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Arch Gynecol Obstet (2010) 282:97–102 DOI 10.1007/s00404-010-1370-z R E P R O D U CT IV E M E D I CI N E EVect of previous uterine surgery on the operative hysteroscopic outcomes in patients with reproductive failure: analysis of 700 cases Tarek Shokeir · Yaser Abdel-Dayem Received: 16 October 2009 / Accepted: 12 January 2010 / Published online: 3 February 2010 © Springer-Verlag 2010 Abstract Objective To determine the eVect of previous uterine surgery according to whether the uterine cavity
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  Arch Gynecol Obstet (2010) 282:97–102DOI 10.1007/s00404-010-1370-z  1 3 REPRODUCTIVE MEDICINE E V  ect of previous uterine surgery on the operative hysteroscopic outcomes in patients with reproductive failure: analysis of 700 cases Tarek Shokeir · Yaser Abdel-Dayem Received: 16 October 2009 / Accepted: 12 January 2010 / Published online: 3 February 2010 󰂩  Springer-Verlag 2010 Abstract Objective To determine the e V  ect of previous uterine sur-gery according to whether the uterine cavity is opened ornot on the operative outcomes in a series of women under-going surgical hysteroscopy guided by concomitant diag-nostic laparoscopy for management of reproductive failure.  Methods Records of 700 consecutive major hysteroscopicsurgical procedures guided by concomitant diagnostic lapa-roscopy and performed for women with previous pelvicsurgery were reviewed. All women were su V  ering fromreproductive failure. Patients were categorized according towhether the uterine cavity was opened or not and according tothe type of hysteroscopic procedure performed. Analysis of overall previous uterine surgery of any type combined and of individual matched types of hysteroscopic procedure sepa-rately was done. Patient age, American Society of Anesthesi-ologists (ASA) patient classi W cation, surgical history,perioperative change in serum sodium concentration andhemoglobin level, X uid balance, transfusion rate, rate of failedhysteroscopic procedure, operative hysteroscopic time, com-plication rate and hospital stay were assessed in each patient.  Results Of the 700 patients, 366 (52%) had never under-gone uterine surgery, 105 (15%) had a history of uterinesurgery with cavity opened and 229 (33%) had uterine sur-gery with cavity not opened. Overall previous uterine sur-gery of any type was associated with an increased age, andhigher ASA score ( P =0.001). A history of uterine surgerywith cavity opened was associated with increased operativetime ( P = 0.03) and increased hospital stay ( P =0.02).No patients have required a transfusion. Di V  erences inperioperative serum sodium concentration and hemoglobinlevel, the complication and failure rates in patients with andwithout a history of uterine surgery did not attain signi W- cance. Outcomes analysis of individual matched typesof hysteroscopic surgery showed similar results except forhysteroscopic metroplasty. In these cases, previous uterinesurgery was not associated with increased age or ASAscore. Conclusion Previous uterine surgery among youngwomen with reproductive failure whether the uterine cavityis opened or not does not appear to a V  ect adversely the per-formance and safety of subsequent major surgical hysteros-copy guided by concomitant diagnostic laparoscopy. Keywords Reproductive failure · Hysteroscopic surgery · Uterine surgery Introduction Pelvic surgery, whether the uterine cavity is opened or not,promotes the formation of adhesions. Autopsy studies showintrapelvic adhesions in 75–90% of patients with a historyof uterine surgery. In contrast, adhesions develop in only10% of patients with no history of surgery [1–3]. In com- pletely unpredictable fashion, adhesions may obscure tissueplanes, alter the position of anatomical landmarks and a Y xbowel to the anterior abdominal wall, making subsequentlaparoscopic access performed concomitantly during majorhysteroscopic surgical procedures subjectively more di Y -cult [4]. However, the role of adhesions in this regardamong women with reproductive failure remains controver-sial. We have recently published a large retrospectivecohort study to better understand the risk of intraabdominal T. Shokeir ( & ) · Y. Abdel-DayemDepartment of Obstetrics and Gynecology, Mansoura Faculty of Medicine, Mansoura University Hospital, Mansoura, Egypte-mail:  98Arch Gynecol Obstet (2010) 282:97–102  1 3 adhesions at surgical laparoscopy for infertility. We reach tothe conclusion that preoperative risk factors for intraabdominaladhesions should not contraindicate surgical laparoscopyfor infertility [5].The severity and pattern of intrauterine adhesion (IUA)development after uterine surgery are generally unrelated tothe type or number of previous uterine surgeries or whetherthe uterine cavity is opened or not [6]. Previous uterine sur-gery may a V  ect subsequent hysteroscopy in several di V  er-ent ways. Di Y cult uterine entry together with improperuterine distention may hinder instrument manipulation dur-ing the procedure. Adhesion lysis may increase the risk of bleeding and uterine wall injury. In addition, the distortionof normal anatomy may decrease the visibility during theprocedure. Concerns remain about potential adverse conse-quences, such as morbidity and complications in somecases. Technical considerations such as these haveprompted many initial reports in the infertility literatureciting previous uterine surgery, especially those with theuterine cavity opened, as a potential risk factor to majorsurgical hysteroscopy for the management of infertility andreproductive failure [7, 8]. Because of the rapidity with which hysteroscopy guidedby concomitant laparoscopy has developed into an integraland widely used component of surgery among women withreproductive failure, evaluating the relative safety ande Y cacy of performing major surgical hysteroscopy in thesewomen with a history of uterine surgery represents a partic-ular salient issue. Such information would prove useful indeveloping suitable plans of care and counseling patientson appropriate surgical options. However, there is a paucityof published data assessing the potentially negative impactof previous uterine surgery among patients with reproduc-tive failure on the overall outcome of subsequent surgicalhysteroscopy for the management of these cases. Therefore,the aim of this study is to determine the e V  ect of previousuterine surgery according to whether the uterine cavity isopened or not on the operative outcomes in a large series of women with reproductive failure undergoing surgical hys-teroscopy guided by concomitant diagnostic laparoscopy. Materials and methods From 2001 to 2008, the records of 700 consecutive majorhysteroscopic surgical procedures guided by concomitantdiagnostic laparoscopy and performed at a single tertiaryreferral center (Mansoura University Hospital, Mansoura,Egypt) were reviewed. All women had previous pelvic sur-gery and, were su V  ering from reproductive failures (infer-tility and/or recurrent pregnancy losses). Age, AmericanSociety of Anesthesiologist (ASA) classi W cation, surgicalhistory, operative hysteroscopic time, pre-and postopera-tive change in serum sodium concentration and hemoglobinlevel, transfusion rate, failure rate, major complication rateand hospital stay were assessed in each patient. In thispaper, major complications are de W ned as any anestheticcomplications and/or those requiring laparotomy for man-agement. Further, failed hysteroscopic procedure is de W nedas failure of uterine entry together with improper uterinedistention.Patients with previous pelvic surgery were grouped intoone of three categories as one-none uterine (Group A), two-uterine with cavity opened (Group B) and three-uterinewith cavity not opened (Group C). Previous uterine surgerywas de W ned as any type of open or closed uterine surgerywith the potential to cause intra-uterine adhesions, includ-ing abdominal myomectomy, cesarean section, abdominalrepair of uterine perforation and abdominal operations forcorrection of double uterus. Manipulated uterine cavitaryprocedures, such as surgical or suction evacuations, anddilatation and curettage (D & C) were considered also asprevious uterine surgery in our series. Previous none-uter-ine surgery was de W ned as any type of open abdominal, X ank or pelvic surgery with the potential to cause intra-abdominal and/or pelvic adhesions, including adnexalsurgery, gastrointestinal procedures, cholecystectomy,urological procedures and appendectomy. Inguinal proce-dures, super W cial abdominal surgery and endoscopic gas-trointestinal, gynecologic or urological procedures were notconsidered open intraabdominal surgery. Thus, unlesspatients had undergone procedures that quali W ed as uterinesurgery, they were classi W ed as having undergone non-uter-ine surgery (Group A). These classi W cation criteria conformto previously established standards in surgical and gyneco-logic reports [5, 6, 9]. Patients were also categorized by the type of hystero-scopic procedure performed for management of reproduc-tive failure. To minimize any potential bias introduced byvariations in surgical technique among individual cases 399cases in whom no associated laparoscopic surgical inter-vention was performed were selected for further outcomeanalysis. These include hysteroscopic lysis of IUAs in 116,hysteroscopic polypectomy in 64, hysteroscopic myomec-tomy in 131 and hysteroscopic metroplasty in 88. At ourinstitution, each of these four types is performed via a stan-dard monopolar electrosurgical resectoscopic technique(26Fr resectoscope, Karl Storz, Germany) and usingglycine (1.5%) as a X uid uterine distention medium. Fluidbalance was assessed using electronic suction irrigationsystem (Endomat, Karl Storz, Germany). All hysteroscopicoperations were performed by the same surgeon.In this article, de W nite criteria for each hysteroscopicprocedure have to be ful W lled for each patient before inclu-sion in our study. “Hysteroscopic myomectomy” is de W nedas any procedure that primarily involves complete excision  Arch Gynecol Obstet (2010) 282:97–10299  1 3 of a single or multiple submucous myomas, largest being<5cm in diameter, with uterine cavity <10cm in lengthand of types 0 or I (according to the classi W cation of Euro-pean Society of Hysteroscopy) [10]. Similarly, “hystero-scopic polypectomy” is de W ned as any procedure thatprimarily involves complete removal of a solitary endome-trial polyp, 2–5cm in diameter and with a uterine cavitylength <10cm. Further, “hysteroscopic lysis of IUA” isde W ned as any procedure that primarily involves cuttingand division adhesions before the endoscope is advanceduntil symmetry of the uterine cavity is achieved and bothcornua and uterotubal ostia should come into view. In allcases in this category, the disease was more than a stage IIUA (according to the classi W cation of the American Fertil-ity Society) [11]. Finally, “hysteroscopic metroplasty” isde W ned as electro-resection of a uterine septum using resec-toscope where dissection should proceed carefully until theoperator is satis W ed that a normal, slightly convex cavitybetween the two tubal ostia has been obtained.As in the groups overall and with respect to surgical his-tory, the perioperative outcome measures were analyzed.The outcomes of the four speci W c hysteroscopic proceduresin the groups with a history of uterine surgery whether thecavity was opened or not versus no previous surgery weredetermined. Further, a separate analysis of the individualmatched types of hysteroscopic surgery was also inter-preted. Cases with incomplete or recurrent surgicalattempts were excluded from our analysis.Statistical analysis was performed with  2 , Kruskal–Wallis, Fisher’s exact tests and one-way ANOVA. All cal-culations were performed using commercially available sta-tistical software. Di V  erences at P <0.05 were consideredstatistically signi W cant. Results Of the 700 patients with reproductive failures, 366 (52%)had never undergone uterine surgery, 105 (15%) had a his-tory of uterine surgery with the uterine cavity opened and229 (33%) had a history of uterine surgery with the cavitynot opened. The prevalence of intrauterine cavitary lesionsin di V  erent patient groups is shown in Table1. Laparo-scopic peritoneal access was successful in all cases.Of the 399 cases who underwent hysteroscopic proce-dures with no associated laparoscopic interventions andselected for further analysis, the overall distribution wasvirtually identical with respect to surgical history. In thesecases, major reproductive hysteroscopic surgical proce-dures performed included hysteroscopic adhesiolysis( n =116), hysteroscopic polypectomy ( n =64), hysteroscopicmyomectomy ( n =131) and hysteroscopic metroplasty( n =88).Of the 399 patients, 206 (52%) had never undergoneuterine surgery, 53 (13%) had a history of uterine surgerywith the uterine cavity opened and 140 (35%) had a historyof uterine surgery with the uterine cavity not opened. Thehistory involved no uterine surgery, uterine surgery inwhich the uterine cavity was opened and uterine surgery inwhich the cavity was not opened in 58, 6 and 26% of thepatients who underwent hysteroscopic adhesiolysis, 59, 6and 25% of those who underwent hysteroscopic polypec-tomy, 62, 10 and 21% of those who underwent hystero-scopic myomectomy and 52, 8 and 20% of those whounderwent hysteroscopic metroplasty, respectively. Di V  er-ences of these percentages in patients with and without ahistory of uterine surgery did not attain signi W cance. Themost common previous uterine surgeries were abdominalmyomectomy, cesarean section, D&C, surgical evacuationsand repair of a uterine perforation.As shown in Table2, with respect to patient characteris-tics those with a history of uterine surgery were likely to beolder with a mean age § SD of 23 § 5.1, 29.2 § 6.1 and37.7 § 5.9years in those without surgery, with surgery atwhich the uterine cavity was opened and with surgery atwhich the uterine cavity was not opened, respectively( P =0.0001). In addition, patients with a history of uterinesurgery whether the uterine cavity was opened or not had ahigher ASA score (mean 1.97 § 0.82, 2.30 § 0.66 and2.40 § 0.65, respectively ( P =0.0001).With respect to perioperative data, patients with a his-tory of uterine surgery whether the uterine cavity wasopened or not had longer operative hysteroscopic times anda longer hospital stay ( P =0.03 and 0.02, respectively). Table 1 Prevalence of intrauterine cavitary lesions in di V  erent groups(700 cases)Data are expressed as number (%)  IUA  intrauterine adhesionsLesionPrevious uterine surgeryNone ( n =366)Cavity opened ( n =105)Cavity not opened ( n =229)IUA (%)Stage II96 (26.2)22 (21.0)25 (10.9)Stage III40 (10.9)8 (7.6)5 (2.2)Myomas (%)Type 022 (6.0)13 (12.4)23 (10.0)Type I18 (4.9)6 (5.7)22 (9.6)Septa (%)Incomplete42 (11.5)11 (10.5)26 (11.4)Complete18 (4.9)4 (3.8)24 (10.5)Polyps (%)25 (6.8)11 (10.5)22 (9.6)Combination (%)105 (28.7)30 (28.6)82 (35.8)  100Arch Gynecol Obstet (2010) 282:97–102  1 3 Change in serum sodium concentration and hemoglobinlevel was slightly higher in the groups with a history of uterine surgery whether the uterine cavity was opened ornot versus no previous uterine surgery, but this di V  erencedid not attain statistical signi W cance in the analysis. Thesame W nding was true for the complication rate and the rateof failed hysteroscopic procedure. No patients in our serieshave required a transfusion.We also determined the outcome of the four speci W c hys-teroscopic procedures in the groups with a history of uter-ine surgery whether the cavity was opened or not versus noprevious surgery. As in the groups overall, there were noobserved di V  erences in patients with uterine surgery versusthose with no history of uterine surgery for any measuredoutcomes. Data regarding the failure rate ( P =0.25), com-plication rate ( P =0.135), changes in hemoglobin andserum sodium levels ( P =0.99 and P =0.99, respectively),hospital stay ( P =0.77) or operative hysteroscopic time( P =0.99) were comparable. However, for cases with hys-teroscopic metroplasty previous uterine surgery was notassociated with increased age or ASA score.On separate analysis of the individual matched types of hysteroscopic surgery, di V  erences in perioperative serumconcentration and hemoglobin levels, operative hystero-scopic time, X uid balance, the complication and failurerates in patients with and without a history of uterine sur-gery did not attain statistical signi W cance ( P >0.05). Discussion Hysteroscopy guided by concomitant laparoscopy hasassumed as an integral role within the reproductive logicalsurgical armamentarium [12]. The importance of individu-ally counseling patients with reproductive failure on thepotential risks of major hysteroscopic surgery guided bylaparoscopy, such as high operative blood loss, conversionto an open procedure and operative complications, is para-mount. Still, there remains a dearth of published materialon factors that may potentially in X uence patient outcomeafter surgical hysteroscopy for reproductive failure, mostnotably the surgical history. Although some groups main-tain that previous uterine surgery remains a highly potentialrisk factor to surgical hysteroscopy in this select patientgroup, there are no supporting series in the recent literature[8, 13]. To the best of our knowledge, this is the W rst studyevaluating the e V  ect of previous uterine surgery accordingto whether the uterine cavity is opened or not on the opera-tive outcome in a large series of women with reproductivefailure who underwent major hysteroscopic surgery guidedby concomitant diagnostic laparoscopy.The analysis of the current study was limited to fourcommon procedures in which no associated laparoscopicoperative intervention was performed, namely hystero-scopic adhesiolysis, hysteroscopic myomectomy, hystero-scopic metroplasty and hysteroscopic polypectomy. It wasdone by the same surgeon and nearly the same techniquewas performed to minimize the bias introduced by manyattending surgeons who performed the same type of surgeryusing di V  erent techniques in the individuals. Such variabil-ity makes comparing operative time and the other outcomeparameters problematic. They also present a representativesample of cases with di V  erent levels of technical complex-ity. Notably, the distribution of patients among the three-uterine surgical history categories was the same for thesefour procedures together with the series overall.Patients with a history of previous uterine surgery of anytype were older. This W nding is not surprising because older Table2 Patient characteristics and operative hysteroscopic outcomes in 399 selected casesCases with no associated laparoscopic interventions  NS   non-signi W cant*The P  values are for comparisons of groups B and C versus group AParameterPrevious uterine surgery  P *None (Group A; n =206)Cavity opened (Group B; n =53)Cavity not opened (Group C; n =140)Mean age § SD23 § 5.129.2 § 6.135.7 § 5.90.0001Mean ASA score § SD1.97 § 0.822.30 § 0.662.40 § 0.650.0001Mean hospital stay § (days)1.0 § 1.94.2 § 1.62.9 § 1.80.02Mean operative time in minutes § SD (min)23 § 1.046 § 4.035 § 3.00.03Mean change in serum Na § SD (mEq/L)0.06 § 3.630.64 § 3.560.60 § 3.50NSMean fall in hemoglobin § SD (g/dL)0.67 § 0.620.82 § 0.780.84 § 0.70NSPercentage of complications1.43.23.0NSPercentage of failed hysteroscopic procedure1.22.32.2NS
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