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Hysteroscopic treatment of a symptomatic isthmocele in a bicorporeal uterus
Clinical case: We report the case of a primigravida 36-year-old woman, with a unicervical bicorporeal uterus type. An isthmocele was diagnosed within a context of postmenstrual abnormal uterine bleeding and secondary infertility arising after C-section. The hydrosonography evidenced a moderate scar defect, the myometrium next to the "niche" measuring 3mm. Because of the symptomatology and the failure of multiple embryo transfer procedures, an operative hysteroscopy was performed. The patient was able to become pregnant spontaneously and give birth to a healthy child via C-section.

Conclusion: A minimally invasive procedure using a hysteroscopic resection of the fibrotic scar tissue is to be considered first, given the existence of an isthmocele in a symptomatic and/or infertile woman, even in the case of a uterine malformation. It is an effective and safe treatment option. However, it has to be considered only if the residual myometrium measures more than 3mm next to the defect.

Key words:
Hysteroscopic resection, isthmocele, cesarean section, bicorporeal uterus.
J Dubuisson, S Wegener, I Streuli
Surgical intervention
1 year ago
5011 views
313 likes
0 comments
05:12
Hysteroscopic treatment of a symptomatic isthmocele in a bicorporeal uterus
Clinical case: We report the case of a primigravida 36-year-old woman, with a unicervical bicorporeal uterus type. An isthmocele was diagnosed within a context of postmenstrual abnormal uterine bleeding and secondary infertility arising after C-section. The hydrosonography evidenced a moderate scar defect, the myometrium next to the "niche" measuring 3mm. Because of the symptomatology and the failure of multiple embryo transfer procedures, an operative hysteroscopy was performed. The patient was able to become pregnant spontaneously and give birth to a healthy child via C-section.

Conclusion: A minimally invasive procedure using a hysteroscopic resection of the fibrotic scar tissue is to be considered first, given the existence of an isthmocele in a symptomatic and/or infertile woman, even in the case of a uterine malformation. It is an effective and safe treatment option. However, it has to be considered only if the residual myometrium measures more than 3mm next to the defect.

Key words:
Hysteroscopic resection, isthmocele, cesarean section, bicorporeal uterus.
Laparoscopic resection of endometriotic fibrotic nodule extending from the posterior lateral aspect of the uterus to the left pelvic sidewall, encasing the internal iliac vessels and adherent to the mid-sigmoid colon
Deep endometriosis is one of the most complex and risky surgeries. Its laparoscopic management requires a systematic approach, a good anatomical knowledge, and a high level of surgical competency.
This is the case of a 37-year-old lady presenting with a complex deep pelvic endometriosis. She had a long history of severe dysmenorrhea, colicky abdominal pain, back pain, and constipation. Imaging studies (MR) showed a large fibrotic endometriotic nodule extending from the posterior lateral aspect of the uterus to the left pelvic sidewall, encasing the internal iliac vessels, nerves, and adherent to a 4cm segment of the mid-sigmoid colon.
This patient has a complicated past history of left ureter ligation during a caesarean section (in 2011), which resulted in a left-sided nephrectomy in 2012. She got a pneumothorax complication, lung drainage, right-side thoracotomy in 2013, and finally a total pleurectomy in 2014.
A Wattiez, R Nasir, I Argay
Surgical intervention
2 years ago
5282 views
312 likes
1 comment
42:42
Laparoscopic resection of endometriotic fibrotic nodule extending from the posterior lateral aspect of the uterus to the left pelvic sidewall, encasing the internal iliac vessels and adherent to the mid-sigmoid colon
Deep endometriosis is one of the most complex and risky surgeries. Its laparoscopic management requires a systematic approach, a good anatomical knowledge, and a high level of surgical competency.
This is the case of a 37-year-old lady presenting with a complex deep pelvic endometriosis. She had a long history of severe dysmenorrhea, colicky abdominal pain, back pain, and constipation. Imaging studies (MR) showed a large fibrotic endometriotic nodule extending from the posterior lateral aspect of the uterus to the left pelvic sidewall, encasing the internal iliac vessels, nerves, and adherent to a 4cm segment of the mid-sigmoid colon.
This patient has a complicated past history of left ureter ligation during a caesarean section (in 2011), which resulted in a left-sided nephrectomy in 2012. She got a pneumothorax complication, lung drainage, right-side thoracotomy in 2013, and finally a total pleurectomy in 2014.
Strategy for laparoscopic total hysterectomy and bilateral salpingectomy in case of large uterus
This video demonstrates the case of a 46-year-old patient presented with menorrhagia and anemia.
Clinical examination revealed a large mass almost reaching the level of the umbilicus.
The uterus appeared much bigger than usual on MRI, with a large myoma coming out of the pelvis.
It was decided to perform total laparoscopic hysterectomy combined with bilateral salpingectomy.
This video demonstrates the appropriate strategy to safely perform total laparoscopic hysterectomy in case of large uterus, showing the appropriate surgical steps and providing safety tips. The specimen weighed more than 1kg.
A Wattiez, F Asencio, J Faria, I Argay, L Schwartz
Surgical intervention
4 years ago
9034 views
310 likes
0 comments
25:01
Strategy for laparoscopic total hysterectomy and bilateral salpingectomy in case of large uterus
This video demonstrates the case of a 46-year-old patient presented with menorrhagia and anemia.
Clinical examination revealed a large mass almost reaching the level of the umbilicus.
The uterus appeared much bigger than usual on MRI, with a large myoma coming out of the pelvis.
It was decided to perform total laparoscopic hysterectomy combined with bilateral salpingectomy.
This video demonstrates the appropriate strategy to safely perform total laparoscopic hysterectomy in case of large uterus, showing the appropriate surgical steps and providing safety tips. The specimen weighed more than 1kg.
Laparoscopic management of a cavitated non-communicating rudimentary uterine horn of a unicornuate uterus: a case report
Introduction: A unicornuate uterus with a cavitated non-communicating rudimentary uterine horn is one of the most uncommon uterine anomalies of the female genital tract. It has an estimated frequency of 1 in 100,000 among the fertile female population. This anomaly results from the abnormal maturation of one Müllerian duct with the normal development of the contralateral one.
Case: This video describes the laparoscopic diagnosis and management of a unicornuate uterus with a left cavitated non-communicating rudimentary uterine horn in a 27-year old woman who presented with lower abdominal pain and severe dysmenorrhea. She was submitted to a preoperative imaging study with a MRI, a uro-CT and a CT-scan of the vertebral column. There were no concomitant urinary anomalies and the sagittal CT-scan revealed abnormalities in the development of the terminal portion of the column. A laparoscopic removal of this cavitated non-communicating uterine horn was performed without any complication in the postoperative period.
Conclusion: Operative laparoscopy proved to be a successful approach in the treatment of this congenital Müllerian anomaly.
H Ferreira Carvalho
Surgical intervention
4 years ago
1772 views
56 likes
0 comments
05:13
Laparoscopic management of a cavitated non-communicating rudimentary uterine horn of a unicornuate uterus: a case report
Introduction: A unicornuate uterus with a cavitated non-communicating rudimentary uterine horn is one of the most uncommon uterine anomalies of the female genital tract. It has an estimated frequency of 1 in 100,000 among the fertile female population. This anomaly results from the abnormal maturation of one Müllerian duct with the normal development of the contralateral one.
Case: This video describes the laparoscopic diagnosis and management of a unicornuate uterus with a left cavitated non-communicating rudimentary uterine horn in a 27-year old woman who presented with lower abdominal pain and severe dysmenorrhea. She was submitted to a preoperative imaging study with a MRI, a uro-CT and a CT-scan of the vertebral column. There were no concomitant urinary anomalies and the sagittal CT-scan revealed abnormalities in the development of the terminal portion of the column. A laparoscopic removal of this cavitated non-communicating uterine horn was performed without any complication in the postoperative period.
Conclusion: Operative laparoscopy proved to be a successful approach in the treatment of this congenital Müllerian anomaly.
Various approaches to uterine artery ligation at laparoscopy
Isolating the uterine artery can be performed safely and efficiently with a proper knowledge of the anatomy, as pelvic vascular anatomy is relatively constant with a very predictive retroperitoneal course. In this video, authors review the anatomy relevant to the uterine artery and demonstrate various approaches to ligating it laparoscopically. It is essential as it provides hemostasis and reduces the incidence of potential injury to bladder and ureter, particularly in cases where anatomical relationships have been distorted by intra-abdominal adhesions as in cases of previous surgery, severe endometriosis or large fibroids or when access to the cervix is limited due to wide uteri or to a fibrogenic cul-de-sac or when access to the vesicouterine space is obliterated due to previous surgeries. The various approaches to ligating the uterine artery in relation to the broad ligament are lateral, posterior, anterior, and medial. These approaches can be used based on the patient’s pathology and requirements.
H Grover, R Syed, A Padmawar
Surgical intervention
3 months ago
7539 views
57 likes
23 comments
07:04
Various approaches to uterine artery ligation at laparoscopy
Isolating the uterine artery can be performed safely and efficiently with a proper knowledge of the anatomy, as pelvic vascular anatomy is relatively constant with a very predictive retroperitoneal course. In this video, authors review the anatomy relevant to the uterine artery and demonstrate various approaches to ligating it laparoscopically. It is essential as it provides hemostasis and reduces the incidence of potential injury to bladder and ureter, particularly in cases where anatomical relationships have been distorted by intra-abdominal adhesions as in cases of previous surgery, severe endometriosis or large fibroids or when access to the cervix is limited due to wide uteri or to a fibrogenic cul-de-sac or when access to the vesicouterine space is obliterated due to previous surgeries. The various approaches to ligating the uterine artery in relation to the broad ligament are lateral, posterior, anterior, and medial. These approaches can be used based on the patient’s pathology and requirements.
Laparoscopic complete parametrectomy associated with upper vaginectomy and bilateral pelvic lymphadenectomy
This video shows a reproducible approach to complete parametrectomy in a patient who had had a hysterectomy. The procedure begins with adhesiolysis and dissection of the lateral pelvic spaces in order to identify and isolate the parametrium. The paravesical fossa is then dissected medially and laterally using the umbilical artery as a landmark. The surgeon identifies the uterine artery and parametrium by following the umbilical artery. Using the uterine artery as a landmark of the parametrium, dissection is continued posteriorly developing the pararectal spaces in order to isolate the posterior part of the parametrium. The ureter is dissected towards the ureteral channel and unroofed. The procedure is carried on with the complete isolation of the ureter in its anterior aspect between the parametrium and the bladder. The bladder pillar is then transected at the level of the bladder. The rectal pillar is transected at the level of the rectum, paying attention to isolate the inferior hypogastric nerve. The parametrium is then cut at the level of the hypogastric vessel. The vagina is cut with ultrasonic scissors using a cap of RUMI II as a guide, and the specimen is extracted vaginally. The surgeon performs a bilateral lymphadenectomy. In this step, the obturator nerve is dissected to prevent injuries at the medial aspect of the obturator artery. The vagina is closed with continued stitches vaginally using an extracorporeal knotting technique.
H Camuzcuoglu, B Sezgin
Surgical intervention
1 year ago
5054 views
451 likes
1 comment
11:55
Laparoscopic complete parametrectomy associated with upper vaginectomy and bilateral pelvic lymphadenectomy
This video shows a reproducible approach to complete parametrectomy in a patient who had had a hysterectomy. The procedure begins with adhesiolysis and dissection of the lateral pelvic spaces in order to identify and isolate the parametrium. The paravesical fossa is then dissected medially and laterally using the umbilical artery as a landmark. The surgeon identifies the uterine artery and parametrium by following the umbilical artery. Using the uterine artery as a landmark of the parametrium, dissection is continued posteriorly developing the pararectal spaces in order to isolate the posterior part of the parametrium. The ureter is dissected towards the ureteral channel and unroofed. The procedure is carried on with the complete isolation of the ureter in its anterior aspect between the parametrium and the bladder. The bladder pillar is then transected at the level of the bladder. The rectal pillar is transected at the level of the rectum, paying attention to isolate the inferior hypogastric nerve. The parametrium is then cut at the level of the hypogastric vessel. The vagina is cut with ultrasonic scissors using a cap of RUMI II as a guide, and the specimen is extracted vaginally. The surgeon performs a bilateral lymphadenectomy. In this step, the obturator nerve is dissected to prevent injuries at the medial aspect of the obturator artery. The vagina is closed with continued stitches vaginally using an extracorporeal knotting technique.
Use of visual cues in hysteroscopic management of Asherman's syndrome
The normal uterine cavity is distorted or obliterated due to severe adhesions in Asherman’s syndrome, which makes surgery difficult to perform. The high-definition vision of the camera can help to identify visual cues and clues during hysteroscopy, which can guide the surgery.
The objective of this video is to demonstrate that the information gathered from various visual cues during hysteroscopy is really helpful to the surgeon.
The video focuses on the use of the following seven visual cues: color of fibrous bands and endometrium which imparts a white spectrum; thread-like texture of fibrotic bands; lacunae and their dilatation in scar tissue; probing and post-probing analysis using scissors (5 French); color and appearance of myometrial fibers which impart a pink spectrum; vascularity differentiation; matching analysis with a normal uterine cavity.
Various techniques described for the management of this condition include fluorescence-guided, ultrasonography-guided, and hysteroscopic adhesiolysis under laparoscopic control, which are expensive procedures. We suggest that the high-definition vision and visual cues during hysteroscopy should be initially used intraoperatively for guidance purposes before using such options. It may be sufficient to achieve the desired result in most cases.
Suy Naval, R Naval, Sud Naval, A Padmawar
Surgical intervention
1 year ago
3357 views
388 likes
0 comments
06:01
Use of visual cues in hysteroscopic management of Asherman's syndrome
The normal uterine cavity is distorted or obliterated due to severe adhesions in Asherman’s syndrome, which makes surgery difficult to perform. The high-definition vision of the camera can help to identify visual cues and clues during hysteroscopy, which can guide the surgery.
The objective of this video is to demonstrate that the information gathered from various visual cues during hysteroscopy is really helpful to the surgeon.
The video focuses on the use of the following seven visual cues: color of fibrous bands and endometrium which imparts a white spectrum; thread-like texture of fibrotic bands; lacunae and their dilatation in scar tissue; probing and post-probing analysis using scissors (5 French); color and appearance of myometrial fibers which impart a pink spectrum; vascularity differentiation; matching analysis with a normal uterine cavity.
Various techniques described for the management of this condition include fluorescence-guided, ultrasonography-guided, and hysteroscopic adhesiolysis under laparoscopic control, which are expensive procedures. We suggest that the high-definition vision and visual cues during hysteroscopy should be initially used intraoperatively for guidance purposes before using such options. It may be sufficient to achieve the desired result in most cases.
Laparoscopic uterovaginal anastomoses for cervical agenesis
Cervical agenesis occurs in one in 80,000 to 100,000 births. According to the American Fertility Society, cervical agenesis should be classified as a type 1b Müllerian anomaly. According to the ESHRE/ESGE classification, it is classified in class C4 category.
This is the case of a 16 year-old female patient with primary amenorrhea and episodes of cyclical lower abdominal pain for one year. After complete examination and investigations, diagnosis of isolated cervical agenesis with hematometra and left ovarian chocolate cyst was established. Laparoscopic uterovaginal anastomoses were performed using an innovative technique and an appropriate management of endometriosis. A hysteroscopy was later performed and showed anastomotic patency. As a result, the patient has been experiencing spontaneous regular menstruation for nine months.
Suy Naval, R Naval, Sud Naval, A Padmawar
Surgical intervention
2 years ago
1980 views
178 likes
1 comment
07:49
Laparoscopic uterovaginal anastomoses for cervical agenesis
Cervical agenesis occurs in one in 80,000 to 100,000 births. According to the American Fertility Society, cervical agenesis should be classified as a type 1b Müllerian anomaly. According to the ESHRE/ESGE classification, it is classified in class C4 category.
This is the case of a 16 year-old female patient with primary amenorrhea and episodes of cyclical lower abdominal pain for one year. After complete examination and investigations, diagnosis of isolated cervical agenesis with hematometra and left ovarian chocolate cyst was established. Laparoscopic uterovaginal anastomoses were performed using an innovative technique and an appropriate management of endometriosis. A hysteroscopy was later performed and showed anastomotic patency. As a result, the patient has been experiencing spontaneous regular menstruation for nine months.
Laparoscopic hysterectomy: removal of a large (1300g) uterus
Some believe that laparoscopy is almost impossible to perform in cases of very big uterus or large adnexal masses that obstruct our view to the pelvis. However, if the same surgical steps are always followed and a specific strategy is determined, it is feasible and safe to choose laparoscopy even in the case of large organs. In this video, we present the case of a 45-year-old patient with a large fibromatous uterus, suffering from abdominal discomfort and bleeding. The patient was anemic and decision was made to perform a laparoscopic total hysterectomy. With the appropriate surgical steps and some safety tips, the operation took place quickly and with success. The weight of the specimen was 1300g.
A Wattiez, P Trompoukis, J Nassif, B Gabriel
Surgical intervention
8 years ago
5330 views
54 likes
0 comments
10:21
Laparoscopic hysterectomy: removal of a large (1300g) uterus
Some believe that laparoscopy is almost impossible to perform in cases of very big uterus or large adnexal masses that obstruct our view to the pelvis. However, if the same surgical steps are always followed and a specific strategy is determined, it is feasible and safe to choose laparoscopy even in the case of large organs. In this video, we present the case of a 45-year-old patient with a large fibromatous uterus, suffering from abdominal discomfort and bleeding. The patient was anemic and decision was made to perform a laparoscopic total hysterectomy. With the appropriate surgical steps and some safety tips, the operation took place quickly and with success. The weight of the specimen was 1300g.
Sentinel node technique in uterine cancers (update of April 2012 lecture)
Endometrial cancer is the most common gynecologic malignancy. In the majority of patients, the disease will present at an early stage, without metastasis, and with an excellent prognosis.
Total hysterectomy and bilateral salpingo-oophorectomy with or without a lymph node dissection is the standard method in the management of endometrial cancer. Although the rate of metastasis in patients with early stage endometrial cancer is low, the standard of treatment still includes a complete or selective pelvic and para-aortic lymphadenectomy for staging, resulting in detrimental side-effects, including lower extremity lymphedema. SLN mapping is based on the concept that lymph node metastasis is the result of an orderly process, that is, the lymph drains in a specific pattern away from the tumor, and therefore if the SLN, or first node, is negative for metastasis, then the nodes after the SLN should also be negative. Among gynecological cancers, a variety of methods have been described to detect a sentinel node in situ including colored dyes and radioisotopes, the latter requiring a specialized gamma detection probe. In this key presentation, Dr. Querleu will talk about the SNL technique in uterine cancers.
D Querleu
Lecture
2 years ago
1459 views
132 likes
0 comments
34:36
Sentinel node technique in uterine cancers (update of April 2012 lecture)
Endometrial cancer is the most common gynecologic malignancy. In the majority of patients, the disease will present at an early stage, without metastasis, and with an excellent prognosis.
Total hysterectomy and bilateral salpingo-oophorectomy with or without a lymph node dissection is the standard method in the management of endometrial cancer. Although the rate of metastasis in patients with early stage endometrial cancer is low, the standard of treatment still includes a complete or selective pelvic and para-aortic lymphadenectomy for staging, resulting in detrimental side-effects, including lower extremity lymphedema. SLN mapping is based on the concept that lymph node metastasis is the result of an orderly process, that is, the lymph drains in a specific pattern away from the tumor, and therefore if the SLN, or first node, is negative for metastasis, then the nodes after the SLN should also be negative. Among gynecological cancers, a variety of methods have been described to detect a sentinel node in situ including colored dyes and radioisotopes, the latter requiring a specialized gamma detection probe. In this key presentation, Dr. Querleu will talk about the SNL technique in uterine cancers.
Role of para-aortic staging lymphadenectomy in advanced cervical cancer (update of September 2014 lecture)
Pelvic and para-aortic lymph node evaluation is a major component of the surgical staging procedure for several gynecologic malignancies. Cervical cancer is clinically staged, but assessment of pelvic and para-aortic lymph nodes is performed with lymphadenectomy and/or imaging. The surgical and oncologic goals of lymph node dissection are to define the extent of disease, and thereby, to guide further treatment. Lymphadenectomy may also have a therapeutic goal in conditions in which removing nodes harboring metastatic disease improves survival. The role of para-aortic lymph node dissection for women diagnosed with LACC had been described in these slides.
F Kridelka
Lecture
2 years ago
1438 views
123 likes
0 comments
27:54
Role of para-aortic staging lymphadenectomy in advanced cervical cancer (update of September 2014 lecture)
Pelvic and para-aortic lymph node evaluation is a major component of the surgical staging procedure for several gynecologic malignancies. Cervical cancer is clinically staged, but assessment of pelvic and para-aortic lymph nodes is performed with lymphadenectomy and/or imaging. The surgical and oncologic goals of lymph node dissection are to define the extent of disease, and thereby, to guide further treatment. Lymphadenectomy may also have a therapeutic goal in conditions in which removing nodes harboring metastatic disease improves survival. The role of para-aortic lymph node dissection for women diagnosed with LACC had been described in these slides.
In bag morcellation of a uterine fibroid
For a long time, morcellation of an undiagnosed malignancy, an old and frightening topic, has been a matter of extensive discussions. Clinicians and pathologists still lack instruments to clearly diagnose specific pathologies such as leiomyosarcomas. Minimally invasive surgery brought numerous advantages for the patient. However, morcellation is a key issue for the extraction of a large uterus and myomas. In this video, we present an option for the extraction of myomas. By insufflating a large Endobag®, a virtual abdominal cavity is created, and the mass is morcellated under direct vision. The resistant bag works not only as a protection for the abdominal cavity in case of an undiagnosed malignancy, but also serves to deviate organs from the morcellator.
R Fernandes, A Silva e Silva, JP Carvalho
Surgical intervention
3 years ago
3375 views
131 likes
0 comments
06:37
In bag morcellation of a uterine fibroid
For a long time, morcellation of an undiagnosed malignancy, an old and frightening topic, has been a matter of extensive discussions. Clinicians and pathologists still lack instruments to clearly diagnose specific pathologies such as leiomyosarcomas. Minimally invasive surgery brought numerous advantages for the patient. However, morcellation is a key issue for the extraction of a large uterus and myomas. In this video, we present an option for the extraction of myomas. By insufflating a large Endobag®, a virtual abdominal cavity is created, and the mass is morcellated under direct vision. The resistant bag works not only as a protection for the abdominal cavity in case of an undiagnosed malignancy, but also serves to deviate organs from the morcellator.
Laparoscopic management of extrauterine leiomyomas
Uterine leiomyomas affect 20 to 30% of women older than 35 years. Extrauterine leiomyomas are rarer, and they present a greater diagnostic challenge. These histologically benign leiomyomas occasionally occur with unusual growth patterns or in unusual locations which make their identification more challenging both clinically and radiologically. Unusual growth patterns may be seen, including benign metastasizing leiomyoma, disseminated peritoneal leiomyomatosis, intravenous leiomyomatosis, parasitic leiomyoma, and retroperitoneal growth. Diffuse peritoneal leiomyomatosis manifests as innumerable peritoneal nodules resembling those in peritoneal carcinomatosis. Parasitic leiomyoma and retroperitoneal leiomyomatosis usually manifest as single or multiple pelvic or retroperitoneal masses. Retroperitoneal growth is yet another unusual growth pattern of leiomyomas. Multiple leiomyomatous masses are usually seen in the pelvic retroperitoneum in women with a concurrent uterine leiomyoma or a history of uterine leiomyoma. Rarely, the extrauterine masses may extend to the upper retroperitoneum, as high as the level of the renal hilum. Occasionally, leiomyomas become adherent to surrounding structures (e.g., broad ligament, omentum, or retroperitoneal connective tissue), develop an auxiliary blood supply, and lose their original attachment to the uterus, hence becoming “parasitic.” We are presenting a case of extrauterine leiomyoma, which was operated for laparoscopic myomectomy for huge cervical leiomyoma 4 years back but was converted to an abdominal myomectomy.
D Limbachiya
Surgical intervention
3 years ago
2884 views
174 likes
0 comments
09:11
Laparoscopic management of extrauterine leiomyomas
Uterine leiomyomas affect 20 to 30% of women older than 35 years. Extrauterine leiomyomas are rarer, and they present a greater diagnostic challenge. These histologically benign leiomyomas occasionally occur with unusual growth patterns or in unusual locations which make their identification more challenging both clinically and radiologically. Unusual growth patterns may be seen, including benign metastasizing leiomyoma, disseminated peritoneal leiomyomatosis, intravenous leiomyomatosis, parasitic leiomyoma, and retroperitoneal growth. Diffuse peritoneal leiomyomatosis manifests as innumerable peritoneal nodules resembling those in peritoneal carcinomatosis. Parasitic leiomyoma and retroperitoneal leiomyomatosis usually manifest as single or multiple pelvic or retroperitoneal masses. Retroperitoneal growth is yet another unusual growth pattern of leiomyomas. Multiple leiomyomatous masses are usually seen in the pelvic retroperitoneum in women with a concurrent uterine leiomyoma or a history of uterine leiomyoma. Rarely, the extrauterine masses may extend to the upper retroperitoneum, as high as the level of the renal hilum. Occasionally, leiomyomas become adherent to surrounding structures (e.g., broad ligament, omentum, or retroperitoneal connective tissue), develop an auxiliary blood supply, and lose their original attachment to the uterus, hence becoming “parasitic.” We are presenting a case of extrauterine leiomyoma, which was operated for laparoscopic myomectomy for huge cervical leiomyoma 4 years back but was converted to an abdominal myomectomy.
Modern hysteroscopy for diagnosis and treatment (office hysteroscopy)
Modern technology has brought diagnostic hysteroscopy as a mainstay of modern gynecologic practice. The ambulatory visualization of the uterine cavity has obvious major benefits for the patient and the diagnostic algorithms. However, it has not been generally implemented by the physicians for obvious drawbacks – it is painful, difficult to get good visualization, difficult to organize and to provide significant tissue for histology.
The new TROPHY hysteroscope is especially designed to counteract the abovementioned drawbacks providing physicians most innovative possibilities resulting in an all in one diagnostic procedure and the highest patient comfort. The most specific feature of this hysteroscope is that it can be loaded with accessory sheaths in an active and passive position providing the possibility of enlarging the visual procedure with endometrial sampling or surgical actions for pathological examination of the endometrium and myometrium without removing the instrument. Additionally, one can remove the hysteroscope and use the accessory sheet to introduce the Trophy D&C suction curette or the Endo-myometrial sampler. Histology from endometrium and myometrium is possible without the need of a speculum and even minor interventions such as polyp or myoma resection are possible in a one-stop procedure.
Magnetic Resonant Imaging (MRI) has demonstrated that the uterus can be separated in 3 important functional areas. For this reason, exploration of the uterus in the infertile patient should implement the evaluation of the endometrium, the junctional zone myometrium (JZ), and the outer myometrium.
MRI cannot be implemented as a screening examination but the combination of transvaginal ultrasound and office hysteroscopy provides a complete one-stop diagnostic and eventually therapeutic procedure.
In this way, myometrial disorders, uterine congenital malformations, endometrium pathologies, and the cervical canal pathway can be evaluated easily.
This lecture describes a modern ambulatory one-stop approach, by combining ultrasound, hysteroscopy and endomyometrial tissue sampling for diagnostic and therapeutic purposes. This one-stop approach opens a totally new and advanced dimension to the screening, diagnosis and treatment of uterine pathologies in the infertile patient.
R Campo
Lecture
4 years ago
2196 views
85 likes
0 comments
24:50
Modern hysteroscopy for diagnosis and treatment (office hysteroscopy)
Modern technology has brought diagnostic hysteroscopy as a mainstay of modern gynecologic practice. The ambulatory visualization of the uterine cavity has obvious major benefits for the patient and the diagnostic algorithms. However, it has not been generally implemented by the physicians for obvious drawbacks – it is painful, difficult to get good visualization, difficult to organize and to provide significant tissue for histology.
The new TROPHY hysteroscope is especially designed to counteract the abovementioned drawbacks providing physicians most innovative possibilities resulting in an all in one diagnostic procedure and the highest patient comfort. The most specific feature of this hysteroscope is that it can be loaded with accessory sheaths in an active and passive position providing the possibility of enlarging the visual procedure with endometrial sampling or surgical actions for pathological examination of the endometrium and myometrium without removing the instrument. Additionally, one can remove the hysteroscope and use the accessory sheet to introduce the Trophy D&C suction curette or the Endo-myometrial sampler. Histology from endometrium and myometrium is possible without the need of a speculum and even minor interventions such as polyp or myoma resection are possible in a one-stop procedure.
Magnetic Resonant Imaging (MRI) has demonstrated that the uterus can be separated in 3 important functional areas. For this reason, exploration of the uterus in the infertile patient should implement the evaluation of the endometrium, the junctional zone myometrium (JZ), and the outer myometrium.
MRI cannot be implemented as a screening examination but the combination of transvaginal ultrasound and office hysteroscopy provides a complete one-stop diagnostic and eventually therapeutic procedure.
In this way, myometrial disorders, uterine congenital malformations, endometrium pathologies, and the cervical canal pathway can be evaluated easily.
This lecture describes a modern ambulatory one-stop approach, by combining ultrasound, hysteroscopy and endomyometrial tissue sampling for diagnostic and therapeutic purposes. This one-stop approach opens a totally new and advanced dimension to the screening, diagnosis and treatment of uterine pathologies in the infertile patient.
Hysteroscopic myomectomy and ART
Fibroids represent an extremely common benign uterine pathology, the incidence of which increases with age, and approximately 10% of women with infertility problems will present a myoma. The association between uterine myoma and infertility is still controversial. Evidence exists that subserosal myomas do not impair the pregnancy rate in IVF whereas submucous myomas significantly decrease the implantation rate. Unfortunately, the effect of intramural myomas upon reproduction outcomes remains unknown, and until now no adequate diagnostic and therapeutic guidelines have been established.
Magnetic resonance imaging (MRI) imaging has redefined the functional anatomy of the uterus. Contrarily to ultrasound, MRI demonstrates that the non-pregnant myometrium is not a homogeneous smooth muscle mass but consists of two different structural and functional entities. The myometrium adjacent to the endometrium is a different hormone-dependent uterine compartment called junctional zone (JZ) myometrium. It is a functionally important entity in reproduction and it is ontogenetically related to the endometrium. Submucosal fibroids originate from this JZ myometrium and differ from subserosal fibroids as they have less cytogenetic abnormalities, less expression of Sex Steroid Hormone receptors, and they are more responsive to GnRH analog treatment and provide fewer recurrences after surgery.
Despite the lack of randomized studies, the sharp decline in pregnancy rates in case of submucous myoma is quite convincing and it is based on the existing evidence that myomectomy should be performed prior to ART for junctional zone myomas which protrude into the uterine cavity.
We demonstrate the different modern techniques of hysteroscopic myomectomy, the new instrumentation, the tips and tricks, the possible complications and clinical outcome.
R Campo
Lecture
4 years ago
2111 views
102 likes
0 comments
27:15
Hysteroscopic myomectomy and ART
Fibroids represent an extremely common benign uterine pathology, the incidence of which increases with age, and approximately 10% of women with infertility problems will present a myoma. The association between uterine myoma and infertility is still controversial. Evidence exists that subserosal myomas do not impair the pregnancy rate in IVF whereas submucous myomas significantly decrease the implantation rate. Unfortunately, the effect of intramural myomas upon reproduction outcomes remains unknown, and until now no adequate diagnostic and therapeutic guidelines have been established.
Magnetic resonance imaging (MRI) imaging has redefined the functional anatomy of the uterus. Contrarily to ultrasound, MRI demonstrates that the non-pregnant myometrium is not a homogeneous smooth muscle mass but consists of two different structural and functional entities. The myometrium adjacent to the endometrium is a different hormone-dependent uterine compartment called junctional zone (JZ) myometrium. It is a functionally important entity in reproduction and it is ontogenetically related to the endometrium. Submucosal fibroids originate from this JZ myometrium and differ from subserosal fibroids as they have less cytogenetic abnormalities, less expression of Sex Steroid Hormone receptors, and they are more responsive to GnRH analog treatment and provide fewer recurrences after surgery.
Despite the lack of randomized studies, the sharp decline in pregnancy rates in case of submucous myoma is quite convincing and it is based on the existing evidence that myomectomy should be performed prior to ART for junctional zone myomas which protrude into the uterine cavity.
We demonstrate the different modern techniques of hysteroscopic myomectomy, the new instrumentation, the tips and tricks, the possible complications and clinical outcome.