Division of Gynecoradiology, the Center for Human Reproduction, Illinois, the Foundation for Reproductive Medicine and the Department of Obstetrics and Gynecology, University of Illinois at Chicago, Chicago, Illinois, USA
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Abstract |
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Key words: gynaecoradiology/infertility/recurrent miscarriages/uterine septum resection
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Introduction |
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Hysterosalpingography (HSG) has traditionally been the diagnostic modality, which most often led to a tentative diagnosis of uterine septum. An HSG, however, cannot with certainty distinguish between the presence of a uterine septum or a bicornuate uterus. Consequently, until recently standard practice required that patients undergo laparoscopy/hysteroscopy to reach a final diagnosis (American Fertility Society, 1988).
The advent of hysterosonography and, to a lesser extent, the availability of the more expensive technique of magnetic resonance imaging, now allow for an accurate differential diagnosis between these two congenital abnormalities in most cases without having to take the patient to the operating room (Yoder and Hall, 1991). The distinction between an arcuate and mildly subseptate or mildly bicornuate uterus still remains difficult whatever the diagnostic modality (Acien, 1997
). These differential diagnoses, in contrast to the differentiation of a truly septate versus bicornuate uterus, nevertheless have only very limited clinical relevance. Another diagnostic modality that may be useful in differentiating between a septate and bicornuate uterus is three-dimensional ultrasound (Raga et al., 1996
).
As long as patients had to be taken to the operating room for diagnostic reasons, it made sense to combine a diagnostic procedure with an immediate therapeutic intervention. Now that a reliable diagnosis can be reached outside the operating room, the question arises whether subsequent therapeutic procedures still have to be performed in an operating room setting.
Surgical resection of a uterine septum appears indicated if it is associated with recurrent pregnancy loss or obstetric problems such as prematurity (Marcus et al., 1996). When it is only an incidental finding, the indication for surgery is less clear (Pellicer, 1997
). Whatever the indication, a hysteroscopic approach towards resection, usually under general anaesthesia, has become the standard surgical approach (March and Israel, 1987
; Jacobsen and DeCherney, 1997
). Other surgical approaches, performed in the operating room, have also been reported (Rock, 1992
). However, more recently fluoroscopically (Valle et al., 1991
; Gleicher et al., 1995
) and ultrasound (Ohl et al., 1996) guided procedures have been reported which lend themselves to ambulatory use outside the operating room.
Our Centre has been experimenting with a fluoroscopically guided approach towards the resection of uterine septa and intrauterine adhesions for years (Gleicher et al., 1995; Karande et al., 1997a
,b
). In this paper we present our most recent advances in developing a technique that allows the ambulatory resection of uterine septa in an ambulatory setting without the use of general anaesthesia, is safe, and highly cost effective.
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Materials and methods |
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Details regarding the X-ray imaging technique used have previously been published (Gleicher et al., 1992; Karande et al., 1995
, 1997a
). The surgical procedures described here are refinements of a previously published technique (Karande et al., 1997a
). A detailed informed consent was nevertheless obtained from each patient describing possible risks and complications, including bleeding, infection and uterine perforation with subsequent bowel injury (March and Israel, 1987
). The amount of radiation exposure was judged to be well within safe limits but this risk was explained to the patient as well (Karande et al., 1997b
). All but the last eight patients in the series (who only received a paracervical block) received i.v. analgesia with a combination of Fentanyl (Elkins-Sinn, Cherry Hill, NJ, USA) and Versed (Roche Pharma, Inc., PA, USA). In these patients, vital signs were continuously monitored with a DinaMap Vital Signs Monitor (Johnson & Johnson Medical Inc., Arlington, TX, USA) and oxygen saturation monitored using a Nelcor N-20 P pulse-oximeter (Nellcor Incorporated, Pleasanton, CA, USA). Patients who received only a paracervical block with 1% lidocaine had no central monitoring placed.
We used two techniques for resection of the uterine septum. In the first six cases, the technique used was very similar to our previously published technique for resection of intra-uterine adhesions (Karande et al., 1997a). Briefly, a specially designed cervical cannula was used (Cook Ob/Gyn, Spencer, IN, USA). It had a central channel with a diameter of 1.35 mm and a 5 ml balloon at its tip, which retained the cannula in the cervix and prevented back leakage of dye. Hysteroscopic scissors (Circon Acmi, Stamford, CT, USA) with a diameter of 1 mm were inserted through the cannula's central channel and were used to resect the septum. The cannula also had a side channel through which an assistant injected contrast dye, so that the septum was delineated throughout the procedure.
The second (previously not described) technique utilized 2 mm microlaparoscopy scissors (US Surgical Corporation, Norwalk, CT, USA) and was used in the subsequent eight cases. The scissors were part of the Auto Suture Minisite laparoscopic reusable instruments set and were designed for use as an accessory during laparoscopy. They were made of stainless steel and had a flush port, which was supposed to be used for irrigation purposes during laparoscopy. They were stronger than the hysteroscopy scissors and therefore easily cut through a septum. These scissors were inserted into the uterine cavity through the central channel of a routinely used cervical cannula (Conceptus, San Carlos, CA, USA). For the purpose of delineating the septum during resection, the radio-opaque dye was injected through the flush port by an assistant (Figure 1).
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A major advantage of this technique was that it offered depth perception regarding completeness of resection. Unlike hysteroscopic resection, where one cannot be sure whether the septum has been completely resected, there were three signs that invariably guided the surgeon during fluoroscopically-guided resection. Firstly, as the fundus was approached, there was invariably extravasation of dye into the myometrium and the fundus was very clearly outlined as a `dome-shaped' structure (Figure 2). This gave the surgeon a very clear estimation regarding the completeness of the resection. Secondly, as the fundal myometrium was approached, the patient started to experience some discomfort, indicating that the resection was complete. Thirdly, and most importantly, the uterine cavity assumed a (normal) triangular shape (Figure 2
).
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Results |
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The case with a complete septum deserves special mention. The cervix was also divided by the septum and the patient had had a vaginal septum, which had previously been excised. We entered the uterine cavity through one side of the cervix and made a nick in the narrow lower end of the septum. Immediately, dye could be seen entering the cavity on the other side of the septum and leaking out of the cervix on the other side, making the cavity appear like the letter `X'. Once the septum was identified, the rest of the resection was carried out routinely. Repeat HSG one month later, however, showed that the septum had partially reformed. We therefore had to repeat the procedure to complete the resection. The radiation time was <7 min in all cases, which was well within the margins of safety (Karande et al., 1997b). The volume of radio-opaque dye used was between 50 and 100 ml. So far there have been three pregnancies, all of which are still ongoing. The rest of the patients are still attempting pregnancy.
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Discussion |
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We have not made any direct comparison between gynaecoradiological resection and hysteroscopic resection of uterine septa. Some advantages of the gynaecoradiological techniques, however, are obvious: since the gynaecoradiological procedures are performed in the office without general anaesthesia, they avoid charges for operating room time and anaesthesia. Also, they do not require laparoscopic control, which is quite often used by hysteroscopic surgeons when they resect a septum. The excellent depth perception with fluoroscopic control makes it easily possible for the surgeon to evaluate completeness of the resection. Also there is no danger of fluid electrolyte imbalance that can occur with hysteroscopy.
There are some limitations to these techniques, which need to be discussed. A sensitive or apprehensive patient is probably not a good candidate for gynaecoradiological resection in the office. Patients with acutely ante- or retroverted uteri where access to the uterine cavity is difficult may also not be good candidates, though we have performed procedures successfully in such patients.
It should be noted that the entire procedure time was between 20 and 30 min. This included time to set up the patient, arrange the equipment and insert the vaginal instruments. The actual procedure, i.e. the time the fluoroscopy machine was used, took only 37 min.
Safety is a primary concern with any surgical procedure. We have so far performed 14 procedures without any complications. We will, in the future, present our larger experience with these techniques as we collect more cases. Also, other groups need to duplicate our results so that their safety and patient tolerance can be confirmed. Like any surgical procedure (including hysteroscopy) the techniques presented here may not be safe in the hands of less experienced physicians. A case of uterine perforation was included when we presented our initial experience in treatment of four cases with fluoroscopically guided septum resection (Gleicher et al., 1995) with no untoward consequences. Those cases were performed using a different cervical catheter, and the shortcomings of that technique have been discussed elsewhere (Gleicher et al., 1995
; Karande et al., 1997a
).
The techniques described here have become the primary surgical approach to a uterine septum by both authors, who are experienced hysteroscopic surgeons and have previously routinely used a hysteroscopic approach.
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Notes |
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References |
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Submitted on July 22, 1998; accepted on January 12, 1999.