Pólipos endometriales: Actualización en diagnóstico y tratamiento / Endometrial polyps: update on diagnosis and treatment

ANTECEDENTES: Los pólipos endometriales son protrusiones nodulares benignas de la superficie endometrial con características clínico-patológicas propias y de origen desconocido. Su prevalencia es alta, especialmente en pacientes con sangrado uterino anormal, se asocia a infertilidad y a cáncer de endometrio, lo que se traduce en que se trata de una patología muy importante en el quehacer ginecológico habitual. OBJETIVOS: Revisar la patogenia, actualizar y evaluar los métodos diagnósticos, y definir las mejores opciones terapéuticas de esta frecuente patología. MÉTODO: Revisión sistemática de la literatura publicada en el tema, mediante búsqueda en base de datos Pub Med. RESULTADOS: La patogenia es aun desconocida, es una patología muy heterogénea y no hay causa única, se han reportado varios hallazgos relacionados con alteraciones genéticas. La ultrasonografía de alta definición, la hidrosonografia y la histeroscopia son el estándar actual en el diagnóstico. Las opciones terapéuticas se extienden desde la observación y seguimiento con imágenes, hasta la histerectomía con biopsia contemporánea, siendo la histeroscopia quirúrgica el método más costo efectivo. CONCLUSIÓN: La patogenia de los pólipos endometriales se encuentra actualmente en revisión, no hay ninguna teoría que explique la génesis de todos los pólipos. La ultrasonografía con contraste y la histeroscopia constituyen el estándar en el diagnóstico. En el tratamiento, la indicación es la cirugía histeroscopica y en especial la resección electroquirúrgica, que permite una extracción completa del pólipo bajo visión directa, con enfoque diagnóstico y terapéutico, con riesgos bajos y recurrencia mínima.

BACKGROUND: Endometrial polyps are benign nodular protrusions of the endometrial surface with clinical and pathological features of unknown origin. Its prevalence is high, especially in patients with abnormal uterine bleeding, it is associated with infertility and endometrial cancer, what constitutes a common and important disease. AIMS: To review the pathogenesis, to update and evaluate diagnostic methods, and to define the best treatment options for this common condition. METHODS: A systematic review of the published literature on the subject by searching PubMed database. RESULTS: The pathogenesis is still unknown, it is a very heterogeneous disease and there is no single cause, there have been several findings related to genetic alterations. High definition ultrasonography, the hidrosonography and hysteroscopy are the current standard in diagnosis. Therapeutic options range from observation and follow up with images to the hysterectomy using contemporary biopsy, surgical hysteroscopy being the most cost effective method. CONCLUSION: The pathogenesis of endometrial polyps are currently under review, there is no theory to explain the genesis of all polyps. Contrast ultrasonography and hysteroscopy are standard in the diagnosis. In the treatment, the indication is histeroscopy surgery and especially electrosurgical resection, which allows complete removal of polyps, diagnostic and therapeutic approach, with low risk and low recurrence.

El futuro de la cirugía reproductiva

Es necesario revisar la intervención de la cirugía reproductiva desde la perspectiva de un tratamiento preparatorio para el de fecundación in vitro (FIV). Si hay hidrosálpinx, es necesaria una salpingectomia laparoscópica antes de ingresar a un programa de FIV, considerando que la cirugía no compromete la estimulación ovárica ni las tasas de embarazo con respecto a las pacientes con las trompas sanas. No se ha demostrado alteraciones en los índices de implantación ni de embarazo por efecto de la endometriosis; por tanto, no vale la pena llevar a la paciente a los riesgos de una cirugía. Frente a una ligadura de trompas, los mejores resultados se logran si se llevó a cabo por aplicación de clips en el parte media del istmo, y los peores cuando el procedimiento se realizó distalmente con la eliminación del extremo fimbrial. Las pacientes con miomas subserosos o intramurales menores a 4 cm, que no afectan la cavidad uterina, tienen resultados de FIV/ICSI similares a las que no los tienen; ellas no requieren una miomectomía. En los casos de pérdida recurrente del embarazo, útero septado y polipectomía (>9 mm), los resultados reproductivos de la resectoscopia (histeroscopia quirúrgica) muestran beneficios significativos. El futuro de la cirugía reproductiva, debe considerar preservar la capacidad de tener hijos antes de pensar en eliminar la patología. Todos los ensayos futuros deberán abordar los posibles efectos a largo plazo en detrimento de la fertilidad femenina.

It is necessary to review reproductive surgery from the perspective of in vitro fertilization (IVF) preparatory treatment. When hydrosalpinx is present, laparoscopic salpingectomy is required before entering to an IVF program, considering that surgery does not compromise ovarian stimulation or pregnancy rates with respect to patients with healthy fallopian tubes. As rates of implantation and pregnancy are not altered by endometriosis, carrying the patient to surgery risks is not worth. Faced with tubal ligation, best results are achieved when clips were applied in the middle of the isthmus and worst results when the procedure removed the distal end of the fimbria. Patients with less than 4 cm subserosal or intramural fibroids that do not alter the uterine cavity have IVF / ICSI results similar to those that do not have them, and do not require myomectomy. In cases of recurrent pregnancy loss, uterine septum and polypectomy (>9 mm), resectoscopy (by hysteroscopy) shows significant reproductive benefits. The future of reproductive surgery should consider preserving the ability to have children before considering eliminating pathology. All future trials should address the potential female fertility detrimental long-term effects.

Gasless Laparoscopic Surgery for Gynecological Diseases:Report of 58 Cases / 中国微创外科杂志

Objective To discuss the safety and efficacy of gasless laparoscopy in gynecological surgery.Methods A total of 58 patients who received gasless laparoscopic surgery from October 2006 to December 2007 were enrolled in this study.Among the patients,31 underwent ovarian cystectomy,23 received myomectomy,3 laparoscopic-assisted transvaginal hysterectomy(LAVH),and 1 salpingectomy(because of ectopic pregnancy).One trocar was used in 13 cases(ovarian cystectomy in 11 and myomectomy in 2) with the assistance of hysteroscopic resectoscopy,two trocars were employed in 27 cases(ovarian cystectomy in 11 and myomectomy in 16),and three trocars in 18 cases(ovarian cystectomy in 9,myomectomy in 5,LAVH in 3,and salpingectomy in 1).The instruments employed in this study were purchased from Daoke Co.Results All of the 58 surgeries were successfully completed.In the patients received ovarian cystectomy,the mean intraoperative blood loss was(46.8?10.1) ml(ranged from 10 to 200 ml),and the mean operation time was(66.3?6.7) min(30-150).While in the patients underwent myomectomy,the mean intraoperative blood loss was(94.3?8.2) ml(10-400),and the mean operation time was(104.3?6.7) min(60-180).For the 3 cases of LAVH,intraoperative blood loss was 100,200,and 150 ml;and operation time was 255,240,and 135 min,respectively.The salpingectomy was finished within 30 min.None of the 58 patients developed complications during and after the operations.They were discharged from the hospital in(7.9?1.6) days,and were followed up for 3 to 6 months,during which no complications occurred.Conclusions Gasless laparoscopic surgery is safe,effective,and minimally invasive for gynecological diseases.The procedure can be used for eldly patients and those who cannot tolerate general anesthesia due to cardiovascular diseases.

Simplified Submucosal Myomectomy by Operating Hysteroscopy on OPD Basis / 대한산부인과학회잡지

OBJECTIVE: To evaluate possibility of simplified hysteroscopic operation instead of resectoscopic operation on OPD basis for sumucosal myoma with small pedicle. MATERIALS AND METHODS: On twenty five patients, who diagnosed submucosal myoma with small pedicle by sonohysterogram and diagnostic hysteroscopy, simplified hyteroscopic operations were performed on OPD. Used expanding media was normal saline. At first, pedicle was incised by hysteroscopic scissors and myoma mass was dissected by pushing of scope. After dissection of myoma mass, remained pedicle was cut by hysteroscopic scissors. The bleeding from cut pedicle site was controlled by bipolar coagulation. Cut myoma mass was removed to outside of uterus by ring forceps. However if removal of myoma mass is failed, let it in uterine cavity and it is removed at second-look hysteroscopy 1 month later after degeneration. RESULTS: On 1 of 25 patients, cutting of pedicle was failed due to fundal invisible pedicle on hysteroscopic view. On 20 of 24 patients, pedicles were completely cut. On 12 of these 20 patients, myoma masses were completely removed to outside of uterus by grasping forceps. However on remained 8 of 20 patients, myoma mass was removed easily on second-look hysteroscopy 1 month later due to shrinkage of mass. On 4 of 24 patients, pedicles were not cut completely due to large submucosal myoma. They were removed also easily on second-look hysteroscopy. Postoperative bleeding from cutting pedicle was surprisingly minimal in most cases and moderate bleeding was only in 3 cases. Severe bleeding case was not observed. Preoperative GnRH agonist therapy had not so big benefit due to these minimal to moderate postoperative bleeding. CONCLUSION: Therefore simplified hysteroscopic operation on OPD basis for submucosal myoma with small pedicle should be considered before resectoscopic operation, because this simplified hysteroscopic operation has many benefit economically and psychologically to patients on submucosal myoma with small pedicle. It is better that resectoscopic operation is performed in failed case of this simplified operation.

The Effectiveness of Resectoscopy in Gynecology / 대한산부인과학회잡지

OBJECTIVE: The purpose of our study is to find out the therapeutic effectiveness, reproductive outcome, and the diagnostic pathologic findings of the patients treated with resectoscopy. METHODS: We examined 110 patients who complained infertility, abnormal uterine bleeding and menorrhagia from May. 1995 to Dec. 2000 via office. Among the infertility and abnormal uterine bleeding patients with abnormal endometrial lesion, resectoscopy was performed and then the resected tissues was sended for pathologic examination, except IUA, uterine septum, and double uterus. After resectoscopy, we inserted Lippes loop and medicated premarin 2.5 mg, 54 days and medroxyprogesterone acetate 10 mg, 10 days to the IUA patients. In AUB patients, we only injected methergin for bleeding control. They visited office after 1 month, and the follow up for endometrial state was done through TVS, HSG, or hysteroscopy. RESULTS: Among the 44 infertility, 41 (93%) had normal endometrium findings. Of twenty pregnancy (48.8%), seven (35%) ended in a second trimester abortion, thirteen (65%) in a full-term infant. Among the 66 with abnormal uterine bleeding, the 62 (93%) had normal endometrial finding and normal menstruation pattern. But 2 patients recurred their symptom, then hysterectomy was done 3, 5 years later respectively. Most of the patients who performed histopathologic study were diagnosed as leiomyoma (59.4%), and then endometrial or endocervical polyp (25.3%) and residual placenta tissue (3.8%) respectively. CONCLUSION: The 101 patients (91.8%) improved their symptoms and intrauterine lesion. we suggest this technique which of diagnostic accuracy, cost safety, convenience, operation time, and patient's satisfaction.

The Prognosis of Resectoscopic Myomectomy of Submucosal Myomas / 대한산부인과학회잡지

OBJECTIVES: To examine the outcome after operative resectoscopic resection of submucosal myomas in symptomatic women. METHODS: Forty eight symptomatic women with submucosal myomas underwent operative resectoscopy for resection of the submucosal myomas. A few months after the myomectomy, I compared postoperaive status of the patients to preoperative status of the patients. RESULTS: No operative or postoperative complications occurred and all patients were discharged within 4 days. The follow-up period was 11.12+/-6.44 months(mean+/-SD). The age of the patients was 37.69+/-9.22 years(mean+/-SD) at the time of the operation. Twelve women out of 16 conceived(pregnancy rate of 75%)and all of them subsequently delivered at term. Thirty two women(menorrhagia of 28 and backache of 4) had been rid of their chief complaints that they had suffered from preoperatively. CONCLUSION: The results of this study indicate that operative resectoscopy achieved a pregnancy rate 75%. These results suggest that operative resectoscopy is an effective procedure to resect submucosal myomas in infertile symptomatic women.

Clinical outcome of intrauterine adhesion after Resectoscopy / 대한산부인과학회잡지

OBJECTIVES: From February 1995 to April 1998, those patients who had visited for evaluation of infertility, shown abnormal endometrial pattern on hysterosalpingography underwent resectoscopic operation. We evaluated about its therapeutic effect, recurrence rate of uterine adhesion and effectiveness of its assisted method. METHOD: We have reviewed 45 cases of intrauterine adhesion, classified as a central type, marginal type and multiple type. We used 26F resectoscope made in Storz for operation and inserted Lippes loop or pediatric foley catheter for prevention of readhesion. For promoting reepithelialization, conjugated estrogens(premarin) 5mg daily for 30 - 50 days were given and then 10mg of medroxyprogesterone acetate(provera) were added daily for the last 10 days. We evaluated the uterine cavity condition preoperatively and postoperatively by using hysterosalpingography. RESULT: In 45 cases, 41 cases were followed up postoperatively. 21 cases were markedly improved, 12 cases were improved and 8 cases were not improved or recurred on hysterosalpingography. In 41 cases, for prevention of readhesion 20 cases were used pediatric foley catheter and 5 cases(25%) were recurred. 21 cases were used Lippes loop and 3 cases(14%) were recurred. Pregnancy outcome was as follows;15 cases were pregnant and 10 cases delivered a viable infant, 3 cases aborted spontaneously, 1 case was ectopic pregnancy and laparoscopic salpingectomy was done, 1 case was ongoing pregnancy. CONCLUSION: This report suggests that resectoscopic operation is very effective in the treatment of intrauterine adhesion(therapeutic rate of 81%) and that the use of Lippes loop seems like to have the less recurrence rate than the use of pediatric foley catheter in prevention of postoperative readhesion, but more experience and further follow-up are necessary to obtain more detailed conclusions.

Clinical Usefulness of Resectoscopic Surgery in Endometrial Factor of Infertility / 대한산부인과학회잡지

From May 1995 to February 1997, 46 patients underwent resectoscopic surgery for infertility. Of 46 patients, 32 patients had uterine synechiae, 5 patients had polyps, 3 patients had septums, 3 patients had bony foreign bodies, 2 patients had submucosal myomas, 1 patient had tuberculous endometritis. The resectoscopic procedure proved of special value for resection of intrauterine adhesion, submucosal myoma, septum and polyp. Except 5 patients, intrauterine conditions were improved and 10 patients were conceived. So it goes without saying that resectoscopic surgery is a effective and acceptable procedure for the management of infertility of endometrial factors. However, with the finding of slightly less satisfactory results with time and number, further follow-up is still needed to establish the usefulness of the procedure.