Resection of uterine septum using gynaecoradiological techniques*

V.C. Karande1 and N. Gleicher

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


    Abstract
 Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 References
 
This paper presents further refinements in our technique for the resection of uterine septum. Fourteen patients [infertility (n = 9) and recurrent miscarriages (n = 5)] underwent in-office resection of a uterine septum under fluoroscopic control. The main outcome measure was complete resection of uterine septum. Resections were carried out using either hysteroscopic scissors in combination with a specially designed uterine balloon catheter, or microlaparoscopy scissors in conjunction with a cervical cannula. In all patients the septum was successfully resected without any intra-operative complications. We conclude that ambulatory gynaecoradiological resection of uterine septa is a safe and simple procedure. It avoids utilization of expensive operating room time, general anaesthesia, and some complications associated with hysteroscopic resection, such as fluid retention and electrolyte imbalance.

Key words: gynaecoradiology/infertility/recurrent miscarriages/uterine septum resection


    Introduction
 Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 References
 
A uterine septum results when lateral fusion of the Müllerian ducts occurs, but the midline fusion is not completely resorbed. A septum therefore may involve only part of the uterine fundus or may be complete through the cervix and, possibly, involve the vagina (American Fertility Society, 1988Go). Septate uteri have been associated with infertility, recurrent pregnancy loss, and obstetric prematurity, though in many cases a uterine septum may be totally asymptomatic (Pellicer, 1997Go).

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, 1988Go).

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, 1991Go). The distinction between an arcuate and mildly subseptate or mildly bicornuate uterus still remains difficult whatever the diagnostic modality (Acien, 1997Go). 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., 1996Go).

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., 1996Go). When it is only an incidental finding, the indication for surgery is less clear (Pellicer, 1997Go). Whatever the indication, a hysteroscopic approach towards resection, usually under general anaesthesia, has become the standard surgical approach (March and Israel, 1987Go; Jacobsen and DeCherney, 1997Go). Other surgical approaches, performed in the operating room, have also been reported (Rock, 1992Go). However, more recently fluoroscopically (Valle et al., 1991Go; Gleicher et al., 1995Go) 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., 1995Go; Karande et al., 1997aGo,bGo). 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.


    Materials and methods
 Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 References
 
Fourteen women underwent resection of uterine septa. The indication for their surgery was a history of recurrent miscarriages (n = 5) and of infertility (n = 9). Of the infertile patients, four were in work-up for an embryo transfer (IVF) cycle. The diagnosis of uterine septum was confirmed with ultrasound in eight patients. To differentiate septate from bicornuate uteri, transvaginal ultrasonography was performed using an Acuson Sequoia 512 ultrasound machine (Acuson Corporation, Mountain View, CA, USA) with a 4–8 MHz or 10 MHz probe. The uterus was examined in the transverse plane and myometrial pattern determined. If the myometrium extended in a circular pattern around each endometrial stripe with free space between right and left myometria, a bicornuate uterus was diagnosed. If no space was observed between right and left medial myometria, a septate uterus was diagnosed. Presence or absence of blood flow within the septum was documented by colour Doppler flow. Circular arcuate artery blood flow was demonstrated in both horns of the bicornuate uterus. Six patients had undergone a previous laparoscopy that ruled out a bicornuate uterus. The septum was partial in 13 patients and reached the cervix with subsequent cervical duplication in one.

Details regarding the X-ray imaging technique used have previously been published (Gleicher et al., 1992Go; Karande et al., 1995Go, 1997aGo). The surgical procedures described here are refinements of a previously published technique (Karande et al., 1997aGo). 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, 1987Go). 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., 1997bGo). 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., 1997aGo). 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 1Go).



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Figure 1. The 2 mm microlaparoscopy scissors have been inserted through the central channel of a cervical cannula. The radio-opaque dye is injected through the flush-port of the scissors by an assistant to delineate the septum as it is being resected.

 
The septum resection was commenced at the lowest point of the septum and carried out systematically, as previously described with hysteroscopic resection, using scissors (March and Israel, 1987Go). A few precautions were needed during septum resection under fluoroscopic guidance. After entering the uterine cavity, the scissor handles were rotated and maintained in the plane of the cavity. This ensured that the blades would open and close in the plane of the cavity so that only the septum would be resected and the scissors would not burrow into the myometrium. When using hysteroscopy, the uterine cavity is usually distended with large volumes of fluid or gas to facilitate visualization. With a distended cavity, it is then imperative that the procedure remains in the proper plane to avoid perforation. Unlike hysteroscopy, with fluoroscopic resection we were using low volumes of contrast medium and the cavity was therefore relatively flat (less distended). It was therefore easy to stay in the proper plane by maintaining the scissor handles (and therefore the blades) in the plane of the cavity. During septum resection the patient experienced only minimal discomfort. If the procedure remained in the plane of the cavity, the resection was quick and practically painless. Burrowing into the myometrium would result in pain and immediate extravasation of dye into the myometrium. Should this have occurred, one only needed to wait for a few minutes to allow for the extravasated dye to clear into the circulation before proceeding with the rest of the resection. If the scissors needed to be rotated during the resection, the jaws should always be closed prior to rotation. If the scissors were rotated with the jaws open, the patient would experience discomfort.

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 2Go). 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 2Go).



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Figure 2. Resection of uterine septum. (A) Uterine septum. (B) The resection was commenced at the lower end (apex) of the septum. (C) Resection with scissors is shown under way. (D) The base of the septum was now resected. (E) Extravasation of dye into the myometrium gave a `dome-shaped' appearance at the fundus. This gave excellent depth perception, enabling assessment of the completeness of the resection. (F) Resection of the septum is complete.

 

    Results
 Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 References
 
A total of 14 patients underwent resection of uterine septa. Of these, six were performed using the hysteroscopic scissors (with the Cook cannula) and eight were performed using the micro-laparoscopy scissors (with the Conceptus cannula). In all cases the septum was successfully resected with no intra-operative complications. There was minimal bleeding in all cases and there were no perforations. All patients underwent repeat HSG 1–3 months after the resection. In 12 cases, repeat HSG showed complete resection of the septum. In one case of a large septum, repeat HSG showed mild intrauterine adhesions, which were lysed under fluoroscopic control at the time of diagnosis (Karande et al., 1997aGo).

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., 1997bGo). 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.


    Discussion
 Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 References
 
We have here described two very similar techniques for the resection of uterine septa, which are performed in the office, under fluoroscopic control using commercially available scissors. Both techniques are well tolerated by the patients, and are fairly easy to perform for an experienced hysteroscopic surgeon. The first technique (n = 6) utilizes a specially designed catheter by Cook Ob/Gyn and regular hysteroscopy scissors (Circon ACMI). The second technique (n = 8) utilizes 2 mm micro-laparoscopy scissors (US Surgical Corporation) in conjunction with a standard cervical cannula (Conceptus) (Figure 1Go). The micro-laparoscopy scissors are stronger than the hysteroscopy scissors and therefore incise the septum more swiftly. This is exemplified by the fact that we were able to complete some of the procedures in <3 min rad time, under paracervical block alone!

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 3–7 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., 1995Go) 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., 1995Go; Karande et al., 1997aGo).

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.


    Notes
 
1 To whom correspondence should be addressed at: The Center for Human Reproduction, Illinois, 750, North Orleans, Chicago, Illinois 60610, USA Back


    References
 Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 References
 
Acien, P. (1997) Incidence of Müllerian defects in fertile and infertile women. Hum. Reprod., 12, 1372–1376.[ISI][Medline]

American Fertility Society (1988) The American Fertility Society classification of adnexal adhesions, distal tubal occlusion, tubal occlusion secondary to tubal ligation, tubal pregnancies, Müllerian anomalies and intrauterine adhesions. Fertil. Steril., 49, 944–955.[ISI][Medline]

Gleicher, N., Parrilli, M., Redding, L. et al. (1992) Standardization of hysterosalpingography and selective salpingography: a valuable adjunct to simple opacification studies. Fertil. Steril., 58, 1136–1141.[ISI][Medline]

Gleicher, N., Pratt, D., Levrant, S. et al. (1995) Gynaecoradiological uterine resection. Hum. Reprod., 10, 1801–1803.[Abstract]

Jacobsen, L.J. and DeCherney, A. (1997) Results of conventional and hysteroscopic surgery. Hum. Reprod., 12, 1376–1381.[Abstract]

Karande, V.C., Pratt, D.E., Rabin, D.S. and Gleicher, N. (1995) The limited value of hysterosalpingography in assessing tubal status and fertility potential. Fertil. Steril., 63, 1167–1171.[ISI][Medline]

Karande, V., Levrant, S., Hoxsey, R. et al. (1997a) Lysis of intrauterine adhesions using gynecoradiologic techniques. Fertil. Steril., 68, 658–662.[ISI][Medline]

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Submitted on July 22, 1998; accepted on January 12, 1999.





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