Conceptos actuales en cirugía histeroscópica: superando barreras y ampliando límites / Current concepts in hysteroscopic surgery: Overcoming barriers by extending limits

Dentro de la patología intracavitaria estructural, los miomas submucosos plantean una mayor dificultad de manejo frente a los pólipos. Dentro de los miomas submucosos los miomas tipo0 y1 son más fáciles de tratar, dado que su separación del miometrio subyacente es técnicamente más fácil. Así, las cirugías histeroscópicas más complicadas son actualmente las miomectomías de miomas submucosos tipo2.Se ha empezado a describir también el manejo histeroscópico de miomas tipo3 por histeroscopia.Con este artículo planteamos hacer una revisión de los puntos más relevantes para llevar a cabo un tratamiento adecuado de este tipo de miomas, revisando su diagnóstico, las técnicas quirúrgicas, la preparación de la paciente y la forma de evitar complicaciones quirúrgicas.(AU)

Within structural intracavitary pathology, submucosal myomas are more difficult to manage than polyps. Of the submucosal myomas, type0 and type1 are easier to treat because their separation from the underlying myometrium is technically easier. Therefore, the most complicated hysteroscopic surgeries are currently type2 submucosal myomectomies.We have also begun to describe the hysteroscopic management of type3 myomas.With this article we propose to make a review of the most relevant points for the correct treatment of this type of myoma, reviewing its diagnosis, surgical techniques, patient preparation, and how to avoid surgical complications.(AU)

Tumor recurrence and tumor-related mortality in endometrial cancer: Analysis in 276 patients.

BACKGROUND: In this manuscript, we assessed tumor recurrence and tumor-related mortality in a clinical series of endometrial cancer patients. MATERIALS AND METHODS: A retrospective evaluation of 276 patients (mean age 64 years) with histologically confirmed endometrial cancer treated at a single hospital in Madrid (Spain) was conducted. The median follow-up was estimated using the inverse Kaplan-Meier method. RESULTS: Salient findings were endometrioid carcinoma (84.8% of cases), grade G1 (48.9%) and stages IB (35.1%) and IC (23.2%). Myometrial infiltration >50% was documented in 31.2% of cases and lymphovascular space invasion in 11.9%. After surgery, 52.5% of patients were classified into the low risk group, 21.4% into the intermediate risk group and 26.1% into the high risk group. Tumor recurrence occurred in 14.5% of patients, with an estimated median follow-up of 45 months (95% confidence interval (CI): 41.2-48.8), locoregional recurrence in 42.5% and distant recurrences in 57.5%. Furthermore, 40% of tumor recurrences developed during the first year after primary treatment and 90% over the first 3 years of follow-up. The tumor-related mortality rate was 15.9%. The estimated median follow-up was 46 months (95% CI: 43.0-49.0). Furthermore, 5.07% of death because of tumor developed during the first year after primary treatment and 13.77% over the first 3 years of follow-up. CONCLUSION: The rates of tumor-related death and tumor recurrence in endometrial cancer patients are low, with the highest percentages occurring within 3 years of primary treatment. Most of the recurrences occur outside the pelvis.

Histeroscopia en hiperplasia y cáncer de endometrio / Hysteroscopy in hyperplasia and endometrial cancer

La histeroscopia permite observar directamente el interior del útero, La hiperplasia endometrial definida como una proliferación de glándulas, de forma y tamaño irregular, no presenta patrón histeroscópico determinado para cada tipo de hiperplasia. Cuando valoramos eficacia y correlación del diagnostico clínico con el histológico, la eficacia diagnóstica para hiperplasia oscila entre el 56 y el 83%, La normalidad de imagen histeroscópica no excluye la posibilidad de patología. La sensibilidad es del 98% con una especificidad del 99.9% en determinados grupos especialmente entrenados, entre los que nos encontramos, en el adenocarcinoma endometrial hacen a la histeroscopia herramienta imprescindible. La afectación cervical es diagnosticada con una sensibilidad que oscila entre el 64-100%, especificidad 73-98%. El VPN es de 100% y un VPP entre el 38.4 y 93.3%. La histeroscopia es el método de elección en el diagnostico y manejo de la patología maligna endometrial, favoreciendo el hallazgo temprano y el estadiaje del cáncer endometrial. Precisa entrenamiento y aprendizaje para la obtención de su mejor rendimiento diagnostico. Con una elevada sensibilidad, especificidad

The hysteroscopy allows to observe the interior of the uterus directly. The endometrial hyperplasia defined as a proliferation of glands, of form and irregular size, it doesn’t present hysteroscopic patron certain for each hyperplasia type. When we value effectiveness and correlation of the diagnose clinical with the histology, the effectiveness diagnostic for hyperplasia oscillates between the 56 and 83%. The normality of image hysteroscopic doesn’t exclude the pathology possibility. The sensibility is of 98% with a specificity of 99.9% in certain specially trained groups, in those that we find ourselves , the carcinoma endometrial makes to the hysteroscopy indispensable tool. The cervical affectation is diagnosed with a sensibility that oscillates between 64-100%, specificity 73-98%. The VPN is of 100% and a VPP between the 38.4 and 93.3%. The hysteroscopy is the election method in the diagnose and manage of the pathology wicked endometrial, favoring the early discovery and the stage of the endometrial cancer. It is necessary a training and a learning for the obtainig of their best yield diagnose. With a high sensibility, specificity

Citología peritoneal positiva posthisteroscopia en los estadios iniciales del carcinoma de endometrio: azar o realidad / Positive peritoneal cytology post hysteroscopy in the initial stages of endometrial carcinoma: chance or fact

El adenocarcinoma de endometrio es la neoplasia ginecológica más frecuente. La histeroscopia es la prueba de referencia en el diagnóstico de la enfermedad endometrial. Se determinará la relación entre la citología peritoneal positiva y la histeroscopia en estadios precoces del carcinoma de endometrio, mediante un estudio retrospectivo. Sólo en 2 casos se obtuvo una citología peritoneal positiva (2,1%). Hay múltiples factores que pueden incrementar el número de citologías positivas, aunque la positividad en estadios precoces no parece tener un papel definitivo (AU)

Endometrial carcinoma is the most common gynaecological tumour. Hysteroscopy is the 'gold standard' in the diagnosis of endometrial pathology. We are going to determine the relationship between positive peritoneal cytology and endometrial carcinoma with a retrospective study. Peritoneal cytology was positive in only two cases (2.1%). Many factors exist which may increase the number of positive cytology, although being positive in the early stages does not seem to have a definitive role (AU)

Hysteroscopic myomectomy: our experience and review.

OBJECTIVE: To analyze the results of hysteroscopic myomectomy in our center and to compare the results to those published in the literature. METHODS: We performed a retrospective study of the clinical histories of patients who had undergone hysteroscopic myomectomy with a resectoscope between January 1992 and December 1999. Procedures were performed at a hysteroscopic clinic in the Department of Obstetrics and Gynecology at the University Public Hospital in Madrid's south zone. One hundred twenty pre-, peri-, and postmenopausal women with submucous myomas were included in the study. All patients underwent hysteroscopic resection with a monopolar loop. RESULTS: We performed 120 hysteroscopic myomectomies. The patients' median age was 44.8 years (23 to 74). Abnormal uterine bleeding (AUB) was the most frequent indication (84.1%). Inability to reproduce was the indication in 14 (11.6%) cases. GnRH analogue preparation was used in 60% of cases. We operated on 52 (43.3%) type 0, 51 (42.5%) type I, and 17 (14.1%) type II myomas, according to Wamsteker and Blok classification. A median of 32.5 (10 to 105) minutes was required for the interventions. The myomectomy was combined with another operation (12 polypectomies, 24 endometrial resections, and 1 laparoscopic ovarian cystectomy) in 32 patients. The median retention of glycemia was 281 cc (0 to 1300). We could not complete the resection in 22 patients. Twelve underwent reoperation (3 hysterectomies and 9 second myomectomies). No serious complications occurred, and the median hospital stay was 25.4 hours. The histological study confirmed leiomyoma in all the cases. The intervention results were satisfactory after a follow-up period of 12 months to 7 years, AUB being controlled in 88.5% of the patients. CONCLUSION: Hysteroscopic myomectomy is a reliable procedure that is effective in controlling abnormal uterine bleeding. It is a good alternative to hysterectomy and has an acceptable surgical time and minimum hospital stay. To reduce the need of reintervention, appropriate patient selection and improved technique are necessary. The technique also offers significant economic savings compared with the conventional surgical methods.

Análisis de la aplicación del índice pronóstico de Van Nuys en carcinoma in situ de mama y su influencia en la adecuación del tratamiento / An analysis of the application of de Van Nuys prognosstic index of in situ breast cancer and its influence on treatment adjustment

En la práctica diaria y por el advenimiento de los programas de detección mamaria, el diagnóstico de carcinoma in situ de mama es cada vez más frecuente. En nuestro material del 10 por ciento en el primer período analizado (1984-1989), hemos pasado al 55 por ciento en el período 1996-2001.La valoración de los carcinomas en función del VNPI fue la siguiente: VN 3 o 4 en 16 casos (17 por ciento); VN 5,6 o 7 en 34 casos (35 por ciento); VN 8 o 9 en 18 casos (19 por ciento) y VN no valorable en 28 casos (29 por ciento).El empleo de puntuación (en este caso el VNPI) nos permite individualizar el tratamiento adecuando nuestro árbol de decisión al tamaño de la lesión, márgenes de seguridad y el grado de diferenciación histológica, unida a la presencia o no de necrosis tumoral. Por tanto, en nuestra casuística la progresión del tratamiento conservador ha pasado del 43 al 65 por ciento en los períodos estudiados (AU)