Three women with a well-differentiated grade 1 endometrioid adenocarcinoma of the endometrium with minimal myometrial infiltration were treated with hysteroscopic resection and hormone therapy. The presence of myometrial infiltration has often been mentioned as an exclusion criterion for conservative management in young patients because of worsening cancer prognosis. The subsequent 5-year follow-up and the pregnancies achieved may confirm the choice of this temporary treatment and indicate a new option for fertility-sparing treatment in highly motivated patients.
Purpose of investigation:The authors' aim is to compare surgical outcome of hysteroscopic G1 and G2 submucous myomectomy using bipolar resectoscope to those performed by monopolar device. Materials and Methods: a multicenter-observational-case-control study was conducted on premenopausal women affected by menorrhagia, pelvic pain or infertility because of submucous uterine myoma. The authors considered eligible: single G1 or G2 submucous uterine myoma, at least 0.5 cm ultrasound 'myometrial-free-margin' and two months GnRH pre-surgical treatment (myoma > three cm). Goup A patients were treated by bipolar resectoscope and Group B by monopolar resectoscope. Primary endpoint was to compare the groups in term of complete or incomplete myomas resection ("second-stepprocedure" rate). Secondary endpoint was to compare two treatments in term of surgical time and intraoperative complications rate. Results: Group A (60 patients) and Group B (216 patients) were homogeneous for general features and myomas location but they differed for G2 type prevalence (73.3% vs 50.5%), mean myomas diameter (33.17 ± 11.93 vs 29.45 ± 9.63), and surgical time (29.43 ± 12.6 vs 23.2 ± 8.2 minutes). In Group A patients both G1 and G2 myomas were completely removed in single step without intraoperative/ postoperative complications; in Group B surgical outcomes of G1 myomas were similar to those of Group A, while G2 myomas required procedure termination in 12% of cases because of light electrolyte disturbance (22 cases) and severe iponatremia in four cases. All intraoperative complications occurred when procedure time exceeded 30 minutes and when myomas diameter was greater than 37.5 millimeters. Conclusion: in the era of mini-invasive surgery, hysteroscopic approach by bipolar device should be considered as a useful, safe, and large scale feasible procedure for submucosal myoma treatment, particularly when G2.
In patients affected by endometriosis, the choice between expectant management versus intervention should be personalized: when the estimated probability of natural conception is low, surgery may be considered as a second-line treatment. Conversely, in all other cases surgery should be offered early (as a first-line approach) as it improves the chance of spontaneous conception. The laparoscopic treatment of infertility due to endometriosis must be performed by a skilled specialized surgeon to ensure a complete "pelvic cleanout" while respecting the anatomical structures and reducing the risk of fertility impairment due to surgical procedures.
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