Hysteroscopic Fenestration with Precise Incision of the Cavity Septum – A Novel Minimally Invasive Surgery of Complete Septate Uterus with Double Cervix

Elsevier

Available online 15 May 2023

Journal of Minimally Invasive GynecologyAuthor links open overlay panel, , , , , , AbstractStudy Objective

This study aimed to develop and describe a novel surgical procedure that involves hysteroscopic fenestration with precise incision of the complete uterine septum and double cervix preservation after MRI evaluation in patients and to evaluate its efficacy.

Design

Prospective consecutive clinical study.

Setting

University teaching hospital.

Patients

Twenty-four patients with complete septate uterus and double cervix.

Interventions

Three-dimensional (3D) reconstruction of uterus was performed with pelvic magnetic resonance imaging (MRI) and 3D SPACE sequence scanning. Hysteroscopic fenestration with precise incision of the cavity septum and double cervix preservation was performed in patients. Three months post operation, follow-up pelvic MRI and second-look hysteroscopy were performed conventionally.

Measurements and Main Results

Operating time, blood loss, operative complications, MRI and hysteroscopic changes of uterus, symptoms improvement and reproductive outcomes were assessed. The surgery was successfully completed without any intraoperative complications in all patients. Operating time was 21.71 ± 8.28 minutes (range, 10-40 minutes) and blood loss was 9.92 ± 7.14 ml (range, 5-30 ml). Postoperative MRI showed the uterine anteroposterior diameter (3.66 cm versus 3.92 cm; P < 0.05) was increased. Postoperative MRI and the second-look hysteroscopy showed the cavity shape and uterine volume were expanded to the normal. Symptoms of dysmenorrhea, abnormal uterine bleeding, and dyspareunia were ameliorated after the surgery in 70% (7 of 10) patients, 60% (3 of 5) patients, and one patient, respectively. The preoperative spontaneous abortion rate was 80% (4 of 5) and the postoperative spontaneous abortion rate was 11.11% (1 of 9). After the surgery, there were two ongoing pregnancies and six pregnancies ended in term births. Two live births were delivered by cesarean section and four by vaginal delivery without cervical incompetence during pregnancy.

Conclusions

Hysteroscopic fenestration with precise incision of the uterine septum and double cervix preservation is an effective surgical procedure.

Section snippetsINTRODUCTION

Septate uterus is the most common congenital anomaly of the female genital tract, often accompanied with poor reproductive outcomes and is subsequently diagnosed in the clinic [1-3]. Septate uterus might impair the reproductive function in 20–25% of infertile women [4, 5]. Patients with septate uterus showed a higher risk of experiencing adverse outcomes such as miscarriage preterm birth, malpresentation at delivery and intrauterine growth restriction compared to the control individuals [6, 7].

Patients

Between July 2021 and July 2022, 24 patients with a complete septate uterus and double cervix were recruited from the Center of Diagnosis and Treatment for Cervical & Uterine Cavity Diseases, Shanghai, China. The presenting symptoms of the enrolled women included dysmenorrhea, abnormal uterine bleeding, dyspareunia, spontaneous abortion, and primary infertility. All the enrolled women sought medical assistance in the outpatient setting with a strong desire for fertility in the future. Table 1

Evaluation of dyspareunia, dysmenorrhea and abnormal uterine bleeding

The severity of pain of dyspareunia and dysmenorrhea was observed by a standard 10 cm visual analogue scale (VAS). The improvement of dyspareunia and dysmenorrhea was a defined as decrease in VAS score. Effective treatment of abnormal uterine bleeding was defined as the volume, duration, or frequency of menstrual period returning to normal without recurrence within 3 months after surgery.

Urogenital tract malformation

Of all the women patients enrolled, 21 (87.50%) patients had coexisting vaginal anomalies. Fifteen (71.43%) patients had longitudinal vaginal septum (one of them had combined unilateral nephrarctia), and 6 (28.57%) patients had obstructed R/L hemivagina (four of them had combined ipsilateral renal agenesis) (Table 2).

Pelvic MRI for diagnosing uterus anomalies

The accuracy of pelvic MRI with 3D SPACE sequence scanning in diagnosing complete septate uterus was 100%. Pelvic MRI with 3D SPACE sequence scanning showed 95.24% sensitivity,

DISCUSSION

The prospective, consecutive clinical study represents one of the largest and most detailed reported series to date, providing a precise and comprehensive procedure for the treatments of complete septate uterus with double cervix. We identified 24 patients with complete septate uterus and double cervix and described their vaginal and kidney anomalies in detailed.

Pelvic MRI is a noninvasive and safe method to diagnose congenital uterine anomalies with high accuracy[16]. Nevertheless, vaginal

CONCLUSION

Overall, hysteroscopic fenestration with precise incision of the uterine septum and double cervix preservation is an effective surgical procedure that requires less operation time. Although the final reproductive outcomes may require more time to follow up, this new procedure has a potential to be a recommended treatment after further exploration.

Reference

1. Ludwin, A. and I. Ludwin, Comparison of the ESHRE-ESGE and ASRM classifications of Mullerian duct anomalies in everyday practice. Hum

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© 2023 Published by Elsevier Inc. on behalf of AAGL.

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