Understanding the Endometrium at Menopause: A Hysteroscopist's View.

The risk of premalignant and malignant endometrial pathologies increases in the postmenopausal period. Dilatation and curettage fail to diagnose one in ten endometrial pathologies. Hysteroscopy is the gold standard to evaluate the endometrial cavity. Hysteroscopy can identify malignant or benign pathology with approximately 20% false-positive results. Hysteroscopy combined with biopsy increases the accuracy of diagnosis up to 100%. This pictorial review takes you through the hysteroscopic view of normal-looking postmenopausal atrophic uterus, cystic atrophy, benign endometrial pathologies, endometrial hyperplasia, endometrial cancer, tamoxifen-induced endometrial hyperplasia and histiocytic endometritis. The purpose of this pictorial review is to guide the operator in systematic evaluation of the endometrial cavity with special attention to the thickness of the endometrium, vascular architecture, location of the lesion and surface aberrations, which adds value to the diagnosis and management of endometrial pathologies.

Three Thousand Cases of Office Hysteroscopy: See and Treat an Indian Experience.

STUDY OBJECTIVE: Assessment of feasibility of office hysteroscopy in Indian setting. DESIGN: Retrospective study design. SETTING: Tertiary care centre: Galaxy care Hospital, Pune, India. PATIENTS: Three thousand consecutive women undergoing office hysteroscopy between 2012 and May 2018. INTERVENTIONS: Office hysteroscopy 2200 cases (2012-2017) with Bettocchi 2.9 scope and Hamou endomat. Eight hundred cases (2017-2018) with Bettocchi 1.9 scope and EASI. Normal saline was used as distension medium. With Hamou endomat, settings have drip rate of 200 ml/min with irrigation pressure of 75 mmHg and suction bar 0.15. With EASI, settings were for Bettocchi 4 (1.9 mm) and Bettocchi 5 (2.9 mm) scope with 45 mmHg. Hysteroscopies were carried out by an experienced operator trained in office hysteroscopy. All hysteroscopies were done in early proliferative phase (4th-11th day). MAIN OUTCOME MEASURES: Success, failure and complication rates. RESULTS: Hysteroscopies were successfully performed in nearly 98.66% of cases with 4 patients requiring a two-step procedure due to > 3 cm pathology. One thousand eight hundred eight (62.2%) were diagnostic hysteroscopies, while operative hysteroscopies were performed in one thousand one hundred twenty (37.8%). One patient (1/3000) had a vasovagal attack. CONCLUSIONS: In outpatient setting, counselling the patient for office hysteroscopy played an important role to overcome pain and anxiety, in addition to low pressure, continuous flow irrigation and vaginoscopic approach. Traditional resectoscopic surgeries should be reserved for challenging cases (i.e. endometrial ablation) or for certain pathologies (myomas > 2.0 cm, broad-base, large-size polyps). Recent advances in technique and instrumentation facilitate this approach and might encourage greater adoption by the gynaecology community. With the right approach, technique and setup, office hysteroscopy is feasible with favourable outcomes.

Novel Anastomotic Technique for Uterine Transplant Using Utero-ovarian Veins for Venous Drainage and Internal Iliac Arteries for Perfusion in Two Laparoscopically Harvested Uteri.

STUDY OBJECTIVE: To evaluate 2 cases of uterine transplant surgery that used utero-ovarian veins as outflow channels, internal iliac arteries for perfusion, and the organ harvest surgery performed laparoscopically. DESIGN: Case study (Canadian Task Force Classification III). SETTING: An urban, private, tertiary care hospital. PATIENTS: Two patients, ages 30 and 24years, diagnosed with absolute uterine factor infertility secondary to Mayer-Rokitansky-Küster-Hauser syndrome underwent related living donor uterine transplants; donors were their mothers with normal menses. INTERVENTIONS: Retrieval of organs through minilaparotomy and laparoscopic harvest of donor internal iliac arteries and ovarian veins. MEASUREMENTS AND MAIN RESULTS: Anastomosis was completed with bilateral donor internal iliac arteries to recipient internal iliac arteries in an end-to-end manner and with bilateral donor ovarian veins to recipient external iliac veins in an end-to-side manner. The lengths of utero-ovarian veins of both donors were 11 and 11cm on both sides; the lengths of the internal iliac arteries of both donors were 10 and 7.5cm on the left side and 10 and 6cm on the right side. The operative times for harvest surgery, bench surgery and transplant surgery were 2:40 and 3:20 hours, 34:32 and 33:30 min and 4:00 and 4:30 hours respectively for recipients 1 and 2. Daily postoperative uterine Doppler was completed through day 8 and then every other day and showed good intrauterine blood flow (i.e., low resistance arcuate vessel flow; resistance index < .5). Cervical biopsies on postoperative days 7 and 14 showed no evidence of rejection in either recipient. Both recipients started menstruating within 2 months of surgery. CONCLUSION: By using ovarian veins as outflow channels, the challenges involved in dissection along the internal iliac vein are avoided, and harvesting the donor internal iliac artery reduces the tension on vascular anastomosis. The selection of vessels to be harvested could make the technique reproducible, although larger studies are warranted to confirm results.

Laparoscopic-Assisted Uterus Retrieval From Live Organ Donors for Uterine Transplant: Our Experience of Two Patients.

STUDY OBJECTIVE: To report the first ever laparoscopic-assisted live donor uterus retrieval in 2 patients for uterus transplant. DESIGN: Case study (Canadian Task Force classification III). SETTING: Galaxy CARE Laparoscopy Institute, Pune, India. PATIENTS: Two patients with absolute uterine factor infertility with their mothers as donors. INTERVENTIONS: In vitro fertilization and uterine transplant. MEASUREMENTS AND MAIN RESULTS: A 12-member team was formed, and approval for transplant was obtained from the institutional review board. Pretransplant, in vitro fertilization for both patients was done. Two consecutive uterine transplants were done on 2 successive days. Vessels were harvested laparoscopically in both donors. Uterus and harvested vessels were retrieved by a small abdominal incision to prevent injury and infection. The uterus was transplanted in the recipients by end to side anastomosis of the harvested vessels to external iliac vessels, followed by anchoring of supports of the donor uterus to those of the recipients. Surgical intra- and postoperative parameters, postoperative investigations, and follow-up data of 6 months were measured. Operative time for laparoscopic donor surgery was 4 hours. Bench surgery took 45 minutes. Recipient surgery time was 4 hours. There were no intraoperative or immediate postoperative complications. Both the recipients started menstruating after 34 days and 48 days, respectively, and have had 6 cycles of menses at regular intervals. Uterine artery Doppler showed good flow in both patients. Hysteroscopy-guided cervical biopsies were used as a method of surveillance of graft rejection after uterine transplant. Office hysteroscopy was done after 2 months in both patients, and hysteroscopy-guided endometrial and cervical biopsies were taken. Minimal slough was seen on the endometrium in the patient with Mayer-Rokitansky-Küster-Hauser syndrome, which was removed. Repeat hysteroscopy after 10 days showed a healthy endometrium. CONCLUSIONS: Laparoscopic-assisted uterus donor retrieval is feasible and affords all the advantages of a minimally invasive technique, thereby reducing the morbidity of the procedure. It helps in better dissection of the vessels, shortens the operative time, and helps to minimize tissue handling of the harvested uterus and vessels.

Laparoscopic-Assisted Uterus Retrieval From Live Organ Donors for Uterine Transplant.

STUDY OBJECTIVE: The authors present the first ever laparoscopic-assisted uterus retrieval in a live donor for uterus transplant. DESIGN: A step-by-step surgical demonstration. SETTING: Galaxy CARE Laparoscopy Institute, Pune, India. PATIENTS: Two patients, ages 21 and 26 years, with Mayer-Rokitansky-Küster-Hauser syndrome and Asherman syndrome, respectively, with their mothers as donors. INTERVENTIONS: A 12-member team was formed. After a review of the available literature on uterine transplant, a protocol was formulated and submitted to the Institutional Review Board (IRB). Approval from the Institutional Review Board was obtained. Thorough screening of the candidates was done. Two consecutive uterine transplants were done on 2 successive days. Vessels were harvested laparoscopically in both donors. Uterus was retrieved through a small abdominal incision, to prevent any injury to the uterus and harvested vessels. Uterus was transplanted in the recipients by end-to-side anastomosis of the harvested vessels to the external iliac vessels, followed by anchoring of supports of the donor uterus to those of the recipients. MEASUREMENTS AND MAIN RESULTS: Surgical intra- and postoperative parameters, postoperative investigations, and follow-up data of 4 months. The operative time for laparoscopic donor surgery was 4 hours. Bench surgery took 45 minutes. The recipient surgery was completed in 4 hours. There were no intraoperative or immediate postoperative complications. Both recipients started menstruating after 34 days and 48 days, respectively, and have had 3 cycles of menses at regular intervals to date. After discharge, follow-up cervical biopsies at 3 weekly intervals showed no signs of rejection. Uterine artery Doppler ultrasound showed good flow in both patients. CONCLUSION: Laparoscopic-assisted donor retrieval is feasible and affords all advantages of a minimally invasive technique. It helps in better dissection of vessels, shortens the operative time, and helps minimize tissue handling, thereby reducing the morbidity of the procedure.