured. Absorbed fluid volume and intrauterine pressure (IUP) were also measured.Main outcome measures Changes in haemodynamics, caerdiodynamics, blood gases and haematological measurements as measured preoperatively and every 15 min for 75 min.Results The trial showed statistically significant variations regarding haematological and biochemical variables, but it was not associated with clinical signs of hyponatraemia. No signs of cardiac overload or cerebral confusion in both groups. Group B was associated with significant hyponatraemia, increased CVP, hypo‐osmolarity, increased PT and PTT, and increased most of the cardiodynamic parameters.Conclusions Hysteroscopic myomectomy, despite being the most risky hysteroscopic procedure, can be safely performed in most cases following the safety precautions. Intraoperative fluid absorption, especially with large myomas, is the trigger of some systemic changes. The procedure should be performed by an experienced hysteroscopist using a quick technique with the least possible glycine volume and minimal intrauterine pressure to achieve the goal of a safe out‐patient minimal access surgery.
ABSTRACTObjective To report the case histories of two patients who presented with haematometra and haematosalpinx 18 and 24 months after endometrial ablation.Design This is a retrospective case note analysis.Subjects A 51‐year‐old woman, who had undergone endometrial ablation 18 months previously, presented with acute abdominal pain. She was known to be taking continuous combined hormone replacement therapy. Pelvic ultrasound scan showed a large cystic mass, and diagnostic laparoscopy revealed a right haematosalpinx. She underwent right salpingectomy and was pain‐free after the operation. A 48‐year‐old woman presented with lower abdominal pain 2 years after endometrial balloon ablation. The ultrasound scan of the pelvis showed a haematometra (4.4 × 2.6 × 3.3 cm). She underwent examination under anaesthesia (EUA), dilation and drainage of the haematometra. A few weeks later she had a recurrence and underwent hysterectomy.Conclusion As more ablation procedures are performed, more delayed complications will arise.
