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.

Esterilização histeroscópica ambulatorial pelo procedimento Essure: stent tubário / Outpatient hysteroscopic sterilization by the Essure procedure: stent tubal

A esterilização cirúrgica é um dos métodos contraceptivos mais populares. Métodos tradicionais de esterilização permanente (por exemplo, ligadura tubária abdominal ou laparoscópica) utilizam a anestesia geral ou regional, necessitando de incisão na parede abdominal ou introdução de trocaters, expondo a paciente aos riscos intrínsecos ao procedimento cirúrgico e à obrigatoriedade da recuperação pós-operatória. A Food and Drug Administration (FDA) dos Estados Unidos aprovou em 2002 o sistema de stent tubário Essure. O Essure oclui as trompas estimulando a fibrose tecidual e a subsequente cicatrização. Esse é um artigo de revisão, que tem o objetivo de apresentar esse método aos tocoginecologistas brasileiros, como uma alternativa eficaz e segura para uso na nossa população. O Hospital da Mulher Mariska Ribeiro é atualmente Centro de Referência no Brasil para o Essure já tendo realizado cerca de 1000 procedimentos.

Surgical sterilization is a popular contraceptive method. Traditional methods of permanent sterilization (eg, abdominal or laparoscopic tubal ligation) use general or regional anesthesia, requiring incision in the abdominal wall or introduction of trocars, exposing the patient to the inherent risks of the surgical procedure and the requirement of postoperative recovery. The Food and Drug Administration (FDA) of the United States in 2002 approved the Essure tubal stent system. The Essure occludes the fallopian tubes stimulating tissue fibrosis and subsequent healing. This is a review article, which aims to present this method to Brazilian obstetricians and gynecologists as an effective and safe alternative for use in our population. The Hospital da Mulher Mariska Ribeiro is currently a Reference Center in Brazil for the Essure having already performed about 1000 procedures.

Histeroscopia quirúrgica: experiencia en una institución privada

Objetivos: Determinar los hallazgos y experiencia con el procedimiento de histeroscopia quirúrgica. Diseño: Estudio retrospectivo. Institución: Centro de Endoscopia Ginecológica Peruano Alemán, Lima, Perú. Participantes: Mujeres con patología uterina. Intervenciones: Se realizó 122 histeroscopias quirúrgicas en mujeres de 23 a 58 años, entre el 01/01/2012 y 31/12/2013. Resultados: En 87 pacientes la histerocopia quirúrgica fue realizada por pólipos, en 24 por miomas, en 6 por adherencias endouterinas y en 5 por otras causas. Los pólipos y los miomas ocurrieron en su mayoría entre los 31 y 48 años. Se hizo el diagnóstico por ultrasonido en 64,8%, histerosonografía en 31,2%, histerosalpingografía en 3,2% y en un caso por tomografía axial computarizada (0,8%). Se usó misoprostol previo en 77 pacientes (63,1%), anestesia general en 99% (solo una epidural) y como medio de distensión glicina en 105 pacientes y suero fisiológico en 17. El tiempo operatorio para polipectomía fue entre 18 y 70 minutos (media de 28 minutos), para las miomectomías entre 20 y 90 minutos (media 48 minutos) y para la liberación de sinequias endouterinas entre 30 y 45 minutos (media 42). Se presentaron 3 casos de enfermedad inflamatoria pélvica, una hemorragia post miomectomía y una perforación uterina en un síndrome de Asherman, al poner el DIU al final del procedimiento. Al evaluar la forma de diagnóstico y la correlación patológica, el ultrasonido falló en 7 de los 53 pólipos, que resultaron ser miomas. De igual modo con la histerosonografía, en pólipos 4 de 32 correspondieron a miomas. En los casos de miomas y síndrome de Asherman, todos los métodos diagnósticos usados dieron resultados correctos. Conclusiones: En la experiencia mostrada, la cirugía uterina endoscópica fue la mejor forma de determinar la clasificación y los hallazgos preoperatorios.

Objectives: To determine surgical hysteroscopy findings and experience. Design: Retrospective study. Setting: Centro de Endoscopia Ginecológica Peruano Alemán, Lima, Peru. Participants: Women with uterine pathology. Interventions: Between January 1 2012 and December 31 2013, 122 surgical histerocopies were performed in 122 women 23-58 years old. Results: Preoperative diagnosis was polyps in 87 patients, myomas in 24 patients, uterine adherences in 6 patients and other causes in 5 patients. Polyps and fibroids diagnosis was mostly in patients 31-48 years old. Diagnosis was by ultrasound in 64.8%, sonohysterography in 31.2%, hysterosalpingography in 3.2%, and computerized axial tomography in one case (0.8%). Misoprostol was used prior to surgery in 77 patients (63.1%), general anesthesia in 99% (only one epidural) and glycine as distension medium in 105 patients as well as saline in 17. Operative time for polypectomy was between 18-70 minutes (average 28 minutes), for myomectomy 20-90 minutes (average 48 minutes), and for liberation of endouterine adhesions 30-45 minutes (mean 42). Complications were 3 cases of pelvic inflammatory disease, post myomectomy bleeding in one case and uterine perforation in a case of Ashermans Syndrome during intrauterine device insertion. In determining diagnosis and pathology correlation, ultrasound failed in 7 of the 53 polyps that proved to be uterine fibroids, sonohysterography failed in 4 of 32 polyps that were fibroids. All diagnostic methods used for uterine fibroids and Ashermans Syndrome cases were correct. Conclusions: In this report uterine surgical endoscopy was the best way to corroborate preoperative findings and classification.

Premalignant and malignant lesions in endometrial polyps in patients undergoing hysteroscopic polypectomy / Lesões precursoras e câncer em pólipos do endométrio de pacientes submetidas à polipectomia histeroscópica / Lesões precursoras e câncer em pólipos do endométrio de pacientes submetidas à polipectomia histeroscópica

Objective : To evaluate the incidence of premalignant lesions and cancer in endometrial polyps, in patients undergoing hysteroscopic polypectomy. Methods : The results of 1,020 pathological examinations of patients submitted to hysteroscopic polypectomy were analyzed, as well as their diagnostic and surgical hysteroscopy findings. As to their menstrual status, 295 (28.9%) patients were in menacme. Of the total, 193 (65.4%) presented abnormal uterine bleeding, and 102 (34.6%) were asymptomatic with altered endometrial echo on transvaginal ultrasound. Out of 725 (71.1%) postmenopausal patients, 171 (23.6%) were symptomatic (abnormal uterine bleeding), and 554 (76.4%) were asymptomatic with endometrial echo >5.0mm. Results : Twenty-one (2.0%) patients presented premalignant lesions in the polyps, 13 had simple glandular hyperplasia, of which 5 had no atypia, and eight presented atypia. Eight polyps presented focal area of complex hyperplasia: 4 with atypia and 4 without lesions. Cancer was diagnosed in 5 (0.5%) polyps. Of the 21 polyps that harbored premalignant lesions, 12 were interpreted as benign in diagnostic and surgical hysteroscopy. Of the polyps with cancer, 4 were also histeroscopically interpreted as normal. Conclusion : Symptomatic polyps in menacme and in all postmenopausal women should be resected and submitted to histopathological examination, since they may have a benign aspect, even when harboring areas of cellular atypia or cancer. .

Objetivo : Avaliar a incidência de lesões precursoras e câncer em pólipos do endométrio de pacientes submetidas à polipectomia histeroscópica. Métodos : Análise dos resultados de 1.020 exames anatomopatológicos de pacientes submetidas, em hospital público, à polipectomia histeroscópica, e achados em suas histeroscopias diagnóstica e cirúrgica. Em termos de estado menstrual, 295 (28,9%) pacientes encontravam-se na menacme. Do total, 193 (65,4%) apresentavam sangramento uterino anormal e 102 (34,6%) eram assintomáticas, com alteração da medida do eco endometrial à ultrassonografia transvaginal. Das 725 (71,1%) pacientes na pós-menopausa, 171 (23,6%) eram sintomáticas (sangramento uterino anormal) e 554 (76,4%) assintomáticas, com eco endometrial >5,0mm. Resultados : Vinte e uma (2,0%) pacientes apresentaram lesões precursoras nos pólipos, 13 com hiperplasia glandular simples, das quais 5 sem atipias e 8 com atipias. Oito pólipos apresentavam área focal de hiperplasia complexa, quatro com atipias e quatro sem lesões. Câncer foi diagnosticado em cinco (0,5%) pólipos. Dos 21 pólipos que abrigavam lesões precursoras, 12 foram interpretados como benignos nas histeroscopias diagnóstica e cirúrgica. Quatro dos pólipos com câncer também foram interpretados histeroscopicamente como normais. Conclusão : Os pólipos sintomáticos na menacme, bem como todos na pós-menopausa, devem ser ressecados para realização de exame anatomopatológico, por poderem apresentar aspecto benigno, mesmo quando abrigam áreas de atipia celular ou câncer. .