efek histrectomy.pdf

8/10/2019 efek histrectomy.pdf

1/7

Arch Gynecol Obstet (2010) 282:97102

DOI 10.1007/s00404-010-1370-z

1 3

REPRODUCTIVE MEDICINE

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 sur-

gery according to whether the uterine cavity is opened or

not 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 hysteroscopic

surgical procedures guided by concomitant diagnostic lapa-

roscopy and performed for women with previous pelvic

surgery were reviewed. All women were suVering from

reproductive failure. Patients were categorized according to

whether the uterine cavity was opened or not and according to

the 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 classiWcation, surgical history,

perioperative change in serum sodium concentration and

hemoglobin level, Xuid balance, transfusion rate, rate of failed

hysteroscopic 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 uterine

surgery 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, and

higher ASA score (P = 0.001). A history of uterine surgery

with cavity opened was associated with increased operative

time (P = 0.03) and increased hospital stay (P = 0.02).

No patients have required a transfusion. DiVerences in

perioperative serum sodium concentration and hemoglobin

level, the complication and failure rates in patients with and

without a history of uterine surgery did not attain signiW-

cance. Outcomes analysis of individual matched types

of hysteroscopic surgery showed similar results except for

hysteroscopic metroplasty. In these cases, previous uterine

surgery was not associated with increased age or ASA

score.

Conclusion Previous uterine surgery among young

women with reproductive failure whether the uterine cavity

is opened or not does not appear to aVect 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 show

intrapelvic adhesions in 7590% of patients with a history

of uterine surgery. In contrast, adhesions develop in only

10% of patients with no history of surgery [13]. In com-

pletely unpredictable fashion, adhesions may obscure tissue

planes, alter the position of anatomical landmarks and aYx

bowel to the anterior abdominal wall, making subsequent

laparoscopic access performed concomitantly during major

hysteroscopic surgical procedures subjectively more diY-

cult [4]. However, the role of adhesions in this regard

among women with reproductive failure remains controver-

sial. We have recently published a large retrospective

cohort study to better understand the risk of intraabdominal

T. Shokeir (&) Y. Abdel-Dayem

Department of Obstetrics and Gynecology,

Mansoura Faculty of Medicine,

Mansoura University Hospital, Mansoura, Egypt

e-mail: [email protected]
http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-


2/7

98 Arch Gynecol Obstet (2010) 282:97102

1 3

adhesions at surgical laparoscopy for infertility. We reach to

the conclusion that preoperative risk factors for intraabdominal

adhesions should not contraindicate surgical laparoscopy

for infertility [5].

The severity and pattern of intrauterine adhesion (IUA)

development after uterine surgery are generally unrelated to

the type or number of previous uterine surgeries or whether

the uterine cavity is opened or not [6]. Previous uterine sur-gery may aVect subsequent hysteroscopy in several diVer-

ent ways. DiYcult uterine entry together with improper

uterine distention may hinder instrument manipulation dur-

ing the procedure. Adhesion lysis may increase the risk of

bleeding and uterine wall injury. In addition, the distortion

of normal anatomy may decrease the visibility during the

procedure. Concerns remain about potential adverse conse-

quences, such as morbidity and complications in some

cases. Technical considerations such as these have

prompted many initial reports in the infertility literature

citing previous uterine surgery, especially those with the

uterine cavity opened, as a potential risk factor to major

surgical hysteroscopy for the management of infertility and

reproductive failure [7, 8].

Because of the rapidity with which hysteroscopy guided

by concomitant laparoscopy has developed into an integral

and widely used component of surgery among women with

reproductive failure, evaluating the relative safety and

eYcacy of performing major surgical hysteroscopy in these

women with a history of uterine surgery represents a partic-

ular salient issue. Such information would prove useful in

developing suitable plans of care and counseling patients

on appropriate surgical options. However, there is a paucity

of published data assessing the potentially negative impact

of previous uterine surgery among patients with reproduc-

tive failure on the overall outcome of subsequent surgical

hysteroscopy for the management of these cases. Therefore,

the aim of this study is to determine the eVect of previous

uterine surgery according to whether the uterine cavity is

opened 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 major

hysteroscopic surgical procedures guided by concomitant

diagnostic laparoscopy and performed at a single tertiary

referral center (Mansoura University Hospital, Mansoura,

Egypt) were reviewed. All women had previous pelvic sur-

gery and, were suVering from reproductive failures (infer-

tility and/or recurrent pregnancy losses). Age, American

Society of Anesthesiologist (ASA) classiWcation, surgical

history, operative hysteroscopic time, pre-and postopera-

tive change in serum sodium concentration and hemoglobin

level, transfusion rate, failure rate, major complication rate

and hospital stay were assessed in each patient. In this

paper, major complications are deWned as any anesthetic

complications and/or those requiring laparotomy for man-

agement. Further, failed hysteroscopic procedure is deWned

as failure of uterine entry together with improper uterine

distention.Patients with previous pelvic surgery were grouped into

one of three categories as one-none uterine (Group A), two-

uterine with cavity opened (Group B) and three-uterine

with cavity not opened (Group C). Previous uterine surgery

was deWned as any type of open or closed uterine surgery

with the potential to cause intra-uterine adhesions, includ-

ing abdominal myomectomy, cesarean section, abdominal

repair of uterine perforation and abdominal operations for

correction of double uterus. Manipulated uterine cavitary

procedures, such as surgical or suction evacuations, and

dilatation and curettage (D & C) were considered also as

previous uterine surgery in our series. Previous none-uter-

ine surgery was deWned as any type of open abdominal,

Xank or pelvic surgery with the potential to cause intra-

abdominal and/or pelvic adhesions, including adnexal

surgery, gastrointestinal procedures, cholecystectomy,

urological procedures and appendectomy. Inguinal proce-

dures, superWcial abdominal surgery and endoscopic gas-

trointestinal, gynecologic or urological procedures were not

considered open intraabdominal surgery. Thus, unless

patients had undergone procedures that qualiWed as uterine

surgery, they were classiWed as having undergone non-uter-

ine surgery (Group A). These classiWcation criteria conform

to 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 by

variations in surgical technique among individual cases 399

cases in whom no associated laparoscopic surgical inter-

vention was performed were selected for further outcome

analysis. These include hysteroscopic lysis of IUAs in 116,

hysteroscopic polypectomy in 64, hysteroscopic myomec-

tomy in 131 and hysteroscopic metroplasty in 88. At our

institution, each of these four types is performed via a stan-

dard monopolar electrosurgical resectoscopic technique

(26 Fr resectoscope, Karl Storz, Germany) and using

glycine (1.5%) as a Xuid uterine distention medium. Fluid

balance was assessed using electronic suction irrigation

system (Endomat, Karl Storz, Germany). All hysteroscopic

operations were performed by the same surgeon.

In this article, deWnite criteria for each hysteroscopic

procedure have to be fulWlled for each patient before inclu-

sion in our study. Hysteroscopic myomectomy is deWned

as any procedure that primarily involves complete excision
http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-


3/7

Arch Gynecol Obstet (2010) 282:97102 99

1 3

of a single or multiple submucous myomas, largest being


4/7


1 3

Change in serum sodium concentration and hemoglobin

level was slightly higher in the groups with a history of

uterine surgery whether the uterine cavity was opened or

not versus no previous uterine surgery, but this diVerence

did not attain statistical signiWcance in the analysis. The

same Wnding was true for the complication rate and the rate

of failed hysteroscopic procedure. No patients in our series

have required a transfusion.

We also determined the outcome of the four speciWc hys-

teroscopic procedures in the groups with a history of uter-

ine surgery whether the cavity was opened or not versus no

previous surgery. As in the groups overall, there were no

observed diVerences in patients with uterine surgery versus

those with no history of uterine surgery for any measured

outcomes. Data regarding the failure rate (P = 0.25), com-

plication rate (P = 0.135), changes in hemoglobin and

serum 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 not

associated with increased age or ASA score.

On separate analysis of the individual matched types of

hysteroscopic surgery, diVerences in perioperative serum

concentration and hemoglobin levels, operative hystero-

scopic time, Xuid balance, the complication and failure

rates in patients with and without a history of uterine sur-

gery did not attain statistical signiWcance (P > 0.05).

Discussion

Hysteroscopy guided by concomitant laparoscopy has

assumed as an integral role within the reproductive logical

surgical armamentarium [12]. The importance of individu-

ally counseling patients with reproductive failure on the

potential risks of major hysteroscopic surgery guided by

laparoscopy, such as high operative blood loss, conversion

to an open procedure and operative complications, is para-

mount. Still, there remains a dearth of published material

on factors that may potentially inXuence patient outcome

after surgical hysteroscopy for reproductive failure, most

notably the surgical history. Although some groups main-

tain that previous uterine surgery remains a highly potential

risk factor to surgical hysteroscopy in this select patient

group, there are no supporting series in the recent literature

[8, 13]. To the best of our knowledge, this is the Wrst study

evaluating the eVect of previous uterine surgery according

to whether the uterine cavity is opened or not on the opera-

tive outcome in a large series of women with reproductive

failure who underwent major hysteroscopic surgery guided

by concomitant diagnostic laparoscopy.

The analysis of the current study was limited to four

common procedures in which no associated laparoscopic

operative intervention was performed, namely hystero-

scopic adhesiolysis, hysteroscopic myomectomy, hystero-

scopic metroplasty and hysteroscopic polypectomy. It was

done by the same surgeon and nearly the same technique

was performed to minimize the bias introduced by many

attending surgeons who performed the same type of surgery

using diVerent techniques in the individuals. Such variabil-

ity makes comparing operative time and the other outcome

parameters problematic. They also present a representative

sample of cases with diVerent levels of technical complex-

ity. Notably, the distribution of patients among the three-

uterine surgical history categories was the same for these

four procedures together with the series overall.

Patients with a history of previous uterine surgery of any

type were older. This Wnding is not surprising because older

Table 2 Patient characteristics and operative hysteroscopic outcomes in 399 selected cases

Cases with no associated laparoscopic interventions

NSnon-signiWcant

* The Pvalues are for comparisons of groups B and C versus group A

Parameter Previous uterine surgery P*

None

(Group A; n = 206)

Cavity opened

(Group B; n = 53)

Cavity not opened

(Group C; n = 140)

Mean age SD 23 5.1 29.2 6.1 35.7 5.9 0.0001

Mean ASA score SD 1.97 0.82 2.30 0.66 2.40 0.65 0.0001

Mean hospital stay (days) 1.0 1.9 4.2 1.6 2.9 1.8 0.02

Mean operative time in minutes SD (min) 23 1.0 46 4.0 35 3.0 0.03

Mean change in serum Na SD (mEq/L) 0.06 3.63 0.64 3.56 0.60 3.50 NS

Mean fall in hemoglobin SD (g/dL) 0.67 0.62 0.82 0.78 0.84 0.70 NS

Percentage of complications 1.4 3.2 3.0 NS

Percentage of failed hysteroscopic procedure 1.2 2.3 2.2 NS
http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-


5/7

Arch Gynecol Obstet (2010) 282:97102 101

1 3

patients lived longer and, therefore, are more likely to have

undergone surgery. They are also more likely to manifest

health problems that require surgical interventions. In fact,

patients with a history of uterine surgery in this series also

had a higher ASA score. A high ASA score reXects a

greater degree of medical co-morbidity and, therefore,

increased operative risk [1214]. In our series, outcome

analysis of individual matched types of hysteroscopic sur-gery showed similar results except for hysteroscopic metro-

plasty. In these cases, previous uterine surgery was not

associated with increased age or ASA score. In fact, we do

not have a possible explanation for this Wnding. However, a

large number of such cases in our series were presented

with recurrent miscarriage and bad obstetric history rather

than inability to conceive. Accordingly, we can assume that

previous uterine surgery as a risk factor alone cannot be

contributed to a higher morbidity, particularly there was no

signiWcant diVerence in the serum sodium concentration

and hemoglobin level, complication or failure rates in these

groups.

Previous uterine surgery with the uterine cavity opened

was associated with longer operative time and increased

hospital stay when compared with no history of surgery and

uterine surgery with the uterine cavity not opened. Longer

operative hysteroscopic time and relative increased compli-

cation rates (although statistically not signiWcant) were

likely associated with the increased diYculty and complex-

ity of hysteroscopic surgery in an anatomical region previ-

ously subjected to operative dissection. The reason for the

increased hospital stay in this particular group is unclear.

However, most of these cases were older and had a higher

ASA score. Therefore, we can speculate that in patients

undergoing surgical hysteroscopy guided by concomitant

laparoscopy, rather than a diagnostic procedure, increased

operative time independently predicted a longer hospital

stay.

In our results, the change in serum sodium concentration

and hemoglobin level as well as the complication rates

were slightly higher in the groups with a history of uterine

surgery whether the uterine cavity was opened or not versus

no previous uterine surgery but this diVerence did not attain

statistical signiWcance in the analysis. Association of con-

comitant IUA (more than stage I IUA), weakness of uterine

musculature, and complexity of surgical hysteroscopic

procedures performed in these cases could be a possible

explanation. However, a prospective randomized study

is required before any conclusions can be drawn regarding

this issue.

In our analysis, the most common previous uterine sur-

geries were not correlated to outcomes. This would have

been particularly interesting to know whether a higher inci-

dence of endoscopic reproductive surgery was performed

for patients with certain types of previous uterine surgery.

In surgical literature, however, it is well known that the

severity and pattern of adhesion development after abdomi-

nal surgery are generally unrelated to the type or number of

previous surgeries [35].

In this cohort study of combined surgical hysteroscopy

and diagnostic laparoscopy, successful laparoscopic access

to the peritoneal cavity was attained in all cases. Because

the natural history of formation of diVerent intraabdominaladhesions in relation to the presence or absence of preoper-

ative risk factors could not be determined exactly [6, 7], in

our study, no attempt was made to correlate the preopera-

tive risk factors of previous uterine or pelvic surgery with

the estimated adhesion severity seen at laparoscopy.

Rather, we analyzed the risk of previous uterine surgery

according to whether the uterine cavity is opened or not on

surgical hysteroscopy guided by concomitant diagnostic

laparoscopy.

The present study does provide some important issues

regarding the eVect of previous uterine surgery on the oper-

ative outcome in a large series of women suVering from

reproductive failure who undergo surgical hysteroscopy.

Accordingly, we support the concept that women with

reproductive failure and with a history of uterine surgery,

whether the uterine cavity is opened or not, may be coun-

seled that subsequent concomitant hysteroscopic and lapa-

roscopic procedures can be performed without signiWcantly

increased risk of operative blood loss, complications or fail-

ure. However, older patients with multiple co-morbidities

should be advised that there may be a higher probability of

increased operative risk and hospital stay.

From this paper, we can conclude that previous uterine

surgery whether the uterine cavity is opened or not among

young women with reproductive failure does not appear to

aVect adversely the performance or safety of subsequent

major surgical hysteroscopy guided by concomitant lapa-

roscopy.

ConXict of interest statement None.

References

1. Weibel MA, Majno G (1973) Peritoneal adhesion and their rela-

tion to abdominal surgery: a postmortem study. Am J Surg126:345

2. Davey AK, Maher PJ (2007) Surgical adhesions : a timely update,

a great challenge for the future. J Minimal Invasive Gynecol

14:1522

3. Baakdah H, Tulandi T (2005) Adhesion in gynecology complica-

tion, cost and prevention: a review. Surg Technol Int 14:185190

4. Brill AI, Nezhat F, Nezhat CH, Nezhat C (1995) The incidence of

adhesions after prior laparoscopy: a laparoscopic appraisal. Obstet

Gynecol 85:269

5. Shokeir T, Badawy A, Abo-Hashem H (2008) Preoperative risk

factors for intraabdominal adhesions should not contraindicate

surgical laparoscopy for infertility. JSLS 12:267272
http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-


6/7


1 3

6. Gavai M, Berkes E, Fekete T, Lazar L, Takacs ZF, Papp Z (2008)

Analysis of perioperative morbidity according to whether the

uterine cavity is opened or remains closed during abdominal

myomectomy: results of abdominal myomectomy. Clin Exp Obstet

Gynecol 35:107112

7. Nappi C, Di Spiezio Sardo A, Greco E, Guida M, Bettocchi S,

Bifulco G (2007) Prevention of adhesions in gynecologic

endoscopy. Hum Reprod Update 13:379394

8. Christianson MS, Barker MA, Lindheim SR (2008) Overcoming

the challenging cervix: techniques to access the uterine cavity.

J Low Genit Tract Dis 12:2431

9. Schirmer BD, Dix J, Schmieg RE Jr, Aguilar M, Urch S (1995)

The impact of previous abdominal surgery on outcome following

laparoscopic cholecystectomy. Surg Endosc 9:1085

10. Wamsteker K, deKruif J (1993) Transcervical hysteroscopic

resection of submucous Wbroids for abnormal uterine bleeding:

results regarding the degree of intramural extension. Obstet Gynecol

82:736740

11. The American Fertility Society (1988) The American Fertility Soci-

ety ClassiWcation of adnexal adhesions, distal tubal occlusion, tubal

occlusion secondary to tubal ligation, tubal pregnancies, Mullerian

anomalies and intrauterine adhesions. Fertil Steril 49:944955

12. Kaminski P, Gajewska M, Wielgos M, Szymusik I, Ziolkowska K,

Bartkowiak R (2006) The usefulness of laparoscopy and hysteros-

copy in the diagnosis and treatment of infertility. Neuro Endocri-

nol Lett 27:813817

13. Bergeron ME, Beaudet C, Bujold E, Rheaume C, Quellet P,

Laberge P (2009) Glycine absorption in operative hysteroscopy:

the impact of anesthesia. Am J Obstet Gynecol 331:e1e5

14. Serocki G, Hanss R, Bauer M, Scholz J, Bein B (2009) The gyne-

cological TURP syndrome: severe hyponatremia and pulmonary

edema during hysteroscopy. Anaesthesist 58:3034


7/7

Copyright of Archives of Gynecology & Obstetrics is the property of Springer Science & Business Media B.V.

and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright

holder's express written permission. However, users may print, download, or email articles for individual use.

efek histrectomy.pdf

Documents

Transcript of efek histrectomy.pdf