This study aimed to assess the feasibility and the short-and long-term efficacy of hysteroscopic myomectomy for submucous myomas with intramural development [grade 1 (G1) and grade 2 (G2)] by using non-electrical "cold" loops and to verify the role of preoperative variables on surgical outcomes. Symptomatic (bleeding and infertility) premenopausal patients with the diagnosis of submucous myoma at transvaginal sonography, and with G1 and G2 grading at sonohysterography, were included in this prospective study. Hysteroscopic myomectomy was performed by the combined monopolar electrical slicing and traction-andleverage manoeuvres by non-electrical "cold" loops. One hundred fifty-nine patients were recruited, and 169 procedures were performed. Operating time, fluid deficit, complications and complete resection at first procedure (perioperative outcomes) and persisting symptoms and additional surgery for persisting symptoms (long-term outcomes) were not significantly different for G1 vs. G2 myomas. Perioperative outcomes were significantly different when comparing myoma mean diameter <3.0 vs. ≥3.0 cm (75th percentile). Multivariate analysis and multiple regression analysis proved that myoma mean diameter was the only significant variable for surgical outcomes. Hysteroscopic myomectomy by non-electrical "cold" loops is an effective and efficient treatment for submucous myomas with intramural development. Myoma mean diameter is the only significant preoperative variable for perioperative outcome, while myoma grading loses its role as a prognostic factor.
Lee et al. 1 report good intra-and interobserver reproducibility of three-dimensional (3D) saline contrast sonohysterography (SCSH) in the preoperative grading of submucous myomas. This is good news, as presurgical sonohysterographic assessment of submucous myomas simplifies the diagnostic triage of women with this lesion. However, no method for the reproducible 3D assessment of submucous myomas with intramural extension (G1, G2) -for which accuracy is lower than that for intracavitary myomas (G0) 2 -was given. We tried to define strict criteria in our recent study, which used traditional monoplanar transvaginal sonohysterographic assessment 3 . We believe that a 3D technique could simplify this methodology when step-by-step processing of the acquired volume is performed as follows:1. Start with the multiplanar display mode; 2. Identify and magnify the selected image of the fibroid:use longitudinal sections of the uterus if the myoma is anterior, posterior or fundal, transverse sections if the myoma is lateral, and coronal sections if the myoma is periostial; 3. Shift the selected plane forwards and backwards until the plane containing the largest diameter of the submucous myoma protruding into the cavity is identified; 4. Rotate the fibroid on its ideal center ('fulcrum') on the z-axis until the line passing through the center of the myoma and the perimetrial point (where the myometrium is thinner) becomes coincident with the y-axis (Figure 1). This axis must be perpendicular to the plane tangential to the perimetrium (x-plane); 5. Carry out fine rotations and shifts to improve the identification of the best plane possibile as defined in Steps 3 and 4.If all these steps are performed correctly, complete rotation of the myoma on the y-axis should not change the relationship between the intramural and intracavitary portions of the myoma. The line joining the two myoma-endomyometrial junctions should divide the myoma into the two portions on which grading is based (intramural/intracavitary ratio; Figure 1). The myometrial free margin (the thickness of myometrium within the deepest intramural portion of the submucous myoma and the perimetrium) can be easily evaluated on this image.In addition to these considerations, accuracy in grading by SCSH is also largely determined by the intrauterine pressure achieved at sonohysterography and hysteroscopy. In the paper by Salim et al. 2 , to which Lee et al. refer for their methodology, we observed that intrauterine pressures on hysteroscopy were much higher (100-120 mmHg) than those generated by gentle instillation of 5-10 mL sterile saline on sonohysterography. This difference in intrauterine pressure renders the two diagnostic techniques incomparable. Not only would the high pressures used for hysteroscopy cause unbearable pain at SCSH but they may have a noticeably different effect on protrusion of myomas into the cavity which could partly explain the lower accuracy observed for submucous myomas with intramural extension (G1-G2) in Salim et al.'s study. We suggest that...
Objectives: Endometrial polyps in asymptomatic postmenopausal women are present in 15-20% of patients. The prevalence of preand malignant endometrial lesion on atrophic endometrium in this group has been recently estimated to be 1.6% and 0.2%, respectively (Ferrazzi et al., AJOG 2009). The objective of this 10 year study was to observe the natural history of endometrial polyps on atrophic endometrium (thickness ≤ 4 mm) in asymptomatic postmenopausal women. Methods: 396 asymptomatic postmenopausal women with sonographic diagnosis of endometrial polyp were prospectively recruited. Patients on HRT and/or TMX treatment were excluded. All patients underwent transvaginal sonography (TVS) with color power Doppler (CD) evaluation, and sonohysterography (SHG). Sonographic follow-up at 3, 6, 12 and every 12 months was proposed as an option to standard hysteroscopic polypectomy. Surgery was considered in case of a high blood flow score (color score 3-4 according to IETA definitions), or in case of bleeding and/or volume growth > 50% at follow-up. Demographic, sonographic and surgical data were recorded. Results: Sonographic follow-up was chosen by 292 patients (group A). 32 patients were lost at follow-up. 40 patients underwent surgery because of drop-out, uterine bleeding or increased volume at follow up, or for other gynaecological indications. Two endometrial cancers were diagnosed after uterine bleeding at 16 and 69 months of followup, respectively. In group B, surgical removal was performed in 104 patients by hysteroscopic polipectomy. One pre-malignant lesion was found in surgically treated patients (simple hyperplasia with focal atypia confirmed at hysterectomy). Conclusions: This observational study adds evidence to the feasibility of a conservative management of asymptomatic polyps. Monitoring criteria by using TVS, CD and SHG assessment need to be established. OC21.04Endometrial thickness and the prevalence of endometrial carcinoma in asymptomatic postmenopausal patients, a systematic review of the literature Objectives: In patients with postmenopausal bleeding (PMB), ultrasonographic measurement of endometrial thickness (ET) is used to determine whether further investigations are necessary to exclude malignancy. However, women without PMB may undergo TVU for other reasons. Inevitably, the endometrium is then visualised and a thickened endometrium might be observed. There is no consensus how to manage such a coincidently observed endometrium. The purpose of the current study was to review the literature and assess the mean ET and prevalence of endometrial carcinoma (EC) and atypical hyperplasia (AH) in asymptomatic postmenopausal patients. Methods: We performed a computerized search in MEDLINE and EMBASE. Keywords used were various synonyms for postmenopausal, asymptomatic, endometrial, thickness, ultrasound, hyperplasia and carcinoma. Studies restricted to patients with PMB, pre-or perimenopausal patients and patients using Tamoxifen or hormone replacement therapy were excluded. Data of selected studies were sum...
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