Hysteroscopic and Laparoscopic Management of Uterine and Vaginal Anomalies

Ola Famuyide, MBBSJanuary 30, 2016

Objectives

• Enumerate common classifications congenital uterine anomalies (CUA)

• Enumerate detailed peri-operative evaluation including diagnostic work-up

• Describe critical steps involved in surgical correction of common anomalies

• Describe surgical outcomes following correction

Embryology of the Female Reproductive System

https://www.youtube.com/watch?v=BIdQjHHXF4I

American Fertility Society Classification of Uterine Anomalies (1988)

ESHRE/ESGE Consensus on the Classification of Female Genital Tract Congenital Anomalies (2013)

Grimbizis G et al Human Reproduction 2013;28(8):2032-44

Prevalence of CUA in Unselected and High Risk Populations: A Systematic ReviewOverall prevalence of 4-7% in normal population and up to 16-25% in recurrent pregnancy losses

Chan YY et al. Human reproduction Update 20011; 17(6):761-771

Clinical Implications of Congenital Uterine Anomalies

•1st Trimester abortion: RR 1.56 (CI 1.17-2.08)•2nd Trimester abortion: RR 2.31 (CI 1.63-3.27)

Venetis C et al. Reproductive Biomedicine Online 2014; 29:665-683

Is there evidence for treating asymptomatic women with uterine septum?

• What to do with the 23 yo nulligravid found to have a septum during US for AUB?

• Good prospective longitudinal observational studies lacking

Tonguc EA et al. Int J Gynecol Obstet 2011; 113:128-130

Diagnosis

•Based on ability to evaluate the vagina, endometrial cavity, contour of the fundus and adnexa (possibly renal system)

•Optimal tests: 3D US, MRI, SonohystogramHysteroscopy +Laparoscopy (laparotomy)

•Sub-optimal: 2D US, hysteroscopy alone, HSG, or laparoscopy alone

Chan YY et al. Human reproduction Update 20011; 17(6):761-771

Pre-operative Renal Anatomy Evaluation

•Associated renal abnormalities in 30% of CUA

• Commonest with müllerian agenesis types II and III and obstructed hemivagina

• Unclear if septate uterus is associated with a higher risk than normal population

• Renal agenesis constitutes 67% of all abnormalities

Hall-Craggs M, Kirkham A, Creighton S. Journal of Pediatric Urology 2013; 9: 27-32

Obstructed Müllerian Anomalies

•Hemivagina, transverse septum, etc.

•Highly associated with ectopic ureters and ureteric remnants

•Accurate knowledge of ureteric course is critical

•Refer!

Uterine Septum Pre-operative Counseling

•Goal is complete septum resection 10mm or less

•Risks of surgery

• Perforation, fluid overload, cervical laceration, incomplete resection

• Misoprostol for cervical prep

• Timing of surgery/endometrial prep

Operative Technique- Incomplete septum

Didelphis or Complete Septum- Chalk or Cheese?

• 25 yo nulligravid planning referred from pre-conceptual counseling for “double cervix”

• 2D-US showed 2 endocervical and 2 endometrial cavities; ?uterine didelphis

Operative Technique-Complete Septum

Immediate Post-Operative Management

•Goal is prevention of endometrial synechia or significant residual septum

• Estrogen therapy (Premarin 2-3mg daily for 6 weeks)

• Intrauterine contraceptive device

• Nothing

Mayo Data (Unpublished)

•Women treated for uterine septum(January 2002 – December 2015) (N = 45)• Age (years) = 28.8 ± 7.6• Clinical characters:

Indication of surgery Number (%)

Gynecologic indications 15 (33.3%)

Abnormal uterine bleeding 11 (24.4%)

Chronic pelvic pain/dysmenorrhea 4 (8.9%)

Incidental 16 (35.5%)

Obstetric indications 14 (31.1%)

Miscarriage 9 (20%)

Preterm labour 3 (6.7%)

Primary infertility 1 (2.2%)

History of malpresentation 1 (2.2%)

Type of septum Number (%)

Isolated uterine septum - Incomplete septum- Complete septum- Not determined

36 (80%)13 (28.9%)6 (13.3%)17 (37.7%)

Utero-vaginal septum 9 (20%)

Mayo Data (Unpublished)

•Complications: No major complications

•Pregnancy outcomes:Among the 13 women who had hysteroscopic metroplasty for obstetric indications: 9 (69%) had full term pregnancy 4 (31%) were lost to follow-up

Outcomes Data

Venetis C et al. Reproductive Biomedicine Online 2014; 29:665-683

Less Commonly- Non Communicating Uterine Horn (type II)

Summary

•CUA are relatively common 4-7%

•Commonest, correctable CUA are septated uterus

•Refer obstructed lesions, in particular, hemivagina or transverse septum

•Hysteroscopic metroplasty is the preferred treatment of choice with excellent outcomes