Dr. Alfonso Arias INSIDE THIS ISSUE

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1 INSIDE THIS ISSUE F or 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. WELCOME 1 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 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

2 TEAM COODINATOR SPAIN L. Alonso EDITORIAL COMMITTEE SPAIN E. Cayuela L. Nieto PICTURES HYSTEROSCOPY 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. Endometrial polyps are overgrowths of endometrial glands and stroma around a vascular core. Detailed aspect of the vascular axis of an early polyp. 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. 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 2

3 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 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. 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.. Ramón Labastida Nicolau Gynecology Consultant Quirón Dexeus University Hospital. Barcelona, Spain. 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! 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 3

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...anyone who is not aware of the role played by hysteroscopy, has not understood the concept. 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. 4

5 TALKING ABOUT STEP-W Classification: My point of view R. Lasmar Discipline of Gynecology of Universidade Federal Fluminense. Brasil 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 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) Hysteroscopy Newsletter 5

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 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. "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 ml, among completely removed myomas and 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" 6

7 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. 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. 7

8 HIGHLIGHT ARTICLES Published on different medias Effectiveness and feasibility of hysteroscopic sterilization techniques: a systematic review and meta-analysis la Chapelle CF1, Veersema S2, Brölmann HA3, Jansen FW4. Fertil Steril Apr 21. pii: S (15) doi: /j.fertnstert [Epub ahead of print] 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. Preoperative ripening of the cervix before operative hysteroscopy. Al-Fozan H1, Firwana B, Al Kadri H, Hassan S, Tulandi T. Cochrane Database Syst Rev Apr 23;4:CD doi: / CD 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 8

9 DID YOU KNOW...? 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. There is no fluid passage through normal fallopian tubes until intrauterine perfusion pressure exceeds 70 mm Hg. 9

10 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: The image is tubal ostial polyp in the left ostium 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, stepby-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. 10

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. 11

12 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%. Hysteroscopic C on will be our new se undrums ction Reach out to Dr Ciccinelli to talk about endometritis Next issue: r Complete cove s on micropolyp tis. and endometri Interested in performing a multicenter trial? Stay tuned And hysteroscopy newsletter, Possible cooperation? se Need to increa number of members from a Asia and Afric 12

13 CongresS INTERNATIONAL 52 Congreso Mexicano de medicina de la reproducción Mérida, Mexico jul rd ISGE African Conference Kenia Society Endoscopic Specialities Nairobi, Kenia August New York, USA Sep nd World Congress on Controversies in Obstetrics, Gynecology & Infertility New European Surgical Academy days th World Congress In Vitro Fertilization (ISIVF 2015) Minimally invasive surgery week Budapest, Hungary Sept Berlin, Germany Sep Copenhagen, Den Sep XXI FIGO World Congress ESGE 24rd anual congress Laparoscopy and Hysteroscopy Procedures in Gynecology and Infertility Vancouver, Canada Oct ASMR 2015 Annual Meeting Baltimore, USA OCT th APAGE Annual Congress Beijing, China nov Your Key to endoscopy Budapest, Hungary October Congress European Society Gynecology Prague, Czech Republic Oct th AAGL Global Congress of Minimally Invasive Gynecology Las Vegas, Nevada nov

14 HYSTEROSCOPY DEVICES Gubbini Mini Hystero-Resectoscope More information: 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 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 Aug;288(2): 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 ± mm. We analyzed the operating time with a mean of ± 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. 14

15 Resident's CORNER 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. 15

16 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 curettesmall 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 Look for us: hysteroscopy group in Linked In What to do? 16

17 HYSTERO Projects Epidemiological evaluation of intrauterine adhesions (IUAs) after hysteroscopic surgery Ethics and methodology: The study will be in accordance with the Declaration of Helsinki, the Committee on Publication Ethics (COPE) guidelines ( 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 ( Patients and Methods The patients will be consecutively selected from a population with suspected endouterine diseasewww.twitter.com/hysteronews 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 diseasehysteroscopy (if the endouterine disease will be not confirmed, the patient will be not enrolled newsletter 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 willhysteroscopy exclude from groupthe 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 Hysteroscopy could increase the risk during surgery. For all the patients, we will record age, BMI, newsletter 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). 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 17

18 Back page HYSTEROSCOPY 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 FIND US ON Hysteroscopy newsletter HYSTEROscopy group Hysteroscopy newsletter The NESA, the New European Surgical Academy, is an international, interdisciplinary 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 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: Dr. Michael Stark President, The New European Surgical Academy (NESA). Berlin. Germany 18