Biomedical subjects
Publications and source records attributed to R F Valle.
The transcervical division of uterine septa is usually described as a simple procedure associated with minimal morbidity. Two cases are presented describing late hemorrhage after this procedure. Approaches to avoiding this complication as well as management principles are described.
This review discusses advances in hysteroscopy in the past decade, including the introduction of small-caliber endoscopes, microhysteroscopy, the flexible steerable hysteroscope, and the use of video systems in monitoring hysteroscopic evaluations. Media for uterine distension are reviewed and possible complications of the use of dextran 70 are discussed. Hysteroscopy is superior to curettage for evaluating abnormal uterine bleeding. Hysteroscopy can be used as an adjunct to hysterosalpingography, endometrial biopsy, and laparoscopy in evaluating infertility, and in detecting and treating intrauterine adhesions. The method has also been applied to the division of uterine septa, the removal of submucous leiomyomas, and tubal cannulation both for treating tubal obstruction at the cornual areas and in conjunction with new reproductive technologies. The use of the microcolpohysteroscope to tailor the size and extension of a cervical conization is described. Finally, hysteroscopy permits evaluation of the extension and involvement of the endocervical canal in patients with endometrial neoplasia and offers an important guide in staging and planning treatment for this condition.
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Endometrial carcinoma is the most frequent genital neoplasia in women. Precursors of this condition include endometrial hyperplasia, particularly when cytologic atypia occurs. Among the frequent early clinical manifestations of endometrial carcinoma is abnormal uterine bleeding that must be differentiated from bleeding associated with benign conditions. Early detection of endometrial carcinoma and its precursors in women at risk is the best prophylactic measure in the final therapeutic outcome. In this review, the accuracy of methods of early diagnosis of endometrial carcinoma and its precursors is assessed, in order to provide early therapy and optimum prognosis. The epidemiology of endometrial carcinoma, as well as the risk factors for the development of this neoplasia, are also reviewed. A histologic classification of endometrial hyperplasia and carcinoma of the endometrium, based on current theories of histopathogenesis, is included.
A soft and rigid diagnostic fiber optic hysteroscope (outer diameter, 3.7 mm) was developed. A total of 1,503 women underwent panoramic, televised fiber optic hysteroscopy without cervical dilation. No anesthesia, analgesia or tenaculum was required. No complication was encountered during or after the operation. The procedure is simple, easy and safe, with the operator in a relaxed and comfortable position even when the patient has acute flexion of the uterus. Our clinical results prove that the soft and rigid structure of the fiberscope offers advantages over rigid scopes or conventional fiberscopes with full-length soft, malleable parts.
One hundred eighty-seven patients were evaluated and treated by hysteroscopy over a 10-year period. To assess therapeutic prognosis, these patients were classified according to the extent of uterine cavity occlusion seen on hysterosalpingography and the type of intrauterine adhesions observed at hysteroscopy. Forty-three patients had mild or filmy intrauterine adhesions, 97 had moderate or fibromuscular adhesions, and 47 patients were classified as having severe connective tissue adhesions. After hysteroscopic treatment, normal menstruation was restored in 88.2% of patients who had menstrual abnormalities including amenorrhea, hypomenorrhea, and dysmenorrhea. Among the 187 patients, 143 women achieved pregnancy; of those, 114 (79.7%) achieved a term pregnancy, 26 (18.2%) had a spontaneous abortion, and 3 (2.1%) had ectopic pregnancies. The reproductive outcome correlated with the type of adhesions and extent of uterine cavity occlusion, ranging from a term pregnancy rate of 81.3% in patients with mild disease to 31.9% in patients with severe disease.
Hysteroscopy has evolved from a diagnostic procedure into a therapeutic method for a variety of conditions. Instruments specifically designed for hysteroscopic operative procedures have improved. The indications for therapeutic hysteroscopy are increasing and its proper applications can improve patient's gynecologic care. These facts should stimulate the gynecologist to become proficient with hysteroscopy for diagnosis and the treatment of many intrauterine abnormalities. In selected patients there are major advantages including the avoidance of a laparotomy with the potential sequelae that can follow operations requiring entrance into the peritoneal cavity. The operative techniques have been refined and, with experience, good postoperative results and low morbidity have become evident. The septate uterus can be treated by hysteroscopic metroplasty with improved reproductive outcome. Symptomatic submucous myomas in selected patients can be removed hysteroscopically. Lysis of intrauterine adhesions has become the standard method of therapy. Foreign bodies lost in the uterine cavity or embedded IUDs can be removed atraumatically under direct vision. As the approach to intrauterine problems is refined, other applications are being investigated such as tubal cannulation, endoscopic chorionic villus sampling, and application of hysteroscopy to new reproductive technologies such as the placement of gametes in the fallopian tubes. Because of the simplicity of approaching the uterotubal ostia transcervically, hysteroscopy remains in the front line of investigation as a possible approach for inducing tubal occlusion as a permanent or temporary method of contraception. Finally, laser energy is being used in patients with intractable uterine bleeding to photocoagulate the endometrium and to create amenorrhea by means of inducing severe intrauterine adhesions.
In less than two decades, hysteroscopy has evolved into a practical technique for the evaluation of the uterine cavity, with well-established indications such as evaluation of abnormal uterine bleeding and abnormal hysterograms as well as the treatment of intrauterine adhesions or the septate uterus, the removal of misplaced or embedded intrauterine devices, and the removal of submucous leiomyomas. As the use of hysteroscopy increases and more practitioners utilize it, new instrumentation and techniques are beginning to evolve, simplifying and facilitating not only a diagnostic examination, but also the more difficult and complex surgical interventions. Flexible endoscopes are being tested for possible use in the uterine cavity, and operative hysteroscopes with practical inflow and outflow accessory channels have been introduced. The accessory operative instrumentation has also been expanded and refined, and portable units for office examinations have been developed. The trend in the development of instrumentation is toward simplicity, effectiveness, and refinement in lenses with wider fields of view and accessory channels without compromising the total outer diameter of the endoscopes. As clinical applications expand as a result of increased use and proficiency in hysteroscopy, new applications undoubtedly will follow, such as closer study of the endometrium with and without additional magnification. This latter may permit a better understanding of the receptivity of the endometrium to the embryo, which may help in predicting successful nidations. Portable laser units with the capability to use the CO2 fiber undoubtedly will increase laser use through hysteroscopy, and in the near future, photodynamic therapy may become the best approach to the selective treatment of intrauterine lesions. The uterotubal junction will remain an attractive area for endoscopists to approach the fallopian tubes transcervically and eventually to accomplish tubal closure safely and effectively with the possibility of future reversibility. The hysteroscope will play an important role in new reproductive technologies, particularly those related to the gamete intrafallopian transfer via the uterine side and perhaps also for direct embryo transfers under visual control. The future of hysteroscopy thus is promising. The present diagnostic and therapeutic applications will not only become a standard of treatment but will expand as gynecologists will gain proficiency and confidence in this endoscopic method.
The detailed clinical response of a patient with absent plasma cholinesterase (genotype E1s E1s) who received tubocurarine (3 mg), succinylcholine (120 mg), pancuronium (2 mg), and reversal with neostigmine (3 mg) is reported. The patient's responses were compared to the responses of a group of patients with genotype E1a E1a evaluated prospectively, and with eight other genotype E1s E1s patients reported in the literature. The present patient demonstrated evidence of a phase II block before and after attempted reversal, suggesting that free succinylcholine was present in her plasma and a mixed block was present at that time. Conservative supportive therapy was continued and a complete recovery resulted five hours and 30 minutes after the succinylcholine administration.
Twelve patients with symptomatic septate uteri underwent hysteroscopic division of the uterine septum, monitored by concomitant laparoscopy, over a six-year period. The preoperative reproductive performance included 42 pregnancies, with only three viable deliveries. Ten of the 12 patients conceived within one year after therapy, and eight of these patients delivered a live infant at term. Two patients had a spontaneous abortion at six and eight weeks after therapy, respectively, but in each, a subsequent pregnancy was carried to term. Three patients are currently pregnant (eight, 12, and 18 weeks). Two patients have not as yet conceived. Two patients required a second hysteroscopic operation because a partial residual septum was observed on the posttreatment hysterogram.
During the past century hysteroscopy has developed into a highly sophisticated and effective technique with increasing applicability. Hysteroscopic instruments have been refined with fiberoptics, allowing light to be introduced into the uterine cavity with high intensity but without danger of thermal injury. Safe methods for uterine distention provide an undistorted panoramic view of the uterine cavity. As a diagnostic technique, hysteroscopy affords accuracy in detecting intrauterine conditions which may not be revealed by traditional methods of exploration. As an operative technique, hysteroscopy increases the precision of surgery and minimizes trauma to the endometrial lining, and may, on some occasions, preclude major surgical intervention. In addition, hysterscopy is potentially useful for female sterilization and offers promise as an investigative tool for studies of the intratubal milieu.
Laparoscopic tubal sterilization has been rapidly gaining acceptance as a nonpuerperal method of permanent fertility control. A number of problems have nonetheless been associated with this technique. For example, tubal destruction often exceeds that necessary for tubal occlusions, increasing the danger of thermal injuries and possibly such dysfunctional disorders as abnormal uterine bleeding and dysmenorrhea. Furthermore, excessive destruction precludes any possibility of later tubal reconstruction. In an attempt to avoid these problems, a new low-voltage unit with a rechargeable battery was evaluated. With this unit, cautery is provided under laparoscopic view with a spring-activated hook which retracts the fallopian tube into a Teflon shield, where it is coagulated and transected. Histopathologic studies of the healthy fallopian tubes of four women in their reproductive years treated by this method while the abdomen was open prior to an elective hysterectomy demonstrated minimal destruction of the mesosalpinx, with complete tubal occlusion and a coagulated area 10 mm in length. One hundred and sixty-five patients have been sterilized successfully by this method. Indications are that it may provide safe tubal occlusion without unnecessary destruction of the fallopian tubes and surrounding vasculature.
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Hysteroscopy has added a new dimension to the management of patients with common clinical problems, increasing the accuracy of diagnosis and serving as an adjunct in treatment of intrauterine conditions. This report summarizes the hysteroscopic experience with 320 selected patients, 104 in the reproductive age group with abnormal uterine bleeding, 91 who underwent hysteroscopy for location and retrieval of intrauterine contraceptive devices, 36 with primary or secondary infertility, 36 with postmenopausal bleeding, and 15 with uterine leiomyomas. Paracervical block anesthesia was used successfully in 214 patients. General anesthesia was used in the remainder because of planned additional surgical intervention. Uterine distention was achieved with D5W in 270 patients, with dextran 32% in 30 patients, and with CO2 gas insufflation in 20 patients. In 71.6 per cent of the patients,visually recognizable or pathologically suspicious intrauterine abnormalities were found. This study further demonstrated the utility of hysteroscopy in diagnosis of endometrial polyps, uterine submucous leiomyomas, uterine malformations, and intrauterine adhesions. Hysteroscopy was also helpful in taking directed biopsies of selected areas of the endometrium in patients with adenomatous hyperplasia and early adenocarcinoma of the endometrium and helpful in removal of intrauterine foreign bodies and evaluation of the recently pregnant uterus when there was a question of persistent pregnancy. Hysteroscopy is a safe ambulatory procedure that is appealing to both patient and gynecologist in its economy and simplicity.
Ninety-one patients using intrauterine devices (IUD with nonvisible filaments on examination underwent hysterscopy for location and retrieval of the devices. These were among 320 patients who underwent hysterscopy for a variety of indications. All but 6 patients for whom additional surgery was planned were given local anesthesia. In 78 patients, the device was found within the uterine cavity and removed under hysterscopic control. In the remaining 13, no intrauterine device was observed. Six of these 13 patients had a translocated device which was removed either by laparoscopy or laparotomy. Hysteroscopy is proposed as a useful and effective method of diagnosis and management in ambulatory patients when the filaments of the IUD are absent.
Four of our patients had classical Fitz-Hugh-Curtis syndrome. Persistent right upper-gradrant pain prompted extensive medical evaluation; anibiotic therapy fialed to relieve the symptoms. In each case, laparoscopy proved to be an ideal method for obtaining definitive diagnosis and therapy. Typical perihepatic violin-string adhesions were cauterized and divided under direct vision with dramatic resolution of symptoms.
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