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To demonstrate our hysteroscopic technique using the mini-resectoscope for the treatment of complete uterine septum with or without cervical anomalies. A step-by-step video demonstration of the technique with the use of an educational video. We present 3 patients diagnosed as having complete uterine septum (U2b according to the ESHRE/ESGE classification) with or without cervical anomalies (C0, normal cervix; C1, septate cervix; C2, double "normal" cervix"), 2 of them with a longitudinal vaginal septum (V1). The first case is a 33-year-old woman with history of primary infertility diagnosed as having a complete uterine septum with normal cervix (class U2bC0V0 according to the ESHRE/ESGE classification). Case 2 is a 34-year-old woman with infertility and abnormal uterine bleeding, diagnosed as having complete uterine and cervical septum and a partial nonobstructive vaginal septum (class U2bC1V1). Case 3 is a 28-year-old woman with infertility and dyspareunia, diagnosed as having a complete uterine septum, double "normal" cervix, and nonobstructive longitudinal vaginal septum (class U2bC2V1) Still 3. The procedures were performed in a tertiary care university hospital. The 3 procedures were performed in the operative room using a 15 Fr continuous flow mini-resectoscope and bipolar energy with the patient under general anesthesia Still 1 and Still 2. No complications were encountered in any of the 3 cases. After all procedures, a gel based on hyaluronic acid was applied to minimize postoperative adhesion formation. Patients were discharged home the same day of the procedure after a short period of observation. Hysteroscopic treatment of patients with uterine septa associated or not with cervical anomalies using miniaturized instruments is a feasible and effective option for the management of patients with these complex müllerian anomalies. [ABSTRACT FROM AUTHOR]

To describe an effective in-office hysteroscopic strategy to restore fertility of patients with severe Asherman's syndrome. A step-by-step video demonstration of the technique with an emphasis on the key portions of the procedure. A detailed narrated description of the steps is provided. Tertiary care University Hospital. Three patients were managed by hysteroscopy performed in the office setting without anesthesia. Case 1 is a 34-year-old woman with obstetrical history of first-trimester incomplete abortion treated with Dilation and Curettage (D&C), followed by a tubal ectopic pregnancy treated with laparoscopic partial salpingectomy and a subsequent pregnancy on the tubal stump treated with uterine artery embolization. Case 2 is a 40-year-old woman with history of tubal ectopic pregnancy treated with salpingectomy, a surgical first-trimester voluntary termination of pregnancy with D&C and a full term vaginal delivery complicated with retained products of conception that were removed with D&C. Case 3 is a 35-year-old woman with two previous first-trimester spontaneous miscarriages both treated with D&C. Case 1 and 3 were treated using miniaturized mechanical instruments only; in case 2, miniaturized mechanical instruments and the 15 Fr bipolar mini-resectoscope were used. Preoperative 2D and 3D ultrasound were used to predict the complexity of the cases and to guide the surgeon during the procedure. Intrauterine lysis of adhesions was concluded when both tubal ostia were visualized, and the uterine cavity was determined to have adequate shape and volume. At the end of the procedures, hyaluronic acid-based gel was applied to prevent new intrauterine adhesion formation. Two weeks after the initial procedure, a second look diagnostic hysteroscopy was performed. Only one patient (#1) needed additional lysis of adhesions; in this case, at the end of the procedure, a Word catheter was inserted as a barrier method for the prevention of adhesion formation. Eight weeks later, the word catheter was removed, and additional lysis of adhesions was performed. All the surgical procedures were performed without complication, and a healthy endometrium was observed at the second look hysteroscopy, in all the three patients. All 3 patients conceived after the procedure. Pregnancy was achieved after one IVF cycle with the transfer of one frozen embryo in case 1 and spontaneously in cases 2 and 3. Patient 1 was delivered by elective caesarean section due to placenta previa, while the other two patients had normal vaginal deliveries. Patient 1 had Retained Products of Conception requiring hysteroscopic removal using a 27 Fr Resectoscope. When using innovative miniaturized instruments and adequate surgical technique, hysteroscopic lysis of adhesions is a feasible and effective in-office strategy to restore fertility in patients with severe Asherman's syndrome. The use of 2D and 3D ultrasound played an important role in the preoperative workup of the patient with Asherman's syndrome. [ABSTRACT FROM AUTHOR]

Cesarean scar ectopic pregnancy is a type of ectopic pregnancy in which the fertilized egg is implanted in the muscle or fibrous tissue of the scar after a previous cesarean delivery. The condition can be catastrophic if not managed on time and can lead to significant morbidity and mortality. Several approaches have been studied for the management of cesarean scar ectopic pregnancy in women who opted for termination of pregnancy with no consensus on the best treatment modality reached so far. This study aimed to compare the success rate of hysteroscopic resection vs ultrasound-guided dilation and evacuation for the treatment of cesarean scar ectopic pregnancy. This was a parallel group, nonblinded, randomized clinical trial conducted at a single center in Italy. Women with singleton gestations at <8 weeks and 6 days of gestation were included in the study. Inclusion criteria were women with a cesarean scar ectopic pregnancy with positive embryonic heart activity who opted for termination of pregnancy. Patients were randomized 1:1 to receive either hysteroscopic resection (ie, intervention group) or ultrasound-guided dilation and evacuation (ie, control group). Both groups received 50 mg/m2 of methotrexate intramuscularly at the time of randomization (day 1) and another dose at day 3. A third dose of methotrexate was planned in case of persistence of positive fetal heart activity at day 5. Participants received either ultrasound-guided dilation and evacuation or hysteroscopic resection from 1 to 5 days after the last dose of methotrexate. Hysteroscopic resection was performed under spinal anesthesia using a 15 Fr bipolar mini-resectoscope. Dilation and evacuation were performed by vacuum aspiration with a Karman cannula, followed by sharp curettage, if necessary, under ultrasound guidance. The primary outcome was the success rate of the treatment protocol, defined as no further treatment required until the complete resolution of the cesarean scar ectopic pregnancy. Resolution of the cesarean scar ectopic pregnancy was evaluated based on decline of beta-hCG and the absence of residual gestational material in the endometrial cavity. Treatment failure was defined as the necessity for further treatment required until the complete resolution of the cesarean scar ectopic pregnancy. A sample size calculation indicated that 54 participants were required to test the hypothesis A total of 54 women were enrolled and randomized. Number of previous cesarean deliveries ranged from 1 to 3. Overall, 10 women received a third dose of methotrexate with 7 of 27 (25.9%) participants in the hysteroscopic resection group and 3 of 27 (11.1%) in the dilation and evacuation group. The success rate was 100% (27/27) in the hysteroscopic resection group and 81.5% (22/27) in the dilation and evacuation group (relative risk, 1.22; 95% confidence interval, 1.01–1.48). Additional procedures were required in 5 cases of the control group, namely 3 hysterectomies, 1 laparotomic uterine segmental resection, and 1 hysteroscopic resection. The length of stay in the hospital was 9.0±2.9 days in the intervention group and 10.0±3.5 days in the control group (mean difference, −1.00 days; 95% confidence interval, −2.71 to 0.71). No cases of admission to intensive care unit or maternal death were reported. Hysteroscopic resection was associated with an increased success rate in the treatment of cesarean scar ectopic pregnancy when compared with ultrasound-guided dilation and evacuation. [ABSTRACT FROM AUTHOR]

Study Objective: To describe the diagnostic workup and laparoscopic management of a noncommunicating left uterine rudimentary horn (class U4aC0V0 European Society of Human Reproduction and Embryology/European Society of Gastrointestinal Endoscopy Classification) with communicating endometriotic bladder nodule.Design: Step-by-step description of the surgical treatment.Patient: A 33-year-old woman with unicornuate uterus and a left-side noncommunicating rudimentary horn affected by primary infertility, mild dysmenorrhea (visual analog scale score 6), severe catamenial dysuria (visual analog scale score 10), and catamenial hematuria.Setting: Noncommunicating rudimentary horns are rare Müllerian anomalies present in 20% to 25% of women with a unicornuate uterus. It is associated with severe dysmenorrhea, pelvic pain, subfertility, and poor obstetric outcomes and usually presents with cyclic pelvic pain that starts early after the menarche. Endometriotic bladder nodules are present in 1% to 2% of patients with endometriosis. In the literature, there are no reported cases of noncommunicating rudimentary horn with communicating endometriotic bladder nodules. Surgical excision of the rudimentary horn is the treatment of choice. In our case, the 2-dimensional/3-dimensional ultrasound revealed a right unicornuate uterus with a left noncommunicating rudimentary horn with hematometra. The uterine fundus presented «gamma sign» vascularization. In addition, a bladder endometriotic nodule (16 × 15 mm) communicating with hematometra was displayed. Magnetic resonance imaging demonstrated no additional malformations. Diagnostic hysteroscopy revealed a single cervix without vaginal malformation and small right uterine cavity with single tubal ostium. At laparoscopy, using hysteroscopic transillumination, a clear plane of dissection was identified between the rudimentary horn and the uterus confirming the presence of a noncommunicating horn. Evaluation of the abdominal cavity showed bilateral normal adnexa with normal ovaries. Chromopertubation showed a patent right Fallopian tube and obstructed left tube.Interventions: A left salpingectomy using bipolar and the ultrasonic energy was performed. The utero-ovarian ligament was transected, and the left ovary was preserved. The left ovary was suspended at the pelvic wall, the retroperitoneum was opened, the ureter was identified, and the left uterine artery was temporary occluded. The left round ligament was transected and the left paravesical space was developed. With a lateromedial approach, we opened the vesicouterine septum to dissect the bladder from the rudimentary horn. The endometriotic bladder nodule was gently detached from the uterine horn with a lateromedial approach. The left uterine artery was coagulated and dissected at level of the cervix. A solution of vasopressin was injected between the uterine horn and the uterus. Resection of the rudimentary horn was performed. The peritoneum was closed. The temporary occlusion of the uterine artery was removed. The specimen was placed in a bag and removed using an extracorporeal tissue extraction technique.Conclusion: The late clinical presentation of our patient with only mild dysmenorrhea could be explained by the drainage of the hematometra from the noncommunicating horn into the endometriotic bladder nodule. The bladder symptoms in patients with Müllerian anomalies should be carefully investigated. The laparoscopic removal of rudimentary horn with mobilization of communicating bladder nodule when present is a safe and feasible method to improve symptomatology. [ABSTRACT FROM AUTHOR]

Objective: Hysteroscopy is considered the gold standard technique for the diagnosis and management of intrauterine pathology allowing to "see and treat" patients in 1 session if desired [1-3]. Pain and the inability to enter the uterine cavity are the most common limitations of hysteroscopy, especially when performed in an office setting [4-7]. Cervical stenosis is a common hysteroscopic finding frequently encountered in postmenopausal women, especially in patients with a history of cervical procedures such as cone biopsy [8]. It represents a challenge even for the most expert hysteroscopist. Overcoming the stenosis of the external cervical os is technically more demanding than facing the obliteration of the internal os. The aim of this video article is to illustrate the use of simple techniques that allow the hysteroscopist to safely identify the location of the external cervical os and to overcome the difficulties in entering the uterine cavity during in-office hysteroscopy in patients with severe cervical stenosis including those with complete obliteration of the external cervical os. These techniques are easy to adopt and can be used in different clinical situations in which the hysteroscopic evaluation of the uterine cavity is needed in women with severe cervical stenosis.Design: A series of videos of challenging cases with severe cervical stenosis with complete obliteration of the external cervical os are presented that demonstrate maneuvers to properly identify and enter the cervical canal, unfolding key aspects of the procedure. Tips and tricks to facilitate the adoption of these useful maneuvers into clinical practice are highlighted.Setting: In-office diagnostic hysteroscopy was performed using a 5-mm rigid continuous flow operative hysteroscope. Patients were placed in a dorsal lithotomy position. The vaginoscopy "no touch" technique was used [9]. No anesthesia or sedation was administered to any of the patients. Normal saline was used as distention media.Interventions: Taking advantage of the magnification provided by the hysteroscope, the location of the external cervical os was determined. In cases in which the external cervical os was not clearly recognized, the cervix was gently probed with the use of the uterine palpator, grasper, or scissors (Fig. 1). Recognition of the landmarks of the cervical canal provides reassurance of the adequate identification of the external cervical os and facilitates the use of the correct plane of dissection that leads into the uterine cavity (Fig. 2). Additional maneuvers that are useful to navigate the endocervical canal to overcome stenosis of the internal cervical os are also illustrated.Conclusion: The combination of a delicate technique and operator experience aids in overcoming the challenge of cervical stenosis in an office setting. Adopting the presented tips and tricks to enter the uterine cavity in the presence of severe cervical stenosis will reduce the rate of failed hysteroscopic procedures, decreasing the need to take patients to the operating room and the use of general anesthesia. [ABSTRACT FROM AUTHOR]