Intrauterine interventions with the aid of ultrasonography

Abstract

Aim: The aim of this study was to research the applicability of the surgical treatment of intrauterine pathologies with the aid of ultrasonography by passing a laparoscopic grasper or scissor through a metal sheath placed in the cervical canal, and compare this method with hysteroscopy, which is considered the gold standard in diagnosis and treatment.

Methods: Our study was conducted with 39 cases where intrauterine pathologies were found with transvaginal ultrasonography (TVUSG). The patients were evaluated for endometrial polyp, submucosal leiomyoma/fibroid and uterine malformations using a transvaginal probe in the 6th to 12th days of the menstrual cycle. Patients with endometrial polyps and submucosal leiomyomas/fibroids were excised with a laparoscopic 5 mm grasper. A laparoscopic plain dissection scissor (5 mm) was used instead of a grasper for the uterine septum. In patients undergoing polypectomy and myomectomy, the uterine cavity was reevaluated by TVUSG about one month later (in the follicular phase after the first menstruation). Patients who underwent resection of the septum after the second menstrual bleeding, intrauterine cavity and tubal were evaluated by hysterosalpingography.

Results: Considering the presence of intrauterine pathologies, TUSVG has sensitivity of 1 (0.87- 1.0), specificity of 0.56 (0.21-0.86), positive predictive value of 0.87 (0.71-0.96), negative predictive value of 1 (0.48-1.0), accuracy of 0.89 and positive likelihood ratio of 2.25 (1.03-4.5) for the detection endometrial polyps. When endometrial polyps were found as the intrauterine pathology during TUSVG, the chance of having endometrial polyps in hysteroscopic diagnosis was found to be 2.25 times more compared to those with no pathology. According to hysteroscopic diagnosis, TUSVG has sensitivity of 0.90 (0.74-0.98), specificity of 0.56 (0.21-0.86), positive predictive value of 0.87 (0.71-0.96), negative predictive value of 0.63 (0.25-0.92), accuracy of 0.82 and positive likelihood ratio of 2.03 (0.95-4.2) for intrauterine pathology. When the intrauterine pathology was found during TVUSG, the chance of having these pathologies in hysteroscopic diagnosis was found to be 2.03 times more compared to those with no pathology.

Conclusion: We think that the surgical treatment of intrauterine pathologies with the aid of ultrasonography can be an alternative for hysteroscopy.

Keywords

• Endometrial polyp,Intrauterine pathologies,Hysteroscopy,Uterine septum

Ultrasonografi eşliğinde intrauterin girişimler

Öz

Amaç: Bu çalışmanın amacı, intrauterin patolojilerin transabdominal ultrasonografi eşliğinde, servikal kanala yerleştirilen metal kılıf içerisinden laparoskopik grasper veya makas geçirilerek cerrahi tedavisinin uygulanabilirliğini araştırmak, tanı ve tedavide altın standart olarak kabul edilen histeroskopi ile karşılaştırmaktır.

Yöntemler: Çalışmamız transvajinal ultrasonografi(TVUSG) ile intrauterin patoloji saptanan 39 olgu ile yapıldı. Hastalar menstrual siklusun 6-12. günleri arasında, transvajinal prob kullanılarak endometrial polip, submuközmyom ve uterin malformasyonlar açısından değerlendirildi. Endometrial polip ve submuköz myomu olan hastalar,laparoskopik 5 mm’lik grasper ile tutularak çıkartıldı. Uterin septum için ise grasper yerine laparoskopik 5 mm’lik düz disseksiyon makası kullanıldı. Polipektomi ve myomektomi yapılan hastalarda uterin kavite ortalama 1 ay sonra ilk mestruasyon sonrası foliküler fazda TVUSG ile tekrar değerlendirildi. Septum rezeksiyonu yapılan hastalarda işlemden sonraki ikinci menstrüel kanama sonrası HSG çekilerek intrauterin kavite ve tubalar değerlendirildi.

Bulgular: İntrauterin patoloji dikkate alındığında TVUSG’de endometrial polip için duyarlılık 1 (0,87- 1,0), özgüllük 0,56 (0,21-0,86), pozitif kestirim değeri 0,87 (0,71-0,96), negatif kestirim değeri 1 (0,48-1,0), doğruluk 0,89 LR (+) 2,25 (1,03-4,5) bulundu. İntrauterin patoloji olarak TVUSG’de endometrial polip bulunduğunda histeroskopik tanıda da endometrial polip olma olasılığı patolojik olmayanlardan 2,25 kat daha fazla bulundu. Histeroskopik tanıya göre, TVUSG ile intrauterin patoloji saptanması için duyarlılık 0,90 (0,74-0.,98), özgüllük 0,56 (0,21-0,86), pozitif kestirim değeri 0,87 (0,71-0,96), negatif kestirim değeri 0,63 (0,25-0,92), doğruluk 0,82  ve pozitif olabilirlik oranı 2,03 (0,95-4,2) bulundu. TVUSG ile intrauterin patoloji tespit edildiğinde, histeroskopik tanıda da patolojik olma olasılığı patolojik olmayanlardan 2,03 kat daha fazla bulunmuştur.

Sonuç: Ultrasonografi eşliğinde intrauterin patolojilerin cerrahi tedavisinin, histeroskopiye alternatif cerrahi olabileceğini düşünmekteyiz.

Anahtar Kelimeler

• Endometrial polip,Intrauterin patolojiler,Histeroskopi,Uterus septumu

Kaynakça

1. 1. Jansen FW, Van Dongen H. Hysteroscopy: Useful in diagnosis and surgical treatment of intrauterine lesions. Ned Tijdschr Geneeskd. 2008;152:1961-6.
2. 2. Berek JS, Novak E. Berek & Novak's Gynecology. 14th ed., Philadelphia: Lippincott Williams & Wilkins; 2007: 302.
3. 3. Troiano RN, McCarthy SM. Mullerian duct anomalies: imaging and clinical issues. Radiology. 2004;233:19–34.
4. 4. Grimbizis GF, Camus M, Tarlatzis BC, Bontis JN, Devroey P. Clinical implications of uterine malformations and hysteroscopic treatment results. Hum Reprod Update. 2001;7:161–74.
5. 5. Stephenson M, Kutteh W. Evaluation and management of recurrent early pregnancy loss. Clin Obstet Gynecol. 2007;50:132-45.
6. 6. Sheiner E, Levy A, Katz M, Mazor M. Pregnancy outcome following recurrent spontaneous abortions. Eur J Obstet Gynecol Reprod Biol. 2005;118:61-5.
7. 7. Ragni G, Diaferia D, Vegetti W, Colombo M, Arnoldi M, Crosignani PG. Effectivness of sonography in infertil patient work-up: a comparision with transvaginal ultrasonography and hysteroscopy. Gynecol Obstet Invest. 2005;59:184-8.
8. 8. Bakour SH, Jones SE, O’Donovan P. Ambulatory hysteroscopy. Evidence-based guide to diagnosis and therapy. Best Pract Res Clin Obstet Gynaecol. 2006;20:953-75.

9. 9. Bettocchi S, Nappi L, Ceci O. Advanced Operative Office Hysteroscopy. State of the Art Atlas of Endoscopic Surgery in Infertility and Gynaecology. New York: McGraw Hill; 2004:465-77
10. 10. Boyar HI. Female infertility and endocrinological diseases. Dicle Med J 2013;40:700-3.
11. 11. Rackow BW, Arici A. Reproductive performance of women with müllerian anomalies. Curr Opin Obstet Gynecol. 2007;19:229-37.
12. 12. Crosignani PG, Rubin BL. Optimal use of infertility diagnostic tests and treatments. The ESHRE Capri Workshop Group. Hum Reprod. 2000;15:723-32.
13. 13. National Institute for Health and Clinical Excellence: Guideline. Fertility: assessment and treatment for people with fertility problems. 2nd edition RCOG Press; 2013: 108.
14. 14. Williams CD, Marshburn PS. A prospective study of transvaginal sonohysterography in the evaluation of abnormal uterine bleeding. Am J Obstet Gynecol. 1998;179:272-8.
15. 15. Kamel HS, Darwish AM, Mohamed SA. Comparison of transvaginal ultrasonography and vaginal sonohysterography in the detection of endometrial polyps. Acta Obstet Gynecol Scand. 2000;79:60-4.
16. 16. Lindheim SR, Cohen M, Sauer MV. Operative ultrasonography for upper genital tract pathology. J Assist Reprod Genet. 1998;15:542-6.
17. 17. Istre O. Managing bleeding, fluid absorption and uterine perforation at hysteroscopy. Best Pract Res Clin Obstet Gynaecol. 2009;23:619-29.
18. 18. Van Kerkvoorde TC, Veersema S, Timmermans A. Long-term complications of office hysteroscopy: analysis of 1028 cases. J Minim Invasive Gynecol. 2012;19:494-7.
19. 19. Chang CY, Chang YT, Chien SC, Yu SS, Hung YC, Lin WC. Factors associated with operative hysteroscopy outcome in patients with uterine adhesions or submucosal myomas. Int J Gynaecol Obstet. 2010;109:125-7.
20. 20. Lee C, Ben-Nagi J, Ofili-Yebovi D, Yazbek J, Davies A, Jurkovic D. A new method of transvaginal ultrasound-guided polypectomy: a feasibility study. Ultrasound Obstet Gynecol. 2006;27:198–201.
21. 21. Gell JS. Müllerian anomalies. Semin Reprod Med. 2003;21:375-88.
22. 22. Ohl J, Bettahar-Lebugle K. Ultrasound-guided transcervical resection of uterine septa: 7 years’ experience. Ultrasound Obstet Gynecol. 1996;7:328-34.
23. 23. Kalvorson LM, AserkoffRD, Oskowitz SP. Spontaneous uterine rupture after hysteroscopicmetroplasty with uterine perforation. J. Reprod Med. 1993;38:236-8.
24. 24. Jurkovic D, Geipel A, Gruboeck K, Jauniaux E, Natucci M, Campbell S. Three-dimensional ultrasound for the assessment of uterine anatomy and detection of congenital anomalies: a comparison with hysterosalpingography and two-dimensional sonography. Ultrasound Obstet Gynecol. 1995;5:233-7.