Vol 1 issue 4 eng definitivo

Jul-Aug 2015 | vol. 1 | issue 4 www.hysteroscopy.info
INSIDE THIS ISSUE
WELCOME 1
Interview of the month 3
Talking about ... 5
Tips and Tricks 7
Highlights articles 8
What's your diagnosis? 10
Case report 11
Devices 14
Conundrum 16
Hystero Project 17
1
For many years, hysteroscopy was only used for early diagnosis of endometrial
adenocarcinoma, considering hysteroscopic surgery an absolute contraindication.
Today, that vision has changed, and hysteroscopic resection is gaining popularity
as an acceptable modality in the conservative treatment of focal endometrial
adenocarcinoma in patients of reproductive age. It is similar to the evolution of
endoscopic treatment of other types of gynecological cancer, as up no more than
one decade ago, endoscopic procedures were contraindicated in nearly all types of
cancer. Such behavior is very different today.
In my opinion, this has happened due to 2 main reasons: First, the introduction of
the Bettocchi hysteroscopic set that allowed the routine practice of in office
hysteroscopy and second, the development of bipolar resectoscopes that allowed
the young endoscopist, with less experience, perform hysteroscopic surgery
making such procedures cleaner, faster and safer.
The Bettocchi hysteroscopic set as well as the insertion technique without
speculum that we have called vagino-hysteroscopy has allowed us to explore
women at younger ages and thus the pathology is now detected at earlier stages
and therefore focal, without myometrium invasion, arising the possibility of
conservative treatment with bipolar resection giving a more precise clean cut with
minimal tissue damage.
These two reasons have led to a higher number of gynecologists interested in
learning and practicing these techniques, which has motivated the experts to do
more teaching resulting in a rapidly increased of hysteroscopists worldwide.
But hysteroscopy needs to become more
popular. Office hysteroscopy should be readily
available in every gynecologic practice. Group
practices should designate one or two member
of the group to become “experts” in office
hysteroscopy. Those of us who already have
some decades in practice are always available
to younger physicians for formal training.
Dr. Alfonso Arias
HYSTEROSCOPY
PICTURES
2

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
Gonzalez A. M.
VENEZUELA
J. Jimenez
SCIENTIFIC
COMMITTEE
A. Tinelli (ITA)
A. Úbeda (Spa)
A. Arias (Ven)
M. Rodrigo (Spa)
A. Di Spiezio (Ita)
E. de la Blanca (Spa)
J. Rios (Spa)
M. Bigozzi (Arg)
S. Haimovich (Spa)
R. Lasmar (Bra)
A. Garcia (USA)
N. Malhotra (Ind)
C. Sutton (UK)
I. Alkatout (Ger)
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
Jul-Aug 2015 | vol. 1 | issue 4www.hysteroscopy.info
2
Endometrial polyps are considered areas of focal proliferation of the endometrial
mucosa. They consist of fibrous stroma and endometrial glands that are arranged
around a vascular axis.
They represent one of the most frequent endometrial pathologies and can lead to
irregular menstrual bleeding and infertility. The prevalence in the general
population is 24 % being even greater in postmenopausal women.
The etiology and pathogenesis of endometrial polyps has been debated for years.
There are several theories that try to explain their etiology. The studies seem to
conclude that their appearance due to a proliferative process associated with
hormonal and inflammatory factors at the level of the endometrium.
There are multiple risk factors for the development of endometrial polyps such as
age, BLC-2 protein, obesity, and estrogen treatment.
Endometrial polyps are
overgrowths of endometrial
glands and stroma around a
vascular core.
Detailed aspect of the
vascular axis of an early
polyp.
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

3
www.hysteroscopy.info
INTERVIEW WITH...
Sitting in his office in the brand new building at the Women's
Health Dexeus Hospital is hard not to feel admiration for the
person who launched the diagnostic and operative hysteroscopy
in our country (Spain) with work, effort and dedication over 40
years ago. I do not know whether to leave or start asking
questions nonstop. I pause for a second and decided to ask him
to reflect aloud and to share with us his feelings looking back in
time at what he has achieved and what are his beliefs about what
hysteroscopy has to come.
The book "Textbook and atlas of
hysteroscopy" published 25 years
ago, was a real revolution in the
world of hysteroscopy. The book,
highly illustrated, is divided into a
first section of general hysteroscopy,
a second part studies the application
of hysteroscopy in the most common
clinical situations and finally, a last
chapter on surgery. A classic yet
current.
A must have!
Ramón Labastida
Nicolau
Gynecology Consultant
Quirón Dexeus University Hospital.
Barcelona, Spain.
The reality is that, it was the thrust of my teachers what prompted me to
face with hysteroscopy, a technique that in the decade of the 70’s was in its
infancy. The optical were not as narrow as they are today, the available
distention media were of high viscosity, and we did not have pressure
pumps or video camera that provided zoom. It was a milestone to get to
perform a single scan. But worst of all, was the scorn of colleagues to the
information you could provide them given the hegemony that had at the
time the uterine curettage over any other technique.
How have you seen the progress of hysteroscopy?
By leaps and bounds thanks to technological improvements. The ability to
obtain video images allowed objectifying what at first seemed subjective
assessments of the endoscopist. Diagnoses have gone from being rude to be
very specific, both as far as structural pathology, as well as organic and
functional. Today we are able to diagnose hormonal and infectious defects
due to the magnified image offered by optical instruments. And the surgery
has represented the best effort-reward ratio for both the endoscopist and the
patient. The diagnostic and therapeutic effectiveness as exceptional.
What is the role of hysteroscopy in current modern gynecology?
The only drawback of current hysteroscopy is that it is still difficult to
insert the endoscope into the uterine cavity safely and with minimal pain.
To learn how to do it is relatively easy. In current gynecology, anyone who
is not aware of the role played by hysteroscopy has not understood the
“ The astute hysteroscopist
must look into functional dysfunction,
organic or inflammatory disease,
in order to explain, as far as possible,
the etiology of clinical symptoms..”
Jul-Aug 2015 | vol. 1 | issue 4

4
concept. It provides high efficiency with minimum cost. To give immediate response to any uterine pathology, help
to better plan uterine surgery or advise against it, reduce the number of hysterectomies, to eliminate the blind
uterine curettage as a diagnostic technique, all done as an outpatient surgery is an achievement that few others
procedures have attained with such excellent results.
Do you think hysteroscopy has achieved a good level? Is there a solid background of knowledge in
hysteroscopy?
There is no doubt that it has improved over time. You can’t use hysteroscopy only to look at the endometrium
without seeing beyond the obvious. The astute hysteroscopist must look into functional dysfunction, organic or
inflammatory disease, in order to explain, as far as possible, the etiology of clinical symptoms. And therein lies the
real technical quality of the hysteroscopist. I extrapolate this concept to surgery: it is not easy to perform advance
hysteroscopy and to manage large intracavitary fibroids or cases of extensive intrauterine adhesions. A sharp
hysteroscopist should always consider not only the anatomy but also the functional aspect of the endometrium and
the uterus.
Why do you think that in surgical gynecology laparoscopy is considered more important than hysteroscopy?
Because surgery is the great attraction of medicine and therefore the more complex it is, the more attractive it
gets. Laparoscopy is obviously much more complex than hysteroscopy, but few surgeries are more effective and
safer than hysteroscopy.
Please give us your future reflections in regards to hysteroscopy.
I think hysteroscopy should be recognized as being a superb and essential technique in gynecology. When
performed well, is both diagnostic and therapeutic, dramatically reducing the economic and social costs of surgery
in terms of treatment and recovery of selected patients.
Do you have any advice for the young physician who is starting in the world of hysteroscopy?
First, he/she must understand what it means and what hysteroscopy provides among all specialty tools. It allows
to see the endometrium "in situ" and, therefore, should lead to the removal of the traditional blind curettage. A
good hysteroscopist should never have the need to perform a blind curettage!
Second, he/she must understand that direct visualization of the uterine cavity provides information beyond of
what a transvaginal ultrasound could provide. Pathologies such as endometritis and functional pathology that does
not thicken the endometrium (such as complex endometrial hyperplasia or adenocarcinoma) benefit greatly from a
seasoned hysteroscopist, with concerns over the diagnosis of organic disease (endometrial polyps and submucosal
fibroids) as well as structural disease (walls and adhesions).
Finally (last, but not the least), the young physician should never forget the effectiveness of a well indicated and
properly performed hysteroscopy, both in office hysteroscopy (where you should take advantage of the excellent
tolerance by most patients) as well as operative hysteroscopy performed in the operating room. Adhesiolysis and
septoplasty have facilitated the recovery of fertility of infertile couples. Endometrial resection or endometrial
ablation improves the quality of life for patients with heavy menstrual flow, effective immediately after the
procedure and without medical side effects with only minimal invasion.
So I encourage anyone who wants to learn hysteroscopy to first understand it, then apply it to their routine
practice, fight and solve any logistical problems, because I guarantee the young physician will end up loving it as
much as those of us who had the privilege to see hysteroscopy born and grow into what it has become today in
modern gynecology. I really hope that hysteroscopy has the same acceptance that other modalities have had, such
as ultrasound.
“ ..anyone who is not aware of the role played by hysteroscopy,
has not understood the concept.”

5
TALKING ABOUT
In 2005, we developed an Hysteroscopic myoma classification, the “STEPW or Lasmar”Classification. Our
purpose was to develop a new preoperative classification of submucous myomas for evaluating the viability and
the degree of difficulty of hysteroscopic myomectomy. The ESGE classification considers only the degree of
penetration of the myoma into the myometrium, and some times it not a good predictor of myomectomy
difficulty. Our classification considers not only the degree of penetration of the myoma into the myometrium, but
also adds in such parameters as the distance of the base of the myoma from the uterine wall, the size of the
nodule (cm), and the topography of the uterine cavity. Each parameter receives a score, and the total sum of
them indicates the myoma group.
Submucous myomas: a new presurgical classification to evaluate the viability of hysteroscopic surgical
treatment--preliminary report. Lasmar RB, Barrozo PR, Dias R, Oliveira MA.J Minim Invasive Gynecol.
2005.
In 2011 we tested with Profs. Indman PD, Sardo ADS and Xinmei Z these classification on multicenter and
international sets. It was clear that Lasmar classification could predict the myomectomy difficulty better than
ESGE classification. The fluid balance, complications rates and surgery time, as well single step or two step
myomectomies could be predicted, showing high complexity hysteroscopic myomectomy in groups 2 and 3.
Feasibility of a new system of classification of submucous myomas: a multicenter study. Lasmar RB et al.
FertilSteril. (2011)
STEP-W Classification: My point of view
R. Lasmar Discipline of Gynecology of Universidade Federal Fluminense. Brasil
Hysteroscopy Newsletter

6
"There was an association between the STEPW classification and the probability of complete removal of the
fibroids. All (100%) of fibroids classified as Group I – with scores from 1 to 4 – were completely removed."
"Complications occurred in all the Groups, however, the major complications occurred in Group II (perforation)
and in Group III (overload)"
"A major advantage of the STEPW classification is in its ability to group the submucous fibroids by score,
identifying a group in which 100% of the myomectomies will be complete and another group in which some
incomplete myomectomies will occur. This will permit the surgeon to plan and better prepare for the surgery, to
better inform the patient prior to consenting to the procedure, and guide the assignment of cases for the purposes of
teaching operating technique to students and trainees in accordance with their degree of experience."
In 2012 we published with Brazilians gynecologists a multicenter study. A new system to classify submucous
myomas: a brazilian multicenter study. Lasmar RB, Lasmar BP, Celeste RK, da Rosa DB, Depes Dde B, Lopes
RG.J Minim Invasive Gynecol. 2012.
"Operative time was calculated as the interval between the beginning of surgery until the end of the procedure.
Operative times ranged from one to 120 minutes; the mean was 30.6 minutes. Higher scores of STEPW were
associated with longer operative time (p<0.01), while ESGE scores were not statistically associated with operative
time (p=0.13)"
" The fluid balance ranged from 0 to 6000 ml and the mean was 448 ml. It was 357.3 ml, among completely
removed myomas and 1596.7 ml among incompletely removed. Again, ESGE scores were not statistically
associated with fluid balance (p=0.30), while higher STEPW scores predicted higher levels of it (p<0.01)"
" Complications occurred in 15 (7.3%) cases. No deaths were reported. Seven complications occurred in fibroids
with STEPW scores ≤ 4, including two cases of fever, two cases with pain, and three cases with bleeding. Eight
complications occurred in fibroids with STEPW scores> 4: six cases with bleeding, one perforation of the uterus,
and one case in which the STEPW score was 8 had fluid overload. Using the ESGE, bleeding occurred in two
cases of myoma type 0, five type 1 and two type 2; perforation in one type 1; fever in two type 0; pain in two type
1 and overload in one type 2"
"STEPW scores >4 were statistically associated (P<0.01) with longer time of surgery, surgery complications,
higher levels of fluid balance, use of GnRH analogue if compared with lower scores"
"Fibroids were completely removed in all 140 (100%) fibroids with a STEPW score ≤ 4 (Group I) and in 50
(76.9%) of the 65 fibroids with a score > 4"
A major advantage of the STEPW classification is in its ability to
group the submucous fibroids by score, identifying a group in which
100% of the myomectomies will be complete and another group in
which some incomplete myomectomies will occur.

7
Between June 2009 and April 2013, 61 patients with symptomatic submucosal fibroids underwent
hysteroscopic myoma enucleation. Nor anesthesia or antibiotic prophylaxis was used. All
enucleated fibroids were left free in the uterine cavity after taking a sample for pathologic
evaluation. All patients were followed with transvaginal ultrasound between 60 and 90 days after
the hysteroscopic procedure, demonstrating absence of intracavitary fibroids in 100% of the
cases. The average diameter of fibroids measured by ultrasound was 22.6 mm. In 29 cases
(47.5%) the diameter of the myoma was greater than 20 mm and in 10 cases (16.4%) greater
than 30mm. After a mean follow-up period of 68.2 days, none of the patients showed residual
fibroid. No cases of painful fibroid expulsion were reported. The degree of patient satisfaction
was high.
This work indicates that to leave enucleated submucosal myoma in the uterine
cavity without removal is a safe and feasible treatment option.
TIPS and TRICKS... 4U
Some things just can’t be learned from books. Some things can only be learned through experience.
In this section the best hysteroscopists will share their tricks with you.
Uterine fibroids are considered the most common benign uterine tumor of the female genital tract. It is
estimated that fibroids are present in 30% of women at age 35 and up to 70% in women 50 years old and
older. From a hysteroscopic standpoint, submucosal fibroids are very important, representing between
5.5% and 16.6% of all fibroids. Symptoms that are most frequently associated with submucosal fibroids
are abnormal menstrual bleeding, pelvic pain and infertility. The most effective treatment is hysteroscopic
resection. The technique called "Resectoscopic slicing" continues to represent the gold standard for the
treatment of submucosal fibroids.
In recent years there have been different alternatives to resectoscopic fibroid resection. These techniques
are based on extracting the myoma after reducing it into small fragments (miniresector, morcellators and
shaver) or destroying the myoma inside the uterine cavity (laser vaporization).
Recently, a group of researchers from the Autonomous University of Barcelona led by Dr. Haimovich
has presented a prospective study, which has the potential to change the classic approach to this pathology
in the coming years.

8
Effectiveness and feasibility of hysteroscopic sterilization techniques: a systematic review
and meta-analysis
la Chapelle CF1, Veersema S2, Brölmann HA3, Jansen FW4.
Fertil Steril. 2015 Apr 21. pii: S0015-0282(15)00208-3. doi: 10.1016/j.fertnstert.2015.03.009. [Epub ahead of print]
Preoperative ripening of the cervix before operative hysteroscopy.
Al-Fozan H1, Firwana B, Al Kadri H, Hassan S, Tulandi T.
Cochrane Database Syst Rev. 2015 Apr 23;4:CD005998. doi: 10.1002/14651858.CD005998.pub2.
OBJECTIVES: To determine whether preoperative cervical preparation facilitates cervical dilatation and reduces the
complications of operative hysteroscopy in women undergoing the procedure for any condition.
SEARCH METHODS:
In August 2014 we searched sources including the Menstrual Disorders and Subfertility Group (MDSG) Trials Register,
Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PsycINFO, CINAHL,
ClinicalTrials.gov and reference lists of relevant articles. We searched for published and unpublished studies in any
language.
AUTHORS' CONCLUSIONS: There is moderate quality evidence that use of misoprostol for preoperative ripening of
the cervix before operative hysteroscopy is more effective than placebo or no treatment and is associated with fewer
intraoperative complications such as lacerations and false tracks. However misoprostol is associated with more side
effects, including preoperative pain and vaginal bleeding. There is low quality evidence to suggest that misoprostol has
fewer intraoperative complications and is more effective than dinoprostone.There is also low quality evidence to suggest
that laminaria may be more effective than misoprostol, with uncertain effects for complication rates. However the
possible benefits of laminaria need to be weighed against the inconvenience of its insertion and retention for one to two
days
OBJECTIVE: To assess whether hysteroscopic sterilization is feasible and effective in preventing pregnancy.
Secondarily, to identify risk factors for failure of hysteroscopic sterilization.
DESIGN: A systematic review and meta-analysis.
PATIENT(S): Women undergoing hysteroscopic sterilization.
INTERVENTION(S): Hysteroscopic sterilization with a commercially available system (Ovabloc Intra Tubal Device,
Essure system, or Adiana permanent contraception system).
MAIN OUTCOME MEASURE(S): Successful placement at first attempt, confirmed correct placement, complications,
incidence of pregnancy, and risk factors for placement failure in hysteroscopic sterilization.
RESULT(S): Of the 429 citations identified, 45 articles were eligible for analyses. No randomized controlled trials
(RCTs) were identified, just cohort studies. Six articles concerned Ovabloc, 37 Essure, and two Adiana sterilization. The
probabilities for successful bilateral placement in a first attempt for Ovabloc, Essure, and Adiana, were, respectively, in
the ranges 78%-84%, 81%-98%, and 94%. The probabilities of successful bilateral placement could not be pooled
because of substantial heterogeneity. The 36 months' cumulative pregnancy rate of Adiana was 16 of 1,000. Reliable
pregnancy rates after sterilization with Ovabloc or Essure method could not be calculated. For all three hysteroscopic
techniques, the incidence of complications and their severity has not been studied adequately and remains unclear. We
also found too little evidence to identify risk factors for placement failure.
CONCLUSION(S): Sterilization by hysteroscopy seems feasible, but the effectiveness and risk factors for failure of
sterilization remain unclear owing to the poor-quality evidence. Both currently applied hysteroscopic sterilization
techniques and the coming new techniques must be evaluated properly for feasibility and effectiveness. Appropriate
RCTs and observational studies with sufficient power and complete and long-term (>10 years) follow-up data on
unintended pregnancies and complications are needed.
HIGHLIGHT ARTICLES
Published on different medias

9
DID YOU KNOW...?
There is no fluid passage through normal fallopian tubes until
intrauterine perfusion pressure exceeds 70 mm Hg.
Although there are no recognized findings on hysteroscopy that are
confirmatory of adenomyosis, the presence of endometrial defects,
altered vascularization, and hemorrhagic cystic lesions could
represent adenomyosis.

10
Resad P. Pasic, Ronald Leon
CRC Press 2004, 284 Pages
Keeping up with the rapid growth in this
field, this book covers current and
emerging endometrial ablation
procedures. It provides practical, step-
by-step illustrated descriptions of basic
and advanced techniques and new
methods. The editors, Resad Pasic and
Ronald L. Levine, have brought together
a group of experts renowned not only for
their knowledge but also their ability to
teach.
Containing the most up-to-date and
thorough material available, the book
addresses the present hysteroscopic
therapies and provides in depth
discussion of the current knowledge of
hysteroscopy and ablation techniques.
Each chapter has the main points
highlighted in boxes separated from the
text for easy review. The illustrations,
whether line drawings or actual color
photographs, clearly deliver the message.
You can quickly grasp what to do, and
just as importantly, what not to do.
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»
WHAT'S YOUR
DIAGNOSIS?
Answer to the previous issue:
The image is tubal ostial polyp in the left ostium

11
CASE REPORT
Malignant Mixed Müllerian Tumor
AM Gonzalez.Hospital Naval. Buenos Aires, Argentina
Malignant Mixed Mullerian Tumor (MMMT) is constituted by epithelial neoplasms with a mesenchymal
component, both of malignant histology, carcinoma and sarcoma. The epithelial component is usually
predominant, with the exception of locations that have polypoid growth in which the sarcomatous component
predominates.
They may be homologous or heterologous in nature, containing elements with various tissue differentiations such
as musculoskeletal, bone, and cartilage.
They are extremely rare and of poor prognosis, frequently diagnosed in advanced stages. Usually present between
the sixth and seventh decade of life with postmenopausal bleeding and abdominal pain.
CASE
A 70-year-old postmenopausal female with incidental finding of asymptomatic endometrial polyp on ultrasound.
Gynecological and obstetrical history:LMP: age 52 Denies postmenopausal bleeding. Gravida 3 Para 3. Last
recent checkpoint:Mammography / breast ultrasound BIRADS 1, PAP smear: No intraepithelial lesion or
malignancy. Transvaginal ultrasound: Normal size uterus; endometrial polyp at the fundus of 6x3 mm; Normal
ovaries bilateral.
Hysteroscopy result: left fundic polyps (Class V) less than 1 cm, atrophic endometrium. The polyp was resected
using a resectoscope (Storz) and a complete polypectomy to muscle up to 10mm was performed. The
anatomopathologist exam revealed a carcinoembryonic sarcomatous proliferation with necrosis and hemorrhage
with cartilaginous areas, consistent with Malignant Mixed Mullerian Tumor (MMMT).
Treatment was completed with total laparoscopic hysterectomy and bilateral salpingo-oophorectomy with negative
sentinel lymph node dissection.

DISCUSSION
Mixed Malignant Mullerian Tumors (MMMT) is biphasic neoplasms with endometrial epithelial and stromal
components which are both malignant. The etiology is uncertain, although several immunohistochemical studies,
based on changes in the p53 protein and staining with vimentin, cytokeratin, epithelial membrane antigen and
other markers, support the theory of a common origin for both components from a single cell clone.
Macroscopically, they present as uterine masses generally friable
and with a polypoid appearance, which usually arise at the bottom of
the cavity or on one of the horns, usually progressing to extend to
the cervix and into the vagina.
The average age of onset is 65 years, and similar to endometrial
adenocarcinoma, hypertension, obesity and diabetes are frequently
associated, but their causal role is not defined. The most common
clinical manifestation is postmenopausal bleeding. There are no
reports in the literature of MMMT found in an asymptomatic polyp
of less than 1cm in size.
The treatment is total hysterectomy and bilateral salpingo-oophorectomy with external radiation if there is
myometrial invasion.
They have about 50% recurrence rate, with distant metastases in up to 40% of the cases. The most common sites
of metastases are the upper abdomen, lungs and lymph nodes, but have also been reported in the brain. Due to the
high recurrence rate and the incidence of distant metastases, chemotherapy may be an option (ifosfamide and
cisplatin), although the response seems to be poor.
The overall prognosis is poor, with a survival rate at 5 years between 25 and 40%.
12
Hysteroscopic Conundrums
will be our new section
Next issue:
Complete cover
on micropolyps
and endometritis.
www.hysteroyou.com
And hysteroscopy
newsletter, Possible
cooperation?
Need to increase
number of
members from
Asia and Africa
Interested in
performing a
multicenter trial?
Stay tuned
Reach out to Dr
Ciccinelli to talk
about
endometritis

13
ESGE 24rd
anual congress
Your Key to endoscopy
Budapest, Hungary |October 7-10|2015
18th
World Congress In Vitro
Fertilization (ISIVF 2015)
Copenhagen , Den |Sep 27-30|2015
3rd
ISGE African Conference
Kenia Society Endoscopic
Specialities
Nairobi, Kenia | August 23-26|2015
22nd World Congress on
Controversies in Obstetrics,
Gynecology & Infertility
Budapest, Hungary |Sept. 17-20|2015
CongresSINTERNATIONAL
44th AAGL Global Congress
of Minimally Invasive
Gynecology
Las Vegas, Nevada |nov 15-19|2015
52 Congreso Mexicano de
medicina de la reproducción
Mérida, Mexico |jul 15-18|2015
44th AAGL Global Congress
of Minimally Invasive
Gynecology
Las Vegas, Nevada |nov 15-19|2015
16th APAGE Annual Congress
Beijing, China |nov 5-8|2015
XXI FIGO World Congress
Laparoscopy and Hysteroscopy
Procedures in Gynecology and Infertility
Vancouver, Canada |Oct 4-9|2015
New European Surgical
Academy days 2015
Berlin, Germany |Sep 18-20|2015
ASMR 2015 Annual Meeting
Baltimore, USA |OCT 17-21|2015
Minimally invasive surgery
week
New York, USA |Sep 2-5|2015
11 Congress European Society
Gynecology
Prague, Czech Republic |Oct 21-24|2015

14
www.hysteroscopy.info Jul-Aug 2015 | vol. 1 | issue 4
HYSTEROSCOPY
DEVICES
Gubbini Mini Hystero-Resectoscope
The Gubbini Mini Hystero-Resectoscope offers a multitude of options for non-invasive diagnostic and therapeutical
Gynaecology. The Gubbini Mini Hystero-Resectoscope System allows both, hysteroscopy and resectoscopy with reduced
diameter of the shaft. The 16 Fr. Mini-Resectoscope with continuous flow and optional 5 Fr. working channel provides the
possibility of a rapid and gentle endoscopic therapy for a wide range of endo-uterine diseases. By way of introducing miniature
loops which are shaped ideally to the given anatomical proportions, the strain to female patients could be clearly reduced. The
miniature loops are presently offered in two different patterns – with and without high frequency current for coagulation. The
loop without HF current is typically used for blunt preparation.
Born on 1947 in
Acqualanga (Italy). He got
his degree in Gynecology
and Obstetrics at the
university of Bologna in
1972 and his specialization
in 1976.
Since 1976 he works at S. Orsola Hospital in Bologna.
Actually he is senior Physician at the hospital "Madre
Fortunate" di Bologna. In 2009 he created and developed
the "Gubbini" Mini-resectoscope
New mini-resectoscope: analysis of preliminary quality results in outpatient
hysteroscopic polypectomy.
Arch Gynecol Obstet. 2013 Aug;288(2):349-53 Dealberti D1, Riboni F, Prigione S, Pisani C, Rovetta E, Montella F, Garuti G.
PURPOSE: We investigated the feasibility and acceptability of office hysteroscopic polypectomy using a new continuous-flow
operative 16 Fr Gubbini's mini-resectoscope. This is a prospective clinical study (Canadian Task Force classification III).
METHODS: The office hysteroscopic polypectomy was performed with a mini-resectoscope without analgesia or anesthesia.
We evaluated the polyp size and the number, the effectiveness of resection, the operating time, the pelvic pain and
complications.
RESULTS: The office hysteroscopic polypectomy was successfully performed in all 33 patients. The polyps ranged in size
from 5 to 50 mm with a mean of 18.15 ± 11.45 mm. We analyzed the operating time with a mean of 11.45 ± 4.71 min: 29
procedures took less than 15 min from the start of vaginoscopy to the end of surgery. Overall mean visual analog scale (VAS)
calculated was 2.48 ± 1.37 (range 0-6). The correlation between the size of the polyps and operating time was statistically
significant (p < 0.001). No major complications were recorded.
CONCLUSION: Our preliminary data demonstrated that can be possible to remove endometrial polyps by hysteroscopy, using
the mini-resectoscope, in an office setting. All procedures were completed successfully and well tolerated with a little
discomfort permitting the removal also of big sized polyps without a statistical correlation between VAS and size of polyps or
operating time. The outpatient polypectomy is a less-costing procedure and represents an acceptable and effective alternative to
inpatient resectoscopic polypectomy, leading to a complete polyp excision in nearly all patients.
Moreinformation:www.tontarra.biz

15
Resident'sCORNER
Role of hysteroscopy in conservative treatment of endometrial cancer. Case Report.
Duro Gómez J. H. U. Reina Sofía. Córdoba. España
The patient is a 27 years old morbidly obese (BMI 49 Kg/m2) nulligravida who presented to the emergency
room complaining of heavy vaginal bleeding. Personal history: Menarche age 11, regular menstrual pattern q 30
days lasting for 5 days. No other relevant personal or family history.
Physical exam was normal, other than morbid obesity and vaginal bleeding. Pelvic ultrasound revealed 2 cm
endometrial thickness. Diagnostic hysteroscopy and endometrial biopsy reported endometroid adenocarcinoma
grade 2. Pelvic MRI revealed the presence of an intrauterine mass growth limited to the endometrium with no
myometrial invasion. Patient reported strong desire of future fertility. Treatment was initiated with
medroxyprogesterone acetate based on a reported regression rate of up to 76.2%.
There is consensus on the need of hysteroscopy with direct visualization and selective endometrial biopsy in the
diagnosis of endometrial cancer. But, what is the role of hysteroscopy in monitoring therapy?
Once the diagnosis of non invasive endomerial cancer has been established, monitoring the progress of treatment
should be performed by diagnostic hysteroscopy for various reasons.
First, to determine the presence of neoproliferation and to ensure that the extensión is confined within the
endometrial cavity. This will allow the physician to monitor progression of the disease. In our patient, follow up
hysteroscopy revealed an endometrial cavity occupied by neoproliferation of tissue located at the lower uterine
segment and both lateral walls of the uterus, consistent of cotton like tissue with atypical vascularization in a
seaweed pattern.
Second, allows to perform follow up biopsy. In this case, follow up biopsy of the most abnormal looking areas
were taken. The pathology revealed "necrotic decidua"
Given the pathology and hysteroscopic findings in this case, we offered one of 2 different options. Continue the
same therapy with quarterly controls by hysteroscopy or endometrial resection. Regarding the latter, although
small series, there is evidence that indicates its usefulness in preserving fertility. Moreover, if complete response is
obtained, pregnancy could be considered.endometrial.

Hysteroscopy Conundrums
Post cesarean bleeding
Clinical Case
37 years old. Twin pregnancy after IVF for endometriosis. Cesarean with
32 weeks for pre-eclampsia:
- Bleeding and accreta suspition
- Uterine Alcides Pereira Hemostatic sutures with resolution of the
bleeding
During the next 6 weeks she mantains bleeding (not very much), no pain,
no fever. Ultrasound: probably piece of placenta and debris sugestive of
blood. B-HCG: 1 (normal). Uterine evacuation using suction curette-
small amount of bloody fluid
3 weeks later (9 weeks after delivery): small bleeding persists- no pain,
no fever. I'm sending the US: To me it looks like: probable placenta
increta- until de serosa margin afeting around 1/3 of the uterus; No
vascularization. Debris inside the uterus. B-HCG<1
What to do?
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16

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Hysteroscopy newsletter
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Projects
HYSTERO
Epidemiological evaluation of intrauterine adhesions (IUAs) after hysteroscopic surgery
Coordinator:
Dr. S. Haimovich
Design:
Dr. A. S. Laganá
Aim of the study:
To evaluate the
prevalence of
intrauterine adhesions
(IUAs) after
hysteroscopic surgery.
Type of the study:
Multicenter, cohort
study.
Outcomes
The risk of IUAs after
hysteroscopic surgery
will be evaluated
according to the
different analyzed
variables (age, BMI,
parity, use of medical
therapy for endometrial
preparation and type of
endouterine disease).
Contact:
If you are interested in
participate in this study,
please contact with
iua.study@gmail.com
Ethics and methodology:
The study will be in accordance with the Declaration of Helsinki, the Committee on
Publication Ethics (COPE) guidelines (http://publicationethics.org/) and will be approved
by the Institutional Review Board (IRB) of each hospital that will join the project.
Each patient who will participate in this study will be well informed regarding the
procedures that she will undergo and will sign a consent form for data collection for
research purposes (important: each hospital that will join the project should provide an
informed consent in line with the purpose of the current study in the native language of the
enrolled patients).
An independent data safety and monitoring committee will evaluate the results of the
study.
All the design, analysis, interpretation of data, drafting and revisions will follow the
Strengthening the Reporting of Observational Studies in Epidemiology (STROBE)
Statement, available through the EQUATOR (Enhancing the QUAlity and Transparency
Of health Research) network (http://www.equatornetwork.org/).
Patients and Methods
The patients will be consecutively selected from a population with suspected endouterine
disease with high risk of post surgical IUA and that will probably require a resectoscopy
(fibroids/septum), resulting from 2D transvaginal ultrasound screening. Subsequently, they
will undergo diagnostic hysteroscopy which will confirm the presence of endouterine
disease (if the endouterine disease will be not confirmed, the patient will be not enrolled
for the current study). This test will be always performed by the same physician for each
center, during the early proliferation phase of the menstrual cycle (seventh or eighth day).
We will exclude from the enrollment patients with adnexal or uterine diseases (including
oncologic ones) for which hysteroscopy does not represent the gold standard management;
and/or cardiovascular, hepatic or renal dysfunctions and any other medical condition
which could increase the risk during surgery. For all the patients, we will record age, BMI,
parity, use of medical therapy for endometrial preparation and type of endouterine disease.
All the patients will undergo hysteroscopic surgery (T0), performed by the same physician
for each center using Mono or Bipolar Resectoscope (describe the type of hysteroscope
that you want to use).
After 3 months all the enrolled patients will undergo diagnostic hysteroscopy (T1) as
described before, performed always by the same physician for each center (different from
who performed hysteroscopic surgery in the first phase of the study), to check whether
IUAs occurred.
The presence of IUAs will be defined and classified according to the European Society for
Hysteroscopy (Grade I-IV), as reported by the AAGL (American Association of
Gynecologic Laparoscopists).
17

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HYSTEROscopy group
Hysteroscopy Newsletter
is an opened forum to
all professionals who
want to contribute with
their knowledge and
even share their doubts
with a word-wide
gynecological
community
HYSTEROSCOPY
Back pagEThe NESA, the New European Surgical Academy, is an international, inter-
disciplinary surgical academy with members in 51 countries whose aim is to revise
existing surgical methods and to introduce modified surgical procedures. The
NESA initiated the first European working group concerning natural orifice
surgery, distributed modified surgical methods like the Cesarean Section and
Vaginal Hysterectomy, and supported the European tele-surgical system with force
feedback.
The NESA Conferences are interdisciplinary and give chance to surgeons from
different disciplines to expose each other to various new ideas across the different
fields.
The trans-oral thyroidectomy is only one example where the collaboration of
General Surgeons, ENT Surgeons and Anatomists created this new approach.
We believe that every new method should not be applied unless it brings added
value to existing methods.
The Hysteroscopy, which was initially introduced as a diagnostic tool, developed
into an important surgical tool. Fibroids and septa which were treated before by
open surgery can be treated today by ambulatory or day-care; so by intrauterine
adhesions and polyps. Therefore, the NESA promotes this advanced mode and
gives it important emphasis during its international conferences.
The NESA Days 2015 Conference will take place in Berlin on 18-20 September
2015 at the Leonardo Royal Hotel Berlin Alexanderplatz.
The conference will be dedicated to acute care surgery and emergencies in surgery
as well as novelties in endoscopy, hysteroscopy and tele-surgery. Participants will
learn about optimal ways of overcoming unexpected situations.
Opinion-leaders from various disciplines and countries will present their
experience and ideas about these important issues.

We invite you to participate in the NESA Days 2015 in the beautiful city of Berlin.
We, the Conference Presidents, welcome you to visit our Conference website for
further information: www.comtecmed.com/nesa
Dr. Michael Stark
18
www.hysteroscopy.info Jul-Aug 2015 | vol. 1 | issue 4
President, The New European Surgical
Academy (NESA). Berlin. Germany

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