Hysteroscopic Treatment of Cesarean-Induced Isthmocele Restores Fertility

www.hysteroscopy.info
1
INSIDE THIS ISSUEI started working in the fascinating field of histeroscopy in the early 80's. I was fortunate to
learn from Prof. JACQUES HAMOU his technique in micro-colpo-hysteroscopy and micro-
hysteroscopy at Port Royale Hospital and at Tenon Maternity Hospital.
Prof. Hamou was a pioneer of modern hysteroscopy, not only for his medical knowledge but
creating the micro-colpo-hysteroscope that allowed the visualization of the cervical
transformation zone. He also created the “Hysteroflator” that allowed uterine cavity distention
with CO2 and the “Hysteromat” currently used to distend the uterine cavity with fluid,
achieving adequate visualization with minimal complications. He taught me how to
differentiate between hysteroscopic benign and malignant lesions and to recognize the
hysteroscopic endometrial characteristics according to the timing of the menstrual cycle and
the age of the patient. I then created a classification based on hysteroscopic images suspicious
for malignancy with pathologic correlation that was published in J Am Gynecol laparos in
2003 and in several specialty books.
Later I spent some time with Prof. Tantini in Florence and Prof. Antonio Perino in Palermo,
where I got the opportunity to learn about operative hysteroscopy. With all these acquired
skills and with enough experience in the field of hysteroscopic surgery and with the help of
Professor Jacques Hamou I conducted in 1998 the first workshop of diagnostic and therapeutic
hysteroscopy in Argentina, with the aim of spreading hysteroscopy in our country and in Latin
America. This event, with the presence of Prof. Hamou, who performed several live surgeries,
was a great success in our country. From that year on, we have uninterruptedly organized high
quality workshops to train histeroscopists in our country and Latin America.
Later, great teachers of hysteroscopy such as Professor Bettocchi S. and Professor L.
Mencaglia have attended several times this workshop to show progress in hysteroscopy
worldwide, introducing in-office hysteroscopy through vaginoscopy and teaching the benefits
of surgery with the use of bipolar energy.
In 2007 we founded the Argentina Medical Society of Hysteroscopy (SAMDHI) with the
objective to disseminate and teach hysteroscopy through courses and workshops for
gynecologists across Argentina and the rest of Latin American countries. Notably SAMDGHI
is currently affiliated to AAGL, ISGE and ESGE.
I think hysteroscopy has a prominent future in all fields this is reflected with the wide use of
hysteroscopy in modern gynecology. I am currently focused on early detection of endometrial
carcinoma and premalignant endometriallesions in High Risk Patients.
I would like to take this opportunity to announce the upcoming
Hysteroscopy World Congress in Barcelona where highly recognized
world leaders will confine to exchange knowledge and share their
experience in the field HYSTEROSCOPY.
FROM ARGENTINA A BIG HUG AND I WILL SEE YOU IN
BARCELONA 2017 !!!!
Welcome 1
Histeroscopy Picures 2
Intrauterine adhesions
Interview of the month 3
Giampietro Gubbini
Original Article 6
Hysteroscopic Polypectomy
Laser Vs Versapoint
Conundrums 10
Hysterosalpingography
Curiosities 11
Cervical Stump
Brief Review 14
Süha-Levent's sign
HisteroTips 17
Adenomyotic Cysts
Original Article 20
Hysteroscopic Polypectomy
TruclearVs Versapoint
Jorge Enrique Dotto
Sep-Oct 2016 | vol. 2 | issue 5

TEAM COODINATOR
SPAIN
L. Alonso
EDITORIAL COMMITTEE
SPAIN
E. Cayuela
L. Nieto
ITALY
G. Gubbini
A. S. Laganà
USA
J. Carugno
L. Bradley
MEXICO
J. Alanis-Fuentes
PORTUGAL
J. Metello
ARGENTINA
A. M. Gonzalez
VENEZUELA
J. Jimenez
SCIENTIFIC
COMMITTEE
A. Tinelli (ITA)
A. Úbeda (Spa)
A. Arias (Ven)
M. Rodrigo (Spa)
A. Di Spiezio Sardo (Ita)
E. de la Blanca (Spa)
A. Favilli (Ita)
M. Bigozzi (Arg)
S. Haimovich (Spa)
R. Lasmar (Bra)
A. Garcia (USA)
N. Malhotra (Ind)
J. Dotto (Arg)
I. Alkatout (Ger)
R. Manchanda (Ind)
M. Medvediev (Ukr)
All rights reserved.
The responsibility of the signed
contributions is primarily of the
authors and does not necessarily
reflect the views of the editorial
or scientific committees.
HYSTEROSCOPY
PICTURES
2
“Under the above name I shall describe a specific type of amenorrhea which, in spite of
its prevalence, has not yet found a fitting place and description in Gynaecological
literature. Following complicated labour or abortion a stenosis o blockage of the internal
os of the cervix may occur under certain condition, thus producing amenorrhoea. This
amenorrhoea is not funtional, but organic; ovulation continues but the uterus do not react
and the endometrium remains in a state of inactivity. Hormonal therapy is neither
reasonable nor effective, whereas simple removal of the blockage is sufficient to restore
menstruation to normal. The diagnosis and recognition of this type of amenorrhoea is
therefore not merely of academic interest, but it also important in practical therapeutics.”
In 1948 , Professor Joseph Asherman from TelAviv Hadassah Hospital published the first
article about the disease that bears his name and which he defined as traumatic
amenorrhea or atretic amenorrhea. Since then, interest in this syndrome has increased
mainly due to the development of hysteroscopy and its relationship with secondary
infertility.
If you are interested in sharing your cases or have a hysteroscopy image that you
consider unique and want to share, send it to hysteronews@gmail.com
Superficial vaginal
endometriotic implant
Detailed aspect of the cystic
area with retained blood
Detailed thin or filmy
adhesion
Overview of the uterine
cavity with adhesions

3
INTERVIEW WITH...
A life devoted to gynecology and to their patients. His relation
with hysteroscopy is summed up in three words: enthusiasm for
their work, curious to learn every day and satisfaction to be able to
transmit his knowledge to the younger ones.
Giampietro
Gubbini
Responsabile chirurgia isteroscopica
Casa di cura Pierangeli
Casa di Cura Villa Toniolo
Bolonia, Italia
Giampietro
Gubbini
Responsabile chirurgia isteroscopica
Casa di cura Pierangeli
Casa di Cura Villa Toniolo
Bolonia, Italia
In 2009 he created and developed his
16 Fr Mini-resectoscope, The Gubbini
Mini Hystero-Resectoscope System
allows both, hysteroscopy and
resectoscopy with reduced diameter of
the shaft.
You have published some very interesting articles about Isthmocele, tell
us your personal experience about this topic.
I started my adventure in the world of hysteroscopy in 1981 but it was not
until 2001, when I defined as Isthmocele the lesion (cavity) in the anterior
uterine wall prodused as a result of a caesarean section. That had already
been described in the past by various authors. I described it in a patient with
secondary infertility who after 6 months from “Isthmoplasty” (Isthmocele
repair) became pregnant and had a smooth pregnancy. Since then, my series
has expanded considerably and to date I have performed the procedure in
over 475 patients. The istmocele is an entity that must be known and only
then it could be diagnosed! The surgical technique that I perform is the one
proposed by Fabres in 2005, with the difference that in addition to the initial
resection of the proximal edge of the defect I also remove the distal
endocervical margin, preserving the isthmus (endocervical ablation),
followed by targeted point-like electrocoagulation of the uterine defect. This
procedure treat the endocervical canal in 360 °. (Resectoscopic correction
of the "isthmocele" in women with postmenstrual abnormal uterine
bleeding and secondary infertility. Gubbini G, Casadio P, Marra E. J
Minim Invasive Gynecol. 2008 Mar-Apr;15(2):172-5.)
The resectoscopic treatment was performed in patients with symptomatic
3rd degree isthmocele in 40% of the cases and with 2nd degree isthmocele
in 50% of the patients. In 10% of cases I had treated patients with 1st degree
isthmocele if they were candidates for assisted reproductive technology or
for the prevention of cervical ectopic pregnancies. (Surgical hysteroscopic
treatment of cesarean-induced isthmocele in restoring fertility:
prospective study. Gubbini G, Centini G, Nascetti D, Marra E, Moncini I,
Bruni L, Petraglia F, Florio P. J Minim Invasive Gynecol. 2011 Mar-
Apr;18(2):234-7.)
There was resolution of the symptoms In 90% of the 475 treated patients.
In cases of persistent symptoms, I repeated a second procedure, followed by
insertion of a Mirena IUD in women with breakthrough bleeding. The
intraoperative complications have been low and they are more common in
cases where the over-the “niche” free margin was less than 3mm. In these
cases, some authors recommend a different surgical approach (laparoscopic
or vaginal).
”The istmocele is an entity that must be known
and only then it could be diagnosed!”

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It is well documented that the correction of the cesarean induced Isthmocele restores fertility. Is the debate about
hysteroscopy and fertility over or it is just starting?
The incidence of isthmocele reported in the literature varies widely: in a recent review, the incidence have been reported
from 56 to 84% in women undergoing caesarean section. In 10% of patients with isthmocele may have symptoms such as
abnormal uterine bleeding, postmestrual spotting, chronic pelvic pain, dyspareunia and infertility. This can also prevent a
successful embryo transference in cases of assisted reproductive technology. ( Hysteroscopic treatment of the cesarean-
induced isthmocele in restoring infertility. Florio P, Filippeschi M, Moncini I, Marra E, Franchini M, Gubbini G. Curr
Opin Obstet Gynecol. 2012 Jun;24(3):180-6.)
Although some scientific societies such as the Japanese always recommend to treat surgically with a corrective procedure, I
believe further studies are needed to demonstrate the effectiveness of isthmoplastica repair in restoring fertility.
However, I consider important an early detection of the isthmocele and to put into context the symptoms that these patients
have, to consider it as a late complication of cesarean birth with the aim to reduce the cesarean section rate.
You have created a 16 Fr mini-resectoscope. Which are the main advantajes of this tool?
The continuous flow “The Gubbini Mini Hystero-Resectoscope System 16 Fr” (TONTARRA Medizintechnik
GmbH) was created for "office" hysteroscopic procedures. When used with a vaginoscopic approach it provides a
quick and effectively treatment to a wide variety of endo-uterine pathologies, using a series of miniature loops of
different types (activated and cold), evolution of the classic resectoscopic loops, with reduced discomfort to the
patient and not requiring the use of analgesia or anaesthesia. A large series of reusable monopolar/bipolar micro-
electrodes and cold loop with different shapes allows to perform hysteroscopic operations with the resectoscope,
making it possible to treat quickly and effectively a variety of uterine cavity pathologies. Moreover, the device,
does not require cervical dilatation as the traditional resectoscopic surgery does, making also possible the
treatment of endocervical disease. Finally, this tool has proved particularly suitable for isthmocele repair, as it not
requires the use of dilators that alter the morphology of the cervical canal, allows a more adequate evaluation and
treatment.
The hysteroscope may be introduced to the uterine cavity for the treatment of intracavitary pathologies such as
endometrial polyps, uterine septum, submucous myomas G0 e G1 (< 2,5 cm). It is important to remember and
emphasize the usual considerations regarding the technical difficulties and the adequate indications of each
specific procedure as well as the limitations that each hysteroscopic surgeon should arise in relation to his
"learning curve".
”I believe further studies are needed to demonstrate the effectiveness
of isthmoplastica repair in restoring fertility.”

5
The hysteroscopic surgery with the Mini-resectoscope 16 Fr
manages to embrace most of the endo-uterine pathology traditionally
treated with resectoscopic surgery (resectoscope 26 Fr) in an office
setting using active electrodes or mechanical instruments of 5Fr. The
avoidance of dilation of the cervical canal significantly reduces the
operating time. The benefits outlined in the treatment of specific
diseases in unfavorable anatomical conditions make this tool unique
in meeting the needs of the hysteroscopic surgeon.
The “Oval” system also now available represents the completion of
the project of mini-resector 16 Fr. The distal section to "beak clarinet"
shirts makes the use of optics for 2,9mm at 0 ° - 12 ° -30 ° allowing
the hysteroscopic to perform more "see and treat" procedures.
Has the hysteroscopy reached its limits?
A unit of outpatient / surgical hysteroscopy should be present in every
gynecologic office because it represents a safe and convenient way for
the diagnosis and treatment of intrauterine pathology. The future will
be to spread more and more this culture that unfortunately even today
in many countries of the world, also industrialized, is not present.
All hysteroscopic procedures that up until a few years ago were
performed in the operating room under anesthesia with a 26 Fr
resectoscope can be now performed in 80% in an ambulatory setting
optimizing the use of health resources.
What's your vision about the learning and training in hysteroscopy?
While describing operative hysteroscopy a minimally invasive surgery is wrong to consider it “simple surgery” that does not
require proper training. When in fact there could be life treatened complications. Is therefore extremely important to follow
proper training, both at accredited schools and through popular science journal and publications such as Hysteroscopy
Newsletter.
Do you have any advice for the young physician who is starting in the world of gynecologic minimally invasive
surgery?
Hysteroscopy should be embraced at the end of the gynecology training and should be no room for improvisation. The old
belief that operative hysteroscopy is minor surgery is a thing of the past. Even the simplest of actions can result in major
complications when faced with superficiality and carelessness.
The message for young people is that they should become familiar with hysteroscopy with proper training to enable them to
enjoy the same enthusiasm, curiosity and satisfaction that even today after so many years of practice I still have.
”Hysteroscopy should be embraced at the end of the
gynecology training and should be no room for improvisation”

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Outpatient hysteroscopic polypectomy:
Bipolar energy system (Versapoint) versus diode laser
Randomized clinical trial
Maria D. Lara-Domínguez(1), Jose E. Arjona-Berral(1), Rafaela Dios-Palomares(2), and Camil Castelo-Branco(3)
(1)Department of Gynecology, Hospital Reina Sofía, Córdoba, Spain, (2)Department of Statistics and Operational Research, University of Córdoba,
Códoba, Spain, and (3)faculty of Medicine-University of Barcelona, Institut Clínic of Gynecology, Obstetrics and Neonatology, Hospital Clínic-Institut
d’Investigacions Biomédiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
This study compares the resection of endometrial polyps using Versapoint bipolar electrode versus Diode Laser. All
procedures were performed with a 30º Bettocchi hysteroscope, introduced by vaginoscopy. Polyp resection in the
Versapoint group was performed using a rigid 5mm hysteroscope with a 5Fr (1.67 mm) working channel through which a
bipolar electrode was introduced that had a twizzle tip connected to an electric generator. Polypectomy in the Diode Laser
group was performed using a rigid 6mm hysteroscope with a 7Fr (2.3 mm) working channel through which a polyfiber was
introduced and connected to a 980 nm Biolitec Ceralas HPD laser device.
Patients were discharged after the procedure and were requested to attend a follow-up three months later. After filling all
questionnaires, a second-look hysteroscopy was performed in order to assess the persistence or relapse of the previous
polyp.
Results
102 women were included in this study. Of these, 50 were assigned to the Diode Laser polypectomy group, of which 46
(92.0%) achieved a complete resection. The other 52 women were allocated to the Versapoint bipolar electrode
polypectomy group of which complete resection was achieved in 50 (96.1%). A total of 45 (90.0%) and 46 (88.5%) women
underwent the second-look hysteroscopy in the Diode Laser and in the Versapoint group, respectively.
Most of the polyps were benign endometrial polyps. One patient was diagnosed with a well-differentiated adenocarcinoma
limited to the polyp and another with an atypical complex hyperplastic polyp. The mean polyp resection time with a Diode
Laser was lower than with Versapoint (245.96±181.9 sec versus 329.56±245.0 sec, respectively; p=0.01). The larger the
polyp size the longer the duration of the resection (p<0.01). Complications related to the procedure included three vaso-
vagal syndromes after the polypectomy, one in the Versapoint group and two in the Laser group; all resolved by resting and
none required hospital admission. Additionally, there was one case of pelvic inflammatory disease three days after the
procedure in the Diode Laser group. No differences were found regarding intraoperative pain as measured with the VAS or
in the ordinal scale. The influence of the polyp location in the uterine cavity on pain scores was also considered but no
differences were found (p=0.56).

7
Finally, incomplete resection of the polyp occurred in 4 and 2 cases in the laser and Versapoint group, respectively. Upon
second-look hysteroscopy, a relapse of the polyp in the same location was observed in 15 (32.6%) cases in the Versapoint
group, whereas in the Diode Laser group polyp relapse was observed in only 1 (2.2%) patient (p=0.001).
To corroborate the occurrence of polyp relapse depending on the procedure and to assess the potential effect of age on the
polyp relapse, a logistic regression was carried out using age as a covariate. The OR estimated for the resection procedure
indicates that the likelihood of there being a relapse with Versapoint compared with Laser is 19.2 (95% CI 2.24–164.75).
Of the four patients with an incomplete resection in the Laser group, three attended to the second-look hysteroscopy and in
all of them no polyp was observed. The fourth patient rejected the check-up due to moving to a different city. Contrary to
this, at the second-look, the polyp persisted in the two patients of the Versapoint group who had incomplete resection.
The rate of very satisfied patients with this outpatient procedure tended to be higher in the Diode Laser group compared
with the Versapoint group (62.2 versus 39.1%). In addition, 71.1% of patients in the Laser group as compared with 28.3%
in the Versapoint group referred the procedure as highly recommendable.
Discussion
It is currently well accepted that outpatient polypectomy is preferred by both physicians and patients when compared to
one-day hospitalization. However, there are scant data when it comes to comparing the different instruments that are most
suitable for outpatient hysteroscopic polypectomy. To the best of our knowledge, this is the first randomized clinical trial
comparing outpatient polypectomy using Diode Laser versus Versapoint.
The most interesting finding of the present study was the higher percentage of patients with polyp relapses in the
Versapoint group as compared to the Laser group at three months. This may be explained by Laser’s capacity to engage
with water and hemoglobin allowing greater penetration in the soft tissues and consequently an adequate ablation and
vaporization effect. Therefore, this may have allowed that Laser assigned patients with an incomplete resection,
subsequently eliminated the polyp three months later; obviously, this did not occur in the Versapoint group.
Finally, patients in laser group were more prone to indicate an improvement of their quality of life. In addition, there
were a higher number of patients in this group who felt very satisfied with the procedure. Moreover, it is noteworthy to
highlight that three out of four patients in the Laser group reported the procedure to be highly recommended.
In conclusion, polypectomy with Diode Laser resulted in fewer relapses and a higher procedure satisfaction rate as
compared to Versapoint.
Panoramic view of endometrial polypEndometrial polyp as seen on ultrasound
Hysteroscopy Newsletter
Hysteroscopy NewsletterHysteroscopy Newsletter

8
DID YOU KNOW...?
Administration of vaginal misoprostol 12h before office
hysteroscopy is more effective than vaginal misoprostol 3 hours
before in relieving pain experienced by patients
When the Essure placement is difficult due to high resistance, more
time or more than two microinsert needed, a hysterosalpingogram
should be performed.

9
The Fine Art Of
Hysteroscopy
Osama Shawki
Sushma Deshmukh
Paras Medical Publishers
Year 2014; 324 pages
The Fine Art of Hysteroscopy a
must have book that offers a global
vision of the art of hysteroscopy.
The known surgical vision of Prof.
Shawki combined with deep
knowledge of the role of
hysteroscopy in infertility, makes
this compendium a basic manual
that should not be missing in any
library.
The book comes with a DVD with
high quality videos that show in
detail several complete surgical
procedures.
WHAT'S YOUR
DIAGNOSIS?
Sometimes, when performing hysteroscopy, it is
important to pay attention to every corner of the
uterus, as Vasari stated «cerca trova», «he who
seeks finds»
Answer to the previous issue:
Detailed view of cesarean scar defect.

10
Hysteroscopy Conundrums
Hysterosalpingogram
37 years old, 1 previous miscarriage and light period. She took oral
contraceptive pills for 6 years when she was young. Result of the HSG.
What's your diagnosis? What to do?
Lookforus:hysteroscopygroupinLinkedIn
Bicornuate uterus ?
It seems a T-shaped uterus as result of maternal exposure to DES
I'm agree with T-shaped uterus
Suspicion of T-shaped uterus. Before the hysteroscopic metroplasty is
important to have an evaluation with 3D ultrasound.

11
Curiosities: Cervical Stump
Many gynecologists favor to perform supracervical hysterectomy instead of total hysterectomy when performed for benign
conditions. Arguments used in favor of such recommendation are that it entails less operating time, less blood loss and faster
patient’s postoperative recovery.
Other arguments are that preserving the cervix has positive impact on the sexual life of the patient as well as better support
of the pelvic floor and urinary function. These last arguments seem not to be supported by solid research evidence.
There are in fact several problems that may arise related to preserving the cervical stump after performing a subtotal
hysterectomy. These complications include cervical stump prolapse, chronic pelvic pain, the development of cervical or
endometrial carcinoma, necrosis of the stump and cyclic recurrent vaginal bleeding.
In regards to cyclic bleeding, its incidence varies between different studies between 0% and 25%, the bleeding is due to the
presence of an excessive amount of residual endometrium at the level of the cervical stump. Although electrocoagulation of
the cervical canal is routinely done at the time of a supracervical hysterectomy, it has not been shown that this practice
significantly reduces the incidence of persistent cyclical bleeding.
The recommended treatment for this condition is to perform a Trachelectomy, usually with a vaginal approach, but also it
can also be performed abdominally or laparoscopically. The vaginal route is associated with a low complication rate, being
urinary tract injuries the most common complication.
Hysteroscopy can be useful both in locating and in treating the residual endometrial tissue. There are papers published on
fulguration of the endometrial-endocervical tissue with bipolar electrode system Versapoint and Spring (Pontrelli et al, 2007)
as well as with the use of a miniresector of 22FR and cutting loop (Alonso et al, 2012). In both cases amenorrhea was
immediately achieved from the time of the intervention. Hysteroscopy should be considered as a valid minimally invasive
alternative for the treatment of continuous cyclic bleeding related to cervical stump after supracervical hysterectomy.

12
DEVICES
HYSTEROSCOPY
Hysteroscopy Endo-Operative System
H.E.O.S (Endo-Operative Hysteroscopy System) A new surgical system that integrates the functions of the resectoscope and
also allows the use of mechanical and electrosurgical laparoscopic instruments.
Equipped with a surgical channel Ch 13 (4.3 mm) allows the insertion into the uterine cavity of monopolar instruments up to 3
mm gauge (scissors, dissectors and clamps) as well as monopolar or bipolar electrodes. The continuous fluid flow provides
constant irrrigation ensuring optimal visualization.
These functions allow to expand the procedure performance of hysteroscopy, limited so far to the use of the resectoscope or
employment micro-intruments through a limiting small 5 Fr (1.6 mm) channel.
www.sopro-comeg.com/
Removal of Retained Adherent Placental Remnants Using the Hysteroscopy Endo-Operative
System.
J Minim Invasive Gynecol. 2016 Jul-Aug;23(5):670-1.
Zhu KA, Huang H, Xue M, Subedi J, Jamail G, Zhao W, Xu D, Xiao S.
STUDY OBJECTIVE: Removal of retained adherent placental remnants (RAPRs) may be challenging using traditional 5Fr or 7Fr
hysteroscopic grasping forceps because they are very small. This is particularly true when the retained placental remnant is large. This
video demonstrates the advantages of using the Hysteroscopy Endo-Operative System (HEOS), a specially designed operative
hysteroscope with a 13Fr working channel, to remove retained placental remnants.
DESIGN: Step-by-step explanation of the technique using videos and pictures (Canadian Task Force Classification III).
SETTING: Third Xiangya Hospital of Central South University, Hunan, China.
PATIENT: A 32-year-old woman was diagnosed with RAPRs 5 weeks after the evacuation of retained placenta after a spontaneous
abortion at 16 weeks' gestation. Gynecologic examination revealed an anterior 8-week uterus and no tenderness. Serum β-human
chorionic gonadotropin was 150 mIU/L. Sonography revealed an irregular intrauterine mass, 3.5 cm × 3.5 cm × 3 cm in size.
INTERVENTION: Removal of RAPRs using HEOS (Sopro-comeg Company, Bordeaux, France).
MEASUREMENT AND MAIN RESULTS: The operation time was only 12 minutes. The RAPRs were removed completely and
quickly in 1 procedure with no complications. The serum β-human chorionic gonadotropin titer normalized 1 week after the procedure.
This study was approved by the institutional review board of the Third Xiangya Hospital of Central South University.
CONCLUSIONS: When indicated, removal of RAPRs using HEOS is safe and simple because of its large and strong cold forceps.
Additionally, it avoids electrical and thermal injury to the endometrium, which is particularly important in a population that wants to
preserve fertility.

13
CongresSINTERNATIONAL
Fertility Society of Australia
Annual Conference
Western Australia, Australia|Sep 4-7|2016
ESGE 25th Annual Congress
Brussels, Belgium |Oct 2-5 |2016
American Society for
Reproductive Medicine Annual
Meeting
Salt Lake City, USA |Oct 15-19|2016
RANZCOG 2016 Annual
Scientific Meeting
Perth, Australia |Oct 16-19 |2016
Kongress der Deutschen
Gesellschaft für Gynäkologie
und Geburtshilfe
Stuttgart, Deutschland |Oct 19-22 |2016
43 International Forum. Update
in Obstetrics, Gynecology and
Reproductive Medicine
Barcelona, Spain | Oct 26-28| 2016
APAGE and TAMIG Annual
Congress
Taipei, Taiwan |Nov 3-6|2016
43 International Forum. Update
in Obstetrics, Gynecology and
Reproductive Medicine
Barcelona, Spain | Oct 26-28| 2016
The 24th World Congress on
Controversies in Obstetrics,
Gynecology & Infertility
Amsterdam, Netherlands |Nov 10-13|2016
45th AAGL Global Congress
Orlando, Florida |Nov 14-18|2016
3rd
International Conference on
Gynecology & Obstetrics
Dubai, EAU Nov 24-26 |2016
3rd
Global Congress on
Hysteroscopy
Barcelona, Spain May 2-5 |2017

14
A septate uterus is the result of a failure in the process of resorption of the medial septum that can range from a minimal
septum in the uterine fundus to a complete one, dividing the uterine cavity completely or even associating double cervix and
vaginal septum
Very few studies have examined the histological features of the septum. Since March stated that “the septum is a fibroelastic
tissue”, there is a widespread perception that the septum is a structure with a small amount of muscle fibers not properly
vascularized in which the fibroelastic tissue is more prevalent. However, this classical theory has changed after the
histological evaluation of the components of the septum. Dabirashrafi et al. studied the amount of connective tissue, the
amount of muscle and the amount of blood vessels in different parts of the septum after resection via Tompkins, they found
less connective tissue in the septum and an increased amount of muscle tissue and muscle interlacing.
The vascularity of this structure has been detected with the use of Color Doppler. With this technique Kupesic found septal
vascularity in 71,22% of the patients, revealing that most of the septa are vascularized. Similar results were reported using
ultrasound examination in other studies.
Besides this, there are also some structural changes in the septal endometrium when it is compared with endometrium from
the lateral uterine wall, and when endometrial samples from the septum are examined by scanning electron microscopy, some
changes indicative of irregular differentiation and estrogenic maturation of septal endometrial mucosa are found.
Brief Review
Süha–Levent’s Sign: A guide to determine the incision line in the
septate uterus
Prof. Dr.Levent Yaşar, Prof. Dr.Murat Ekin
Bakırköy Dr Sadi Konuk Research and Teaching Hospital.İstanbul.Turkey

Hysteroscopic metroplasty is actually considered the Gold Standar for the treatment of the septum. This tecniche is, in fact,
a transversal incision of the uterine septum instead a resection. This incision has to be made in the middle of the septum,
equidistant to the anterior and posterior uterine walls. Visualization of the bilateral tubal ostia is helpful to mantain the right
plane avoiding the lesion of the normal myometrium.
The determination of the correct incision line is one of the most important part of the hysteroscopic metroplasty but this
imaginary line is not always easy to determine. Levent Yasar and Ali Süha Sönmez described the “Süha-Levent sign.”. After
methylene blue injection, they found a well defined blue line of 2-3 mm, over the septum between the tubal ostiae and
equidistant to the anterior and the posterior walls. This blue guide helped them to identify the correct incision line.
The authors have three postulations for this sign. First and the simplest postulation is that; this appearance may be due to the
high speed jet or the turbulence of the methylene blue dye in the top and the deepest area of uterine cavity. The second
postulation is; high metilen dye injection may lead to cracking in the mucosa and the dye can be absorbed by the cracked
zone.The third and the last postulation is a congenital mucosal defect or a mucosal abnormality (molecular and/or
hystological) at the septum may increase the affinity of the blue dye.
The Suha-Levent sign creates a safe hysteroscopic incision line that facilitates the surgical approach.
15
Illustration of inappropriate incision of uterine septum:
Blue line depicts right incision line Red lines depict inappropriate incision line

16
Congress Committee Chair: Sergio Haimovich (Spa)
CoChairs: Andrea Tinelli (Ita)
Luis Alonso (Spa)
Congress Committee: Jose Alanis Fuentes (Mex)
Linda Bradley (USA)
Jorge Dotto (Arg)
Ricardo Lasmar (Bra)
Narendra Malhotra (Ind)
Osama Shawki (Egy)
Honorary Committee: Stefano Bettocchi (Ita)
Rafael Valle (USA)
R. Alfonso Arias (Ven)

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HYSTEROTIPS
Adenomyotic cyst is an unusual presentation, which a lot of gynaecologists are not aware of and while there is some
literature available, detail studies are still needed to understand this enigma.
In a lot of ways it basically is “Endometriotic cysts” present inside the body of the uterus and myometrium, IN behavior,
postulated theories of origin as well as management principles.
WE have recently published the largest series of hysteroscopically diagnosed and managed Adenomyotic cysts. This is
a series of 9 cases managed hysteroscopically over a period of 8 years in 1173 hysteroscopies done.
Kuntz etal, Brosens et al, Gordts etal, Kumar et al etc to name just a few have done work on this entity.
Here we in steps discuss the important points:
1- Definition: Adenomyosis is defined as presence of endometrial glands and stoma in the uterine myometrium. It
can be diffuse or focal. Diffuse form is commonly seen while focal adenomyotic cyst is a rare entity
2- Presentation: Clinical features of presentation are non-specific. The various symptoms are dysmenorrhea,
abnormal uterine bleeding, chronic pelvic pain and infertility. Of these, one of the most common symptoms is dysmenorrhea,
which starts at an early age, around the time of menarche, tends to increase progressively with age and is resistant to medical
therapy including analgesics or cyclic oral contraceptives.
In our series, 77.8% of women presented with infertility and 22.2% presented with abnormal uterine bleeding.
3- Pathogenesis: One of the theories is invagination of endometrial tissue into the myometrial tissue leading to
formation of cystic adenomyosis. Secondly, stimulation of Mullerian.remnants in the myometrium by estrogens leads to
development of adenomyotic cyst. Lastly, iatrogenic implantation of endometrial tissue into the myometrium during uterine
surgery can also cause formation of focal adenomyotic cyst.
Adenomyotic Cysts
Dr. Prabha Manchanda, Dr. Rahul Manchanda, MD, Manchanda's Endoscopic Center, New Delhi. India
Proposed by I. Brosens

18
4- Imaging techniques to diagnose: On 3 D ultrasound or MRI, it appears as cystic structure with an
internal diameter of ≥10 mm, surrounded by myometrial tissue. However, adenomyotic cyst might not be visualized on
ultrasound and may appear just as a sub endometrial hemorrhagic area, thus get missed on these techniques. The differential
diagnosis of uterine intramural cystic lesions includes non-communicating rudimentary horn, cystic degeneration in a
leiomyoma and adenomyosis.
5- Classification System: A classification system for adenomyotic cyst has been given by Brosens et al.
He suggested the acronym MUSCLE for its classification which includes M: myometrial location (intramural, sub mucous,
subserous), U: uterine site (midline, paramedian, lateral), S: structure (cystic, mixed, polypoid), C: contents (clear,
hemorrhagic), L: level (fundus, body, cervix), and E: (endometrial or inner lining endometrium, metaplastic).
6- Hysteroscopy as a tool: Hysteroscopy is an emerging as the gold standard diagnostic as well as
therapeutic tool for submucosal adenomyotic cyst. It is visualized as a cystic structure bulging into the uterine cavity.
Lowering the intrauterine pressure is helpful for a better identification of the sub mucosal cystic structures. However, when
sometimes diagnostic hysteroscopy is not able to reveal the pathognomonic signs and visible clues include: 1- Bulge in
endometrial cavity. 2- An irregular endometrium with endometrial defects. 3- Altered vascularization and 4- Cystic
hemorrhagic/ bluish lesion.
7- Resection Minutae: Hysteroscopic resection remains the gold standard for treatment with dramatic results
in cases of both infertility and dysmenorrhea usually. Resection can be done with scissors or by ablation methods using a
loop electrode and resectoscope. Radiofrequency ablation by radiofrequency needle inserted into the cyst through
the cervix has also been reported For Deeper intra-myometrial adenomyotic cyst resectoscope is the preferred choice to use.
The goal is to resect the cyst in its entirety using the same principles as in endometriosis. Ultrasound guidance may be
helpful in locating deeper adenomyotic cysts while resecting also.
8- Conclusion: Adenomyotic cyst/ Cystic adenomyosis is a rare form of adenomyosis the incidence of which in our
study was 0.76% over 8 years. Nowadays its incidence is increasing due to delayed age of conception and availability of
accurate imaging techniques. Hysteroscopy is a diagnostic tool for visualization of uterine cavity with a direct access to
Adenomyotic cyst. It also allows the simultaneous treatment of adenomyotic cyst via excision or ablation.
It is important to make the Gynaecologist aware of such an entity and also the hysteroscopist of the ability / power he/she has
to treat and manage this rare entity in a novel and minimally invasive method through hysteroscopy affording much relief in
symptoms to the sufferer.
Secuence: 1- Hysteroscopic image showing elevated area on posterior wall of uterus. 2- Hysteroscopic image showing
drainage of hemorrhagic fluid after resection with resectoscope. 3- Hysteroscopic image showing complete excision of
adenomyotic cyst on posterior wall of uterus.
Hysteroscopy NewsletterHysteroscopy NewsletterHysteroscopy Newsletter

19
HIGHLIGHT ARTICLES
Published on different medias
OBJECTIVE: To evaluate the efficacy of a hysteroscopic site-specific local endometrial injury (LEI) in a group of women
with unexplained infertility (UI) undergoing expectant management with no fertility treatment versus no intervention.
METHODS: This open-label, randomized controlled trial (RCT) was conducted between June 2013 and July 2015.
Hysteroscopic site-specific LEI was determined by patient identification number, and 120 women were included. Eligible
participants were randomly assigned to receive either a single, site-specific LEI guided by hysteroscopy (study group, n =
60) or no intervention (control group, n = 60). Natural cycle folliculometry and timed intercourse were carried out for all
participants for 3 months. Successful clinical pregnancy confirmed on ultrasound was the primary outcome measure, and
first trimester miscarriage rate was the secondary outcome.
RESULTS: After identification, baseline clinical demographics were similar in the two groups. No statistically significant
differences were noted in cumulative pregnancy rates in women with LEI compared with those without (16.7% and 11.7 %,
respectively; OR, 2.83; 95%CI: 1.07-7.48; P = 0.4). One first trimester miscarriage was reported in the control group
(14.3%).
CONCLUSION: Local endometrial injury for natural cycle conception in women with UI is not justified. Further RCT are
warranted to prove or disprove this.
Hysteroscopic-guided local endometrial injury does not improve natural cycle
pregnancy rate in women with unexplained infertility: Randomized controlled trial.
Shokeir T, Ebrahim M, El-Mogy H.
J Obstet Gynaecol Res. 2016 Jul [Epub ahead of print]
Reproductive Outcomes Following Hysteroscopic Resection of Retained Products of
Conception.
Ikhena DE, Bortoletto P, Lawson AK, Confino R, Marsh EE, Milad MP, Steinberg ML, Confino E, Pavone ME.
J Minim Invasive Gynecol. 2016 Jul 19.[Epub ahead of print]
STUDY OBJECTIVE: The objective of this study is to characterize pregnancy outcomes following hysteroscopic resection
of retained products of conception (RPOC), especially as it relates to abnormal placentation.
DESIGN: Retrospective cohort study. Classification: Canadian Task Force classification II-2
SETTING: Academic Medical Center
PATIENTS: All women who underwent hysteroscopic resection of retained products of conception at Northwestern Prentice
Women's Hospital between January 2004 and December 2014
INTERVENTIONS: Hysteroscopic resection of retained products of conception
MEASUREMENTS AND MAIN RESULTS: The medical records of all cases of hysteroscopic resection of RPOCs between
January 2004 and December 2014 were reviewed. Demographic characteristics, operative findings, surgical procedure,
surgical pathology and pregnancy outcomes for preceding and subsequent pregnancies were obtained. Our primary outcome
was abnormal placentation in the pregnancy following the procedure. There were a total of 55 subsequent pregnancies and
38 live births. Among these pregnancies, 54.5% (30/55) were vaginal deliveries, 34.5% (19/55) were cesarean delivery and
7.3% (4/55) were early pregnancy loss. Abnormal placentation was present in 18.1% (10/55) of subsequent pregnancies.
This consisted of 3 patients with placenta previa, 2 with placenta accreta and 5 with retained placenta.
CONCLUSIONS: Women who undergo hysteroscopic resection of RPOC have a higher rate of abnormal placentation in
subsequent pregnancies when compared to the general population. Although the etiology is likely multifactorial, the
underlying pathology leading to the initial diagnosis of RPOC is believed to play a major role.

20
Introduction
Today endoscopic procedures are a fundamental part of routine clinical practice in most surgical specialties. In gynecology,
hysteroscopy has contributed greatly to it.
The new hysteroscopic system 5.0 Truclear that offer the option of being diagnostic and therapeutic is presented in the
gynecological market as an innovative technique. Its special design and ease of operation in conjunction with the use of
mechanical energy for resection of intrauterine pathology, promotes efficiency significantly increasing the number of cases
that can be performed on an outpatient basis.
Objectives
Primary objective: To compare the efficacy of hysteroscope with mechanical energy (5.0 Truclear System) with bipolar
energy system (Versapoint) for the resection of endometrial polyps.
Secondary objective: To analyze the differences betwee operating time of both hysteroscopic techniques. To evaluate the
learning curve in each of the techniques by resident or trainees.
Method
Study design: randomized controlled clinical trial at the Hospital of Igualada. With inclusion period ranging from March
2013 to January 2015.
Study population: A total of 192 patients with ultrasound diagnosis of endometrial polyp of 1 cm or larger who agreed to
participate in the study were included.
These patients were randomized into four groups according to the hysteroscopic technique (Truclear System versus
Versapoint) and the experience of the provider performing the procedure.
Results
The mean age was 53.9 years. Of the total patients (n = 192), 57.8% were menopausal. 82.3% had at least one child, being
vaginal delivery the most common route of delivery in 69.3%. The most common symptom was postmenopausal vaginal
bleeding in 30.7%. No significant differences was found in characteristics and location of the resected polyps in the different
groups. In 90% of cases, the polyps were less than 20 millimeters in size. Pathology of these formations confirmed the
presence of polyps in 92.8% of cases. In 2.5% of the cases some form of malignancy was present on the polyp.
In Office Hysteroscopic Polypectomy Using Mechanical Energy. A
Comparative Study Vs Bipolar Energy Systems.
Jennifer Rovira Pampalona. Servicio de Ginecología y Obstetricia. Hospital de Igualada. Spain
Original Article

21
Regarding how successful or effective the device was in achieving complete polypectomy during the procedure in the
Truclear group was 92.3%, versus 73.3% in the Versapoint group (p <0.05).
In 5 of the 7 patient in which the Truclear failed to completly remove the polyp, the reason was the inability of pass through
the endocervical canal. In the case of Versapoint group, there was a 44.4% failure to achieve a complete resection of the
polyp.
The efficiency of techniques in regard to operating time, there was a difference between the two techniques with a total time
of hysteroscopy nearly 6 minutes for the hysteroscope with mechanical energy (p <0.05). This difference was at the expense
of the average time of polypectomy that was significantly lower with the hysteroscope Truclear (Versapoint Truclear 9.56
min vs 3.58 min, p = 0.000) (Table 1)
To evaluate the learning curve of residents in training for each of the techniques, it was assessed through a numerical scale (1
to 5) evaluating the degree of autonomy and knowledge of the technique. We noted that all residents required some help
(practical or verbal) in each of the interventions with the system of bipolar electrosurgery Versapont, unlike the Truclear,
where the resident 25% of the time felt comfortable to perform the complete polypectomy without any help.
Discussion
In total, the procedure was successfully performed 82.3% of the time (92.3% hysteroscope mechanical energy and 73.3%
with bipolar energy) (p <0.001). While the values are somewhat lower, our results are similar to those reported by Smith et
al, who report successful completion of resection of polyps with hysteroscope morcellator 98% (61/62) compared to 83%
(49/59) with the bipolar electrosurgical system.
By analyzing the operating times employed by both techniques for performing polypectomy, like Smith et al, we observed a
significantly shorter time for the Truclear group, with a 63% reduction in time polypectomy compared to Versapoint system
(3.58 min Truclear Versapoint min vs 9.56, p <0.05).
We do not find a reason to explain the higher failure rate and prolonged operative times with Versapoint system. The
production of bubbles during the procedure by the continuous release of the resected tissue in the field made difficult the
hysteroscopic procedure, which may result in a slower and more laborious procedure and causing discomfort to the patient.
The results of the questionnaire assessing autonomy and knowledge by the residents, indicated a greater need for practical
and verbal help at the beginning of the training period when the procedure was performed with the system of bipolar energy.
Possible advantages of the Truclear system are that this system requires less complex movements during resection and
provides better visualization of the operative field. On the contrary, maneuvering in and out through the endocervical canal
for removal of tissue with Versapoint system, require more experience and skill by the provider who performs the procedure.
Conclusions
The diagnostic/therapeutic hysteroscope mechanical energy (5.0 Truclear System) was more effectively in achieving full
polypectomy and a significant decrease in the total operative time of hysteroscopic polypectomy when compared to the
bipolar power system (Versapoint).
Moreover, the learning curve was shorter with the hysteroscope Truclear System than with the Versapoint.

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HYSTEROSCOPY
22
FIND US ON
The endoscope, an instrument that allows to look inside the human body, was first used in ancient
Greece and Rome. As a matter of fact, an instrument considered a prototype of endoscopes was first
found in the ruins of Pompei.
It was Philip Bozzini who, in 1805, first tried to “look inside” the living human body directly
through a tube he created, known as the Lichtleiter (light guided instrument) that he first employed
to study the urinary tract, rectum and pharynx. In 1853, Antoine Jean Desormeaux developed an
instrument specially designed to examine the urinary tract and bladder. He called it "endoscope" and
it was the first time the term “endoscope” was used in medicine.
Since then, the evolution has been uncontainable, the gastrocamera was created, followed by
fiberoptic scopes for video-endoscopy and today we have capsules that once swallowed record the
entire gastro-intestinal tract.
But the endoscopic diagnosis of a disease led to the need of minimally invasive techniques to treat
them. The maximum advance in treatment has been obtained with the creation of laparoscopy.
In 1975, Dr. Tarasconi, from the Department of Obstetrics and Gynecology, Faculty of Medicine,
University of Passo Fundo (Passo Fundo, Rio Grande do Sul, Brasil), began his experience with
laparoscopic excision of pelvic organs (salpingectomy), which he first reported in the third congress
of the AAGL, held in Atlanta (Georgia) in November 1976. This new laparoscopic surgical
technique was subsequently published in 1981. This was the first laparoscopic organ excision
reported in the medical literature.
Since then, most resources in research and development in endoscopy have been devoted to
laparoscopy. If we look specifically in gynecology, historically most papers and academic activity is
performed on laparoscopy. But this trend began to change in recent years with the growing of the
"little sister" of gynecologic endoscopy, also known as hysteroscopy!
We are witnessing the development of multiple new devices, instruments and energy sources
adapted to hysteroscopy as well as new surgical techniques that increasingly allow performing a
greater number of procedures with increase in complexity.
Hysteroscopy is today the gynecologic outpatient procedure most commonly performed. A larger
number of performed procedures leads to an increase in diagnosis of pathology that also require
treatment which brings the concept of "see and treat", that is becoming more prevalent in
hysteroscopy.
Hysteroscopy has now reached its maturity, the number of publications on hysteroscopy has
increased exponentially in recent years, more and more specialists dedicate their professional
activity to exclusively performing hysteroscopy. We even have an independent publication of high
level and scientific rigor with nearly 3,000 followers, the "Hysteroscopy Newsletter".
Following the example of the natural development of endoscopy in surgery, where different societies
are organized according to their specific interests, it is possible that the time to create an
independent hysteroscopy society has arrived.
We have the interest in hysteroscopy, we have the support of several leaders worldwide, the starting
of a dedicated journal and even a global conference to be held in May 2017 in Barcelona. Is it time
to stop being the "little sister" of gynecologic endoscopy and be an independent society?
The time to discuss this issue has arrived!
Sergio Haimovich

Hysteroscopic Treatment of Cesarean-Induced Isthmocele Restores Fertility

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